Use this checklist to ensure that each element is included in your letter. Use language that is client specific; do not simply copy this checklist.
Identification of the procedure and diagnosis (per WPATH SOC p. 28)
- The client’s general identifying characteristics (their appearance, to prevent letter swapping)
- The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date
- Results of the client’s psychosocial assessment, including any diagnoses
- *Procedure needed
Narrative account of gender dysphoria
- Show “Persistent, well-documented gender dysphoria” (SOC p. 59)
- Narrative of the person’s trans history, including hormone use. If no hormone use, explain why that is clinically appropriate for that person.
- If the patient is nonbinary, explain their chest dysphoria or gender goals
- Narrative of symptoms
- Long-standing desire for surgery
- Note any history of depression, anxiety, self-harm, suicidality, etc.
Describe specific harms experienced by untreated patient
- List steps taken to transition so far, how they have helped, and their inadequacy to resolve their gender dysphoria
- Use of binder, problems associated with it
- Describe specific examples of impairment (how they are limited presently socially, school, physically, etc.)
- Harms associated with not having or delaying surgery
Capacity to make a fully informed decision and to consent for treatment
- Capacity to make a fully informed decision (SOC p. 59)
- A statement about the fact that informed consent has been obtained from the patient (SOC p. 28)
- Address age-related concerns, indicate the maturity of person
- Indicate if the parents consent to and are supportive of this treatment
- Show “If significant medical or mental health concerns are present, they must be reasonably well controlled” (SOC p. 59)
Statement of medical necessity
- Explain that WPATH criteria for surgery (p. 59) have been met.
- Note that WPATH SOC (p. 21) do not specify a minimum age requirement for top surgery.
- If one year of testosterone and social transition have been met, note that. If not, note why that is not necessary in this case.
- If you find it to be accurate, use the phrase “medically necessary,” which is defined in insurance policies simply to mean clinically appropriate care to treat a condition in accordance with generally recognized standards of care
- Indicate if the surgery will help to alleviate the person’s gender dysphoria
- “A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.” (SOC p. 28)
- Some insurance companies require a “Treatment plan that includes ongoing follow-up and care by a qualified behavioral health provider experienced in treating gender dysphoria.” You can indicate that the patient intends to continue seeing you after surgery.
State the qualifications of the provider (bolster your credibility as applicable, omit things that do not apply)
- Education and degree
- Length of time & experience working with/diagnosing trans patients
- Number/percentage of trans patients seen, if a significant part of your practice
- Note any training in childhood and adolescent developmental psychopathology
- Note any specific competence in diagnosing and treating children and adolescents with gender dysphoria
- Continuing education in the assessment and treatment of gender dysphoria
- Professional associations
- Trainings given, courses taught
- Consider attaching CV
If you need any additional information, please do not hesitate to contact me at [phone].
Updated on Nov 19, 2020