The Ultimate Guide to Getting a Therapist Support Letter for Gender-Affirming Surgery

Medically reviewed by Paul Gonzales on May 28, 2024.

Many gender-affirming surgical practices like the Gender Confirmation Center (GCC) use the informed consent model in determining who is eligible for top surgery, facial feminization surgery, facial masculinization surgery and gender-affirming body contouring. However, some surgical practices and insurance companies require patients to submit support letters from one or more mental health professionals to undergo surgery and/or to cover its costs. In our case, per the WPATH Soc 8 guidelines, Dr. Ley requires a support letter for first-time bottom surgery patients.

In this article go over how to get a therapist support letter for gender-affirming surgery, the requirements for the support letter(s) as well as the additional value a gender-competent mental health professional can have during the surgical journey.

If you are interested in getting gender-affirming surgery, you can schedule a free, virtual consultation with one of our board-certified surgeons today.

Why do I need a support letter for surgery?

Eligibility

Some gender-affirming surgeons may require at least one support letter from a mental health professional to clear a patient to be eligible for surgery. The purpose of these letters is to assess a patient’s readiness for surgery.

In the case of bottom surgery, per the WPATH’s Soc 8 guidelines, patients will need to present one support letter from a licensed mental health professional to be eligible for bottom surgery. However, Dr. Ley does not require that patients present a support letter to undergo a bottom surgery revision procedure. Whether or not you underwent your initial bottom surgery procedure with her, the support letter eligibility requirement will be waived.

In the case of adolescents who are not yet legal adults, a letter of support from a licensed mental health professional and/or a medical healthcare provider (such as a physician or endocrinologist) that is part of their multidisciplinary care team will be necessary to establish their readiness for gender-affirming surgery.

Insurance Coverage

Most insurance companies that cover gender-affirming surgeries require one letter of support from a licensed mental health provider (e.g. therapist, psychiatrist) to prove that surgery is medically necessary or is part of transition-related care. However, most insurance companies require two support letters to cover bottom surgery. In this case, at least one should come from a licensed mental health professional. The second can come from a mental health or a healthcare provider: for example, an endocrinologist or primary care provider who has been involved in your hormone therapy.

Depending on your insurance plan, your primary care provider may need to write you a referral letter to get gender-affirming surgery. Likewise, if the surgeon is outside your insurance’s list of in-network providers. For more information about which types of insurance we take and how to get coverage, you can refer to this article.

We recognize that the letter requirements for insurance can be an extra barrier for patients to access medically necessary, gender-affirming care. For this reason, once you have requested a surgical consultation, we can help you through securing this and any other documentation.

How can I find a gender-affirming therapist to write me a letter?

For some patients, it can be difficult to find a gender-competent mental health professional to support them through gender transition, or more specifically, to get a support letter for surgery. Though it may take time, finding someone you are comfortable with is worth the effort. Patients can consult the list of WPATH members or the directory of the Gender Affirmative Letter Access Project (GALAP) to find a gender-competent, licensed mental health provider. Additionally, there are multiple online therapist directories that can filter for experience working with transgender individuals, the types of insurance they take, and their current availability.

If you have gender-affirming therapists in your area then this will help tremendously. If not, you can pick someone who is committed to learning, or look into support groups and online resources. If you cannot afford therapy, consider reaching out to health centers or local LGBTQ centers for free or low-cost options.

If you select a therapist and end up not liking them, you can always choose to stop seeing them. Some therapists provide a free consultation to assess whether they would be a good fit for you.

What questions should I ask?

When you are looking for a licensed psychiatrist or psychotherapist to write you a referral letter for surgery, these are some questions you might want to ask them:

• If you are seeking a therapist exclusively to get a referral letter for top surgery, ask if this is something they can provide and what the process is.
• How familiar are they with the WPATH Standards of Care?
• What experience do they have with clients who are transgender and/or non-binary?
• Do they take your insurance?
• If they don’t take your insurance ask: Do you offer a sliding scale? (meaning, do they offer more accessible rates for lower-income clients)

What are the requirements for support letters?

Adolescents

According to the World Professional Association for Transgnder Health (WPATH) Standards of Care (SOC) version 8, a support letter needs to be written by a member of a multi-disciplinary team of mental health and medical care providers involved in providing gender-affirming care to the adolescent. Since the patient is not yet a legal adult, the multi-disciplinary team needs to work with the parent(s)/guardian(s) in assessing the patient’s eligibility for surgery. Please note that top surgery is the only kind of gender-affirming procedure that adolescents are eligible for, even with parental consent and the approval of their multidisciplinary care team.

In the case of adolescent care, some surgical practices have a list of vetted mental health providers that they accept support letters from. If you have questions about the specific requirements for your adolescent’s surgery, you should contact your surgeon’s office.

Adults

According to SOC 8, the purpose of a support letter for an adult seeking medically necessary gender-affirming medical treatments should be assessed by a licensed mental health professional with at least a master’s-level education in their clinical field (psychiatry, social work/LCSW, marriage and family therapy/LMFT, etc.). Providers should be able to assess a patient’s capacity to consent to surgical treatment, discuss mental and physical health conditions that could negatively impact the outcome of gender-affirming care, discuss the impact of the surgery on reproductive health, and more.

In the case of bottom surgery, WPATH recommends that two licensed mental health professionals provide a support letter. This can be in the form of one letter signed by two professionals or two letters provided by the professionals, separately.

According to SOC 7, the set of WPATH standards that many providers and insurance companies still follow, letters should include the following components:

1. The client’s general identifying characteristics;
2. Results of the client’s psychosocial assessment, including any diagnoses;
3. The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;
4. An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery;
5. A statement about the fact that informed consent has been obtained from the patient;
6. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.

Mental health support before and after surgery

In many cases, requiring adults to present referral or support letters from mental health professionals in order to undergo gender-affirming surgery can be considered a form of gatekeeping. At the GCC, we simultaneously recognize and value the role of mental health professionals in supporting patients through the process of surgical gender-affirmation.

Both the process of preparing for and recovering from surgery can take an emotional toll on patients. Having an active support network of loved ones and a mental health professional can strengthen your ability to cope with challenges that may arise. Specifically, gender-competent mental health professionals can support patients through:

• Helping you figure out which procedures are right for you
• Setting realistic expectations for the results and recovery of surgery
• Figuring out how and to which people in your life you would like to reveal that you undergoing surgery
• Organizing a support network or plan for your physical and emotional recovery from surgery
• Helping you navigate temporary feelings of post-operative depression and regret that might come up as you deal with the physical limitations and inflammation (having to wait to see the final results of your surgery)
• Celebrating your gender affirmation with you!

Conclusion:

• A support letter from a licensed mental health professional–a psychotherapist or psychiatrist–may be necessary to be eligible for surgery. Likewise, most insurance companies require a letter from a mental health procedure to justify covering the costs of gender-affirming surgery. In the case of bottom surgery, most insurance plans require two letters.
• You can find a gender-competent provider to write you a support letter through the Gender Affirmative Letter Access Project (GALAP), the list of WPATH members or other online search engines like Psychology Today. Generally speaking, your provider should be a licensed clinical mental health professional (MD/DO, LCSW, LMFT, etc.), with at least a master’s-level education and a familiarity with the WPATH’s Standards of Care.
• For adolescent surgical care, the requirements are generally stricter. Contact your surgeon to see what they require of your adolescent’s care team for them to be eligible to undergo top surgery. No other forms of gender-affirming surgeries are performed on adolescents, even with parent/guardian approval.
• Although the requirement for a therapist support letter for gender-affirming surgery is often a form of gatekeeping, we recognize that mental health professionals often provide an invaluable role in supporting patients through surgery.