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Writing Letters of Support to Insurers and Surgeons

Learn about the basics of writing support letters for gender-affirming procedures.

  • Health professionals will be asked by insurance companies and surgeons to write letters prior to a patient receiving gender-confirming surgery.
  • When considering writings letters, it is best to think about what the goals are in terms of assessing the patient’s capacity to make a decision.
  • Mental health clinicians can provide capacity evaluations for TGNC surgical procedures just as they would any surgical procedure.
  • Remember that capacity is based on the evaluation of a clinician and competency is decided by legal authority.


Capacity involves four major components:

  1. Understand
  2. Retain
  3. Weigh
  4. Communicate
  • The patient understands the information about the surgery, retains the information for long enough to make a decision, weighs the information in making the decision, and communicates that decision in a clear and consistent manner.
  • Remember that decision-making capacity is not a static state. The letter must only reflect the presence of capacity at the time of the evaluation.
  • The goal of the letter is not to identify if the patient is transgender or not. While many insurance companies and surgeons will ask for this, identifying where one is on the gender spectrum is very personal and cannot be determined by a clinician.
  • In the letter, include the surgical procedure being performed, a brief mental health history, and a statement as to why the person is ready for surgery at this time.
  • If a patient is not able to make a decision about surgery (e.g., due to untreated mental illness or cognitive impairment), then do not write a letter.

Sample Letters

Included below are two example letters that clinicians can use as a template. Insurance companies and surgeons maybe have different requirements before they provide services. Adjust the letters as needed but continue to question if the WPATH Standards of Care are being followed and if unnecessary barriers are being put in place (ex. An insurance company requiring more than year of individual therapy for someone who has identified as TGNC for many years).

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