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So, you have decided now that it is time to have top surgery which you fully expect to be the perfect anti-dote for your gender dysphoria. You are very excited – having done extensive research online as well as talking with others who already have had their FTM/FTN procedure and state that it was a great decision that changed their lives.

One issue that keeps popping up that you find confusing is that in order to be able to have your surgery, you will need to have letters that document your gender dysphoria. This may raise the following questions:

Let’s examine the answer to each of these questions.

Why do I need to provide letters in order to have my top surgery?

It is critically important that there is firm documentation in a letter that you have gender dysphoria and that a behavioral health professional highly familiar with transgender issues completely supports your decision. This is a major procedure and the decision to have it must be well founded with virtually no risk that it will be reversed at a later date. In line with this, the World Professional Association for Transgender Health (WPATH) Standards of Care (v7) recommends this letter for top surgery as the standard of care. In addition, there are medical-legal ramifications as well.

Outpatient centers and hospitals typically will require this letter in order for you to use their facilities for your top surgery.

Exactly what kind of letter(s) do I need?

There are several issues that need to be clearly addressed in this letter with the most important ones being strong documentation of persistent gender dysphoria and approximately how long it has been present with a minimum acceptable requirement often being 24 months. It should also be stated that you are living successfully and full-time in your chosen gender and do not or have not reverted back to your original gender. Many insurance companies and surgical facilities require a minimum of 12 continuous months for this.

What specifically needs to or should be covered in the letter, though, also depends on what health care provider is writing it. The one from a behavioral health care professional will be more thorough and comprehensive as compared to one written by your primary care doctor or endocrinologist.

Who must write the letter(s)?

The one letter that must be obtained in all circumstances is that from a behavioral healthcare professional. Many (insurance companies, plastic surgeons, surgical facilities) further stipulate that it must be written by someone with a doctoral degree such as an M.D., Ph.D., Ed.D., D.Sc.,D.S.W. or Psy.D. This will be the most stringent and comprehensive letter.

If two letters are needed, the second one can be from an internist, family practitioner or endocrinologist that has been treating you as relates to your gender dysphoria. There often are stipulations as to the minimum amount of time they have been treating or monitoring you continuously for this.

How many letters do I need?

If you are attempting to obtain insurance authorization for your FTM/FTN top surgery, two letters are mandatory before you will even be considered. This is true of the largest insurance companies such as Blue Cross/Blue Shield, United Healthcare, Aetna and Cigna. You also should know that virtually all of the time, you must be at least 18 years of age for consideration.

For top surgery done without insurance coverage (self-pay), usually only one letter is required with that one coming from the behavioral healthcare professional.


The above information should serve as a helpful and informative but general guideline for FTM/FTN top surgery in the present day. This can and probably will change with time and your specific situation may even vary from the above. My staff and I can and will help you with this so as to make the whole process for you as easy and stress free as possible.

For more information or to schedule your consultation, you can call my office at (480) 451-300 or contact us by email.

Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona

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