If you’re considering FTM or FTN gender-affirming top surgery, you’ve likely heard about the letter that you will need from your therapist in order to be able to have surgery. This document, sometimes called a WPATH or surgical readiness letter, is required by most plastic surgeons, surgical facilities and insurance companies. It’s based on the World Professional Association for Transgender Health (WPATH) Standards of Care Version 8 (SOC 8), which sets guidelines for transgender healthcare.
This may already sound very daunting to you. However, the following guide will walk you through what the letter is and why it’s needed, who can write it and what must be included in it.
The goal here is to help you feel informed and ready as you take this important step in your gender-affirming journey.
Why This Letter Matters
This surgical readiness letter is a formal document that confirms you’re prepared for top surgery – medically, emotionally and mentally. It’s not just paperwork; it’s a way to better ensure you’re set up for a safe and successful experience. Furthermore, it can also reduce the risk for some who might not be making the right decisions for themselves, thereby avoiding postoperative regret and later de-transitioning.
Most plastic surgeons and insurance providers require this letter before approving top surgery or covering costs. Surgical facilities typically mandate this letter as well.
Here’s why it’s so important:
- Proves Medical Need: The letter definitively states that you have gender dysphoria – distress from a mismatch between your body and gender identity – and that top surgery is absolutely necessary to address it. This is required by most insurance plans when you are seeking coverage.
- Ensures You’re Informed: It confirms you have the mental capacity to understand the surgery, its implications and other related issues. In other words, you are able to give informed consent.
- Supports Your Well-Being: By checking your mental and physical health, the letter helps make sure you’re ready for the changes surgery brings, reducing risks and boosting positive outcomes.
Your plastic surgeon should inform you whether or not you will need to have this letter in order to proceed with surgery.
Who Can Write this Letter?
In practice, this letter needs to come from a qualified mental health professional and, preferably, one who understands transgender care and WPATH guidelines. This would include:
- Licensed clinical social workers (LCSW)
- Psychologists
- Psychiatrists
- Licensed professional counselors (LPC)
In some situations, letters from other healthcare professionals may be accepted.
Ultimately, it is absolutely in your best interest to work with a mental health professional who has extensive knowledge and experience in dealing with transgender and gender nonbinary patients and issues.
If you are presently seeing a therapist regarding gender issues or have seen one in the recent past that falls into one of the above groups, they would an ideal choice to write your letter. However, if you don’t know of anyone, your plastic surgeon may be able to provide you with some recommendations. You can also obtain recommendations from other individuals in the transgender community who have already had surgery or are presently seeing therapists.
What Goes into the Letter?
The letter written for you should have specific information that meets the SOC 8 guidelines and satisfies your surgeon and insurer. It can also be viewed as a checklist that proves that gender affirming surgery is appropriate for you and that you are mentally, emotionally and intellectually prepared for it.
Listed below are the specifics and the importance of them:
1. Your Personal Details
- What’s needed: Your full legal name, preferred name (if you use one), date of birth, gender identity and contact information.
- Why it’s included: This keeps everything clear in medical and insurance records, linking the letter to you and avoiding mix-ups.
2. Diagnosis of Gender Incongruence/Gender Dysphoria
- What’s needed: A statement confirming you have gender dysphoria/gender incongruence. It should include a short summary of when this started, how it’s affected your life and steps you’ve taken, like social transition or counseling.
- Why it’s included: This shows top surgery is medically necessary to relieve distress from a mismatch between your body and gender identity. Insurance needs this diagnosis for coverage and it confirms your experiences are ongoing, not temporary.
3. History of Gender-Affirming Steps
- What’s needed: A record of any previous steps in your transition, like hormone replacement therapy, counseling or other surgeries. For example, if you’re on testosterone, note how it has positively helped you and reinforced your desire for transitioning.
- Why it’s included: This shows surgery is part of a thoughtful plan. Studies suggest that trying reversible steps like HRT first can lead to better outcomes, as it gives you time to explore changes before something permanent like surgery.
4. Mental and Emotional Health Check
- What’s needed: An evaluation of your mental health, noting any conditions like anxiety or depression and confirming that they are well managed. It’s not about needing therapy for months—just an honest look at how you’re doing.
- Why it’s included: Surgery can be emotionally stressful so this indicates that you’re ready and have support (like friends or family) for recovery. It also separates gender incongruence from other mental health issues, keeping the focus on your needs.
5. Readiness
- What’s needed: Proof that you’re mentally prepared and have realistic expectations about surgery outcomes.
- Why it’s included: Top surgery is a big, relatively permanent step. This confirms you know what to expect and are ready for the physical changes.
6. Therapist Support of Your Decision to Pursue Top Surgery
- What’s needed: This is a direct statement agreeing with your desire to undergo gender affirming top surgery is needed.
- Why it’s included: This definitively states that based on the thorough evaluation by your mental health professional, they fully support your decision to proceed with surgery. It is, in essence, the official “go-ahead” for your surgeon and insurance company.
Final Thoughts: Getting Your Letter and Moving Forward
Obtaining your letter is most often necessary in order for you to be able to have top surgery. However, it is also a worthwhile investment intellectually, mentally and emotionally, on many levels, in your journey that can serve you well.
Find out how your plastic surgeon wants to receive the letter. Either:
- directly from your therapist as a written letter or a PDF or
- from you after you have received it from your therapist
Once it is received by your plastic surgeon, you are that much closer to making your gender affirming top surgery a reality.
Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona
