This blog is specific to letters for adult patients!!!!!
Table of Contents
- What Is A Mental Health Support Letter?
- What Is Informed Consent?
- When Might I Need A Mental Health Support Letter?
- Who Can Write Mental Health Support Letters?
- Yeah, Yeah, What Does “have at least a master’s degree or equal clinical training” Mean?
- Can I Get A Mental Health Support Letter At QueerDoc?
- What Does WPATH Say About Evaluating A Person’s Readiness?
- How Are They Different From Surgical Referral or Insurance Letters?
- How Do I Find Out What MY Provider or Insurance Company Requires In a Letter?
- How Can I Find Someone To Write A Mental Health Support Letter?
- Any Other Resources For Preparing for Surgery?
What Is A Mental Health Support Letter?
The quick answer is that a mental health support letter is a document provided to a physical health clinician, surgeon, or insurance company stating that the individual is mentally and emotionally ready to receive care.
It may go by many names:
Gender Affirming Care (or GAC) letter
Letter of Support
Surgery Letter
Surgical Readiness Letter
Letter of Medical Necessity
These letters aren’t unique to gender affirming care, but they are barriers to receiving care that are not frequently required in other kinds of healthcare (excepting reproductive health.) We have opinions about that, as we’re sure you can understand.
In gender affirming care, mental health support letters may include any or all of the below statements. The requesting provider or insurance company may have specific requirements for which information is included:
- the individual meets the requirements for a diagnosis of gender dysphoria.
- the individual has experience living in their gender.
- the individual has completed the therapeutic course required by the clinician, surgeon, or insurance company.
- that the individual is emotionally and mentally ready for the care
- for surgery, the individual is also aware of and ready for the course of aftercare.
- the individual is able to understand the risks and benefits of medical care and can make decisions for themselves regarding gender affirming care.
- that the informed consent discussion (or discussions!) have happened
- the informed consent discussion must include information about potential impacts to reproductive health and a discussion about reproductive options.
- that the individual consents to the desired care.
- an evaluation of the individual’s emotional and mental health.
- if any other mental health concerns are present, that their potential impacts have been discussed as a part of informed consent
- if any physical health concerns are present, that their potential impacts have been discussed as a part of informed consent.
- the individual understands the impacts of this surgical procedure on future fertility.
What Is Informed Consent?
Consent is sexy. We love it. We practice an informed-consent model of care. Informed consent describes the legal and ethical requirements for how we discuss potential medical treatments with patients and what must be included in those discussions.
Most people have the capacity to provide informed consent for gender-affirming care, so letters of support are not typically required at QueerDoc. An informed consent model allows us to individualize care based on each person’s goals, needs, and health history. Occasionally, someone may benefit from additional evaluation or support to clarify how other health conditions could affect their care and to confirm that gender-affirming care is likely to support their goals and needs.
When Might I Need A Mental Health Support Letter?
The WPATH (World Professional Association for Transgender Health) Standards of Care (SOC) Version 8 provides guidance for providing gender affirming care. Their Standards of Care document includes recommendations for when a mental health support letter might be recommended or required.
WPATH has a complicated history as an organization that has pathologized gender diversity, gatekept care, and operated within systems shaped by colonialism, misogyny, and transphobia, while also serving as an institution that has helped “legitimize” transgender medicine. We appreciate SOC 8’s movement toward greater respect for human rights and bodily autonomy, including its recommendation against universal letter requirements for adults seeking gender affirming interventions, whether medications or surgery.
WPATH SOC Version 8 recommends that if a letter is required, only one should be required.
Adoption of these recommendations varies across insurance and care providers.
Some clinicians require a mental health letter before starting hormone therapy or other medical treatments or non-surgical procedures.
Most surgeons require a mental health support letter before scheduling surgery.
Most insurance companies require a mental health support letter before agreeing to pay for surgeries. Some require them before non-surgical procedures or hormones will be covered.
Who Can Write Mental Health Support Letters?
The WPATH (SOC) Version 8 recommends minimum qualifications for which mental health clinicians can write mental health support letters.
They must:
- have at least a master’s degree or equal clinical training.
- are licensed by their regulatory association.
- are able to identify gender dysphoria, gender diversity, and gender incongruence and distinguish them from other potentially co-existing mental health or psychosocial concerns.
- have experience doing so!
- keep their skills up to date by regularly completing continuing education in gender diversity, dysphoria, and incongruence.
- are able to assess capacity for treatment. “Capacity” means that
- the person understands the risks and benefits of a treatment
- the person understands the potential positive and negative outcomes of this treatment
- the person also understands the risks and benefits of not getting this treatment
- the person can remember this information over time
- the person can use their understanding to make a decision about wanting or not wanting specific care
- the person can communicate this with their care team
- WPATH also suggests that professionals who write support letters work with other professionals experienced in gender affirming care when needed (if a clinician has questions, they should ask someone who has specific knowledge of gender affirming care!)
Yeah, Yeah, What Does “have at least a master’s degree or equal clinical training” Mean?
The world of mental health provider training, licensing, and degrees is vast and complicated.
In general, mental health clinicians who are qualified to write letters of support for surgery and insurance include:
- Psychiatrists
- Psychologists
- Psychiatric Advanced Registered Nurse Practitioners (ARNP)
- Psychiatric Mental Health Nurse Practitioners – Board Certified (PMHNP-BC)
- Licensed Mental Health Counselors (LMHC)
- Licensed Independent Clinical Social Workers (LICSW)
- Licensed Advanced Social Workers (LASW)
- Licensed Marriage and Family Therapists (LMFT)
Can I Get A Mental Health Support Letter At QueerDoc?
No – currently none of our team members are mental health providers, so we don’t meet the requirements for these letters!
We can write surgical referral letters and insurance letters for people who are getting care with us. (See below and our previous blog on the letter writing maze for more on surgical referral letters and insurance letters!)
What Does WPATH Say About Evaluating A Person’s Readiness?
- the person should have experienced marked gender incongruence.
- they’ve experienced this for a while.
- it impacts their life in a significant way – but it doesn’t have to be severe!
- If a diagnosis is required, the person meets the standards of the diagnosis.
- does this person have any existing mental health concerns that could impact either the ability to consent to care or the ability to undergo care? Does the person understand these possible impacts?
- does this person have any existing medical conditions that could impact either the ability to consent to care or the risks of care? Does the person understand these possible impacts?
- Common medical conditions that can impact risks of care include, but are not limited to, smoking status, alcohol intake, existing heart disease, and diabetes.
How Are They Different From Surgical Referral or Insurance Letters?
Surgical referral letters are written by a physician, nurse practitioner, or physician’s assistant, and “introduce” an individual to a surgeon. Surgical referral letters may also include information about having a diagnosis of gender dysphoria, lived experience, medicines taken by the person, and the person’s physical readiness for surgery.
Insurance companies may require a letter from a medical clinician in addition to a mental health letter. Often this letter includes statements that the patient meets medical requirements for surgery.
How Do I Find Out What MY Provider or Insurance Company Requires In a Letter?
We wish that letters were standardized. Most likely, you’ll need to ask your provider, surgeon, or insurance company what information they want to see in a mental health letter. Many will provide suggested templates to use.
Some examples:
From the Gender Confirmation Center, accessed 7/27/26:
From the Crane Center for Transgender Surgery, accessed 7/27/26.
MozaicCare’s letter requirements, accessed 7/27/26.
Download OHSU’s sample letter of support, accessed 7/27/26.
We didn’t find a letter template at UW’s Insurance Requirements & Coverage for Gender Affirming Care page, but we did find this super-helpful list of links to gender affirming care medical policies by insurance company. (accessed 7/27/26)
How Can I Find Someone To Write A Mental Health Support Letter?
Directories Dedicated to Letter Writers
We love the No More Gatekeeping Directory. This is a list of clinicians who have agreed to write a letter for gender affirming care, including hormones, surgery or other procedures, legal identification document changes, and other reasons after ONE SESSION.
This is an amazing resource. It can be filtered by:
- State
- Pricing
- Insurance
- Type of Clinician
- Language
Each provider has a profile where you can find more about them and their contact information.
The GALAP (Currently on hiatus)
“GALAP” is short for The Gender Affirming Letter Access Project. This is another set of clinicians who have signed a pledge agreeing to write at least one mental health support letter for gender affirming care a month at no cost to the patient.
The GALAP has been offline for a couple of years but has posted that it is hiring a developer to bring the directory back online. We are on their list for updates, so we’ll update this section if/when we hear that they are back online.
Directories of Affirming Providers (Not Affiliated With A Pledge To Write Letters)
We also love the National Queer and Trans Therapists of Color Network and love referring patients to them. Queer, trans, and people of color deserve therapists who understand their lived experiences, especially when those identities overlap multiple areas of systemically undervalued identities.
Clinician and Provider Directories Not Limited to Mental Health Specialties
QueerDoc Listed Resources
Any Other Resources For Preparing for Surgery?
Why, yes! We’ve several blogs about preparing for gender affirming surgeries!
- Your Bottom Line: Preparing For Bottom Surgery
- 7/17 Physically Preparing for Bottom Surgery
- What Exercises Should I Do to Get Ready for Top Flattening Surgery?
- 9/18 Hospital Stay Phalloplasty Checklist
- 8/21 QueerDoc’s VulvoVaginoplasty Checklist
- 9/11 Metoidioplasty Checklist for Your Hospital Stay and Recovery
- 9/25 – Chest Flattening Top Surgery Checklist
- 10/2 Breast Augmentation Checklist for Hospital and Recovery
- 7/10 Hospital Stays When You Have Sensory Needs, Allergies, or Sensitivities