Gender-Affirming Surgery Letters 101

Learn how to get a letter for gender-affirming surgery from a medical provider. FOLX offers surgery referral letters for all kinds of gender-affirming procedures!

November 1, 2022
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This article was updated 7/12/23. The illustrations are by Leo.

This article reviews the basics of getting a letter for gender-affirming surgery from a medical provider. At FOLX, we write letters for all kinds of gender-affirming surgeries. Not every person wants or needs a gender-affirming surgery, but for those who do, this guide reviews the types of letters you’ll need.

What are surgery letters?

Usually, both the surgeon and the insurance company require a letter of support for gender-affirming surgery. The letter helps a surgeon who is just starting to get to know you evaluate your needs, and understand your situation and medical history in a more thorough way. A letter of support will inform the surgeon and insurance company about the type of surgery you want. Letters of support may be required for both the surgeon and the insurer to evaluate your coverage for: top surgeries (male chest construction or breast augmentation); bottom surgeries (removal of ovaries or uterus, testes or penis, constructing a new penis or vagina); and facial feminization or tracheal shaves. The insurance company wants to make sure that the procedure is medically necessary, that you understand what this surgery involves, and that it will be safe and effective.

Different letters of support for your gender affirmation 

There are a few different kinds of letters you may need. These include:

  • Introduction from a medical provider to a surgeon as they get to know you and evaluate you for appropriate surgical options
  • Mental health letters of support, which are sometimes needed for gender-affirming procedures
  • Providing the insurer with diagnostic codes, an indication of medical necessity and safety for the patient and the procedure 
  • Physical exam clearance letters or “pre-operative” clearance immediately before the actual surgery
  • Letters of support for changing or updating your legal name in court
  • Letters of support for changing your name and sex/gender on birth certificates, licenses, or passports

You don’t need to change the name on your IDs before having surgery. Of course, if you are more comfortable changing your name before surgery, go for it. Do what feels right or easiest for you.

Insurance companies, letters, and diagnostic codes

Insurance companies usually require a medical diagnostic code for "Gender Dysphoria" in order to cover transition-related care as medically necessary. You may not fit this diagnostic code exactly, but in some cases, the code is needed in order for insurers to pay for the surgery. A good example of this might be a letter for a person who identifies as nonbinary and does not have a lot of “dysphoria.” They might still need a gender dysphoria diagnostic code attached in order for insurance to cover the surgery.

Why does the World Professional Association of Transgender Health standards of care (WPATH SOC) require letters?

Letters of support for gender-affirming surgery are required by the international transgender organization WPATH in order to ensure that patients are appropriate and prepared for their upcoming gender surgery. They help surgeons prepare and get paid for these surgeries. They also help the insurance company make sure the surgery is going to be effective and safe for that patient.

WPATH updates

Updated guidelines from the WPATH standards of care (WPATH SOC 8) require only one letter of assessment from a healthcare professional. This provider must be competent in caring for transgender and gender-diverse people.

Before September 2022, WPATH guidelines required those seeking bottom surgery to provide two medical letters. One had to be from a mental health provider, and the other from a medical provider, like your hormone-prescribing clinician. If your insurance company requires a letter from your hormone provider for any surgery, your FOLX clinician can provide one.

Insurance approval letters

There are usually two steps in getting insurers to cover payment for the surgery, which is what a surgeon will require before they book a time in the operating room, if you plan to use insurance to cover any part of surgery.

Step 1: Pre-certification or prior authorization. This indicates that your insurance coverage does include this in their list of benefits.

Step 2: Insurance approval. The second important step is when the insurance company lets the surgeon know how much they will pay for the surgery and operating room or hospitalization costs.

Your surgeon will need both of these things before they can perform your surgery. It's important for you to know this, too, because it will help you figure out how much money you will need to pay for expenses that your insurance won't cover.

Letters for gender-affirming surgery

Ideally, letters for insurance approval can also provide the same information a surgeon might need to evaluate you for gender-affirming surgery. One letter can often be used for two purposes.

Some surgeons require a letter from your hormone treatment provider. Other surgeons suggest you be on hormones for a while before having some surgeries, although some people have surgeries without ever using hormones as part of their transition. Most surgeons want a letter from someone who understands your needs, your previous and current care, and your suitability for a particular surgery. For instance, letters may include a person’s history of gender affirmation care, hormone use, and whether gender dysphoria is ongoing–even with hormone therapy. These details may help establish the medical necessity for surgery.

A surgery letter may need to be provider-specific and insurance specific. This means that some providers and insurance companies may require certain language and information in these letters. Some surgeons and insurers still require two letters before agreeing to GAS (gender-affirming surgery). This complies with old WPATH standards of care (SOC 7) guidelines. Only one letter is required in the updated WPATH SOC 8 guidelines, acknowledging some of the history of gatekeeping in GAS care. 

It’s quite possible the information in a letter may not be specific to you. For example, they may use a gender dysphoria diagnosis, but you really do not have dysphoria, even if you want top surgery. Even if some of the details are not as specific to you and your situation as you would like, it may be more helpful to understand some of the “whys” behind including such information for coding and or payment requirements. Be aware providers can use different versions of letter templates to meet these requirements.

Keep in mind that not all medical providers are informed on WPATH guidelines or gender-affirming care in general. That’s why it’s crucial to find a culturally competent provider who understands how to write a surgery letter.

What FOLX offers

Our team of LGBTQIA+-specialized clinicians provides surgery letters according to WPATH SOC guidelines.

What we can provide:

  • We can provide medical letters for gender-affirming surgery.
  • We can provide surgery referral letters for those seeking top surgery (including breast augmentation) and facial feminization surgery (FFS).
  • We can provide referral letters for bottom surgery (including vaginoplasty and hysterectomies).
  • We can provide medical letters to get insurance approval and coverage. 

What we can’t provide:

  • We do not offer physical exam clearance letters for surgery.
  • We cannot provide medical clearance for surgery.
  • At present, we only offer mental health letters for surgery in select states (with more to come). (Surgeons sometimes require mental health letters before gender-affirming surgery.)

How to meet requirements for gender-affirming surgery

For FOLX to write a letter for gender-affirming surgery, we make sure you meet the WPATH standards of care so you get the care you need. These include:

  • A desire to undergo gender-affirming surgery
  • Understanding of the effect of gender-affirming surgery or procedure
  • The ability to consent to the procedure
  • Clearance from other mental health or medical conditions that could negatively affect the outcome of the gender-affirming surgery
  • If taking hormones or other medications, an assessment that you are doing well on all your medications 

Other things to note: 

  • WPATH prefers that a person is under the care of a gender-affirming expert provider for 6-12 months before surgery. This is something you can discuss with both your medical and surgical providers. 
  • Many insurers require a diagnosis of Gender Dysphoria for insurance coverage and billing.

Getting referrals and surgery letters

Submit a request via the FOLX Help Center so our Member Navigators can help you get a referral or request a surgery letter. For all FOLX and non-FOLX members seeking a gender-affirming surgeon in your area, please inquire about our referral network of over 20,000 healthcare providers and community resources nationwide.

If you’re an existing FOLX member, you can schedule an appointment with your clinician in your Athena Patient Portal to discuss surgery letters. If you're not yet a member, but you're interested in this service, book a virtual primary care appointment. Either way, your clinician needs to review your medical history and gather information so you can get your surgery letter. One of the best parts about being a FOLX member is that we’re here every step of the way to help and guide you. We make getting the gender-affirming care you need as easy and seamless as possible.


FOLX Health is the first digital healthcare company designed by and for the LGBTQIA+ community. Our services include expert, gender-affirming virtual primary care, gender-affirming hormone therapy (sometimes known as HRT or hormone replacement therapy), mental healthcare, sexual healthcare, and more. We offer memberships for testosterone and estrogen, sexual health products like PrEP, and peer support groups. Whether you’re lesbian, gay, bisexual, transgender, queer, gender non-conforming, or nonbinary, you can find LGBTQ-friendly healthcare with FOLX. FOLX Health is for everybody and every body in the LGBTQIA+ community. You deserve to feel fabulous. To become a FOLX member, click here.