Letters of Support

By Nick Peplow·Founder and editor

Last reviewed 9 September 2026· How this site is researched

For most people the letter of support is the single most annoying piece of paperwork between them and surgery. It is also usually simpler than it sounds. This page covers which procedures need one, what it has to say, who can write it, and how to get it without waiting six months.

Which procedures need letters

Under the current WPATH Standards of Care (SOC8), the recommendation is one letter from a qualified health professional for any gender-affirming surgery. In practice:

• Top surgery: one letter is the norm. Some private surgeons operating on an informed-consent basis require none. US insurers almost always require one.
• Hysterectomy and oophorectomy: one letter under SOC8. Some insurers still ask for two because the procedure is sterilising.
• Metoidioplasty and phalloplasty: one letter under SOC8, but two is still common. Many US insurers, NHS England and a lot of surgeons have not moved off the older SOC7 two-letter rule. Assume two until told otherwise.

The full breakdown of what SOC8 requires is on WPATH SOC8 Criteria. The letter requirement is the part that insurers and hospitals have been slowest to update.

What the letter has to contain

The content is fairly standardised. A letter that meets most insurer and surgeon templates includes:

• Your name, date of birth, and how long the writer has known or assessed you
• The writer's qualifications, licence number and contact details
• A statement that you meet the criteria for gender incongruence or gender dysphoria, usually with the ICD-11 or DSM-5 code
• A note that other causes of apparent incongruence have been considered
• Confirmation that any mental health or physical conditions are stable or managed well enough not to compromise surgery or recovery
• Confirmation that you have capacity to consent and understand the risks, benefits and permanence of the procedure
• Duration of hormone therapy, if relevant to the procedure
• An explicit statement recommending the specific procedure by name

That last point matters more than people expect. A letter recommending "gender-affirming surgery" in general can be bounced by an insurer that wants to see "bilateral mastectomy with chest reconstruction" or "phalloplasty with urethral lengthening". Ask your surgeon's office for their template or a list of what they need before the letter is written.

Who can write it

SOC8 says the assessor should be a health professional with competence in assessing transgender and gender diverse people. That does not have to be a psychiatrist or psychologist. Depending on where you are and who is paying, acceptable writers include:

• Licensed therapists, counsellors and clinical social workers
• Psychologists and psychiatrists
• GPs or primary care doctors with relevant experience
• Nurse practitioners and physician assistants in some US states
• Gender clinic staff in public systems

Insurers are the ones who narrow this list. Some require a doctoral-level mental health professional for at least one letter for genital surgery. Check the written policy.

How to get one quickly

There are three routes, roughly in order of speed.

Your existing therapist or prescribing clinician. If you already see someone for hormones or mental health, ask them. Most will write a letter after one or two conversations focused on surgery, and they already know your history. This is usually free or costs a normal session fee.

Single-session assessment services. In the US, several therapists and organisations offer a one-off assessment by video and turn a letter around in days. Fees are typically in the low hundreds of dollars, and some run sliding scales or free clinics. In the UK, private gender clinics and some independent psychologists offer the same for a few hundred pounds. Search terms like "informed consent letter writer" or "WPATH letter single session" will find them; check reviews and that they are licensed where you live, as some insurers require in-state licensure.

Public gender clinic. Slowest by a wide margin. NHS gender clinics currently have multi-year waits for a first appointment (see NHS Pathway and Waiting Lists), and the letters come at the end of the assessment process, not the start. If you are self-paying in the UK, it is common to get a private letter rather than wait.

Things that trip people up

• Expiry. Some insurers and surgeons want letters dated within the last twelve months. If your surgery date slips, you may need an updated letter.
• Wrong procedure named. See above. Get the exact procedure and CPT or OPCS code if your insurer uses them.
• Missing hormone duration. For genital surgery, most policies want the letter to state how long you have been on testosterone. If you are not on T by choice, the letter should say so and why; see Testosterone Requirements.

The mental health part

People worry that a diagnosis, past hospitalisation or current medication will block the letter. Generally it does not. The letter writer is asked whether your conditions are managed well enough to get through surgery and recovery, not whether you have any. Stable depression on medication, managed ADHD, or a history of self-harm years ago are routine and do not stop letters being written. Active psychosis, an uncontrolled eating disorder or current substance dependence are the kinds of things that might lead to a "not yet" rather than a "no".