This Gender Affirming Surgery Letter

For the sake of allowing folks to have a copy of a generalized, boilerplate psychiatric gender affirming surgery recommendation letter, here then, in all it's gatekeepy glory, is a blank copy of the letter I have used and curated for years successfully. Feel free to use, share, copy, give helpful feedback, etc etc. 

Date: today

Re: John Q Lastname (the Q stands for queer)

DOB: 26 June 2019 

To Whom It May Concern:

I am writing this letter of support on behalf of John Q Lastname in his pursuit of medical treatment and evaluation for gender reassignment and affirmation surgery.  He is a 28 year old Black trans male, assigned female at birth.  He first met with this clinician on your mom’s birthday for a comprehensive psychosocial assessment that included an evaluation of gender dysphoria history, support network, awareness of risks and benefits related to said procedure, and for an assessment of his ability to give informed consent.

After the comprehensive psychosocial assessment detailing past experiences and gender identity, it became evident that John Q Lastname meets the criteria for Gender Dysphoria, as set forth by the World Professional Association for Transgender Health in the seventh edition of the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, and as defined by the American Psychiatric Association in the DSM 5.

The goal of the psychosocial assessment is to provide a holistic client portrait, gauge the client’s readiness for medical treatment, and to inform a treatment plan from a behavioral health perspective.  The purpose of the psychosocial assessment includes the following six factors:

1. To facilitate the wellbeing, empowerment, and support of the client;
2. To highlight the diagnostic criteria for Gender Identity Disorder, that is met by the client, as defined by the DSM IV-TR or for Gender Dysphoria, as defined by the DSM-V;
3. To facilitate appropriate referrals for mental health, psychiatric, medical and/or surgical interventions as indicated, and if client is seeking medical intervention, to make assessment of the client’s mental health and readiness for these interventions;
4. To rule out the presence of psychiatric or psychosocial stressors which could interfere with the client’s ability to engage in treatment, or be able to describe how these are controlled;
5. To assess the client’s ability to make informed decisions about her/her/their care; and
6. To identify with the client any issues which could be addressed in on-going behavioral health treatment.

The assessment process generally includes, but is not limited to: childhood development, gender identity, sexual orientation, trauma history, prior mental health treatment and/or hormone replacement treatment, social support and finances, substance abuse history, and the client’s understanding of medical intervention as part of the transition process.

John Q Lastname has a long history of cross-gender identification and gender dysphoria. This has impacted work, school, and social functionality historically.  He has been living socially under his preferred name of John Q Lastname for approximately 5 years, which also has contributed to reduction in gender dysphoria.

This clinician believes that he is able to provide informed consent in pursuing or engaging in any prescribed medical treatment to alleviate gender dysphoria.  He has a more than adequate social support network in place to support him during the recovery process as well.

John Q Lastname has been undergoing hormone replacement therapy for 4 years under the supervision of Dr Jacob Feelgoode at this clinic.  John Q Lastname has been living fulltime as his identified gender for over 5 years.  He has been binding his chest off and on to reduce feeling of dysphoria as well as wearing oversized clothing to obfuscate his figure.  Avoids binders only due to the discomfort they cause and the exacerbation of feelings of claustrophobia and difficulty respirating.  Further medical/surgical gender affirming intervention, including chest reconstruction surgery, would seem to be the logical next step in relieving any remaining gender dysphoria symptoms.

John Q Lastname is both able to assess and is aware of risks and benefits associated with medical intervention to relieve gender dysphoria including surgical procedures.  Judgment and insight have remained intact and unimpaired consistently as have mental status exams overall.

In all, I am confident that John Q Lastname understands the implications of surgical treatment.  It is my clinical opinion that pursuing further reduction in feelings of dysphoria will greatly improve his quality of life.  I support his decision to pursue medical intervention related to gender identity/dysphoria.  If you have any further questions, please contact my office at 503-460-0405. I would be happy to discuss the matter further, with the client’s written consent.

Sincerely,

Jacob Balinky, PMHNP-BC