Gender Transition Letters

Gender-Affirming Surgery Letters

Supportive assessments grounded in respect, autonomy, and informed consent.

At Caretta Counseling, we recognize that accessing gender-affirming medical care often includes navigating complex systems that require documentation from mental health professionals.

While we don't believe you should need a letter to prove your identity or worthiness, we’re here to support you with compassion, clarity, and without gatekeeping.

Whether you’re seeking a procedure that helps you feel more aligned and comfortable in your body, we offer respectful, collaborative assessments and letters to support your access to care.

Our process is rooted in informed consent and grounded in trust — honoring your lived experience and your right to make decisions about your body.

As required by many providers and insurance companies, you may need a letter of support from a mental health professional to proceed with gender-affirming surgery or to obtain insurance authorization. This applies to procedures such as chest reconstruction, breast removal or reduction, and breast augmentation (commonly referred to as “top” surgeries); as well as orchiectomy, vaginoplasty, phalloplasty (commonly referred to as “bottom” surgeries); and additional procedures such as facial feminization surgery, electrolysis, rhinoplasty, and tracheal shave.

To obtain a letter of support, you must undergo an assessment session with a mental health professional, during which they will inquire about your journey, identity, and life experiences.

We understand that the experience of gender is deeply personal and varied — there’s no one right way to be trans or nonbinary. Our process reflects this, and our goal is to offer supportive, affirming documentation that opens doors, not roadblocks.

Most assessments can be completed in one or two sessions, with letters typically written within 1–2 weeks. If you’re requesting multiple procedures or more in-depth documentation, we’re happy to work with you to ensure your letter reflects your needs fully and respectfully.

According to the latest Standards of Care, all gender-affirming surgeries require only one letter of support from a qualified healthcare provider, who must hold at least a master’s degree.

Such providers may identify as counselors, therapists, psychotherapists, or mental health professionals. However, many insurance companies continue to follow an older version of the Standards of Care, which requires two letters for ‘bottom’ surgeries (e.g., orchiectomy, vaginoplasty, phalloplasty). Some surgeons or insurers also stipulate that the second letter be provided by a doctoral-level practitioner.

Our Approach to Standards of Care

While our therapists are trained and qualified under current WPATH guidelines to provide surgery support letters, we also understand and acknowledge critiques of these systems.

At Caretta Counseling, we value informed consent and the dignity of trans and gender-diverse people. We are familiar with both WPATH and ICATH standards and often assist clients in navigating their requirements in healthcare and insurance settings.

For more about informed consent and the ICATH model, visit the ICATH website.

What is the purpose of the assessment session?
The purpose of an assessment session is to support the individual in establishing a diagnosis and identifying appropriate treatment. In this instance, an assessment session aims to determine if you have Gender Dysphoria, which is recognized as a diagnosis in the DSM-V (the Diagnostic and Statistical Manual of Mental Disorders used by mental health providers in the United States) and the ICD-11 (the International Classification of Diseases). This diagnosis will be evaluated by asking questions regarding your life, history, and potential symptoms of Gender Dysphoria.

If it is determined that you meet the criteria for a diagnosis of Gender Dysphoria, we can provide a letter of support. This letter can assist in securing necessary treatments from your insurance or healthcare providers, including surgical procedures. Additionally, the assessment session serves to identify any other mental health diagnoses that may account for your symptoms more accurately than Gender Dysphoria or might impact your ability to make well-informed medical decisions independently.

Will the assessment help me determine if I want surgery?
The purpose of this assessment is to establish a diagnosis and advocate for care that can provide relief and affirmation for many individuals with that diagnosis. It is crucial to consider whether you believe you will benefit from such care, and to take the time to explore and address this question independently, as well as with trusted individuals, including friends, family, or a regular therapist. Although not required for transition, engaging regularly with a therapist to discuss feelings about gender, identity, sexuality, and personal experiences is highly recommended. This can significantly aid in determining your transition goals and what feels right for you, as well as in managing some of the challenges associated with transitioning and living in a world that can be transphobic or hostile towards transgender individuals.

Gender variant and transgender people constitute a highly diverse group, each having a unique and personal relationship with their body, identity, and gender. While we can provide more information on surgical procedures, recovery, and research on surgical satisfaction, it is important to note that the assessment session is not a substitute for a thorough and personal decision-making process.

The reasons individuals choose to pursue or refrain from medical transition and specific procedures are complex. It is highly recommended to spend ample time discussing and exploring this decision, considering how it aligns with your understanding of your gender and personal goals. If you are interested in therapy with us or another professional to further examine these questions, please reach out. We would be happy to connect with you if we have availability, or provide referrals to trans-competent providers who can assist in this exploration.

As providers, do you agree with this process?
No, we do not support that view. Transgender individuals, like all people, have the right to bodily autonomy and to make decisions regarding their bodies, as well as to manage the consequences of those decisions. It is important to note that the criteria for obtaining letters and evaluations from mental health professionals were originally established to facilitate access to care, rather than to obstruct it. The Standards of Care (SOC), which require individuals to obtain letters of support, were initially implemented by the World Professional Association for Transgender Health (WPATH). These standards aimed to demonstrate that transgender individuals could benefit from medical treatments, thereby reducing distress at a time when transgender identity was pathologized and deemed delusional, with the misguided belief that such identities should be eradicated.

The SOC were created to validate the reality and reasonableness of gender dysphoria and to show that it can be alleviated through medical interventions. This approach has shown that transgender individuals experience improved well-being and happiness through the affirmation and medical empowerment of their gender identities.

However, in our current era, these processes can sometimes hinder individuals from pursuing surgeries they might otherwise seek, infringe on their privacy, or impose unnecessary steps, costs, and burdens on already burdened individuals. As healthcare providers, we operate from an informed consent perspective. We believe that the same criteria of mental fitness that qualify individuals to sign legal documents, work, and make other binding decisions (including medical ones) should also enable them to make medical decisions related to transitioning.

In our practice and advocacy, we aspire to a world where the need for such letters is entirely obsolete.

In alignment with our ethical commitment to accessible, affirming care, we offer all gender-affirming assessment sessions on a sliding scale, pay-what-you-can basis.

Our full hourly rate is $200, and paying the full fee reflects the value of our time and supports the sustainability of this work.

However, we invite you to choose a fee between $0 and $200 that feels financially manageable for you.

Being able to offer sliding scale care means that those who can afford to pay the full rate make it possible for us to continue offering reduced-cost and free services to others in our community.

No one is ever turned away due to lack of funds, and you will never be asked to pay for services you don’t want or need.