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In September 2022, WPATH released the Standards of Care (SOC) version 8, for trans and gender-diverse medical and mental healthcare.  Included in Appendix D are the new letter referral suggestions for gender-affirming surgery (GAS). 

Though WPATH has released the new SOC, it will take insurance companies time to evolve.  Until then, CCTS will continue to require all patients using insurance for GAS to follow the SOC v7 guidelines.  This adherence to the outdated guidelines will prevent any last-minute and unfortunate denials based on insufficient letter submission. 

Please be aware some insurance companies/plan have additional requirements, outside the published SOC. We recommend verifying letter requirements with your specific insurance plan.

  • All health plans require letters for revisions if original letters are greater than 1 year old
  • Blue Cross Blue Shield (all subsidiaries): prefer letters to be from Doctorate level providers
  • Anthem BCBS: 2 MH letters for Top and bottom surgery dated within 6 months

*Please note that WPATH Standards of Care state that the patient should be the age of majority (18 years of age in the US) for surgery coverage. It is very uncommon for a minor to have this procedure approved.*

If you are pursuing surgery as a self-pay patient and have submitted a signed agreement along with your deposit, we will gladly honor the new SOC v8, 1 mental health letter from a licensed mental health provider.

Current SOC v7 requirements

All letters must be:

  • Dated within one year of surgery
  • On letterhead
  • Indicate the type of procedure (top surgery, vaginoplasty, phalloplasty, etc.).
    • We cannot accept letters that say gender reassignment/gender confirmation/gender affirmation surgery.
  • Signed by the provider with their license number
  • Letters cannot be written by an intern or resident.

Top Surgery, Breast Augmentation & Facial Feminization Surgery:

One letter from a licensed mental health specialist (LCSW, MFT, LMFT, CSW, Ph.D., Psy.D., etc.)

Bottom Surgery:

Two Letters from two different licensed mental health specialists.

  • 1 letter can be from a provider who has only had an evaluative
  • It is highly recommended that at least one of the letters be from a provider with a doctorate-level degree (Ph.D., Psy.D., etc.).

Mental health provider letter(s) must include ALL of the following:

  • Patient’s legal and preferred name
  • Patient’s date of birth
  • Date provider/patient relationship began and the frequency of contact
  • A statement that the patient has been diagnosed with persistent, well-documented gender dysphoria/gender identity disorder and exhibits all of the following:
    • The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
    • The transgender identity has been present persistently for at least two years; and
    • The disorder is not a symptom of another mental health disorder; and
    • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • Documentation that the patient has completed a minimum of 12 continuous months of living in a gender role that is congruent with their gender identity, across a wide range of life experiences and events that may occur throughout the year.
  • The patient has undergone a minimum of 12 continuous months of hormone therapy. (RECOMMENDED FOR BOTTOM SURGERY & BREAST AUGMENTATION ONLY).
  • A statement that the patient has the capacity to make fully informed decisions and to consent to treatment.
    • That the patient can comply with long-term follow-up requirements and post-operative expectations have been addressed.
  •  If the patient has significant medical or mental health issues present, they must be reasonably well controlled.
  • Any substance use (marijuana, alcohol, etc.) is well controlled for at least 6 months prior to the patient’s surgical date.
  • The provider must state their experience with treating patients diagnosed with gender dysphoria.

 Hormone provider letter must include:

  • Patient’s legal and preferred name
  • Patient’s date of birth
  • Date provider/patient relationship began and the frequency of contact
  • Date hormone therapy began and the frequency of treatment
  • That the patient has undergone a minimum of 12 continuous months of hormone replacement therapy
  • If the patient has a contraindication to hormone therapy, please note this

Letters can be emailed to or

We cannot accept a photo of a letter.  You can utilize an app (CamScanner) to convert your letter to a PDF if you do not have access to a scanner.

Warning !

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