In September 2022, WPATH unveiled its new SOC 8 for trans and gender-diverse (TGD) medical and mental health care.  Included in Appendix D are the new letter referral suggestions.  Like many of you, the Crane Center is thrilled with the reduction of many barriers preventing TGD individuals from obtaining gender-affirming surgeries (GAS).  Thus far, insurance companies have followed the SOC 7 guidelines requiring 3 letters for any bottom surgery and 1 letter for any top/FFS surgery.  Some insurance companies have additional requirements for GAS.  
Though WPATH has unveiled its new suggestions, it will take insurance companies time to evolve.  Until then, the Crane Center will continue to require all patients using insurance for GAS to follow the SOC 7 guidelines.  This adherence to the outdated guidelines will prevent any last-minute and unfortunate denials based on insufficient letter submission.

WPATH Standards of Care recommend letters of support from licensed mental health providers and/or hormone providers as part of the surgical transition process. Your insurance provider also will require the same letters to approve coverage.

Below are the letter requirements pertaining to each procedure type and the WPATH Soc V.7 criteria that must be met for each letter, as well as additional criteria imposed by certain insurance plans.

*Please note: All letters must be on letterhead and signed by the provider with their license number. Letters cannot be written by an intern or resident. Letters should be sent in as a PDF document, without password protection.

  • Letters for Texas patients can be faxed to 512.597.0402 or emailed to
  • Letters for California patients can be faxed to 415.461.3233 or emailed to

Top Surgery, Breast Augmentation & Facial Feminization Surgery:

  • One letter from a licensed mental health specialist (LCSW, MFT, LMFT, CSW, Ph.D., Psy.D., etc.)
  • California patients: Anthem Blue Cross requires two letters from two separate mental health specialists
  • Texas patients: Blue Cross Blue Shield of Texas requires one letter from a Doctorate level provider (Ph.D., Psy.D. or Psychiatrist)
  • Blue Cross Blue Shield Federal Employee Program patients: BCBS FEP requires 12 months of continuous hormone therapy & 2 referral letters from qualified mental health professionals (one must be from the psychotherapist who has treated the member for a minimum of 12 months)

Bottom Surgery:

Two Letters from 2 different licensed mental health specialists

  • 1 letter can be from a provider who has only had an evaluative role
  •  At least one of the letters must be from a provider with a doctorate level degree (Ph.D., Psy.D., etc.)
  • Texas patients: Blue Cross Blue Shield of Texas requires two letters from a Doctorate level provider (Ph.D., Psy.D. or Psychiatrist) 

The 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 experience 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 and breast augmentation only).
    • A statement that the patient has the capacity to make fully informed decisions and to consent for treatment.
    • That the patient is able to 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.

The letter from your Hormone Provider 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

*Please note that WPATH Standards of Care states that patients should be the age of majority (18 years of age in the US) for surgery coverage. Patients under the age of 18 require the consent of both patents or legal guardians.  Additional requirements will be discussed at the time of consultation. 

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