What is a gender affirming care letter and do I need one?
If you've been exploring affirming medical care — whether that's hormones, surgery, or another step on your path — you may have heard that you need a "letter" from a therapist before you can move forward. That can feel like yet another hoop, another gatekeeper, another person you have to convince before you're allowed to exist in your own body.
I want to demystify this process, because it doesn't have to be that way.
So what actually is it?
An affirming letter (sometimes called a support letter or a readiness letter) is a document written by a licensed mental health professional — like a therapist or counselor — that supports your access to gender affirming medical treatment.
Depending on what you're pursuing, a letter might be used to:
Access hormone therapy (HRT) through an endocrinologist or primary care provider
Move forward with surgeries (top surgery, bottom surgery, facial feminization, orchiectomy, etc.)
Support a legal name or gender marker change in some contexts
Meet requirements set by a surgeon, insurance company, or medical provider
Why is a letter even required?
Historically, the Standards of Care from the World Professional Association for Transgender Health (WPATH) required mental health evaluations and letters before people could access most gender affirming medical treatments. The reasoning was framed around "readiness" — which, let's be honest, carried a lot of gatekeeping energy.
The good news: things have shifted significantly. The most recent WPATH Standards of Care (SOC8, released in 2022) moved away from requiring letters for many procedures and emphasized informed consent models of care. More and more providers — especially informed consent clinics — no longer require a letter at all.
That said, many surgeons and some insurance plans still ask for one. In addition as legislation continues to tighten on us these models continue to be in flux. So even if the clinical landscape is evolving, the practical reality is that letters are still part of many people's journeys.
What’s the process?
A gender affirming care letter should NOT be a psychiatric evaluation designed to determine whether you're "really" trans or "ready enough.". This letter should be a collaborative document that simply provides clinical context for your care.
Typically it includes:
Your gender identity and history of gender dysphoria or gender incongruence
Confirmation that you have the capacity to make informed medical decisions
That you understand the potential outcomes and permanence (where relevant) of the procedure
Any relevant mental health context — not to pathologize you, but to support your care team in understanding you holistically
The therapist's professional recommendation for the requested treatment
At Rogue Therapy & Wellness, letter writing sessions are a single, focused appointment. You don't need to be an ongoing therapy client to request one, and you don't need to "prove" anything to me. My job is to hear your experience, make sure you have the information you need, and write a letter that accurately reflects who you are and what you're pursuing.
How long does the process take?
For most people, a single session is all that's needed. You will fill out a few consent documents and then we schedule a session. I can typically get folks in within a week of signed paperwork. We meet virtually over zoom (I'm licensed in California and work exclusively online), talk through your experience and goals, and I write the letter from there.
That said, some insurance companies or surgeons have specific formatting requirements or want letters that address particular criteria. If you know your provider has requirements, it's worth sharing that with me before or at the start of our session so I can make sure we cover everything.
Letters at Rogue Therapy & Wellness are $155 and don't require a free consultation beforehand — you can book directly. Please note I do not withhold a letter if the fee is a barrier, if you can pay the full fee wonderful if not still wonderful, let’s get you what you need!
Currently the letter should be valid for one year from when it is written. During that year any and all edits are included in the service.
Do I need to be in therapy first?
No. You don't need to have a pre-existing therapeutic relationship with me, or anyone else, to request a letter. Many people who come to me for letters are already well-resourced, clear about their path, and simply need a clinician to document their experience in a format their surgeon or doctor requires.
If you do want ongoing support — whether around your gender journey, relationship stuff, trauma, or just navigating life as a queer or trans person — I'm always open to that conversation too. But it's not a prerequisite.
What if I've been told I need multiple letters?
Some surgeries, particularly certain “bottom surgeries”, have historically required two letters from two separate providers and one with a higher degree level (i.e. PsyD, PhD)
If you need a second letter I can share resources for other clinicians, especially those holding a higher degree who also hold a commitment to making the process as easy as possible.
A note on the emotional side of this
For a lot of people, needing a letter brings up complicated feelings. It can feel infantilizing to need someone else's permission to access your own care. It can feel scary to be "evaluated," even by a therapist who is affirming. For those who've had bad experiences with mental health providers in the past — and there are many in our community who have — it can be genuinely anxiety-producing.
Please know: I take that seriously. I truly believe that even having to work to get this letter is harmful, many (mainly cis) folks access care that makes them feel more whole and healthy without having to navigate these extra steps.
I'm absolutely not here to assess whether you're trans enough, queer enough, or ready enough. You know yourself. I'm here to support your path, use my experience and knowledge to write a letter that get you the care you are desiring and make the process as low-barrier as possible.
All identities are welcome here. Trans, non-binary, gender fluid, gender questioning, agender, two-spirit — wherever you are in your exploration, you deserve access to affirming care.
It is my dream and my desire that one day this blog is absolutely void because access to care is accessible and without barriers.
Whats next?
If you're in California and need a gender affirming care letter, you can reach out directly to discuss scheduling. Letters are $155 for a single session, all ages welcome, and I work exclusively via telehealth so no commute required.
And if you're not sure whether you need a letter for what you're pursuing, feel free to reach out with questions first — I'm happy to help you figure out the logistics before you book.
If you are outside of California you can still reach out and I can share if I have resources in that state you are looking for care in
Ro McKeon (they/them) is a Licensed Marriage and Family Therapist (LMFT #152423) based in California. Rogue Therapy & Wellness offers virtual therapy, coaching, and gender affirming care letters to queers, gender explorers, neurodivergent folks, and anyone navigating non-normative paths through life.