Letters of Support: A Trans-Centered Guide to Surgical Consultations

If you’re a trans or non-binary adult in New York preparing for gender affirming surgery, chances are someone has told you: You’ll need a letter. That phrase alone can stir up anxiety, anger, or just a deep sigh. This “mental health letter” can be a hurdle, or worse—like you need someone else’s permission to make decisions about your own body.

This guide is for anyone navigating the mental health letter requirement—what it is, why it exists, and how it can be approached in a way that centers your needs and affirms your experience.

What Is a Gender Affirming Surgery Letter?

It’s a document written by a licensed mental health provider that says you’re ready for surgery and that it’s a medically appropriate step for you. The letter usually includes a diagnosis (like gender dysphoria or gender incongruence) and a statement that you understand the procedure and are emotionally prepared for it. It’s not a test. And it’s definitely not about proving your gender.

Why Are Letters Required?

Most of the time, these letters are required by surgeons or insurance companies before they’ll approve gender affirming surgery.  This requirement comes from problematic systems that see trans healthcare as something that needs extra oversight or permission and fail to respect your ability to make decisions. 

At Therapists of New York, we don’t agree with the gatekeeping behind this process. We also know it’s often a necessary step to get covered or scheduled. So we work with you to get it done in a way that’s affirming, respectful, and as smooth as possible.

What the Assessment Looks Like

While it can vary from different centers or providers, at Therapists of NY, we usually meet for 1 to 3 sessions, each lasting about 45 to 60 minutes. That timeline depends on what’s needed for your specific surgical provider or insurance plan.

These sessions aren’t tests with right or wrong answers. We’ll talk with you about your goals for surgery, how you’re thinking about recovery and support, and any questions or concerns that are coming up. We also gather the information needed for the letter, including a clinical diagnosis if required.

The goal is to work together—not to pressure you to prove or convince who you are, but to have a collaborative conversation. You bring your lived experience; we bring our clinical language. The result is a letter that helps move things forward.

Readiness Isn’t Linear—And That’s Not a Problem

Being ready doesn’t mean being 100% certain, emotionally neutral, or able to predict every post-op feeling in advance. It’s okay to have mixed emotions. It’s okay to feel grief, excitement, fear, or nothing at all.

Therapy for gender transition—especially in the context of assessments—shouldn’t require a perfectly scripted narrative. We hold space for the parts of you that are still figuring it out, without using that as a reason to delay or withhold care.

Do I Have to Be in Therapy?

Typically, no. You don’t typically need to be in ongoing therapy at Therapists of New York or elsewhere to receive a letter of support. These consultation sessions are specifically for the purpose of the pre-surgical assessment and documentation. We’ll note that for some surgeons and insurance plans, there is sometimes an exception where one letter has to come from a clinician you've been in therapy with, typically for around at least six months.

That said, if you’re looking for longer-term, gender affirming therapy, we have clinicians who specialize in working with LGBTQIA and TGNB clients. If that’s something you want to explore, we are happy to talk about options.

Can I be in therapy?

Absolutely. You may be (or wish to be) in therapy for any number of reasons — possibly related to gender and identity, or completely unrelated. If gender is part of what you’re exploring in therapy, we believe this process is not about reducing gender to something fully known, clearly named, or neatly articulated. Instead, we hold space for ambiguity and movement, as well as certainty, to be parts of your story.

A Process That Respects You

We know that needing a letter can bring up complex feelings—especially when it’s tied to something as personal and important as gender affirming surgery. We approach this process with respect, clarity, and the understanding that you shouldn’t have to explain or justify your identity to access care.

We think you’ll find the gender affirming care letter process at TNY to be responsive, respectful, and human.  

If you’re ready to start the process, or if you just have questions, we’re here to schedule a first meeting or just talk it through.