Surgery referral assessment requirements

Surgical referral letters are required for surgical procedures, per insurance guidelines and WPATH Standards of Care.

Patients may undergo assessment by and provide referral letters from their own outside mental health providers. Due to temporary staffing challenges we are not able to conduct these assessments at UCSF, however we expect to resume conducting these assessments here at UCSF starting in November, 2021. 

The UCSF Gender Affirming Health Program adheres to the guidelines for surgical assessment as described in the World Professional Association for Transgender Health Standards of Care, 7th Version. Most insurance companies also adhere to these guidelines. The guidelines are focused on undergoing an assessment by a licensed mental health provider, who then generates a referral letter (two providers, assessments, and letters required in the case of genital procedures).

We recognize that this model "medicalizes" the concept of being transgender, and we aim to minimize the impact of this model on individuals seeking treatment. The guidelines do not specify a particular process or minimum number of sessions or length of time a patient should have with a mental health provider. When conducted by UCSF, the assessment process begins with a single meeting with our program social worker. During that session, any additional needs or areas for support will be identified.

Beyond the specific criteria set forth by the WPATH Standards of Care, there are two other important areas for assessment of anyone undergoing major surgery for any reason, including hip replacements, organ transplants, open heart surgery, etc....

1) Insuring realistic expectations of what surgery can and can not do, being emotionally prepared for the realities of potential complications or less-than-satisfactory outcomes.

2) Insuring adequate support during the pre- and post-surgery period. This includes having someone to take you to and from surgery, and be with you after surgery to assist with recovery needs. This could include anything from obtaining supplies at the pharmacy, to preparing meals and assisting with domestic needs. For those who do not have someone to fill these roles, arrangements can be made for home health assistance or even short term placement in a skilled nursing facility.

In all, our goal is to get you to surgery, with a minimum of barriers or gatekeeping, and support a positive and satisfactory surgical outcome.

Learn more here about general behavioral and mental health services available with UCSF Transgender Care.


One referral letter from a licensed mental health provider required:

Chest surgeries

Facial surgeries

Two referral letters from two different licensed mental health providers required:

Hysterectomy/oopherectomy (removal of uterus/ovaries)

All genital procedures


All surgical procedures also require a referral letter from a medical provider (see template here).


Separate letter(s) are required for each surgery sought (this is an insurance requirement).


Referral letters should contain two key areas of focus as below:

Content specific to gender-affirming services/WPATH criteria

  • Contact information for mental health provider, include credentials and license state/number
  • Chosen name and pronouns used
  • Legal name if different
  • Date of birth
  • Duration of their relationship with you, including the type of evaluation, counseling, and therapy provided to date
  • Type of surgery sought (each procedure requires a separate letter, to fulfill insurance requirements)
  • Statement of persistent and well documented gender dysphoria
  • Psychosocial assessment, including any diagnoses present
  • Statement identifying any mental health conditions or history, as well as documentation that they are reasonably well controlled and will not impact surgical course
  • Documentation of any hormone use, including duration
  • Statement that WPATH criteria for the specific surgery sought are met, and the clinical rationale for supporting your request for surgery
  • If under 18, statement that the patient meets WPATH criteria for surgery in adolescents
  • Statement that the patient has capacity to provide informed consent for this surgery, and that you have obtained informed consent for the specific procedure from a mental health perspective
  • A statement that the mental health provider is available to contact for care coordination, including their telephone number or email

Standard preoperative assessment content (not specific to gender affirming surgery)

  • Documentation of a discussion of realistic expectations of what surgery can and cannot do, and emotional preparedness for potential complications or less-than-satisfactory outcomes.
  • Housing status: (city, with whom, stability, access to private bathroom)
  • Documentation of any relevant disability, such as limitations in mobility, learning, etc…
  • Presence of adequate support during the pre- and post-surgery period. This includes having someone to take the patient to and from surgery, and be with them after surgery to assist with recovery needs. This could include anything from shopping for groceries, obtaining supplies at the pharmacy, to preparing meals and assisting with domestic needs. Patients who experience barriers in these areas will be referred to our social worker to explore strategies for addressing these needs. Referring outside mental health providers should highlight such areas of need in their referral letter.



Referral letters and supporting documentation should be sent to:

UCSF Gender Affirming Health Program
1725 Montgomery St. Suite 250
San Francisco, CA 94111

Phone: 415-885-7770
Fax: 415-353-3399
[email protected]