What is a WPATH Letter for Top Surgery?

Criteria to Get a WPATH Letter for Top Surgery

Gender-affirming surgeries play a significant role in the journey of transgender individuals towards aligning their physical appearance with their gender identity. Top surgery, also known as chest surgery, is a crucial aspect of gender-affirming procedures for both male-to-female (MTF) and female-to-male (FTM) individuals. To undergo this procedure, many individuals, including those seeking male-to-female top surgery and female-to-male top surgery, require a World Professional Association for Transgender Health (WPATH) letter. In this blog, we will discuss the importance of the WPATH letter for top surgery, understanding the process, and addressing common questions and concerns.

Sydney Specialist Plastic Surgeon Dr Michael Kernohan performs male-to-female top surgery and female-to-male top surgery.

What Is the WPATH Letter?

A WPATH letter holds significant importance in the context of undergoing top surgery as part of gender-affirming care. The World Professional Association for Transgender Health (WPATH) plays a pivotal role in establishing comprehensive guidelines and standards of care for transgender individuals seeking various forms of medical intervention. These guidelines serve as a compass for healthcare professionals, ensuring that transgender individuals receive safe, ethical, and effective gender-affirming surgeries that align with their gender identity.

At the heart of the WPATH guidelines lies the requirement for a WPATH letter, which serves as a crucial document in the journey toward top surgery. This letter, authored by a qualified mental health professional, carries several key functions:

  • Psychological Preparedness: The WPATH letter serves as an endorsement and attestation by a mental health professional. It signifies that the individual seeking top surgery is psychologically prepared for the procedure. This psychological readiness is crucial, as it ensures that the person has undergone a thorough evaluation of their mental and emotional state concerning the surgery. It confirms that they possess the necessary coping mechanisms and support systems to navigate the challenges associated with the surgical process
  • Validation of Criteria: The WPATH letter also serves as validation that the patient has met the specific criteria outlined by WPATH. These criteria may include factors such as a consistent and persistent gender identity, adequate time living in their affirmed gender role, and a genuine desire for top surgery as part of their gender-affirming journey. The letter essentially confirms that the individual’s situation aligns with the established standards of care
  • Collaborative Healthcare: Additionally, the WPATH letter promotes a collaborative approach to gender-affirming care. It signifies that healthcare professionals from different specialties, such as mental health and surgical care, work together to ensure the well-being of the patient. This collaborative aspect highlights the comprehensive nature of gender-affirming care, acknowledging that it extends beyond surgery to encompass mental and emotional health

The WPATH letter is more than just a document; it represents a critical milestone in the gender-affirming journey. It demonstrates that an individual’s readiness for top surgery has been assessed by professionals well-versed in transgender healthcare. Furthermore, it upholds the standards and criteria set by WPATH, reinforcing the commitment to safe and ethical gender-affirming surgeries.

Elements of a WPATH-Compliant Assessment Letter

A WPATH-compliant assessment letter is a crucial document in the process of gender-affirming surgeries like top surgery. This letter should be jointly signed by both the individual seeking the assessment and the mental health professional conducting it. To meet the WPATH standards, the letter should include the following essential components:

  • Date of Assessment: This indicates the specific day on which the assessment took place. It serves as a record of the timing of your evaluation in relation to your journey towards gender-affirming surgery
  • Date of Letter: This date reflects when the assessment letter was drafted and officially signed. It is essential for maintaining the chronology of the documentation process and ensuring that it aligns with your assessment
  • Statement of Informed Consent: The statement of informed consent is a pivotal part of the assessment letter. It signifies that you, as the individual seeking gender-affirming treatment, have been thoroughly informed about all potential risks and benefits associated with the surgery. Furthermore, it confirms that you have been granted sufficient time to deliberate your decision and that your choice to proceed with the treatment is entirely voluntary. This statement underscores the importance of understanding the implications of top surgery and underscores your capacity to make an informed choice regarding your gender-affirming journey

Eligibility Criteria for Obtaining a WPATH Letter for Top Surgery

The path to gender-affirming surgeries, such as top surgery, involves meeting specific criteria outlined by the WPATH Standards of Care. These criteria ensure that individuals are well-prepared and informed for their surgery. Here are the essential requirements for obtaining a WPATH letter:

  • Diagnosis of Gender Dysphoria: To qualify, individuals must receive a formal diagnosis of gender dysphoria from a qualified mental health professional. Gender dysphoria is the distress individuals feel when their gender identity doesn’t align with their assigned sex at birth. This diagnosis validates the individual’s profound and genuine experience of gender incongruence
  • Psychological Assessment: Comprehensive psychological assessments, counselling, or therapy sessions are integral to the process. These sessions provide individuals with vital support, insights, and guidance as they navigate their gender identity
  • Hormone Therapy (Optional): While undergoing hormone therapy (e.g., testosterone or estrogen) is encouraged, it is not mandatory. In some cases, it may be waived if not clinically indicated or if individuals are unable or unwilling to pursue hormone therapy
  • Real-Life Experience: The “Real-Life Experience” phase entails living in one’s self-identified gender role within the community for at least one year. This period allows individuals to gain valuable insights into various aspects of life aligned with their affirmed gender
  • Informed Consent: Individuals must demonstrate their capacity to make informed decisions and provide informed consent for the treatment. This highlights the importance of understanding the treatment process fully
  • No Contraindications to Surgery: Medical and mental health assessments must not reveal any concerns that would jeopardise an individual’s safety during surgery. This step ensures that individuals are physically and mentally prepared for the procedure
  • Understanding of Risks and Benefits: A clear comprehension of the potential risks and benefits associated with top surgery is essential. This knowledge empowers individuals to make informed choices regarding their gender-affirming journey
  • Realistic Expectations: It is crucial that individuals maintain realistic expectations about the outcomes of top surgery. This helps prevent disappointment and fosters a healthier adjustment post-surgery
  • Two Referral Letters: Finally, confirmation of eligibility for top surgery requires two referral letters from separate mental health professionals. These letters serve as a testament to the individual’s readiness and commitment to their gender-affirming path. They offer additional layers of assessment and support to ensure a well-rounded and informed decision-making process

Requirements for a WPATH Assessment

The process of obtaining a WPATH (World Professional Association for Transgender Health) assessment is an essential step in accessing gender-affirming care. These requirements, set forth by the WPATH Standards of Care (SOC), ensure a comprehensive and informed approach to gender-affirming care. To qualify for a WPATH assessment, individuals must meet the following criteria:

  • Age Requirement: Applicants must be at least 18 years of age to undergo a WPATH assessment
  • Documentation from a Mental Health Professional: Individuals are required to present valid documentation from a qualified mental health professional who can attest to their readiness for gender-affirming care
  • Financial Ability: Providing evidence of financial ability to pay for health care is essential to ensure that individuals can access the necessary medical services
  • Comprehensive Medical History: Submission of a comprehensive medical history allows healthcare providers to have a complete understanding of an individual’s health background
  • Referral Letter: Furnishing a referral letter from a mental health professional is a crucial step in the process. This letter serves as an endorsement of an individual’s need for gender-affirming care
  • Proof of Identity: Valid proof of identity is required to confirm the individual’s identity and ensure accurate record-keeping
  • Written Statement of Desire: Individuals must submit a written statement expressing their desire for gender-affirming care. This statement reflects their informed decision to pursue such treatment
  • Photographs: Two photographs of the individual are required as part of the assessment process
  • Statement of Informed Consent: A statement of informed consent underscores the individual’s understanding of the treatment process, including its potential risks and benefits
  • Commitment to Follow-Up Visits: Individuals must commit to regular follow-up visits with their healthcare provider to monitor their progress and address any concerns

Additionally, WPATH mandates that individuals seeking gender-affirming care must have undergone at least three months of mental health care, hormone therapy, and/or hair removal before becoming eligible for a WPATH assessment. These prerequisites ensure that individuals have taken essential steps in their gender-affirming journey before pursuing specific medical interventions.

The Process of Obtaining a WPATH Letter

Obtaining a WPATH letter is a process that involves collaboration with a qualified mental health professional who specialises in gender dysphoria and transgender healthcare. Here, we delve deeper into the steps involved in securing this crucial document:

  1. Seek a Qualified Mental Health Professional: The initial step is to connect with a mental health expert who possesses expertise in gender dysphoria and transgender healthcare. This specialist could be a licensed psychiatrist, psychologist, or clinical social worker. It’s imperative to select a professional who is not only knowledgeable about the psychological aspects of gender identity but also supportive and affirming of your unique journey
  2. Establish a Therapeutic Relationship: Building a strong therapeutic relationship with your chosen mental health professional is paramount. This relationship forms the foundation for the evaluation process. During your sessions, you’ll work together to explore your gender identity, delve into your personal history, and discuss your experiences and feelings related to your gender journey. The goal is to create a safe and open space where you can express yourself honestly and comfortably
  3. Multiple Sessions: Obtaining a WPATH letter typically involves attending several sessions with your mental health professional. These sessions serve as a comprehensive exploration of your gender identity and your readiness for top surgery. It’s essential to be patient and allow time for this process, as it ensures a thorough assessment and provides you with an opportunity to address any concerns or anxieties you may have about the surgery
  4. Evaluation and Assessment: Within the sessions, your mental health professional will conduct a thorough evaluation of your mental and emotional well-being. This assessment aims to ascertain that you are making an informed decision regarding top surgery. It also assesses your capacity to provide informed consent, highlighting the importance of understanding the surgical process, potential risks, and benefits
  5. Informed Consent: Your mental health professional will discuss the implications of top surgery with you, ensuring that you are fully aware of what the procedure entails and your decision to pursue the surgery is voluntary and well-considered. This includes discussing the potential physical and emotional changes associated with the surgery

FAQs about WPATH Letter for Top Surgery


Is a WPATH letter always required for top surgery?

  • Yes, in most cases, a WPATH letter is required by surgeons to ensure that patients are adequately prepared, both mentally and emotionally, for the procedure.

How long does it take to obtain a WPATH letter?

  • The process of obtaining a WPATH letter can vary from a few weeks to several months, depending on the mental health professional’s assessment and your individual progress.

Can I choose any mental health professional for the evaluation?

  • It’s recommended to seek a mental health professional with experience in transgender healthcare and is knowledgeable about WPATH guidelines.  

Can I use the same WPATH letter for different surgeries?

  • Yes, in some cases, the same WPATH letter may be used for multiple gender-affirming surgeries if they occur within a reasonable timeframe.  

What happens if my WPATH letter is denied?

  • If your WPATH letter is denied, it’s crucial to engage in open communication with your mental health professional. They can provide guidance on what steps to take to address any concerns or issues that led to the denial.

Further Reading about Gender Affirmation Surgery with Dr Kernohan

Medical References about Top Surgery