Chest Surgery Example:

[Date]

To: [Your Recipients Name & Address]

Fax: [Number]

Patient: [Patient’s Name], He/Him/His

Re: Chest Surgery

 Dear [Physician’s name],

 Please accept this letter and the attached application as my recommendation for the above-named patient for gender-affirming chest surgery, including bilateral mastectomy and male chest contouring. I am a [family Physician etc.] in good standing with the College of [Physicians & Surgeons of…], license number [#], and have training and experience in the management of gender dysphoria. I have been designated as a surgical assessor for gender-affirming surgeries in the Province of [province name].

 As indicated in the attached application, [patient’s name] meets the four criteria for chest surgery: he has persistent well-documented gender dysphoria, he has full capacity to consent to the treatment, he is above the age of the majority and there are no uncontrolled medical or mental health conditions.

 [Patient’s name] was seen on [appointment date] for consideration of male chest contouring in the context of female to male gender transition.

 [Patient’s name] is a [patient’s age]-year-old transgender man, who has been aware of his male gender identity since [date]. [Patient’s name] has been known to our team at [Clinic/Practice] since [date], when he presented requesting support with [medical and] surgical transition. His gender identity is [male/female/etc.]. He has been living socially as male since [date], including male name and pronouns. (Keep in mind there is no requirement for being on hormone therapy or having transitioned socially)

(This section only applies if he has started hormone affirmation therapy, exclude if not relevant. If hormone assessment and care was done elsewhere):
He began his transition in [     ], having an assessment with [     ] and starting on hormone therapy with [     ].) He was assessed by [Endocrinologist/Physician] and given that he met WPATH criteria, was started on hormone therapy in [month]. [Patient’s name] has done very well on testosterone therapy and in regard to his social transition. There have been no concerns with respect to physical or mental health related to the gender affirming care he has received so far.

[Patient’s name] is physically and mentally healthy and fit to undergo surgery. There is nothing significant in the past medical history/medical conditions, which include [list or declare none], and these are reasonably well-controlled. Mental health history includes [list or declare none] and he has been stable from this perspective for [length of time]. Past surgeries include [list or declare none]. Medications include [list or declare none]. Allergies [list or declare none]. He is a non-smoker who drinks moderate amounts of alcohol and doesn’t use any other substances. (Edit as needed – if smoking, document that he is aware of the need to stop smoking in advance of surgery and the risks of smoking in the peri-operative period)

 [Patient’s name] identifies his social supports as [friend/family/partner etc.]. He has stable housing [describe living situation] and is currently [working as a _______/studying at _______/ on disability etc.]

[Patient’s name] and I met on [date] for a thorough discussion of his desire for chest surgery. He has significant dysphoria related to his chest and is finding binding increasingly uncomfortable physically. (Revise with patient’s own reasons for wanting surgery) He has therefore, therefore and after careful consideration, decided to proceed with chest reconstruction to have a permanently flat, masculine appearing chest. Risks discussed with [Patient’s name] include general anaesthetic risk, death, bleeding & possible need for transfusion, damage to surrounding structures, blood clots, hematomas, seromas, problems with wound dehiscence, nipple graft failure, scarring, loss of sensation, dissatisfaction with the appearance of his chest, need for revision and potential for regret. [Patient’s name] understands the typical post-operative course including pain and swelling, drains, compression vest and the need for reduced activities and close medical follow-up. He understands he will need extensive support in the post-op period and his plan is [describe patients support plan].

[Insert any mental status exam comments here as appropriate] I found him to have a clear understanding of the information discussed, and realistic expectations of the outcome. He is fully competent to consent to the procedure.

 In summary, [Patient’s name] is an ideal candidate for bilateral mastectomy and male chest contouring in the context of gender transition. He meets all WPATH criteria for surgical intervention, has been successful so far in his social and [and medical – only if hormonally transitioned] transition. They are ready from a psychosocial point of view and have a solid aftercare plan in place. I, therefore, recommend [Patient’s name] receive full funding for the procedure.

Please do not hesitate to contact me if you require further information. I am available for coordination of care and would welcome a phone call to establish this.

 Sincerely, 

[Your Name]

Contact: [#/email]

Vaginoplasty Example:

[Date]

To: [Your Recipients Name & Address]

Fax: [Number]

Patient: [Patient’s Name], She/Her/Hers

Re: Vaginoplasty

Dear [Physician’s name],

 Please accept this letter and the attached application as my recommendation for the above-named patient for g genital surgery including vaginoplasty, penectomy and orchiectomy. I am a [family Physician etc.] in good standing with the College of [Physicians & Surgeons of…], license number [#], and have training and experience in the management of gender dysphoria. I have been designated as a surgical assessor for gender-affirming surgeries in the Province of [province name].

 As indicated in the attached application, [patient’s name] meets the six criteria for genital surgery: she has persistent well-documented gender dysphoria, she has full capacity to consent to the treatment, she is above the age of the majority, there are no uncontrolled medical or mental health conditions, she has been on hormone therapy for over a year and has been living full-time as a woman for [# of years].

 [Patient’s name] was seen on [appointment date] for consideration of vaginoplasty in the context of male to female gender transition. This is the second assessment, the first having been completed on [date]. (Add other info relevant to prior assessments)

[Patient’s name] is a [patient’s age]-year-old transgender woman who has been known to our team at [clinic/practice] since [date], when she first presented requesting support with medical and surgical transition. [Patient’s name]’s gender identity is [male/female/etc.]. She has been living socially as female since [date], including using a female name and pronouns. She began hormone therapy in [month] after being assessed and found to meet WPATH criteria. She has experienced significant benefit from the steps she has taken so far including reduced dysphoria and improved mental health. She continues to experience dysphoria related to her genitals and feels that she is ready to proceed with permanent surgical reconstruction to feminize her genitals.

(This section only applies if she has started hormone affirmation therapy, exclude if not relevant. If hormone assessment and care was done elsewhere): She began their transition in [     ], having an assessment with [     ] and starting on hormone therapy with [     ].) She was assessed by [Endocrinologist/Physician] and given that they met WPATH criteria, were started on hormone therapy in [month]. [Patient’s name] has done very well with gender affirming therapy and in regard to their social transition. There have been no concerns with respect to physical or mental health-related to the gender-affirming care she has received so far.

 There is nothing significant in the past medical history/medical conditions, which include [list or declare none], and these are reasonably well-controlled. Mental health history includes [list or declare none] and they have been stable from this perspective for [length of time]. Past surgeries include [list or declare none]. Medications include [list or declare none]. Allergies [list or declare none]. She is a non-smoker who drinks moderate amounts of alcohol and doesn’t use any other substances. (Edit as needed – if smoking, document that they are aware of the need to stop smoking in advance of surgery and the risks of smoking in the peri-operative period)

[Patient’s name] identifies their social supports as [friend/family/partner etc.]. She has stable housing [describe living situation] and is currently [working as a _______/studying at _______/ on disability etc.]

[Patient’s name] and I met on [date] for a thorough discussion of her desire for genital surgery. She has significant dysphoria related to her genitals which has been present since [date]. The main goals for her are to have receptive vaginal sex and feel greater comfort with her body especially in intimate situations. (Revise with patient’s own reasons for wanting surgery) She has therefore, after careful consideration, decided to proceed with permanent feminization of her genitals including vaginoplasty, penectomy and orchiectomy. (Alter as needed for different surgical plans) I am confident that [Patient’s name] understands what to expect, including the need to travel to [Montreal/Vancouver/Toronto] for these procedures and the fact that the procedures result in sterility.

 [Patient’s name] and I have had a full discussion of the potential risks including risk related to general anaesthetic (including death), excessive blood loss and need for transfusion, blood clots, damage to surrounding structures, hematomas, seromas, infection or abscess, wound dehiscence, nerve damage and loss of sensation, decreased sexual satisfaction, inability to orgasm, urinary complications such as fistula, stricture, stenosis, excessive scarring, dissatisfaction with appearance and or function of the genitals, need for revisions, and post-op regret.

[Patient’s name] understands the typical post-operative course including pain, bruising, bleeding, swelling, numbness and or shooting/burning pains, urinary catheter and constipation. She understands the importance of adhering to the required aftercare routine of dilation, douching and sitz baths. She understands the need to reduce activities & take time off from work to allow for proper healing. She understands she will need extensive support in the post-op period and her plan is [provide what supports/living situation/ability to support finances patient has to support her healing].  She also understands the importance of close medical follow-up & nursing care.

[Insert any mental status exam comments here as appropriate] I found [Patient’s name] to have a clear understanding of the information discussed, and realistic expectations of the outcome. She is fully competent to consent to the procedure.

In summary, [Patient’s name] is an ideal candidate for vaginoplasty in the context of gender transition. She meets all WPATH criteria for this surgical intervention, has been successful so far in her social and medical transition, is ready from a psychosocial point of view and has a solid aftercare plan in place. I, therefore, recommend [Patient’s name] receive full funding for the procedure.

Please do not hesitate to contact me if you require further information. I am available for coordination of care and would welcome a phone call to establish this.

Sincerely, 

[Your Name]

Contact: [#/email]