The GALAP Harm Reduction Guide to Letter Writing

We envision a future in which people do not need to obtain assessments/letters from mental health providers in order to access gender-affirming medical care. This guide supports a harm reduction approach to letter writing, as we acknowledge the reality of harmful gatekeeping practices that are a current reality.


  • Do respect self-determination, listen, and follow the client’s lead. Always use the correct name, pronouns, and language someone uses to describe their gender.
  • Do ask what name/pronouns the client would like you to use for the purposes of the letter.
  • Do acknowledge the privilege/power you hold, and be sensitive about how this may impact the client.
  • Do educate yourself about the history of harmful gatekeeping practices.
  • Do educate yourself about people who are nonbinary, neurodivergent, or may not fit the most common trans narratives.
  • Do ask if the client needs any resources, information, or referrals related to:
    • Risks and benefits of requested service/procedure
    • Understanding how reproductive options or bone health may be affected
    • Surgical preparation and recovery
    • Building social support and coping skills
    • Understanding the impact of substances on surgical outcomes
    • Smoking cessation (as nicotine impairs healing, many surgeons require this)
    • Navigating time off work/school, any financial concerns
    • Sexuality or sexual functioning concerns
    • Mental health needs/concerns
    • Rights/advocacy against surgeon BMI requirements (weight/size discrimination)
  • Do make brief statements to indicate that the client meets WPATH criteria for the requested service.
    • “Client is the age of majority.”
    • “Client has the capacity to give informed consent.”
    • “Client has no mental health concerns that should impede access to surgery or which would negatively impact recovery.”
    • “Client meets criteria for gender dysphoria.”
  • Do make a strong, clear statement in support of the client’s goals.
    • “The client meets all criteria for the requested surgery.”
  • Do share the letter with the client and ask if they have any edits or concerns with the contents.


  • Don’t position yourself in the role of determining whether someone is “really trans”; respect trans self-determination. Don’t ask intrusive questions about a person’s gender history, including childhood toys, mannerisms, or preferences.
  • Don’t ask intrusive questions about sexual practices, attractions, or orientations, unless the client wants to discuss these topics, as these are not relevant to informed consent about a requested medical procedure.
  • Don’t refuse to write a letter because the client’s family/friends/co-workers don’t know or are not supportive of the client’s gender or related choices.
  • Don’t put up barriers because someone is nonbinary or their gender doesn’t fit the most common trans narratives.
  • Don’t exceed 1-2 pages in length. Stick to the information needed by the surgeon/ insurance.

Note: This is only a basic primer for reducing harm when providing letters. We do not advocate for people operating outside their scope of expertise. When in doubt, we recommend seeking clinical consultation for further support in letter writing.

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