[Name, address, and phone number]
Dear [ Dr. Preforming Surgery]:
[Patient name] is a [Patients appropriate age] year old female to male transgender individual who has established a longstanding and strong identity as male. He has been living as male consistently and on hormones since [date patient start HRT or social transition]. He has had [if any previous surgeries put here with dates if no other procedures remove this line]. He is now seeking [name of surgery] to aid in his complete medical transition.
[Patient name] reports a prior history of anxiety which appears to have been in response to the stressors during his early stages of transitioning. He was entered into therapy in [date patient began therapy]. At this time, he presents with no apparent residual psychiatric symptoms and is quite stable. He intends to continue his therapy regime which he believes has been helpful.
[Patient name] seems to have significant progress in his transitioning and seems very happy in his decision to be male. He has a strong support system that includes a loving partner and family. He has steady employment that provides his benefits and is attending school for his professional aspirations. His judgment appears sound and good. He has good knowledge of, and had the ability to follow to Standards of Care for surgery.
I met with [Patient name] for an evaluation on [date of evaluation] . I have no hesitation in recommending him for the procedure he has requested. He meets and exceeds the criteria as set forth by the Harry Benjamin International Gender Dysphoria Association. If you need any more information or have questions, please do not hesitate to contact me at [therapist phone number].
Sincerely,
[Therapist name], [qualifications]
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