How many letters do I need for surgery?

The WPATH Standards of Care, Version 8 (2022) call for one assessment letter from one qualified professional for adult surgery. Some surgical programs and insurance plans still ask for two letters for genital surgery. Your surgeon's office and your insurer set the final requirement, and I match the letter to what they ask for.

Do I need a letter to start hormones?

Often no. Many clinics, including telehealth services that see Iowa patients, prescribe hormones through informed consent without a letter. Some providers and insurers still require one. If yours does, that is a letter I can write after an assessment.

Is gender-affirming care still legal for adults in Iowa?

Yes. No Iowa law restricts gender-affirming medical care for adults. Iowa Code section 147.164 (2023) prohibits gender transition procedures for minors. Iowa Medicaid stopped covering gender-affirming surgery and hormone therapy in 2025 (House File 1049), but the care itself remains legal for adults, and Medicaid still covers mental health care.

What does the letter actually say?

A letter documents the clinical assessment: identity and history in your words, the assessment findings, capacity for informed consent, and the documentation your surgeon or insurer requires. You review and approve the draft before anything is signed or sent out.

Does an assessment guarantee a letter?

No. Letters are clinical documents provided when clinically indicated. When the clinical criteria are met, the letter goes out the same day.

LETTERS

THE 2026 GUIDE

HOW LETTERS WORK
IN IOWA

How many letters you need, what the standards actually require, and where care stands in Iowa right now. Written from the chair of a clinician who writes these letters every week.

Chad Mohammad, MSW, LISW · Iowa license 110423 · Last reviewed August 2026

HOW MANY LETTERS YOU ACTUALLY NEED

The WPATH Standards of Care, Version 8 (2022) call for one assessment letter from one qualified professional for adult surgery. That replaced the old two-letter rule for genital surgery.

In practice, requirements are set by whoever you are dealing with. Most surgeons and insurers ask for one letter. Some genital surgery programs and some insurance plans still ask for two, one from a licensed mental health professional and one from a second clinician such as the hormone prescriber. Self-pay top surgery at some practices runs on informed consent with no letter at all.

The practical move: ask your surgeon’s office what they require, or bring me their requirements and I will match the documentation to them. Coordination with your surgeon’s office is included.

HORMONES: USUALLY NO LETTER

Many clinics prescribe hormones through informed consent and do not require a letter. That includes telehealth services that see Iowa patients and in-person informed consent clinics. Some providers and insurers still require a letter, and prior authorization sometimes asks for documentation even when the clinic itself does not.

If you are told you need a letter for hormones, that is a letter I can write after an assessment, usually in one visit.

WHERE CARE STANDS IN IOWA, 2026

Adults. No Iowa law restricts gender-affirming medical care for adults. Care remains legal statewide.
Minors. Iowa Code section 147.164 (2023) prohibits gender transition procedures for minors. Talk therapy is not restricted. I see teens for therapy.
Coverage. Iowa Medicaid stopped covering gender-affirming surgery and hormone therapy effective July 1, 2025 (House File 1049). Mental health coverage remains. Commercial plans vary; their letter requirements are the ones that matter for documentation.
Access. In-person options have narrowed statewide, and much of Iowa has no local prescriber. Telehealth fills most of that gap. For affirming clinics, financial help, and mutual aid, see the community resources page.

WHAT A LETTER CONTAINS

A letter is a clinical document, not a test you pass or fail. Mine document the assessment: your identity and history in your words, the clinical findings, capacity for informed consent, and the specific documentation your surgeon or insurer requires. Signed, on letterhead, sent where it needs to go.

You review and approve the draft before anything is signed or sent out. If an insurance reviewer asks for different wording later, updates and re-submissions are included at zero cost.

GETTING A LETTER

Letter visits are free, usually one visit, telehealth anywhere in Iowa or in person in Cedar Falls. You do not have to become my therapy client. The letters page has the full picture.

SCHEDULE APPOINTMENTFREE LETTER VISIT • TELEHEALTH & IN-PERSON

Or text (619) 559-5769 and say you need a letter.

QUESTIONS

How many letters do I need for surgery?: The WPATH Standards of Care, Version 8 (2022) call for one assessment letter from one qualified professional for adult surgery. Some surgical programs and insurance plans still ask for two letters for genital surgery. Your surgeon's office and your insurer set the final requirement, and I match the letter to what they ask for.
Do I need a letter to start hormones?: Often no. Many clinics, including telehealth services that see Iowa patients, prescribe hormones through informed consent without a letter. Some providers and insurers still require one. If yours does, that is a letter I can write after an assessment.
Is gender-affirming care still legal for adults in Iowa?: Yes. No Iowa law restricts gender-affirming medical care for adults. Iowa Code section 147.164 (2023) prohibits gender transition procedures for minors. Iowa Medicaid stopped covering gender-affirming surgery and hormone therapy in 2025 (House File 1049), but the care itself remains legal for adults, and Medicaid still covers mental health care.
What does the letter actually say?: A letter documents the clinical assessment: identity and history in your words, the assessment findings, capacity for informed consent, and the documentation your surgeon or insurer requires. You review and approve the draft before anything is signed or sent out.
Does an assessment guarantee a letter?: No. Letters are clinical documents provided when clinically indicated. When the clinical criteria are met, the letter goes out the same day.

SOURCES AND SCOPE

Standards referenced: WPATH Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (2022). Individual surgeons and insurers set their own documentation requirements, which control in practice.
Iowa law referenced: Iowa Code section 147.164 (2023); Senate File 418 (2025); House File 1049 (2025), effective July 1, 2025.
This page is general information about how letters and access work. It is not legal or medical advice. Facts last reviewed August 2026.