​​​​​​CONTENTS


Purpose of referral letters
Elements of a referral letter
Mental health professional’s qualifications
Client’s readiness criteria
Performing the assessment
Sample letters


 

PURPOSE OF REFERRAL LETTERS

When a transgender patient wants to receive gender-affirming hormone treatment, bottom surgery, or top surgery (sometimes called sex reassignment or medical transition), the medical provider will typically follow the WPATH Standards of Care by requiring a letter from a qualified mental health professional (2 letters for bottom surgery), indicating that a psychosocial assessment has been made and that the client meets the WPATH readiness criteria.

There are exceptions. First, some medical facilities have an interdisciplinary team including mental health professionals, and include the psychosocial assessment in the patient’s medical chart instead of requiring a letter. Second, the Standards of Care are not a legal requirement, but a widely accepted set of recommendations; so there are a few medical providers who do not require a letter. Third, because the psychosocial assessment is seen by many in the transgender community as a hurdle and a form of discrimination in terms of access to necessary medical care, some clinics make it their policy to offer “hormones on demand,” without requiring a psychotherapist’s letter.

While medical providers typically follow the latest version of the SOC, some insurance companies still use an older version. An example of this is that, for bottom surgery, the current SOC (Version 7) simply requires two licensed mental health professionals to write letters, while an earlier version required at least one of the two to have a doctoral level license. It may not be legal for an insurance company to require this before paying for bottom surgery, and you may wish to encourage a client to challenge such a requirement. However, many clients will choose to comply with their insurance companies’ criteria in order to get access to surgery without an added delay. The medical aspect of gender transition is a vulnerable, stressful process, and not everyone wants to be a trailblazer while trying to get their needs met!

For hormone treatment or top surgery (breast/chest surgery such as mastectomy, chest reconstruction, or augmentation mammoplasty), one letter is required.

For bottom surgery (genital surgery such as hysterectomy/salpingo-oophorectomy, orchiectomy, or genital reconstructive surgeries), letters are needed from TWO mental health professionals who have assessed the patient independently. If the first referral is from the patient’s psychotherapist, the second referral should be from a person who has only had an evaluative role with the patient.

It is not necessary for either letter to come from the patient’s psychotherapist. In fact, the SOC explicitly states that “psychotherapy is not an absolute requirement for hormone therapy and surgery.”


 
The SOC do not state criteria for other surgical procedures, such as feminizing or masculinizing facial surgery.

ELEMENTS OF A REFERRAL LETTER

The referral letter should include:

1. The client’s general identifying characteristics;

2. Results of the client’s psychosocial assessment, including any diagnoses;

3. The duration of the referring health professional’s relationship with the client, including the
type of evaluation and therapy or counseling to date;

4. An explanation that the criteria for hormone therapy / surgery have been met, and a brief description of the clinical rationale for supporting the client’s request for surgery / hormone therapy;

5. A statement that informed consent has been obtained from the patient;

6. A statement that the referring health professional is available for coordination of care and
welcomes a phone call to establish this.

It is a good rule of thumb to state, briefly, why you are qualified to make the assessment.

The psychosocial assessment might include a brief developmental history, with an emphasis on the way the client’s gender identity appeared or evolved.

The explanation that readiness criteria are met might include a statement about the client’s mental capacity to make an informed decision, including the client’s knowledge of the risks and benefits of the medical intervention they are seeking; and an assessment of the client’s support system (which may or may not include psychotherapy) for handling the stressors involved in transition.

 

 MENTAL HEALTH PROFESSIONAL’S QUALIFICATIONS

Here are the SOC minimum qualifications for mental health professionals working with adults with Gender Dysphoria (this would include psychosocial assessments for hormones or surgery):

1. A master’s degree or equivalent in a clinical behavioral science field.

2. Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Diseases for diagnostic purposes.

3. Ability to recognize and diagnose coexisting mental health concerns and to distinguish these from gender dysphoria.

4. Documented supervised training and competence in psychotherapy or counseling.

5. Knowledgeable about gender-nonconforming identities and expressions, and the assessment and treatment of gender dysphoria.

6. Continuing education in the assessment and treatment of gender dysphoria.

Beyond the minimum qualifications, the SOC states:

“It is recommended that mental health professionals develop and maintain cultural competence to facilitate their work with transsexual, transgender, and gender-nonconforming clients. This may involve, for example, becoming knowledgeable about current community, advocacy, and public policy issues relevant to these clients and their families. Additionally, knowledge about sexuality, sexual health concerns, and the assessment and treatment of sexual disorders is preferred.”

 


CLIENT’S READINESS CRITERIA

 

Criteria for hormone therapy:

1. Persistent, well-documented gender dysphoria;

2. Capacity to make a fully informed decision and to consent for treatment;

3. Age of majority in a given country (if younger, follow the SOC outlined in section VI);

4. If significant medical or mental health concerns are present, they must be reasonably well-controlled.

The presence of coexisting mental health concerns does not necessarily preclude access to feminizing/masculinizing hormones; rather, these concerns need to be managed prior to, or concurrent with hormone treatment. In some cases, it may be acceptable practice to provide hormones to patients who have not fulfilled these criteria, for example, to provide monitored hormones of known quality as an alternative to illicit or unsupervised hormone use.


 

Criteria for top surgeries

Criteria for mastectomy and creation of a male chest in FtM (female-to-male, or female-assigned-at-birth) patients:

1. Persistent, well-documented gender dysphoria;

2. Capacity to make a fully informed decision and to consent for treatment;

3. Age of majority in a given country (if younger, follow the SOC for children and adolescents);

4. If significant medical or mental health concerns are present, they must be reasonably well controlled.

Hormone therapy is not a prerequisite.

Criteria for breast augmentation (implants/lipofilling) in MtF (male-to-female, or male-assigned-at-birth) patients:

1. Persistent, well-documented gender dysphoria;

2. Capacity to make a fully informed decision and to consent for treatment;

3. Age of majority in a given country (if younger, follow the SOC for children and adolescents);

4. If significant medical or mental health concerns are present, they must be reasonably well controlled.

Although not an explicit criterion, it is recommended that MtF patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results. In fact, some MtF patients find that they are satisfied with the breast growth produced by hormones and elect not to have top surgery.


Criteria for bottom surgery

Criteria for hysterectomy and salpingo-oophorectomy in FtM patients and for orchiectomy in MtF patients:

1. Persistent, well-documented gender dysphoria;

2. Capacity to make a fully informed decision and to consent for treatment;

3. Age of majority in a given country;

4. If significant medical or mental health concerns are present, they must be well controlled.

5. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual).

The aim of hormone therapy prior to gonadectomy is primarily to introduce a period of reversible estrogen or testosterone suppression, before the patient undergoes irreversible surgical intervention.


 
Criteria for metoidioplasty or phalloplasty in FtM patients and for vaginoplasty in MtF patients:

Same as criteria for hysterectomy,  salpingo-oophorectomy, and orchiectomy, above. PLUS

6. 12 continuous months of living in a gender role that is congruent with their gender identity.

This final criterion is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, on a day-to-day basis and across all settings of life, before undergoing irreversible surgery.

Previous versions of the Standards of Care required 12 months of psychotherapy, as well.


PERFORMING THE PSYCHOSOCIAL ASSESSMENT

Assumptions to avoid

Every transgender or gender-non-conforming person is unique in terms of what, if anything, they want to do about medical gender transition. And each individual’s needs in this regard can evolve over time. It is important not to assume, for example, that if a client takes hormones, their next step will be top surgery, followed by bottom surgery. A referral letter you are asked to write at any given time, will likely be for just one type of treatment, either hormones or a specific surgery. Your job in assessing the client’s readiness (and/or providing ongoing psychotherapy) is to learn about the client’s internal experience of gender and the client’s own assessment of which medical interventions will help them with, in the words of the  SOC, “achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment.”

Another assumption to avoid is that everyone’s gender is binary. The criteria listed above refer to “MtF” and “FtM” patients. But some gender-non-conforming people do not identify as male or female, and they, too, may require hormone or surgical intervention for their well-being and gender congruity. One of the sample letters at the end of this course is for a non-binary, trans-masculine, female-assigned-at-birth individual who had gender dysphoria associated with their breasts, and needed a referral for top surgery.


Establishing rapport

When meeting with a person who is asking you for a hormone/surgery referral letter, it is important to consider the power dynamics in that transaction. You may be seen as a gatekeeper, a hurdle to get past, or as part of the mainstream establishment which is laden with cis-normative privilege. (Cis or cis-gendered is the term for people whose felt sense of gender matches their gender assigned at birth.) In addition to the internal distress of gender dysphoria, the person asking you for the letter has probably undergone a great deal of trauma from transphobia in every facet of society: being misunderstood and misgendered even by people they love, economic and social discrimination, harassment and possibly even violence. 

So, do not be surprised if they appear a bit distrustful at first. You may be able to put them at ease by establishing yourself as an ally and letting it be known that your intention is to help them get the medical services they need. (Although it would be unethical to predict the outcome of your assessment before you talk with them and learn about their situation, most psychotherapists know how to project an air of cooperation and empathy, as opposed to a cold clinical stance.)

Do not be surprised, either, if the person coming to you for a letter seems eager to get the assessment done and reluctant to undergo a prolonged process of psychotherapy.  You should, of course, assess how much effort the client has put into understanding their gender and learning about medical options. But chances are,  by the time they come to you, they have spent a great deal of time, perhaps a lifetime, struggling to make sense of their gender experience, and they will have put a lot of work into learning about what surgeries and hormones can do to help them live more authentically.

Finally, do not be surprised if they are still presenting, at least part of the time, as their gender assigned at birth. One of the paradoxes of assessing someone’s readiness for medical intervention is that, before agreeing to recommend hormones or surgery, the gatekeepers historically have expected transgender people to first prove their commitment to transition by presenting themselves to the world, over a period of time, in the gender to which they want to transition. (The current SOC still requires this for certain bottom surgeries.) The problem is that, before medical intervention, a person’s body may have traits that other people look at and associate with the wrong gender (breasts on a man, stubble or leathery skin on a woman, etc.). Dressing and acting the part of a woman while looking very much like a man, or vice versa, can put a person at risk for ridicule, discrimination, and violence. In addition to providing an internal sense of authenticity, congruence, and confidence about gender; hormones and surgeries change the outward physical appearance, which mitigates those risks.


Therapist’s role

It is crucial, as a psychotherapist writing a referral letter, that you be clear on what your role is. If the client is already seeing you for psychotherapy, you will need to be aware of any power shifts that might occur in your relationship, since the client will now be relying on you to approve a necessary step in their gender transition process. As a psychotherapist, the power dynamic is usually about transference and emotional dependency.  In making a psychosocial assessment for a surgeon or endocrinologist, you hold a different kind of authority , wielding power over the client’s access to these medical services.

If the person is not your psychotherapy client, and is seeking you out specifically to get a referral letter, you may be tempted to think of all the ways they could benefit from continuing to see you for therapy after – or perhaps before - the letter is written. It is important to distinguish this from a need, if there is one, to include a recommendation for psychotherapy as part of your assessment. If you believe that the stress of  hormones or surgery could be destabilizing to the person’s mental health and that these interventions should be contingent on the person receiving ongoing psychotherapy, you should state that in the letter. (The SOC has a specific section on working with psychotic clients in gender transition.) If you think psychotherapy would be helpful but not essential, state that clearly in the letter so that the medical providers do not end up adding another hurdle by making psychotherapy a requirement.

Finally, if a client asks you for a hormone/surgery referral, whether it is a current psychotherapy client or someone only wanting a letter, and you do not believe you possess the knowledge necessary to make the assessment, you should refer the client to, or get consultation from, a colleague who does.

 


SAMPLE LETTERS

It is possible that the client’s medical provider or insurance company will have a template they want you to follow in writing the letter. (Sample Letter Three below is loosely based on such a template.) Within that structure, or if there is no such template, it is best to write in your own voice and be specific about the individual client. Just be sure to include the SOC required elements (listed above) of the letter.


SAMPLE LETTER ONE

     John Doe (aka Jane Doe) is a 29-year-old transgender man who sought my services because of my experience doing recommendations / assessments such as this one for members of the transgender community. I have been a licensed psychotherapist since 1992, specializing in LGBT clients, and have worked with transgender adults and their families for over 20 years. I have also provided training, supervision, and consultation on transgender issues for private practice therapists and mental health clinics.
     I conducted an interview with John on May 31, 2020, to assess readiness for top surgery. (I am referring to John as “he,” which is his preferred pronoun some of the time. There are also times when he prefers the non-binary gender-neutral pronouns “they” and “them.” This is not uncommon for transgender men and masculine gender-non-conforming individuals, and it does not indicate any lack of readiness for surgery.) John says he first realized that his assigned sex differed from his gender identity at age nineteen. For 10 years, he has been engaging in careful self-reflection about his gender and researching the medical and psychological aspects of transition. He has been consistently and successfully living as a transgender man since at least two years ago, when he began hormone therapy.
     By my independent evaluation, I diagnosed him with Gender Dysphoria in Adults (ICD-10 F64.0, DSM-V 302.85).
     Based on John’s report of his mental health history, I do not believe he has any mental health diagnosis other than Gender Dysphoria. He attended about ten sessions of psychotherapy on one occasion five years ago, when he needed support to deal with his mother’s death. He has a history of mild anxiety symptoms which I do not believe meet the severity, duration, or frequency criteria for any DSM diagnosis at this time.  He feels his anxiety has been exacerbated by Gender Dysphoria. He does not smoke cigarettes or use any illicit drugs. He drinks alcohol socially and infrequently and has followed medical advice to avoid it in preparation for surgery. Overall, I found John to be articulate, intelligent, self-aware, and emotionally stable. I believe he is fully capable of making wise decisions about his gender transition, including the decision to have top surgery.
     Although hormone therapy has helped John feel more aligned in his identity, his symptoms of Gender Dysphoria have persisted. He relates much of his Gender Dysphoria to his chest size. He binds his chest tightly to feel more comfortable in his body, which causes pain. John has expressed a persistent desire for bilateral mastectomy. I believe that bilateral mastectomy with male chest reconstruction is the next logical step in John’s transition, and is necessary at this time for his psychological well-being.
     His friends and family are supportive of his decision to move forward with his transition. He has been in a relationship with his partner for over 3 years and has a strong community of friends. Although his father has had some difficulty accepting his transition, he has managed to maintain a close relationship with him while still asserting his gender identity. He is stably housed and has planned for post-op recovery.
     John has met the WPATH SOCv7 criteria for surgery. I have assessed his readiness for surgery and I fully support his decision to move forward. I recommend and refer John Smith for this surgery.

     Please feel free to contact me with any questions or concerns.


SAMPLE LETTER TWO

     I am writing to recommend bottom surgery for Janet Doe (legal name James Doe), a 45-year-old transgender woman.
     I have been a licensed psychotherapist since 1992, specializing in LGBT clients, and have worked with transgender adults and their families for over 20 years. I have also provided training, supervision, and consultation on transgender issues for private practice therapists and mental health clinics.
     I have met with Janet three times to evaluate her readiness. Based on my evaluation, she is an excellent candidate for bottom surgery, and has the capacity to make fully informed decisions and consent to treatment.
     Janet meets the criteria for Gender Dysphoria. She began her gender transition with hormone treatment two years ago and has been living successfully as a woman since that time. At the time she began hormone treatment, she also engaged in psychotherapy for one year. She clearly demonstrates the desire to live and be accepted as female, accompanied by a strong desire to make her body congruent with her preferred gender through surgery and hormones.
     Janet does not appear to have any history of mental health disorders or emotional instability. Because of a recent stressor, i.e. having her preparation for surgery delayed by financial concerns, Janet is currently exhibiting some mild, most likely temporary depressive symptoms: tearfulness, some lability of mood, and slightly decreased motivation to attend to self-care. However, she is able to go to work, socialize, and function normally in most ways. She is making good use of emotional support from friends. She is insightful, psychologically minded, and determined not to let this stress get the better of her.
     While I certainly believe Janet could benefit from psychotherapy to help her cope with this situation if she chooses, I have taken into account her history of good mental health, her support system, and her previous year of transition-related psychotherapy, and therefore I do NOT see psychotherapy as a prerequisite for proceeding with her plan for surgery.
     At this point, I believe bottom surgery is the next logical step in her transition, and is of utmost importance to her sense of wellbeing and quality of life.

     Please feel free to contact me with any questions or concerns.

 

SAMPLE LETTER THREE

     I am writing to recommend masculinizing hormone treatment for Jake Doe (whose legal name was recently changed from Jill Doe), a 22-year-old transgender man.
     I have been a licensed psychotherapist since 1992, specializing in LGBT clients, and have worked with transgender adults and their families for over 20 years. I have also provided training, supervision, and consultation on transgender issues for private practice therapists and mental health clinics.
     Readiness for medical transition. I have met with Jake for weekly psychotherapy for six months, and gender dysphoria has been a frequent topic or our sessions. The way he experiences his gender, currently and historically, follows a pattern consistent with numerous individuals I have known who required and derived great benefit from medical female-to-male transition. Jake has done significant research about his options, taking social, emotional, and physical consequences into careful consideration. I believe he is fully capable of making this decision in his own best interest.
     History. Jake recalls being aware that he was different from girls at least as early as the second grade. Despite the conflict and upset it caused, he managed to resist pressure from his parents to adjust his physical appearance, friendships, and play activities to fit norms associated with femininity. He hated the developing female characteristics of his body, and was severely distressed by the onset of menses. As a teenager, he began to identify as a lesbian. During the past year, he researched the experiences and stories of transmen and found that they resonated deeply with his own identity and history.
     Support system. Despite some social isolation as a child, caused by his gender identity clashing with social and family norms, Jake has developed a strong support system. He currently has several friends, including one who is transgender. At my suggestion, he is looking into a local peer-led support group for female-to-male transgender adults, and will research other resources as well. Jake has a realistic view of the difficulties that might arise when he discloses his gender identity and transition to his parents. However, their history of coming to accept his former lesbian identity, bodes well for this anticipated communication.
     Mental health. By his report, apart from distress that was secondary to his Gender Dysphoria, his only history of mental health symptoms has been a single episode of depression, lasting two to three weeks, around the age of 15, evidenced at the time by lethargy, isolation, insomnia, low appetite, and depressed mood. Currently, all aspects of his mental status appear to be within normal limits. He presents as socially engaging, with a range of affect appropriate to the content of our discussion about his experiences. He appears to be a reliable historian with excellent judgment and insight, and his attitude tends toward optimism and hope. It is my opinion that, while anyone undergoing this process could probably benefit from the support of a psychotherapist, there is no need to make Jake’s medical transition contingent on mental health treatment or further assessment.
     Recommendation. Jake is a mentally healthy individual with good judgment and a strong support system, fully prepared to make this important decision about his medical care. I believe hormone treatment is the next logical step in his transition.
     Please feel free to contact me with any questions or concerns.


​SOURCE: World Professional Association for Transgender Health (WPATH). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.  International Journal of Transgenderism, 13 (4), 165–232. Available and free to public at www.wpath.org.

Copyright 2020 Jeanne Courtney, MFT

 

EXAM QUESTIONS
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Law and Ethics: Transgender Referral Letters

Writing recommendations for Gender-Affirming Hormone Treatment and Surgery

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