Internationally, the scientific community faces increasing politicization of medically necessary gender-affirming care for transgender and nonbinary people. Two years ago, the World Professional Association for Transgender Health (WPATH) published updated international guidelines (Version 8)opens in new window regarding standards of care (SOC) for medical interventions for transgender and nonbinary people (Coleman et al., 2022). The guidelines provide evidence-based recommendations for medical and mental health providers working with transgender and nonbinary individuals seeking hormone therapy and gender-affirming surgeries. In the wake of legislation limiting or banning access to medical gender-affirming care, providers often encounter barriers to delivering community-informed, evidence-based care for transgender and nonbinary patients and educating the public on best practices.
In the recent past, transgender and nonbinary patients seeking access to gender-affirming medical care were required by insurance companies and medical providers to undergo an assessment to receive a referral letter from a mental health or medical provider. Historically, this letter has been called a “letter of readiness.” Its contents often documented outdated practices, such as a transgender or nonbinary person following the “real-life experience,” wherein they socially transitioned for at least 3 months; engaged in psychotherapy for 3 months; or both prior to receiving the letter from a provider. The WPATH SOC Version 8 guidelines (Coleman et al., 2022) do not mandate these referral letters as a best practice, but the guidelines do identify information that should be included in a referral letter should an insurance company or medical provider require one.
Stephanie L. Budge, Joonwoo Lee, Elliot A. Tebbe, and Sergio Domínguez Jr. set out to provide a model that can guide clinicians through the process of writing referral letters for transgender and nonbinary adults who are seeking transition-related medical care. They note that although their recommendations are in alignment with the informed consent model, they recognize the necessity of educating clinicians who write referral letters. They designed their model—the companionship model—to make the referral process as affirming as possible, adding to the scholarly literature regarding methods for conducting referral letter–writing sessions and writing referral letters for transgender and nonbinary clients.
The companionship model incorporates scientific evidence of transgender and nonbinary people’s experiences in obtaining referral letters and also all four authors’ clinical experiences writing referral letters for transgender and nonbinary clients. The purposes of the companionship model are to emphasize the clinician’s role in collaboratively navigating institutional gatekeeping alongside the client and to increase patients’ and clients’ access to critical resources for positive medical transition experiences. Clinicians are encouraged to use four actions to process gatekeeping with clients: validate, ask, share, and engage. The referral letter session consists of the clinician validating the client’s assumptions, reactions, and normative mistrust of gatekeeping processes; asking for the client's reactions to the letter-writing process; sharing the clinician’s critical understanding of the letter-writing session as a gatekeeping process; and engaging the client as a collaborative decision-maker in writing the letter.
In their article, Budge et al. also offer suggestions for therapists on ways to ensure that they are providing affirming support to transgender and nonbinary clients. They recommend that therapists become familiar with APA’s (2015) guidelines for clinical practice with transgender and nonbinary clients as well as clinical resources written by transgender and nonbinary therapists. They also provide commentary on ways to improve clinical training programs and include reflective practice questions for therapists. Additionally, they propose ways for therapists to provide pro bono services to reduce gatekeeping within gender-affirming care and facilitate the referral letter–writing process.