A large majority of transgender (trans) clients will seek therapy at some point during their lifetimes. Trans is an inclusive term that refers to any individual whose assigned sex at birth does not match their current gender identity.
Despite the fact that many trans clients will arrive to therapy with the purpose of attaining medically necessary surgeries and treatments, most therapists have no idea how to write a letter as part of the patient's evidence of readiness for these treatments. Most training programs do not teach therapists how to gain cultural competence with trans clients, thus leaving therapists to refer their trans clients to other mental health professionals to receive a letter.
Because trans individuals need a letter written by at least one mental health professional in order to receive medically necessary treatments, therapists find themselves in the role of a gatekeeper — they are the ones who get to say if their client should have hormone therapy or gender reassignment surgery.
To demystify the process of letter writing, in her article published in Psychotherapy, Budge (2015) provides a case example of her therapeutic work with a trans client. The case example provides information about Lia (pseudonym), an 18 year old Latina-Italian trans woman who arrived to therapy with the intention of socially transitioning (e.g. changing her name, changing her pronouns, coming out to others) and medically transitioning (e.g. engaging in hormone therapy, having breast augmentation, and surgery on her genitals).
Lia filled out outcome measures over a period of 8 assessments throughout a year of psychotherapy and also consented to share excerpts of a therapy session in which she discussed having a letter written for hormone therapy with the author. From the beginning to the end of therapy, Lia reported less anxiety, less depression, higher well-being, more social support, greater change attributed to psychotherapy, and an increasingly better relationship with her therapist.
Perhaps most important in the findings was Lia's report during therapy that she perceived the interaction of hormones and psychotherapy as improving her mood and that she felt it was important for a therapist to discuss the psychological impact of receiving a gender dysphoria diagnosis.
The implications for this case study are manifold. From a practical standpoint, the article provides the link to the World Professional Association of Transgender Health Standards of Care (WPATH SOC) while also providing a masked version of the letter written for Lia to obtain hormones. The WPATH SOC indicate that only professionals who are well-trained in trans health should be able to write these letters, but therapists should not shy away from learning this useful skill of writing letters for trans clients; it can be anticipated that more and more trans individuals will continue to seek therapy and it is reasonable for therapists to learn how to write these letters.
This study also sheds light on the important link between psychological support and hormones in improving the mood and well-being of trans clients. Earlier studies have hinted at this link, but it is important for well-designed experimental studies to provide additional evidence.
Citation:
Budge, S. L. (2015). Psychotherapists as gatekeepers: An evidence-based case study highlighting the role and process of letter writing for transgender clients. Psychotherapy, 52(3), 287–297. http://dx.doi.org/10.1037/pst0000034
Note: This article is in the Clinical Psychology topic area. View more articles in the Clinical Psychology topic area.