Therapy Letter Requirements

Source: WPATH Standards of Care

Letter Requirements

The mental health professional letter is a crucial part of a successful transition. As more and more patients seek gender confirmation surgery and hormone therapy, we are noticing a drop in the quality of the therapy letters. In our experience, patients with weak letters have more mental health issues following treatment. We provide our requirements here so that your clients will be better prepared for treatment. If you have any questions or need clarification, please call. Letters that do not follow the format below will be returned for completion. To avoid delay of patient treatment, please take the time to review the following requirements.
1. The patient's general indentifying characteristics;
2. The initial and evolving gender, sexual and other psychiatric diagnosis. This is to include Axis II diagnosis. Any psychiatric medications MUST be accompanied with a diagnosis. This area should discuss the patient's initial cross-gender feelings*;
3. The duration of their professional relationship including the type of psychotherapy or evaluation that the patient underwent (This area should discuss any purging events)*;
4. The eligibility criteria that have been met and the mental health professional's rationale for hormone therapy or surgery;
5. The degree to which the patient has followed the Standards of Care to date and the likelihood of future compliance (Main areas of transition should be covered here and should include name change, Contra-Hormone Therapy (CHT), timeline of any gender related surgeries, history of gender presentation at work and home. This section should also discuss any spousal or parental obligations.)*;
6. The author should list their experience in treating transgender clients. This should include years experience, number of clients treated and currency of training in transgender issues. The author should list any transgender organization memberships and if they are part of a gender team.*;
7. That the sender welcomes a phone call to verify the fact that the mental health professional actually wrote the letter as described in this document.
8. The therapist should comment on the patient's demonstrated ability to choose a surgeon wisely and have economic/social support plans in place for unexpected complications. This discussion should include the current insurance situation as it relates to unforeseen complications. Some suggested areas of discussion are the surgeon's training in transgender specific surgery, distance of surgeon from patient's residence, surgeon outcomes, surgeon technique and most importantly, the surgeon's record for handling any complications.*
9. In addition, Dr. McGinn requires the therapist to discuss the patient's emotional, economic and logistical support systems for the perioperative period. The letter should address plans for postoperative therapy to monitor the patient's progress.*
The organization and completeness of these letters provide the hormone-prescribing physician and the surgeon an important degree of assurance that the mental health professional(s) is knowledgeable and competent concerning gender identity disorders.
One Letter is Required for Instituting Hormone Therapy or Breast Surgery
Hormone Therapy, Breast Augmentation, Mastectomy

One letter from a mental health professional, including the above eight points, written to the physician who will be responsnible for the patient's medical treatment, is sufficient for instituting hormone therapy or for a referral for breast surgery (e.g. mastectomy, chest reconstruction, or augmentation mammoplasty).
Two Letters are Generally Required for Genital Surgery
Vaginoplasty, Orchiectomy, Metoidioplasty

Genital surgery for biological males may include orchiectomy, penectomy, clitoroplasty, labiaplasty or creation of a neovaginal for biologic females it may include hysterectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty, scrotoplasty, urethroplasty, placement of testicular prosthesis, or creation of a neophallus.

It is ideal if mental health professionls conduct their tasks and periodically report on these processes as part of a team of other mental health professionals and non-psychiatric physicians. One letter to the phyisician performing genital surgery will generally suffice as long as two mental health professionals sign it.

More commonly, however, letters of recommendation are from mental health professionals who work alone without colleagues experienced with gender identity disorders. Because professionals working independantly may not have the benefit of ongoing professional consulation on gender cases, two letters of recommendation are required prior to initiating genital surgery. If the first letter is from a person with a master's degree, the second letter should be from a psychiatrist or a Ph.D. clinical psychologist, who can be expected to adequately evaluate co-morbid psychiatric conditions. If the first letter is from the patient's psychotherapist, the second letter should be from a person who has only played an evaluative role for the patient. Each letter, however, is expected to cover the same topics. At least one of the letters should be an extensive report. The second letter writer, having read the first letter, may choose to offer a briefer summary and an agreement with the recommendation.

* Contributed by Papillon Center