How I Approach Letters of Recommendation for Body Modification

I usually need to meet you only once (specific clinical reasons may necessitate more than one appointment). The purpose of the appointment is for me to assess you for the ability to provide informed consent, and not to provide therapy.

Prior to the day we meet, I need the following from you:

  • Authorization allowing me to communicate with your surgeon or prescribing physician pre-filled and signed prior to our appointment
  • Your contact information and necessary forms −read, filled, signed (sent and returned through email)

Three-Step Process

  • You write your own letter. This is your life, body, journey, mind, and choice, and therefore your words.
  • I ask you to include the items below (under What to Include in the Letter), whatever and however you wish.
  • I include the necessary clinical language and convert the client's own words into a clinical assessment and report for other medical professionals.

What to Include in the Letter (suggestions, not requirements; include whatever you like from this list or elsewhere, as much or as little as you need)

  1. General characteristics including name, physical description, age, date of birth, affect, occupation, interests
  2. Your gender journey
  3. How you would describe your gender
  4. Procedure(s)
  5. Reason(s) for surgery
  6. What you understand as the risks and known side effects
  7. Desired outcomes
  8. Future plans
  9. Some indication that you understand that you are capable of giving informed consent
  10. Anything else you wish


Background Information for Gender Affirmation Surgery

Assessment for Informed Consent is NOT the Same as Therapy. Psychotherapy is not required for hormones or surgery.

Psychotherapy is not an absolute requirement for hormone therapy and surgery. Psychotherapy…is not a requirement (p. 28). Surgical treatments for gender dysphoria can be initiated with a referral (one or two, depending on the type of surgery) from a qualified mental health professional (p. 27). “…Qualified mental health professional[s]…” are best prepared to conduct this assessment of gender dysphoria. However, this task may instead be conducted by another type of health professional who has appropriate training in behavioral health and is competent in the assessment of gender dysphoria, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy. This professional may be the prescribing hormone therapy provider or a member of that provider’s health care team, for example, nurse, nurse practitioner, or physician’s assistant (p. 24).

The WPATH Standards of Care do not recommend a minimum number of psychotherapy sessions prior to hormone therapy or surgery. The reasons for this are multifaceted (Lev, 2009). First, trans individuals have viewed having a minimum number of sessions as an unnecessary and discriminatory hurdle, discouraging the genuine opportunity for personal growth. Second, mental health professionals can offer important support to clients throughout all phases of exploration of gender identity, gender expression, and possible transition – not just prior to any possible medical interventions. Third, clients differ in their abilities to attain similar goals in a specified time period (p. 28-29).

Recommendation letters, strictly speaking, are not required, for hormones OR surgery. Though the SOC v.7 uses the phrase “referral letter,” it also heavily emphasizes that clinicians must treat each patient and circumstance individually. It also leaves off any previously mentioned suggested lengths of time found in earlier versions for things such as “real life tests,” assessment, and therapy.

Note: The previous SOC, v.6, made use of the concept called "triadic therapy," in which a person diagnosed with GID would undergo "full time experience," hormone therapy, then surgical interventions, usually in that order. This version, v.7, has completely done away with this concept in favor of more explicitly emphasizing tailoring transition, even the very meaning of this word, for each individual, in a number of ways throughout the document. It should be noted that v.6 also allowed for a great deal of flexibility within the triadic model, though more subtly worded. From SOC v.6: "Psychotherapy is Not an Absolute Requirement for Triadic Therapy. Not every adult gender patient requires psychotherapy in order to proceed with hormone therapy, the real-life experience, hormones, or surgery (p. 11)."

IF a Letter is Required:

  • No one board, governing body, state agency, or government regulates this process.
  • Many surgeons and hormone-prescribing physicians do not require “referral letters.”
  • When prospective clients call seeking a letter, they usually have in mind either a set of requirements from a specific physician/surgeon, or a vague set of requirements from word-of-mouth. They may also think that therapy is a requirement for recommendation letters (it is not).
  • While the SOC might describe suggested guidelines for letters for surgery, if required by the surgeon, it also emphasizes treating each case individually.

Physicians perform their own mental status exams as part of a full assessment. In order to have surgery, an individual need only demonstrate that they can give informed consent. The same mental and emotional wherewithal necessary to give informed consent for a bypass surgery, for example, is the same as for any gender-confirming surgery.

Further Reading

  • Bettcher, T. M. (2009). Transidentities and first person authority. In L. J.Schrage (ed.). You’ve changed: Sex reassignment and personal identity (pp. 98-120). NY: Oxford University Press.
  • Rachlin, K. (2002). Transgender Individuals’ Experiences of Psychotherapy. International Journal of Transgenderism. 6(1). Retrieved May 28, 2010 from http://www.symposion.com/ijt/ijtvo06no01_03.htm
  • The World Professional Association for Transgender Health, “Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th Version,” 2011, http://www.wpath.org.
  • World Professional Association of Transgender Health (WPATH). The Standards of Care for Gender Identity Disorders (6th edition). (2001). Dusseldorf, Germany: Symposion.