Everyone’s gender journey is different towards achieving gender euphoria. For some people, social transition helps them achieve feelings of congruence within themselves and within relationships. But for some, medical interventions are necessary to achieve this. There is a wide range of options available from voice therapy to chest surgery to genital surgery.
Simply navigating the medical system is hard enough, but there are extra layers that can make it more difficult for transgender and nonbinary people. For example, many insurance companies and/or physicians require at least one letter from a mental health professional in order to access care. This can be a huge barrier for some transgender and nonbinary people! We work to limit that barrier by making this process as helpful as we can.
Letters of Recommendation for Gender Affirming Hormones
If you are over 18 years old and in California, you are not required to have a letter for hormones. That said, some physicians may still require one, especially if you have a complex medical or mental health history.
If your physician requires letters from every patient they work with, we recommend trying to find another provider that comes from an informed consent model rather than a gatekeeping one. However, if you still need a letter due to insurance requirements, lack of access to an affirming provider, or whatever other reason, we are happy to meet with you!
If you are a minor, many physicians require at least one letter from mental health providers. We have a licensed masters level provider that can write letters for minors seeking puberty blockers and/or hormones as young as 12 years old.
Letters of Recommendation for Gender Affirming Surgery
If you are seeking gender affirming surgery, some surgeons or insurance companies will require:
- more than one letter despite the fact that the World Professional Association of Transgender Health (WPATH) Standards of Care 8 (the most current) only recommend one
- the mental health profession providing the letter has a doctorate (PsyD, PhD, etc.)
- the mental health professional is licensed
We have both licensed and doctorate level providers available. We recommend that you check with your surgeon and/or insurance provider to make sure that you book an appointment with someone who meets their requirements. We don’t want you to waste your time jumping through the wrong hoops!
We write letters according to WPATH SOC 8, but can adjust the language to meet the surgeon’s and/or insurance company’s requirements.
Assessment Process for Letters
First, our job is not to assess whether you are “really” transgender or nonbinary or even if this is “right” decision for you. We are not gatekeepers towards medical care for transgender and nonbinary people.
What we are assessing for is informed consent. Informed consent means two things: one that you have the capacity to consent, and that you are informed about the decision that you are making. To that end, we are going to ask questions about your knowledge of:
- The procedure specific to your surgeon
- How to prepare for surgery
- What you know about aftercare
- Whether you have adequate support
- Risks and how they can be managed
- Minimizing infection risk
- Impact on reproduction (if applicable)
You don’t need to be an expert on the surgery, but we want to make sure that you have as best a surgical experience you can have. Knowing what to expect and having realistic expectations can make a big difference! For most people, all this information can be gathered within one appointment.
For some folks that may have complex medical or mental health histories, we may recommend a few sessions in order to help you prepare for the procedure. Our goal is to be able to write an honest letter that someone is informed and ready; if you aren’t, we are happy to help you there!
Cost
If you are a patient of Out Couch Psychoanalytic Psychotherapy, you can get your letter through your clinician for no additional charge. If you are being seen by an associate, you may need to meet with another member of our team if a licensed provider is required.
If you would like to begin therapy services and also want a letter, please mention that in your inquiry form. There is no additional charge for the letter.
If you are not a patient and do not want ongoing therapy, please mention that in your inquiry form. The letter writing service available is “pay what you can (based on income)” to help support your clinician’s livelihood while making this service as accessible as possible. Our recommendation is:
- $150 for those making over 100k
- $100 for those making over 80k
- $75 for those making over 60k
- $50 for those making over 40k
- Free for those making under 40k
We will not turn away clients for lack of funds for letters. If you are able to pay more, this allows us to provide more free and low-cost services to other transgender and non-binary people.
Timeline
Most of our clinicians have availability within 1-2 weeks of an inquiry for an assessment appointment. If the relevant WPATH SOC 8 criteria are met, then a draft of the letter will be sent within 3 business days.
Non-California Residents
Out Couch Psychoanalytic Psychotherapy can only provide services (including letters) to people located in California. The Gender Affirming Letter Access Project is a nationwide directory of transgender affirmative providers who offer assessments and letters at no charge. We cannot attest to the skills or expertise of anyone on the GALAP directory. Please do your due diligence in finding a provider to ensure quality care.
