The Mental Health Provider’s Role in Gender-Affirming Medical Care: The Trouble with Templates

As someone who provides mental health services to transgender and gender nonconforming clients, letter-writing in support of accessing gender-affirming medical services is a service I provide on a regular basis. However, I hesitate to simply call it letter-writing; competent gender therapists understand that the letter is really documentation of a conversation and process that requires clinical skill and cultural responsivity on the part of the clinician.

a person-shaped cookie cutter with a red slash across it

On at least a weekly basis, I encounter another mental health provider asking for a “template” of a letter to be used in support of a transgender or gender nonconforming person’s surgery, hormones, or other medical intervention. Sometimes this is request that is directed at me as a more experienced clinician or gender therapist. Oftentimes I see these requests on professional network listservs. I hope that in my sharing this may help others to understand why asking for these templates instead of seeking professional training and consultation does not support a true learning process and may lead clients to receive inadequate care.

Transgender and gender nonconforming people should have access to medical interventions that will help them live happily and wholly in their bodies and their lives. Clinical experience, research, and personal experience have shown me that transgender and gender nonconforming people who are supported in their affirmed (i.e., self-identified) gender have increased physical, emotional, and psychological wellbeing. Transgender and gender nonconforming people should also have access to information, education, and guidance from health care providers so that they feel empowered and supported in navigating interactions with medical providers and systems.

I have a complicated relationship to being in the role of providing letters for clients, and I have long advocated for more agency and sovereignty for trans people concerning their bodies and lives. I believe in building the capacity of providers to provide affirming care to transgender and gender nonconforming people and minimizing/avoiding harm, and for this reason I have devoted years of work to training and education of other health care professionals. The simple sharing of templates cannot provide this training and often reduces transgender people and their health needs to a cookie-cutter experience.

A skilled and experienced gender therapist is someone who has put time and effort into understanding the complex ways that gender identity and health care choices influence each other, as well as the ways that the medical industrial complex impacts transgender people and their choices. A template curtails the opportunity for the client and the clinician to think together about the meaning of medical interventions for each client at a specific time. Relying on another clinician’s template without learning about the skillset that is necessary to have clinically useful and respectful conversations with transgender clients can create a false sense of expertise for a clinician.

A clothing tag on a green garment saying "One size does not fit all"

Clinicians who do not have experience supporting transgender and gender nonconforming clients in navigating medical systems or choices and are not informed about different aspects of transition-related medical care may shortchange clients who deserve better. I believe there is a way to minimize gatekeeping and avoid the lengthy interrogation-like process that many trans people have had to endure while also being responsible to our clients. For example, explorations around social support are often far more useful than having the client recount all the ways that they may or may not have fit into binary gender expectations. Unskilled clinicians in the letter-writing role often overrely or overfocus on the storytelling aspect of a trans person’s experience and fail to address concrete aspects of how gender-affirming medical care may affect them or what their needs are in the here and now. In seeking training from experienced gender therapists, clinicians can learn appropriate areas of exploration and conversation and avoid asking questions that are harmful or do not center the client’s current goals.

If you are a clinician interested in advocating for your trans clients by writing letters for them, I encourage you to seek the following professional support and development:

  1. Familiarize yourself with the different models of how therapists play a role in assisting a trans client in transition-related or gender-affirming medical care. This may include understanding if and how medical providers (e.g., primary care, endocrinologists, surgeons) adhere to WPATH Standards of Care (be sure to pay attention to which version of the SOC they are using! It should be SOC 7 if they use SOC at all). Knowing about the gatekeeping role of mental health providers throughout the history of transgender health is crucial to understanding why transgender people may feel ambivalent or suspicious when seeking mental health services. My personal stance is to approach the assessment and letter-writing process as a collaboration that involves transparency.
  2. Learn how to talk about the risks and benefits associated with different transition-related medical procedures or surgeries. This includes understanding specific issues related to preparation and recovery. For example, preparation for or recovery from some surgeries require behavioral changes (time-limited or continuous) that may impact a person’s health or wellbeing, such as having to adjust hormones, undergo hair removal, or go through extensive physical therapy to adjust to changes. A couple helpful resources to support clinicians in deepening their knowledge base in this regard are the UCSF Transgender Health Learning Center and The Fenway Institute’s TransTalks series.
  3. Stay up-to-date. Take responsibility for keeping current with recent updates in transgender health, including availability of procedures, surgical techniques, and medical coverage. Understand that transgender health is a rapidly changing landscape, and what was true even a year ago may no longer be relevant.
  4. Learn about different medical systems’ definitions of “medical necessity” and how a diagnosis of gender dysphoria may or may not be in line with every transgender person’s experience. Whether you agree or disagree with the current medical model of access to care for gender-affirming health care, it is important that you seek to understand and help your clients understand how it affects them.
  5. Seek professional consultation from an experienced gender therapist or specialist. This can be enriching and allow you to be in a learning experience rather than enact a cookie-cutter approach. With this professional support, you will better understand how your role far exceeds simply writing a letter.
  6. Build community. Consultation groups with other professionals who do work related to transgender health are a great way to acquire more knowledge and skill in community and share resources. Our clients shouldn’t be isolated, and neither should we. When we stay in community and contact with others, we can stay current in a continually evolving field.
  7. Learn about the history of transgender health care, globally and within the U.S. Learn about the history of university gender clinics and the ways that forced/singular medicalized narratives systematically exclude poor people, nonbinary people, and people of color.
  8. Support leadership efforts from transgender communities. While it is important to stay current with how providers are practicing, it is equally, if not more important, to listen to what trans people are saying about themselves, the medical care they need, the kind of access they need, and what kind of support they would like from mental health providers.

These recommendations are in line with recommendations I would make for clinicians or providers with any area of expertise or skill: Seek training and consultation. Refrain from providing services outside your scope. Invest deeply in the process of building your knowledge, awareness, and skills so that you can provide the best possible care to your clients.