If you are a clinician who writes letters in support of HRT therapy, what do you need to consider prior to writing it? For the record, I am referring a trans client out to a reputable clinician who is known for providing gender-affirming care... but the curious/student in me is wondering how one goes about evaluating readiness for this. What if the patient has severe mood issues and SI (thinking of the patient who came to me for the initial session)? Can the clinician still write the letter? I am hoping to spend the next year or so learning as much as possible/seekin consultation, and am hopeful that i can one day treat this population.
This is a much-needed service that very few trained psychologists offer (perhaps because it’s a medical recommendation based on a mental health evaluation?).
Seek training and consultation. I would strongly discourage ANY therapist from doing letters without additional training, memorizing WPATH standards and extensive self-education, and consultation (some clinicians agree to write letters for the money having no idea about the areas they need to be educated in to assess readiness, which is practicing way outside of competence).
I attended a training in this awhile back but knew I needed further consultation given all of the factors one needs to weigh (need to consult with doctors and/or seek collateral info, need to assess several domains like social supports, education level on the medical aspects of transition, comorbity, pervasiveness and length of gender dysphoria diagnosis, psychosocial/mental health history, etc.). I had planned to consult further but stopped there due to the time commitment needed for further training.
Most folks I know take about 2-3 sessions to provide this type evaluation, if they’re sought out specifically for a letter. If this is an ongoing client, a clinician has more client information to draw from in this process and can advocate for their client with close consultation and education.
In my area, evaluation for surgery/hormones is a closely-guarded skill. I had to search for several months before I could find anyone who offered consultation for this, and some charge “package” rates of thousands of dollars to train clinicians. Personally I don’t agree with this because I’m more on the advocacy side; trans folks in my area tend to not have a lot of financial means (and they need multiple letters from different clinicians for surgery), so to greatly restrict the number of clinicians offering letters by charging exorbitant consultation fees and not providing group-based trainings is a bit frustrating. I should also mention I’m in the most sought-out area in the country for gender-affirming care and yet it was difficult to figure out where to go for consultation for this and find out what kinds of education were needed to offer evaluations.
As to your question about comorbidity and/or SI and readiness, this is complicated. It depends on the diagnoses/symptoms and (partially) whether they are indirectly related to gender dysphoria (i.e. depression rather than a psychotic disorder), but they can be unrelated diagnoses and one can still move forward; it just depends, and is assessed on a case-by-case basis. I would also add that assessing coping skills, social & financial supports, and stability is hugely important when considering diagnoses. The research out there on transition says that for the small number of folks with transition regret (estimated to be around 2% depending on the study, although some likely goes unreported), comorbidity is a risk factor in regret (as are surgical complications, family rejection, poor social outcomes, etc.). However, hormones are just the first step in that process and they are not as permanent as surgery.
Whomever you referred the person to is a good place to start for your own consultation.
EDIT: I would add that for liability purposes, clinicians also need to make it very clear when they offer this service that an evaluation doesn’t guarantee a strong recommendation in support of HRT or surgery; clients are paying for the service of the evaluation, not the letter outcome. Some write letters that conditionally support hormones or surgery with X supports in place, after a certain period of stability, etc.
