Professional Psychology: Research and

Practice
Blessing or BS? The Therapy Experiences of Transgender
and Gender Nonconforming Clients Obtaining Referral
Letters for Gender Affirming Medical Treatment
Holly M. Brown, Sharon Scales Rostosky, Robert J. Reese, Christopher J. Gunderson, Cheryl Kwok,
and Todd Ryser-Oatman
Online First Publication, October 17, 2019. http://dx.doi.org/10.1037/pro0000274

CITATION
Brown, H. M., Rostosky, S. S., Reese, R. J., Gunderson, C. J., Kwok, C., & Ryser-Oatman, T. (2019,
October 17). Blessing or BS? The Therapy Experiences of Transgender and Gender
Nonconforming Clients Obtaining Referral Letters for Gender Affirming Medical Treatment.
Professional Psychology: Research and Practice. Advance online publication.
http://dx.doi.org/10.1037/pro0000274
 Professional Psychology: Research and Practice
© 2019 American Psychological Association 2019, Vol. 1, No. 999, 000
ISSN: 0735-7028 http://dx.doi.org/10.1037/pro0000274

Blessing or BS? The Therapy Experiences of Transgender and Gender

Nonconforming Clients Obtaining Referral Letters for Gender Affirming
Medical Treatment
Holly M. Brown, Sharon Scales Rostosky, Robert J. Reese, Christopher J. Gunderson, Cheryl Kwok,
and Todd Ryser-Oatman
University of Kentucky
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Many transgender and gender nonconforming (TGNC) clients seek to obtain referral letters for gender
This document is copyrighted by the American Psychological Association or one of its allied publishers.

affirming medical treatment from their mental health providers, but little is known about how the process of
obtaining referral letters impacts TGNC clients’ therapy experiences. We conducted semistructured interviews
with 15 TGNC individuals who obtained a referral letter for gender affirming medical intervention from their
therapists. Thematic analysis revealed 2 core themes: (a) “bullshⴱt” (or “BS”) participants endured due to the
referral letter requirement and (b) “blessings” that TGNC individuals experienced because of this requirement.
Participants revealed that they had better therapy experiences when their therapists actively affirmed their
gender and choices related to transition, acted to facilitate transition, provided knowledge and resources to help
them navigate transition, and collaborated with them to determine the focus of therapy. Recommendations for
training, practice, and future research are provided.

Public Significance Statement

Transgender and gender nonconforming (TGNC) therapy clients identified both positive and negative
experiences related to obtaining referral letters for gender affirming medical treatment. Clients who
experienced the letter process negatively noted lost time and money, felt stigma, and sensed added strain
in their therapeutic relationships. On the other hand, clients benefited when their therapists helped them
navigate the transition process by supporting and affirming their identities and autonomy.

Keywords: TGNC, transgender, gender affirming health care, referral letter, gender affirming therapy

Supplemental materials: http://dx.doi.org/10.1037/pro0000274.supp

CHERYL KWOK completed her BA in psychology from the University of

X HOLLY M. BROWN received her PhD in counseling psychology from
the University of Kentucky. She is currently a postdoctoral fellow at
Compass Counseling and Psychology Services in Louisville, Kentucky.
Her professional interests include affirming therapy for LGBTQ clients,
trauma work, couples treatment, and psychotherapy process and outcomes.
X SHARON SCALES ROSTOSKY received her PhD in counseling psychol-
ogy from the University of Tennessee, Knoxville. She is professor of
counseling psychology at the University of Kentucky and a licensed
psychologist. Her research focuses broadly on LGBTQ health and well-
being with an emphasis on same-sex couples and their families.
ROBERT J. REESE received his PhD in counseling psychology from Texas
A&M University. He is currently a professor in the Department of Edu-
cational, School, and Counseling Psychology at the University of Ken-
tucky. His areas of professional interest include psychotherapy process and
outcome and telepsychology.
X CHRISTOPHER J. GUNDERSON (Chrys) received their MS in counseling
psychology from the University of Kentucky. They are currently working
outside the field and figuring out future education possibilities. Their areas
of professional interest include barriers to transition (social, legal, and
medical) for transgender and gender nonconforming individuals as well as
psychological changes in sexual arousal of transgender and gender non-
conforming individuals starting hormone replacement therapy.
Delhi in 2014 and her MA in applied psychology with specialization in
counseling psychology from Tata Institute of Social Sciences, Mumbai in
2016. She is currently a fourth-year doctoral candidate in counseling
psychology at the University of Kentucky. Her clinical experiences include
working with LGBTQⴱ individuals, students, couples, families, veterans,
older adults, and individuals with substance use disorders. Broadly, her
research interests focus on diversity and the influence of intersecting
identities on lived experiences, minority identities within the LGBTQⴱ
community, and social justice advocacy.
TODD RYSER-OATMAN received his MA in counseling psychology from
the University of Kentucky. He is currently a counseling psychology
doctoral candidate at the University of Kentucky. His areas of professional
interest include the well-being of sexual minority individuals, specifically
focusing on sexual minority men’s help-seeking for intimate partner vio-
lence.
THANK YOU TO the University of Kentucky Office of LGBTQ Resources,
which provided $1,000 in grant funding for this study. We owe additional
thanks to Holly M. Brown’s dissertation committee, members of the TGNC
community who offered their time and perspectives to provide consultation
for this study, and our research participants.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to
Holly M. Brown, P.O. Box 4037 Louisville, KY 40204. E-mail: holly
.michelle.brown@gmail.com

1
 2 BROWN ET AL.
Most transgender and gender nonconforming (TGNC) individ-
uals have either been in therapy or plan to engage in therapy (Grant
et al., 2011; James et al., 2016). However, therapists are under-
prepared to work with this population (Holt et al., 2019; O’Hara,
Dispenza, Brack, & Blood, 2013), and we know little about the
experiences of TGNC clients in therapy or the relationships ther-
apists build with their TGNC clients (Benson, 2013; Bess & Stabb,
2009; Elder, 2016). Further, few guidelines exist on services
specific to TGNC clients, such as providing letters for gender
affirming medical treatment (Budge, 2015; Coleman et al., 2012).
Gender affirming medical interventions are treatments or pro-
cedures that some TGNC individuals undergo to help them achieve
a gender expression that better matches their gender identity (Cole-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
man et al., 2012). Health care providers who offer gender affirm-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ing medical interventions to TGNC clients, such as hormone
replacement therapy (HRT) and gender affirming surgeries, often
require their patients to supply referral letters from mental health
professionals before agreeing to offer services. These letters are
used to confirm that TGNC individuals seeking gender affirming
medical treatments meet criteria for gender dysphoria, are prepared
for medical aspects of their transition, are aware of the potential
risks and side effects of gender affirming medical interventions
(Budge, 2015; Coleman et al., 2012), and are unlikely to regret
their decision to have surgery (Benson, 2013; Bess & Stabb, 2009).
Some professional organizations have created guidelines that offer
advice on what to include in referral letters, such as the World
Professional Association for Transgender Health (WPATH)’s Stan-
dards of Care (SOC) version 7 (Coleman et al., 2012). The latest
version of the SOC recommends TGNC individuals obtain referral
letters before accessing gender affirming surgeries and suggests that
medical providers with some behavioral health training determine
whether TGNC patients are appropriate for HRT. The current SOC
avoids mandating psychotherapy for TGNC individuals seeking gen-
der affirming medical treatment, instead recommending mental health
professionals assess TGNC individuals’ gender identity and dyspho-
ria, history of gender dysphoria, how stigma of gender nonconformity
impacts their mental health, and their available social support. How-
ever, medical providers and insurance companies ultimately set re-
quirements for what letters their TGNC patients must provide to
access gender affirming treatment. Additionally, therapists who pro-
vide referral letters to TGNC clients are left to their own discretion on
whether and when they will provide clients with referral letters
(Budge, 2015; Coleman et al., 2012).
Many TGNC individuals have called for a transgender health
care system in which TGNC individuals are allowed to self-refer
for gender affirming treatment (Bess & Stabb, 2009; Denny,
1992). This informed consent model of treatment (Cavanaugh,
Hopwood, & Lambert, 2016) contrasts with the gatekeeping model
of treatment in which TGNC people must obtain referral letters
from mental health professionals before accessing certain treat-
ments (Budge, 2015; Cavanaugh et al., 2016). Some scholars have
argued that TGNC individuals benefit from the current gatekeep-
ing system because it encourages them to process their transition
experiences with a mental health professional and ensures that they
receive information about the risks associated with their transition
(Bess & Stabb, 2009; Coleman et al., 2012). Proponents of the
current gatekeeping system also argue that it protects physicians
and mental health professionals from lawsuits from inadequately
informed or prepared patients who might regret their gender af-
firming treatment (Bess & Stabb, 2009). Therapists also arguably
benefit, as needing a referral letter for medical interventions may
motivate TGNC individuals to seek therapeutic services (Budge,
2015).
Although many therapists and researchers support the current
referral system, others argue that it may have potential harms.
These harms are likely to impact the most vulnerable stakeholders:
TGNC individuals in need of gender affirming medical interven-
tions. Adding this component to the therapist role may shift power
dynamics in therapeutic relationships between TGNC clients and
their mental health providers and negatively affect the experiences
that TGNC clients have in therapy (Budge, 2015).
Requiring therapists’ approval before TGNC clients can access
gender affirming medical care invalidates and pathologizes TGNC
identities by implying that TGNC people are not capable of self-
determining what gender affirming medical treatments are appro-
priate for them. Several studies cast doubt on the effectiveness of
graduate training programs for preparing therapists to competently
work with TGNC clients, much less act as fair and unbiased
gatekeepers to gender affirming health care (Austin, Craig, &
McInroy, 2016; Holt et al., 2019; O’Hara et al., 2013). Further, the
subjectivity of the gatekeeping system has historically contributed
to exploitation and mistreatment of TGNC individuals (Denny,
1992; Elder, 2016). TGNC individuals perceive that some health
care professionals have based referral decisions on cisnormative
beauty standards and other discriminatory beliefs (Denny, 1992;
Elder, 2016). Accounts of early gender affirming medical treat-
ment in the United States during the late 1960s and early 1970s
even include examples of providers who used their own level of
sexual interest in potential patients to determine who was eligible
for services (Denny, 1992).
Because of the exploitation that can and has occurred in the
referral process, and the unpreparedness of many therapists to
work with TGNC clients, many TGNC individuals report distrust
toward the field of psychology and skepticism about therapy’s
usefulness for them (Bess & Stabb, 2009; Cavanaugh et al., 2016;
Denny, 1992). Conversely, some scholars suspect that TGNC
individuals shift narratives about their experiences to present
themselves as good candidates for gender affirming treatment
(Bess & Stabb, 2009; Cavanaugh et al., 2016; Denny, 1992).
Consequently, the gatekeeping function of therapy with TGNC
clients seeking referral letters for gender affirming medical treat-
ment may undermine the therapeutic alliance, a significant predic-
tor of client outcomes in psychotherapy (Horvath, 2001).
Only a small number of studies have gathered information about
how TGNC clients perceive their experiences of obtaining referral
letters, but this information has all been in the broader context of
their general therapy experiences. All of these studies have been
based on qualitative interviews, with the exception of Austin and
Goodman’s (2018) survey on transgender individuals’ perceptions
of gender affirming health care finding that 25% of participants
accessed therapy to obtain referral letters, 26% of participants had
difficulty finding a therapist knowledgeable on transgender issues,
and 19% of participants reported difficulty accessing a trans-
affirming therapist (Austin & Goodman, 2018). Some participants
in Elder’s (2016) study of older transgender individuals’ therapy
experiences perceived that therapy was helpful partially because
their providers wrote referral letters giving them access to HRT,
while some participants expressed frustration about working with
 TGNC LETTER EXPERIENCES
therapists who were hesitant or declined to provide referral letters.
Although many of Bess and Stabb’s (2009) participants in a study
on therapeutic alliance and client satisfaction felt supported by
their therapist in their choices to medically transition, some par-
ticipants believed their therapists were biased in their decisions
about which clients they recommended for gender affirming med-
ical treatment. In a study on positive experiences among Canadian
transgender individuals accessing health care, transgender peo-
ple, their friends/family, and mental health providers noted the
importance of allowing transgender individuals to take charge
of their transition and offering support, including referral letters,
along the way (Ross, Law, & Bell, 2016). In a study on barriers to
health care for transgender individuals, some participants consid-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
ered obtaining referral letters to be a barrier to gender affirming
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medical treatment (Puckett, Cleary, Rossman, Mustanski, & New-
comb, 2018). Another study on TGNC therapy clients’ experiences
with therapist missteps identified therapists’ excessive focus on
their gatekeeping role as a barrier to trans-affirming therapy (Miz-
ock & Lundquist, 2016). As these studies demonstrate, existing
data on TGNC therapy clients’ experiences of gatekeeping are
only briefly mentioned in the broader context of TGNC individu-
als’ overall experiences in therapy. The existing empirical litera-
ture does not specifically address how the referral letter process
affects the therapeutic relationship and impacts TGNC individuals’
experiences of therapy.
Currently, there is little empirical justification for recommenda-
tions in the SOC that create the current gatekeeping system for
gender affirming medical care (Coleman et al., 2012). Existing
guidelines on when and how TGNC people can access gender
affirming care seem to be based more on tradition and stereotypes
held by health care professionals, rather than on the expressed
perspectives and needs of the population these guidelines are
intended to protect. Little systematic research effort has been
directed to considering whether gatekeeping is a useful safeguard
or simply a barrier to treatment. We could locate no published
studies of the lived experiences of TGNC clients who have sought
letters from their therapists for gender affirming medical interven-
tions. Therefore, the purpose of this study was to address this
research question: How does the referral letter requirement impact
TGNC individuals’ therapy experiences and overall transition pro-
cesses? We used qualitative methodology based on a grounded
theory approach (Charmaz, 2006, 2014) to address this research
question. Grounded theory allows for exploration of an area with
little existing research, can be used to inductively generate theory
based on participant perspectives and experiences, and facilitates a
collaborative research approach consistent with ethical guidelines
for conducting research with TGNC people (American Psycholog-
ical Association, 2015).
Method
Participants
Fifteen self-identified transgender and gender nonconforming
individuals participated in this study. Female-affirmed individuals
accounted for 46.67% of the sample (n ⫽ 7), male-affirmed
individuals accounted for 40% (n ⫽ 6), and nonbinary individuals
accounted for 13.33% (n ⫽ 2). Most participants reported begin-
ning therapy with their letter-writing therapist at least in part
3
because they hoped to obtain a referral letter (n ⫽ 13), while two
participants reported seeking therapy to address transition-related
concerns but not specifically to pursue referral letters. Eight par-
ticipants identified as White, three participants identified as Black
or African American, and three participants identified as multira-
cial. Participant ages ranged from 19 –53. Two participants were
currently in graduate programs, two had associate degrees, nine
had completed some college, and two had GEDs. Twelve partic-
ipants lived in urban areas and three lived in rural areas. Additional
demographics are provided in Table 1.
Procedures
Interview protocol development. The interview protocol
was initially drafted based on a literature review of TGNC therapy
experiences and input from members of the TGNC community.
Members of the TGNC community provided invaluable informa-
tion and feedback on the content of the protocol drawing on their
own therapy experiences and other lived experiences (Vincent,
2018). Feedback on the interview protocol’s content, phrasing, and
length led to multiple revisions. The protocol was also refined
based on feedback from the first author’s dissertation committee,
which included the second and third authors. The protocol was
pilot tested with two volunteers from the TGNC community who
met most of the study criteria. Pilot interviews were recorded, and
afterward volunteers offered feedback related to the wording of
questions, length of the interview, and the interview process.
Following pilot interviews, we rephrased questions to improve
protocol clarity about what transition steps participants had taken
and why participants considered transition important. Pilot inter-
viewees also provided feedback about interview pacing and effec-
tiveness of follow-up questions that was incorporated into the
interview process. The final interview protocol is available online
as online supplementary material.
Recruitment and data collection. Prospective participants
were recruited from regional and national LGBTQ⫹ (lesbian, gay,
bisexual, transgender, queer) and TGNC-specific listservs and
social media outlets. Participants were also asked to refer other
individuals who might be eligible for the study. Eligible partici-
pants were 18 or older, identified as TGNC individuals, had prior
therapy experience, had obtained a referral letter for transition-
related medical services from a mental health professional, and had
seen the mental health professional who wrote their letter for therapy
within the past year. Approximately 80 individuals emailed to ex-
press interest in participating in the study. The first wave of
participants were the first eligible individuals to express interest in
the study, and the second wave of participants were selected to add
additional perspectives to the sample, with a focus on nonbinary
individuals and people of color. All interviews were conducted by
the first author, a cisgender, bisexual woman. Before the interview,
participants were given information about the study and had an
opportunity to ask questions. Verbal informed consent was ob-
tained by the interviewer before participants began the formal
interview. All interviews were conducted over telephone, audio
recorded, and later transcribed by the first author. Interviews were
conducted between July 2017 and November 2017, and each
interview lasted between one and two hours depending on the level
of detail participants shared. To protect their privacy, participants’
names were changed in their transcripts and all subsequent writ-
 4 BROWN ET AL.

ings about them. Participants had the option of choosing their own

Both cisgender women

Transgender woman
Therapist gender pseudonym. After the interview, participants received $50 to com-
Cisgender woman

Cisgender woman
Cisgender woman

woman
woman
woman
woman

woman
woman

Cisgender woman
Cisgender woman
pensate for their time. Participants had an opportunity to review

man
man
their transcript for accuracy. Two participants responded after

Cisgender
Cisgender
Cisgender
Cisgender
Cisgender
Cisgender
Cisgender
Cisgender
receiving their transcript, and neither of them reported any inac-
curacies or requested changes.
Data analysis. Our data analysis team included a cisgender,
bisexual woman (first author); an agender transfeminine pansexual
person (fourth author); a cisgender heterosexual woman (fifth

therapist 2: late 50s

Therapist 1: 30s–40s;
author); and a cisgender gay man (sixth author). These team

Late 40s to mid 50s

Therapist age

members used a grounded theory approach, an inductive qualita-

45–55

32–33
28–30
Early–mid 50s

Early–mid 60s
tive approach that privileges the lived experience of key infor-
40s
33

40
40

60
33

mants (Charmaz, 2006; Glaser & Strauss, 1967). Initial line-by-

Mid 40s

Mid 40s
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line coding of the first 12 interviews began while data collection

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was ongoing. Initial coding was followed by focused coding of all

15 interviews. The team met multiple times to review coding
procedures and discuss emerging themes during the data analysis
State

WA
MN

MA
NY

KY

NY
KY

KY
CO

CA

NC
NC

process. Throughout the analysis process, the coding team revised

TX

MI

MI
the generated categories list and its organization using the constant
comparative method. This involved comparing data to data, data to
Lesbian (attracted to women

codes, codes to categories, and back again (Charmaz, 2014).

and nonbinary people)
Sexual orientation

During the first focused coding meeting, the coding team deter-
mined that no new codes were emerging from the final set of
interviews and that saturation had been achieved. Two faculty
advisors, a cisgender bisexual woman (second author) and cisgen-
Heterosexual

Heterosexual
Pansexual

der heterosexual man (third author), provided feedback on each

Bisexual

Bisexual
Lesbian

Lesbian

Straight

Lesbian

stage of the coding process and collaborated on theoretical sorting,

Queer

Queer

Queer

Queer
None

involving further examining the links between categories and

reorganizing categories to create a clearer and more parsimonious
representation of the data (Charmaz, 2014). Member checking
Age

33

23
19
49

22
55
49
53
34
20
19
25

41
26

27

helped verify the trustworthiness of the findings that were emerg-

ing. Research participants were invited to review initial categories
Multiracial (self-identified

and provide feedback. Two participants responded, affirming that

Multiracial (South Asian
as Black in interview)
Multiracial (Polynesian

the categories were consistent with their own experiences.

Race/Ethnicity

African American
African American

Results
and White)

and White)

Two broad themes emerged from participants’ lived experiences

White

White
White

White
White
White
White

White

White

with the referral letter process. Some participants described the

Black

requirement of obtaining a referral letter as “BS,” or an infringe-

ment on their autonomy that reduced the benefit they received
from therapy that ultimately made transition more challenging to
They/them
They/them
Pronouns

access. Other participants described the letter as a “blessing” in

She/her

She/her
She/her
She/her

She/her

She/her
She/her
He/him

He/him
He/him
He/him

He/him
Ze/hir

disguise that ultimately resulted in a beneficial therapeutic expe-

rience and access to support during their transition process. These
themes and subcategories are described below. Participants’ expe-
Trans-masculine nonbinary

riences and perspectives are illustrated with quotes transcribed

Gender nonconforming,

directly from their interviews. Quotes are presented verbatim ex-

Demigirl/trans woman
Transgender female

Transgender female

cept for minor changes to promote flow or to protect confidenti-

Transgender MTF
trans-masculine
Gender

Transgender man

ality. Additions are represented by brackets ([]) and signal any

Participant Demographics

modification to participants’ transcripts, while ellipses (. . .) note

Trans male

Trans man

Trans man

any omission of words or phrases to improve the flow and brevity

Female

Female
Female

of quotes. Following quotes, participants’ pseudonyms and pro-

Male
FTM

nouns are provided.

Pseudonym

BS
Sebastian
Cameron

Victoria

Vincent
Table 1

Moore
Karen
Bryce

Space
Stella
Mary

Trish
Alex

Gina

“For someone such as myself, who is an adult, who knows the

Jim

Liz

consequences, and doesn’t have any other issues, I think it’s

 TGNC LETTER EXPERIENCES
absolutely asinine . . . Asinine, ridiculous, bullshit. I’ll let you fill
in the blanks there” (Mary, she/her). Most participants (n ⫽ 13)
described ways in which they were negatively impacted by the
referral letter requirement. Three participants (20%) specifically
described the referral letter requirement as BS. Participants per-
ceived that they were subjected to negative interactions in the
process of seeking a letter that undermined their trust in the
therapeutic relationship, reduced the benefits they experienced
from therapy, added to their oppressive experiences, and interfered
with their transition process.
Negatively impacted therapeutic alliance. Forty percent of
participants (n ⫽ 6) shared ways in which the letter requirement
negatively impacted their relationship with their therapist. One
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third of the participants (n ⫽ 5) in this sample worried that their
This document is copyrighted by the American Psychological Association or one of its allied publishers.
therapist might reject their request for a referral letter. This fear
caused participants distress and created challenges as participants
worked to build trusting, open relationships with their therapists.
It scared me to ask her for something, in that she could say no. And
I built my trust with this person. This person knows all about my
deepest darkest secrets. And to possibly face rejection from her made
me afraid to ever see her again. Because how can I go back to this
therapist who would deny me something that’s life saving? I prepared
myself for the worst. I’ve read all the stories, I’ve talked to people
whose therapist had said no, you’re too unstable. How can I continue
that relationship? It’s such a strange power dynamic that, frankly, is
unethical. (Vincent, he/him)
Similarly, 20% of participants (n ⫽ 3) felt that their need for a
referral letter increased the amount of power their therapist had in
the therapeutic relationship. This increased power differential cre-
ated a barrier to establishing a strong and collaborative therapeutic
alliance, regardless of whether the therapist assumed a gatekeeping
role or not. One participant perceived that her therapist required a
lengthy letter writing process to avoid legal liability in case she
later regretted her decision to transition. This participant expressed
frustration, perceiving her therapist’s decision to delay writing her
letter as self-serving rather than client-serving.
If she had given me the letter in the first session and something went
wrong, for lack of a better expression, then she’d be opening up
herself to liability, versus waiting three to six months, giving the
letter, saying well I know I can document I did this, I did this, I did
this, I did this. And that’s why. So it gives them more time to
document and to protect themselves in the event that treatment hits the
air conditioner. Because, yes, they’ve got to protect their own liveli-
hood just like we want to protect our own. . . . That leaves all the
clients on the short end of the stick. But that’s a legal thing versus an
actual treatment thing. And it’s sad when legal matters interfere with
real treatment matters. (Liz, she/her)
Reduced benefits of therapy. One third of participants (n ⫽
5) thought the referral letter requirement reduced the benefits they
received from therapy and forced them to see their therapists as
possible obstacles to their goals rather than supportive facilitators.
Two participants shared that therapy was not a beneficial experi-
ence for them and expressed frustration about having to attend
therapy due to the letter requirement. Some participants (n ⫽ 3)
felt pressure to minimize their stress and struggles when working
with their letter-writing therapist because they feared that being
5
open and honest might cause their therapist to decide they were not
mentally stable enough for gender affirming medical treatment.
In some ways [needing the letter] made me a little bit reluctant to talk
about some things because I thought it might affect not getting it. . .
. If they ask how does this make you feel, how does that make you
feel, you wanna make it sound like you were less affected than you
were about various things. Because you’re like wait a minute, that put
them over here, going away from the letter instead of going toward it.
(Liz, she/her)
Two participants thought that the referral letter requirement en-
couraged TGNC people, and perhaps their therapists, to focus on
the letter rather than other important therapy goals.
Added to oppressive experiences. Two thirds of participants
(n ⫽ 10) shared ways in which the letter requirement added to the
oppression they experience in society as TGNC individuals. Four
participants experienced the letter requirement as stigmatizing,
patronizing, and alienating.
I think the main thing is it medicalizes trans identity. And makes . . .
people see being trans as more of a mental illness, because trans
people are required to go to a therapist. And I think a lot of people
already think that being trans is a mental illness, which is just
upsetting on so many different levels. . . . So I think it kind of
reinforces that in a lot of different people’s minds. (Cameron,
they/them)
Eight participants shared frustrations related to the referral letter
and how this requirement limits their personal autonomy. Partic-
ipants perceived that the referral letter process disregarded their
capacity for making decisions about their health care. Two partic-
ipants perceived that they needed to prove their gender identity to
their therapist in order to get their referral letter, which was
frustrating and demeaning. As a result of this belief, some partic-
ipants (n ⫽ 3) felt pressure to conform to stereotypes related to
their gender and worried that if they did not conform to gender
roles in expected ways it would negatively affect their ability to
obtain referral letters.
I’m pretty sure I was just like, yeah I’m a trans man, I hate everything
girly. You know what I mean. I think I probably overgeneralized
masculine stereotypes at first, and even now I feel, I feel like generally
masculine. But like a lot of people I go to the goth club with my
friends sometimes, and we’ll paint our nails and do our eyeliner
because it’s the goth club. And like, I do collect dolls. . . . I’m afraid
to share hobbies that are gender nonconforming even still, I think a
little bit. Just because I do not want it to be misread as like, oh no we
let you be a man but you’re actually not good enough at being a man
to be a man. Which I think is a little bit how it seems sometimes. Not
necessarily particularly like [my therapist] but just in general. There’s
this sense that we can only let you be a valid masculine person if you
promise not to be like, you know, not a good enough one. (Jim,
he/him)
Created barriers to transition. Two thirds of participants
(n ⫽ 10) felt that their transition process was slowed down or
made more difficult due to the referral letter requirement. Three
participants (n ⫽ 3) expressed frustration that the letter was yet
another requirement they had to fulfill to access transition. As
Mary (she/her) stated, “It really irks the hell out of me that we have
to jump through hoops to get surgery when we’re adults.” Five
participants had to wait to obtain a referral letter. In some cases,
 6 BROWN ET AL.
these participants’ therapists were willing to write a letter but
invoked a gatekeeper role, requiring participants to attend more
therapy sessions first. In other cases, participants waited to ask
their therapists for a letter because they expected their therapist
would want to see them for several sessions first or because they
worried their therapist would refuse to provide a letter if they
asked about it too soon or too often. Four participants had to wait
weeks for their letter even after their therapist agreed to write one.
Two participants shared that they were denied letters by past
therapists, which required them to find new therapists and start the
process over. Participants whose therapists denied or delayed their
letter noted that these experiences added unnecessary barriers to
their transition processes. Eight participants discussed ways in
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
which the referral letter requirement made transition more difficult
This document is copyrighted by the American Psychological Association or one of its allied publishers.
because of the challenges of finding and accessing affirming
therapists and the burden on financial resources, time, and energy
to attend therapy.
Like a consultation to talk and be like, hey, I’m [Sebastian], I’m trans,
it’s like a hundred bucks anywhere you go. . . . Most places you have
to have a therapy letter, proof that you’re seeing a therapist for a
driver’s license or a passport or even a surgery in some states, you
have to have proof from a therapist . . . I just wish it was not, trans
people have to pay for so much as it is. To change in surgery and ID,
paperwork, documents, lawyers, court—it’s just so much money as it
is. . . [Therapy] costs money and then you kind of lose money cause
it’s taking time out of your day and your week that you could be
working to get money to pay for those surgeries. (Sebastian, he/him)
Blessings
“It was really a blessing in disguise. . . . I don’t think I would
be the quality of person that I am today if I hadn’t been required
to get my letters” (Karen, she/her). Fourteen participants identified
ways they benefitted from the process of obtaining referral letters.
Blessings included connecting with a supportive therapist, affirm-
ing their gender identity, and propelling their transition forward.
Connecting with a supportive therapist. Thirteen partici-
pants felt that the letter requirement motivated them to connect
with a therapist and ultimately to receive the benefits of engaging
in therapy. Two participants shared experiences of working with
therapists who valued their autonomy and explicitly supported
participants’ pursuit of gender affirming medical treatment. These
participants reported this support positively impacted their rela-
tionship with their therapist.
[The letter] was something that was always on the table. I think she
just wanted to know that I was mentally ready and less like convince
her that I’m so trans. She didn’t need anything like that, she was just,
are you here for this? Are you ready for this? And I think that was
really helpful because it was respectful to me and my gender to not be
like gatekeepy or anything like that. She was very much like, “I want
to make sure that you’re ok. And that you’re ready for this.” (Stella,
she/her)
Seven participants said the letter requirement led them to con-
nect with a therapist who served as a resource and advocate during
their transition process. These participants noted that their therapist
was a person they could come to when they wanted to discuss the
details of their transition. They perceived their therapist as some-
one who was knowledgeable about the transition process and the
steps participants needed to take, and someone who could provide
advocacy and emotional support during transition.
Six participants (40%) noted that seeking a referral letter gave
them the opportunity to explore their gender and transition in
therapy. The process of obtaining referral letters helped these
participants to feel certain about their decision to move forward in
pursing gender affirming medical treatment. Four participants said
they felt affirmed by their therapist as a result of receiving their
referral letter. Providing the letter was one way their therapist
communicated acceptance of their gender and support for their
decision to move forward with gender affirming medical treat-
ment. These participants felt they could present themselves au-
thentically in therapy without worrying about how it would affect
obtaining their referral letter. They also perceived that their ther-
apists were willing to provide referral letters when participants
decided it was the right time to pursue gender affirming medical
treatment. Sixty percent of participants (n ⫽ 9) reported that
receiving their letter felt like a natural step in their therapy process.
They perceived that obtaining a referral letter was smoothly inte-
grated into their larger therapy process rather than tacked on in a
distracting or disruptive way.
Affirming gender identity. Eight participants shared ways in
which completing the referral letter process and receiving their
referral letter benefitted them. Participants shared how giving their
therapist information about their gender history to include in the
letter helped them feel more confident in their gender identity.
They also experienced a sense of accomplishment once they had
obtained their letter. The letter represented an exciting, welcome,
validating, and tangible affirmation.
At the end of that process, you’re gonna feel so good about having
somebody else stamp their name on how you feel. It’s not inside you
anymore, not getting out. It’s out there in the world. Somebody
supports you. Somebody backs you up. Somebody’s got your back.
With those letters, that’s how it felt for me. The positive aspect of that
is that. . . . I can prove who I am. And that was impossible to do
otherwise. If there was a positive thing to come out of that, it’s that I
can parade that around forever and show it to the judge, show it to
anybody. It’s admissible in court. (Trish, she/her)
In sum, obtaining the letter validated participants’ choices to
pursue affirming professional service in psychosocial, medical,
and legal arenas.
Propelling transition forward. One third of participants (n ⫽
5) perceived that their referral letter process and work with their
letter-writing therapist sped up their transition. Some reported that
their therapists challenged them to take their next transition steps
and, in some cases, offered to write a referral letter before partic-
ipants felt they were ready for it.
I knew that I had no reason to say no anymore. Like I had no reason
to say this is too hard. And [my therapist] was definitely kind of the
slap in the face, quit dragging your feet, you want this, just do the
thing. And that’s when we came to the realization that I was dragging
my feet because I didn’t want to be told I couldn’t have it. Because
[my therapist] is also a fucking wizard. And once we realized that,
that’s when I was like yeah, you’ll give me that letter. She was like,
sweet. (Vincent, he/him)
This challenge and support felt affirming to these participants.
 TGNC LETTER EXPERIENCES
Discussion
Participants’ lived experiences of obtaining referral letters shed
light on how the referral letter requirement affects TGNC people’s
therapy experiences and transition processes. We interviewed 15
transgender and gender nonconforming adults and analyzed their
experiences using an approach based on grounded theory. Almost
all participants shared both ways they benefitted from the letter
requirement (n ⫽ 14), and ways the requirement negatively af-
fected them (n ⫽ 13).
Although we interviewed a diverse sample of TGNC individu-
als, this study does not represent the lived experience of all TGNC
people. Rather, the strength of qualitative interview studies such as
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
this one is the ability to understand a phenomenon and the mean-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ings that it holds for key informants. Likewise, while we worked
to include perspectives of TGNC individuals through peer consul-
tation when planning the study and through member checks on the
emergent findings, a research team of different backgrounds and
experiences may have generated other insights.
The focus of this study was the therapy experiences of TGNC
adults obtaining referral letters for gender affirming medical treat-
ment. We did not gather information on experiences of TGNC
youth obtaining referral letters. Neither did we gather information
on TGNC individuals’ experiences obtaining letters related to
social and legal aspects of transition. Finally, we did not inquire
about the larger treatment setting in which participants sought
letters, including whether participants’ therapists worked indepen-
dently or as part of larger gender affirming treatment teams.
A central finding from this study is that therapists’ behaviors
play a key role in determining how participants experience obtain-
ing referral letters for gender affirming medical treatment. Con-
sidering how therapists can serve as “gateways” or “gatekeepers”
to clients’ transitions provides a useful metaphor for conceptual-
izing affirmative work with TGNC clients who are in the process
of transition. Participants tended to describe the letter requirement
as a blessing when their therapist acted as a gateway to transition
rather than a gatekeeper. Gatekeeper behaviors that participants
experienced as oppressive barriers to their transition process in-
cluded failing to address power issues and differentials, creating an
environment where clients felt they needed to present their expe-
riences a certain way to obtain letters, and taking longer than
necessary to provide letters. Overall, participants felt that their
autonomy and competency to make their own decisions were
invalidated and disrespected. These results echo previous research
findings that therapists who emphasize their gatekeeping role may
create negative therapy experiences for their TGNC clients (Miz-
ock & Lundquist, 2016). Many participants expressed frustration
with how the referral letter requirement contributed to systemic
barriers to transition, including difficulty accessing affirming ther-
apists, a finding consistent with past research (Austin & Goodman,
2018). The letter requirement also demanded time, energy, and
financial resources and limited client autonomy.
Gateway therapist behaviors that participants felt facilitated
their transitions included affirming the client’s gender, clearly
expressing a willingness to provide letters, and supporting the
client in moving forward with transition. This finding is consistent
with previous research findings that supportive mental health
professionals can help their transgender clients access positive
health care experiences (Ross et al., 2016). Even participants who
7
disagreed with the referral letter requirement often reported posi-
tive therapy experiences when their therapist acted as a gateway to
gender affirming medical treatment. These participants appreciated
the support and affirmation their therapists provided as they nav-
igated what participants considered a flawed system. This finding
supports previous recommendations that therapists shift from roles
as gatekeepers to advocates for their TGNC clients (Singh &
Burnes, 2010).
Therapy Implications
Therapists’ efforts to act as a gateway for TGNC clients seeking
gender affirming health care may mitigate the oppressive experi-
ences TGNC clients associate with the referral letter requirement
and help TGNC clients benefit from their therapy experiences.
Gateway behaviors that emerged from this study align with and
lend some initial empirical support to recent guidelines and rec-
ommendations in the TGNC psychology literature (American Psy-
chological Association, 2015; Cavanaugh et al., 2016). Therapists
should work to create an affirming environment for clients who are
pursuing gender affirming medical treatment by trusting clients’
experiences of their genders rather than asking clients to provide
evidence for their gender identity or otherwise evaluating clients’
appropriateness for gender affirming medical treatment. Some
participants expressed appreciation for therapists who allowed
them to take the lead in their own transition, and some participants
expressed appreciation for therapists who more actively encour-
aged them to take their next transition step. Therapists working
with TGNC clients should be prepared to discuss clients’ transition
processes, supporting clients who are ready to take their next step,
and exploring available options with clients who are unsure about
moving forward. Although clients’ autonomy should always be
prioritized, TGNC clients may appreciate discussions related to
factors that hold them back from moving forward in transition.
Therapists should directly state their willingness to provide letters
early in treatment so TGNC clients’ fears about potential rejection
do not serve as a barrier to pursuing gender affirming medical
treatment. Participants in this study also noted the benefits of
working with a therapist who could provide information and
resources related to the transition process. Therapists should have
a working knowledge of how to access medical and legal aspects
of transition, as well as resources and supports for TGNC people
that are available in their local communities. Therapists are also
encouraged to take opportunities to make therapy accessible to
TGNC clients, which may include providing sliding scale services
to reduce the financial burden TGNC therapy clients face (Elder,
2016).
Therapists are encouraged to use informed consent approaches
when working with clients who are interested in pursuing gender
affirming medical treatment and to advocate that other health care
professionals and organizations transition to using informed con-
sent models rather than gatekeeping approaches to gender affirm-
ing medical care. Informed consent models of treatment allow
therapists and other health care professionals to provide the edu-
cation necessary to help clients make informed decisions about
their gender affirming health care while respecting clients’ auton-
omy and competency to make their own decisions (Cavanaugh et
al., 2016). One potential area of advocacy is encouraging WPATH
to reduce or remove letter recommendations from the next version
 8 BROWN ET AL.
of the SOC and instead to encourage providers of gender affirming
medical treatment to use informed consent models of care. These
models might require physicians to ensure their TGNC patients are
aware of risks to gender affirming medical treatment without
requiring additional assessment and referral by psychotherapists.
Although most participants in this study reported negative expe-
riences related to letters, it is important to note that not all partic-
ipants recommended that the letter requirement be removed. Any
advocacy work by therapists, particularly therapists who identify
as cisgender, should rely on clinical experience and research but
avoid presuming to speak on behalf of the TGNC community or
treating the TGNC community as a monolith.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Training Implications
This document is copyrighted by the American Psychological Association or one of its allied publishers.
These findings suggest the need to train therapists specifically in
affirmative behaviors toward TGNC clients seeking referral letters
for gender affirming medical treatment. This is especially critical
given existing research indicating that graduate programs are not
effectively training therapists to provide knowledgeable service
and support to TGNC therapy clients (Austin et al., 2016; O’Hara
et al., 2013). Graduate programs seeking to adequately train ther-
apists to provide competent services to TGNC clients should
educate trainees about gender identity, gender affirming health
care, social and legal transition steps, discriminatory experiences
faced by TGNC individuals, and factors that contribute to the
well-being of TGNC people. Training should include instruction
about existing recommendations for what to include in referral
letters for gender affirming medical treatment (Budge, 2015; Cole-
man et al., 2012), as well as information about the referral letter
requirement’s potential risks to TGNC clients and the importance
of recognizing client autonomy (Cavanaugh et al., 2016). Training
programs are encouraged to provide opportunities for therapists-
in-training to work with TGNC clients in practicum settings and to
ensure that students working with TGNC clients are receiving
adequate, trans-affirming supervision. Training programs are es-
pecially encouraged to address the history of overpathologization
of TGNC identities in health care and psychology professional
communities (Denny, 1992) and to direct trainees to attend to the
strength, resilience, and capacity for self-determination of their
TGNC clients.
Policy Implications
Existing guidelines for TGNC health care recommend that doc-
tors working with TGNC patient populations require referral let-
ters from patients seeking to access gender affirming medical
treatment (Coleman et al., 2012). Future iterations of guidelines for
providing health services to TGNC populations, such as the next
iteration of the SOC, should take into consideration the negative
effects that referral letter requirements may have on TGNC indi-
viduals and the additional barriers these recommendations create
to transition. Possible ways to address the concerns presented by
participants in this study include adding language to further clarify
that ongoing psychotherapy is not required before clients can
receive a referral letter, recommending limits on the number of
sessions a gender assessment for a referral letter should take,
reducing the number of letters required for bottom surgeries, or
removing the letter requirement altogether. Most participants in
this study perceived the letter requirement to both negatively and
positively impact their psychotherapy and transition experiences.
Multiple participants firmly stated that the letter requirement cre-
ated an unnecessary barrier to their transition, but some partici-
pants indicated that the letter requirement was helpful either be-
cause they benefitted from meeting with a mental health
professional or because they believed the gatekeeping system
prevented inappropriate use of gender affirming health care. Be-
cause the TGNC community is not monolithic, professional orga-
nizations such as WPATH should consult multiple TGNC focused
organizations and solicit input from members of the TGNC com-
munity at large when developing future iterations of the SOC or
other guidelines related to TGNC health care. Physicians and
insurance companies should also consider these factors when
establishing letter requirements for the TGNC patients they serve.
Future Research
Future research can build upon these findings. Qualitative in-
vestigations might include client and therapist dyads who have
been through the letter writing process to obtain multiple perspec-
tives on how the referral letter process affects the therapeutic
relationship and psychotherapy experience. Inquiring into the ex-
periences of TGNC individuals who have received gender affirm-
ing care through informed consent methods of treatment would
also help extend the findings of the current study to better under-
stand how this emerging approach to TGNC health care impacts
the transition processes and well-being of TGNC people. Exam-
ining relationships between gender affirming therapist behaviors
and client ratings of therapeutic outcome and alliance would
further contribute to the literature. Future studies might consider
whether TGNC individuals’ experiences obtaining referral letters
vary when their therapists practice independently or as part of an
interdisciplinary, affirming treatment team. Further research might
also consider the experiences of TGNC youth seeking letters or the
experiences of TGNC individuals seeking letters that address other
aspects of transition, such as legal name and gender marker
changes.
TGNC individuals who seek gender affirming health care de-
serve respectful and competent providers. Findings from this study
indicate that therapists who affirm their TGNC clients and support
their autonomous decisions related to transition may be able to
mitigate some of the negative effects the letter requirement has on
their clients’ therapy experiences. Based on these findings, thera-
pists who work with TGNC clients are encouraged to act as
gateways for their clients rather than gatekeepers. As gateways to
transition, therapists respect their clients’ autonomy over medical
decisions, gather and provide knowledge, and act as guides as their
clients navigate the transition process.
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Received May 27, 2019
Revision received August 19, 2019
Accepted September 13, 2019 䡲