The "Letter"

[PretzelGirl]

Last Friday, I went into my therapy and took over the discussion from the beginning. I went over my progress over the last year and a half (not all therapy). I then looked at my therapist and asked what he was willing to diagnose at this point and that I was ready to move on to HRT and asked if he was ready to support it. He said the diagnosis was Gender Dysphoria and that he was ready to approve HRT.

After a talk about everything related to the diagnosis and what he saw in me, he said he needed more history for the letter. There was enough that we had another appointment this week to finish that talk. Of course a lot of his questions would go off on discussions exploring underlying thoughts. So due to him going on vacation and then me going on vacation, I will get it on April 11th, my next appointment.

But the process has left me with a curiosity. I know I like to compare my experiences to others and I think consistency gives us a level of comfort. I have heard others say they asked for a letter and walked out with it that day which has put my frame of mind in the place where I always envisioned it as a form letter. My therapist stated he is going off for a few hours to write mine.

I don't recall anyone talking content, so I am curious what everyone else's experience is here. My therapist (a psychologist) pretty much follows WPATH. I went out and found what I believe is the only reference in it (I didn't have time to read the entire document). So I am including the appropriate extract here since I can't find a way to link into the middle of a 68 page document.

The recommended content of the referral letter for feminizing/masculinizing hormone therapy is as follows:
1. The client’s general identifying characteristics;
2. Results of the client’s psychosocial assessment, including any diagnoses;
3. The duration of the referring health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;
4. An explanation that the criteria for hormone therapy have been met and a brief description of the clinical rationale for supporting the client’s request for hormone therapy;
5. A statement that informed consent has been obtained from the patient;
6. A statement that the referring health professional is available for coordination of care and welcomes a phone call to establish this.

[Angela Campbell]

except for #5 that is what was in my letter. It was addressed to a particular Doctor as well.

[I Am Paula]

I've never seen my letter. It was an email. I'm sure it is the same as every other. Due to the fact the WPATH no longer actually requires the letter, I'm sure it's form and content has some leeway these days. I really don't care that much about it's content, because it got the job done.

[LeaP]

My letter contained all of the above at one level of detail or another. I was given the original, delivered it to my doctor who took a copy, and gave it back to me. My therapist had already let the doctor know that she had written the letter. The letter itself was highly personalized, using my female name as well as female pronouns. (After first referencing my given name for identification, of course.)

The content as given in the WPATH guideline leaves room for a lot of interpretation.

[Sue Too]

My experience was much the same as Paula's. I never saw the actual letter. After my visit to the therapist, she told me to make my appointment with the endo. After the appointment was made she directed me to call her and then she sent an email to the endo. For me, it worked!

Susan in Phoenix

[Lisa O]

My experience is in Melbourne, Australia. I started out with the psychiatrist by telling him my goal was HRT at this stage and then public transition. The letter the psychiatrist sent to me GP approving HRT was read out to me and seems to follow all the things WPATH sets out. I signed a few agreements with the psych about informed consent and declining an offer for sperm banking. After that, a more detailed report was prepared, also read out to me and sent to my GP. I haven't kept a copy of either. A possible difference in my process was that the psychiatrist was making a diagnosis, with not much therapy. As a result, he followed a set process of gathering personal, health, life history and recorded everything covered. We also did a handful of the diagnostic tests. It may have kept the process focussed on my desired outcome. I still took a few more visits than I should have!! As an aside, I get therapy from a different gender specialist.

[sandra-leigh]

My letter did not have the informed consent bit, as that is something done at the prescribing clinic here.

I do not recall exactly what was in my letter. It was pretty sparse. Beyond the official ID bit, it basically just said "Yup, I think she would be a good candidate for HRT". Maybe there was the how-many-years and maybe there was "Gender Dysphoria" mentioned, but if so in minimal words. The clinic I was going to would have gone ahead without the letter, but it was easier on them to have the letter for reporting stats purposes (the political funders prefer to see that people have gone through the channels; they don't want the boat rocked by undue suggestion that HRT is being negligently prescribed.)

[I Am Paula]

Sandra-leigh- I think that it Canada it is much more of a formality than an obligation. It also may help share the liability if there was a problem down the road.

[Angela Campbell]

For me there was no "informed consent" discussed or implied by either the therapist or the Doctor. I did have one therapy session where the effects and risks of HRT was fully explored. The Doctor as well discussed with me what I could expect. No question of if I consent or not....I guess the fact I purchased the prescription is consent enough.

[PretzelGirl]

Interesting the variances, which is what I thought I would see. Paula, I think it is a formality for some here in the US too. I am asking around the community for recommendations and I have run into one Endo that wanted the letter and labs sent in and she will decide whether to take you as a patient. Another that was recommended apparently doesn't care about getting a letter. So it varies.

Angela, I think my therapist handled it roughly the same. We had many sections of our discussions where I talked about the effects and whether I was ready to handle any signs that might come up before being full time. I suspect that talk was in depth enough, that he felt it covered understanding the effects period. I believe there was even a small discussion before I committed myself to moving forward where we talked about what was reversible and what wasn't. I don't care about that now obviously.

[tori-e]

So you need a letter from your therapist to give to an endo for hormones?

I saw a physician that specialized in TG patients. We met for a number of months before he agreed to HRT. Aside from having one extra appointment with his colleague, he did everything from evaluation to blood work and wrote the prescription. (He even did post-op exams for the first year.)

The only letter I ever heard of was written by a government appointed therapist for surgery approval.

[Angela Campbell]

Yes the long standing way has been for a therapist to give the letter for hormones then you need two letters for SRS. (one from therapist and one from a psychologist) It seems this is getting to be done less than before, but that was the standard for a long time.

[PretzelGirl]

The letter I am referring to is a WPATH recommended letter. Since WPATH is a set of guidelines, they may not be applied in all countries and in fact, may not be universally required in the same country. In the US, it seems to be required more often as a person may go to a GP or Endo without their therapist directly performing a referral. So the letter becomes a validation of a diagnosis so the GP or Endo can feel reassured that the right steps have been taken for the patient to move forward.

[sandra-leigh]

I think my therapist handled it roughly the same. We had many sections of our discussions where I talked about the effects and whether I was ready to handle any signs that might come up before being full time.

My gender therapist and I never had that kind of talk. We had occasionally mentioned HRT as an option, more or less in passing, with me saying, "Oh, it doesn't feel right for me now, but I have the sneaking suspicion that some day, when I get older, I wont be able to resist trying it." Then during the session I said that I wanted to go to the clinic and investigate seriously what HRT would mean for me, she replied, "Well, Hallelujah!" -- in other words she thought early on that it was something I really should do and was waiting and waiting for me to ask. :o

We already knew that I wasn't going to even try to hide the signs before I went full-time, that I was going to "own it": I had had spontaneous breast growth (water retention maybe) during which I had automatically chosen clothes that tended to follow the curves. Just like I had said some time before that, that if I ever had breasts develop that I was definitely not going to use minimizers or binding.

[Kerigirl2009]

I started HRT on Nov 19 of 2013 after seeing my therapist for about five months but as far as the letter everyone speaks of I didn't need one as they said it is not a requirement.
However. My therapist did actually speak with my doctor who is treating me for Gender dysphoria and monitoring my changes.

I am happy with the changes so far and so are my doctor and therapist

[I Am Paula]

It appears that the general concensus here it that there is no universal SOC anymore, and that your doctor, and therapist (if you have one) will decide the coarse of action.
While this would seem to make the process easier, it can actually be more confusing. Ask your Doctor beforehand. If you feel you don't need therapy, he may work with informed consent, of even just let you start. It's best to know what the protocol is in YOUR case before spending time on the couch. I told the therapist, as I walked in her door, that I would stay until she gave me my letter, and I didn't need a third party to tell me what my gender was. She gave me my letter 50 minutes later.

[Marleena]

First of all congrats Sue!

I too followed the WPATH SOC but never saw the letter either. My endo will not give anybody the time of day without that referral letter that was faxed from therapists office.

[LeaP]

The WPATH SOC is still an excellent guideline. Why anyone would want to bypass a psychological evaluation - and why any physician would start HRT for a patient without one - is beyond me.

My estradiol dosage was just bumped up. My doctor went through informed consent for the change.

[stefan37]

Once you are treated by a doctor any tweaking of the dosages would be by informed consent.

[Rianna Humble]

I do get fed up with people making the phony distinction between working to a recognised standard of care and "informed consent".

Think about what you are saying when you make this distinction - if they are mutually exclusive, then any doctor who works by asking you to agree to what he is offering is by definition working to a lower standard of behaviour than someone who follows the WPATH guidelines. Are you honestly trying to tell us that it is better to receive substandard care because you can sign a piece of paper to say you have understood what the doctore has told you? It just does not make sense.

For me, it seems that the problem comes in some peoples mind because in addition to requiring you to understand how you are being treated, WPATH has worked out a consensus of what is the mimumum standard to which we (trans* patients) are entitled. I don't know whether in your minds it is evil to offer you good quality care, but in mine it certainly is not.

Fortunately for me, the professionals who are supporting my transition work to an agreed standard and also make sure that I understand what they are proposing, when and why. Guess what? I like that. I am happy that they have set themselves standards to ensure I get what I am entitled to get. I applaud the fact that I am consulted and they explain things to me to get my consent. I am also glad that before they started treating me, they ensured that there were no other problems that needed to be treated at the same time. I am joyful that because they did not just ask me to consent to sub-standard care, they discovered and began treating a new health threat in the course of their monitoring. You see for me, it is not a dichotomy between care and consent, I get both (which is what WPATH offers).

[Angela Campbell]

I have to agree. When a therapist and a medical doctor go by the WPATH standards it tells you first of all that they are familiar with the treatment for transsexual people and are educated in the process and treatment. If you are transsexual the correct treatment is a good start to transition. Transition is hard. It is so hard that attempting to do so without the best help you can get would be asking for problems. There is much more to it than taking pills, putting on a patch and growing boobies.

Walking into a Doctors office and getting hormones alone is a terrible way to begin transition.

[Leah Lynn]

Wow. I was with a psychiatrist about half an hour to get mine. She was typing on her computer most of the time we were talking, i assumed taking notes. After revealing a few more facts about myself, I asked if she thought there was a chance I'd ever get to hrt. She replied that she was emailing it to the endocrinologist then.

Leah

[Angela Campbell]

Then you wasted your time and money on that psychiatrist.

[LeaP]

I agree.

BTW, the bit about my going through informed consent again when my dosages were changed was due to my age and being explicit about increased risk. My doctor works in the classical informed consent model, one where you are treated with full disclosure, yet never bypassing applicable and reasonable standards of care, from which a GOOD doctor will only deviate on firm grounds of medical care, not to escape responsibility.

[PretzelGirl]

I can certainly say that for me I do agree with certain things above. First, a therapist following WPATH tells me that they have done some work in this specialty, so I have increased faith based on that fact. Second, if someone is suppose to diagnose me before recommending a treatment, I expect there to be something to diagnose me with. I don't expect an MD to say I have high blood sugar without testing for it and I don't expect a GD diagnosis without a bit of talking. I am not here to diagnose myself, I am not a professional and I certainly don't have objectivity. So if my therapist gave me a letter on the first trip, I would probably be getting a second opinion. And last, Informed Consent is only #5 of the list of items WPATH recommends be covered by the letter. There is likely a reason knowledgeable doctors recommended additional items.

[Lisa O]

I agree with the view that there is nothing wrong with accessing the acquired wisdom (both past and current) that WPATH offers. My psychiatrist has worked with a large number of MTFs (hundreds) and I just trusted him to get me to where I want to be AND assess if there was anything else that I might need assistance with. My psychologist once said it was a process with "very well informed consent" and that seemed to cover it well.

[I Am Paula]

An excellent thread.
There's no concensus here, but I'll add. I went into therapy having been full time almost a year and a half. I'm 55 years old now. I had read everything from medical journals, to bathroom graffiti on the subject of transition. THAT is a whole different kind of informed consent than an 18 year old who is having problems in school that may relate to gender issues. That person needs extensive therapy, and I'm glad most Doctors would insist on it.
The SOC must have some leeway.

[LeaP]

As another sidelight on informed consent for those wedded to the idea that it substitutes for psychological evaluation when "performed" on the physical medicine side: I went through informed consent with my *therapist* before she issued the letter (and this after 6 months of therapy) as well as with my physician before she wrote the prescriptions.

[Rianna Humble]

The SOC must have some leeway.

I would recommend actually reading the WPATH Standards of Care (either v6 which is still in use or v7 which is gaining in adoption).

You will see that Standards are exactly that and give the practitioner a very large amount of leeway to adapt the care to the needs of the patient.
Were you able to certify to your doctor that there was absolutely no chance of any form of co-morbidity at all? If not, then all the informed consent in the world doesn't excuse skipping that part of the SOC.

[Madie]

My letter was really simple which surprised me.
on his office stationary he put "I believe xxx has GID and is a valid candidate for HRT, if you have any questions you can contact me at..." and that was about the extent of it.