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Thread: Therapeutic tool: How do you know if you're ready?

  1. #1
    If only you could see me sarahcsc's Avatar
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    Dec 2011

    Therapeutic tool: How do you know if you're ready?

    Dear forum members,

    Today I present to you an interesting article around a therapeutic tool (or rather guidelines maybe) recommended for gender therapists in assessing one's readiness to undergo Gender Affirmation Surgery (GAS, or any major milestone in transition).

    Ref: Coolhart, Deborah, et al. "Recommending transsexual clients for gender transition: A therapeutic tool for assessing readiness." Journal of GLBT Family Studies 4.3 (2008): 301-324.


    Here's a breakdown of what the article is about, and my appraisal of it:

    • Do not be misled by the title of this article, claiming this to be 'tool', when it is actually a set of guidelines for gender therapists (or any therapists working with the trans community) to assess an individual's readiness for surgical transition. That means that this isn't like a questionnaire with a scoring system to indicate some objective measure of one's level of readiness, the tool still calls for a degree of subjective assessment.
    • Despite that, this guideline offers some very sound suggestions for questions for therapists to ask their clients to assess their readiness. The author acknowledged that this idea is not novel and it was built on previous literature which includes the SOC from WPATH and other independent studies.
    • This tool is not meant as a 'one-off' assessment, and the author clearly indicates some follow-up is necessary. In other words, the effectiveness of this tool is somewhat reliant on the therapeutic relationship built between the client and the therapist. It will be less accurate or effective if the client has a poor relationship with their therapist.
    • This tool is also subject to a therapist's skill and experience in working with transgender clients.
    • This tool takes a holistic view of a person's readiness for GAS by looking into several domains including family/childhood contexts, current gender expression, sexual/relationship development, current intimate relationships, physical and mental health, support, and last but not least, future plans and expectations.

    Here is an example of the kind of questions therapists and clients ought to consider according to this guideline:


    (The complete list of the question can be obtained from the article itself)

    Here are things to be cautious about when reading this article:

    • Remember, this is not a 'tool' per se, and there is no objective scoring system to assess one's readiness objectively.
    • The author is writing an opinion piece, in other words, this is not backed up by any form of statistical analysis to indicate any predictive value. In other words, there's no way to tell if this guideline can predict any form of outcomes in the future.
    • As with any opinion pieces, this is heavily reliant on the author's experience with his/her clients. It is something like a qualitative piece rather than a quantitative piece which has less of an impact in the peer-reviewed articles. But it is an important contribution nonetheless.
    • The article does not describe it's target population, this I believe applies mostly to clients from the US (where the author works), thus it may not be generalisable to other cultures.
    • The article is targetted towards therapists and it advises therapists to ask these questions appropriately or risk coming across as unnecessarily intrusive. Please do NOT assume that every therapist should go through the entire list of questions if you're a layperson reading this.
    • If you are a layperson, please take this is as food for thought for yourself and it is not a substitute for seeing a therapist.
    • As with any opinion pieces, you need to do your own research on the author's credentials (Deborah Coolhart). You can google her up.
    • The article's conclusion is kinda weak and it doesn't include a 'limitations' section.

    Here are some of the things I like about this article:

    • The author takes a holistic view on the issue which reflects the complexity of the kind of decisions that transgender people have to make. It also reflects her insight into the challenges we face.
    • The author states very clearly that such a list of question is potentially harmful if it is too cumbersome because it will give individuals a sense that they have to jump through inhumane and unnecessary hurdles to get approval for surgery. It advises caution and empathy for therapists conducting assessments, but at the same time acknowledges the importance of not skimping on important details. Again this is a reflection on her insight.
    • The author is a licensed family therapist. This in itself bears no significance in the clinical world, but it is highly relevant when dealing with gender dysphoria and transgender individuals because it is a complex phenomenon that almost always involves families. Being a family therapist lends credence to her theories and hypothesis.

    Last but not least, why am I doing this, and why should you trust (or not trust) me?

    • I'm doing this to create more informed debates and discussions by citing some of the literature that is already OPEN to everybody.
    • I believe everybody has the right to be informed by evidence, and not just personal opinions from forum members.
    • I do this to dispel some myths and misinformation I see getting spread around here.
    • You should NOT trust me. You should google up this article. This is an OPEN source article you can find on google scholar. The reference is up there.
    • If you have any questions, you can PM me.
    • If this thread gets taken down, then PM me and I will send you the article.
    • Please PM me if you would like to request any articles. I might have some which you'll find interesting to read.


    I also posted this article in response to an unusual, untherapeutic, and unhelpful list of questions being circulating here recently:

    Quote Originally Posted by Annonymous View Post
    If you do not pass will you be comfortable being stared at, pointed at, laughed at, ect.. ?
    If you pass and someone finds out and thinks you deceived them and becomes abusive and or violent are you prepared to deal with this ?
    If you are of the age where you want children are you OK with adoption if you want your own family or will you save your sperm and than transition and try to explain to your child ?
    If you voice is deep you will likely never have a passable voice. Is this OK ?
    Are you OK with the health risks that taking synthetic hormones for the rest of your life pose ?
    Are you prepared to have your career negatively impacted regardless of how many laws are in place to supposedly protect you?
    Are you prepared to be socially isolated by those who do not except trans people ?
    If you attend church, does the church accept trans people or are you prepared to find one that does ?
    Will your family continue to associate with you?
    Are you prepared to lose a significant amount of physical strength no matter how much time you spend working out?
    You will experience very little breast growth in proportion to your size so to appear proportional you will likely need breast implants to balance your frame/shoulders against your breast size unless you can accept what otherwise is referred to as man boobs
    If you do not get SRS but do have breast implants will you experience dissonance seeing yourself with breasts and a penis?
    Do you have 100K available to transition?
    Can you handle social rejection at any and all levels?
    Are you prepared to have your dignity and privacy stripped away through the many medical procedures along with the "Mind Probe" of therapy?
    Here is some good news if you do end up getting SRS . Now they do not require electrolysis on your scrotum to perform SRS. Is life not getting wonderful for transsexuals?
    If you are over weight or smoke or have any health issues such as diabetes/high blood pressure this increases the possibility of complications related to taking hormones/blockers.

    Are you willing to risk death to transition ?

    My advice is always the same. Do not transition unless your life depends on it. Unless it is a life or death decision. Because it is.
    You should definitely switch therapist if they recommend that 'you don't do anything unless your life depended on it'. It is like a doctor saying don't take your antihypertensives until you're about to have a stroke.

    Last edited by sarahcsc; 06-11-2019 at 08:59 AM.
    "The question isn't who is going to let me; it's who is going to stop me" - Ayn Rand

  2. #2
    Platinum Member Teresa's Avatar
    Join Date
    Dec 2013
    The same problem always arises because we are all different , one size just doesn't fit all .

    It might be interesting if members did try and answer the questions just to see how many permutations you do receive .
    The real me ,no going back.

  3. #3
    Silver Member Aunt Kelly's Avatar
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    Nov 2016
    Greater Houston
    Those types of questions are what any qualified therapist is likely to ask about any patient's chief complaint. Most of those specific questions, almost word for word, were asked by my therapist as we explored my gender identity. No, not in one session, nor in any particular order, but I in retrospective, I can see their efficacy in getting to a necessary understanding (for both of us) of what is going on with me.

    Yes, we are all different. That's not a problem, per se. It just is, and that is the reason the "tool" has no "answer key". There is no "score", no pass/fail grade. The tool is a presented as an approach that the authors found helpful in learning enough about their patients to determine whether or not a recommendation for GRS is appropriate.
    Well, somebody has to make up that base of the bell curve that defines "normal".

  4. #4
    Gold Member Kaitlyn Michele's Avatar
    Join Date
    Aug 2005
    My reaction is that’s it’s a helpful beginners or intro for a therapist with little knowledge
    Or can be used a conversation starter for more experienced therapists

    It’s common sense and these types of questions are not about filling in the boxes but about starting a dialog.

    Anyone considering this should spend a lot of time thinking about these questions and be willing to work hard
    At making sure they are honest.
    I am real

  5. #5
    Isn't Life Grand? AllieSF's Avatar
    Join Date
    Feb 2007
    San Francisco Area
    I personally am dealing with an informed consent medical and mental clinic for the LGBTQ+ community. These type of questions are pretty standard for their therapists and their psychologist who worked with me. These type of questions are also the questions with corresponding patient answers that here in the San Francisco have been determined to be needed for insurance coverage of gender confirming surgeries, including Breast Augmentation BA), bottom surgery and Facial Feminization surgery (FFS). In essence, the patients answers are quoted throughout the required therapist and psychologists letter that will be submitted to the surgeon and then on to the insurance companies. In California, insurance companies cannot deny these surgeries if they are determined to be medically necessary for the health of the patient. That is except for seniors' Medicare, which is funded by the Federal Government. However, so far, Medicare will cover them, until our current President finds a way to deny them.

  6. #6
    Gold Member Kaitlyn Michele's Avatar
    Join Date
    Aug 2005
    Excellent point

    Documenting for legal and insurance purposes is very helpful
    I am real

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