Consider the following scenario: a client you have been working with for over a year comes into your office and says “I have something to tell you—I’ve been waiting to let you know for a long time. I am a trans man and I would like your help to transition.” Of course, first reactions from you (as the therapist) should include validation and support, as well as some processing about how you feel toward the client and finding out about how they are feeling about you.

Most therapists have never had explicit training about working with trans clients (clients who identify with a gender that is different from their assigned sex at birth). To be clear, most therapists do not need to have a specialty in gender or trans issues in order to work with trans clients.

The common factors for what makes psychotherapy generally effective will also work with trans clients, with one exception—the letter-writing process.

Unless therapists have experiences writing letters for bariatric patients to receive medically necessary care, they will likely have zero experience writing a letter that assesses mental health and readiness for trans-related medical care. The process can seem daunting to therapists who are writing the letter for the first time. I know I felt nervous about “getting it right.”

For therapists who are afraid of clients changing their minds about medically transitioning “after the fact”, it is helpful to keep a couple of things in mind: a) researchers have found that most clients do not change their minds, and b) in the unlikely event that clients do change their minds in the future, you can have frank conversations about what that might look like for them and how they can adapt post-hormones/surgery if they are concerned about this process. Longitudinal studies indicate that the majority of trans individuals experience better physical and mental health post-medical transition procedures (Weyers et al., 2009; Dhejne, Oberg, Arver, & Landen, 2014).

I entered the following search terms into Google: “writing a letter for trans clients” and saw that several therapists had put examples of letters online. While this process was somewhat helpful for me as I was beginning to embark on this process, I have also learned that most medical providers actually want more specific information than what is provided on the example letters from my Google searches.

My first recommendation to mental health professionals writing a letter for the first time is to confront their intimidation of this new process by gaining knowledge to decrease feelings of uncertainty. The actual writing of the letter is not difficult, but perhaps the time of learning the specifics of what to include in the letter might feel nerve-wracking. Luckily, there are now checklists of what to include in letters. In May 2015, I received an email from a clinic that specializes in medical interventions with trans youth—they requested the following information to be included in letters:

” 1. Confirmation of diagnosis of gender identity disorder

2. Assessment/discussion of patient’s expectations regarding pubertal suppression and hormone therapy

3. Assessment of the patient’s mental health (i.e., is it stable or improving)

4. Assessment of any other psychological comorbidities and whether these may interfere with diagnosis or treatment

5. That the patient has/will have adequate psychological and social support during treatment”

In contrast, when I requested what another clinic would require in their letters, there was a list of 8 factors that were required to be included (see Budge, 2015 for specifics) with 14 subheadings. Once mental health professionals get over the psychological hurdle that there are specific pieces of information to include in the letter, it is important to be reminded that the years of training received sets them up perfectly to write excellent letters. But, like anything new, receiving consultation for the first few times will be important.

Therapists’ Expectations and Feelings When Writing Letters

Specific procedures for how to go about writing the letter and talking to clients are included in Budge (2015), but left unspoken within the article is how mental health professionals may personally feel about writing these letters.

If you have religious and/or personal feelings that you feel restrict you from working with trans clients, my next pieces of advice do not address those issues. If you do experience religious and/or personal feelings that are not in alignment with trans-allyship, I recommend in-depth consultation with other mental health professionals working with trans clients and also seeking spiritual/religious guidance from people who have experience working with trans individuals.

Most mental health professionals find themselves in the position of asking, “why do I need to write a letter to certify that it is okay for someone to have medical care or elect to have surgery?” The answer to this question is nuanced and convoluted—however, it will be important for you to understand where you are personally coming from because your trans clients will ask you about this. Start here:

1. Do you personally think that having a trans identity should be classified as a mental disorder?
2. Do you personally think it is important for mental health professionals to certify trans individuals as ready (or not) for medical interventions?
3. What specific diagnoses or issues would have to be present in order for you not to certify someone as ready for medical interventions?

The trans clients I work with want to know how I feel about these issues—and I suggest that you do not sugarcoat your responses to any of these issues. Trans individuals, like most other marginalized populations, are adept (and hypervigilant) at reading people for judgment, bias, acceptance, and understanding. Most of the trans clients I have worked with indicate that they have had a negative experience with mental health professionals at some point in their life and can be wary and distrustful of the profession.

If you have never said out loud how you feel about the diagnosis of gender dysphoria, I suggest that you have conversations in consultation groups or with colleagues about the criteria and your own biases and assumptions about this diagnosis. I also suggest reading about the history of this diagnosis—Arlene Istar Lev has spent several decades discussing this topic academically.

Making Informed Decisions

There are several pieces of information that may assist mental health professionals in making decisions about how they feel about the gender dysphoria diagnosis.

A short history

When I talk with clients about the diagnosis, I provide them with a short history of the diagnosis. Gender Identity Disorder (GID) was first introduced into the DSM-III—coincidentally (or not) when homosexuality was taken out of the DSM. The diagnosis was changed from GID to Gender Dysphoria (GD) in the DSM-5, in order to de-stigmatize the label and to be more descriptive of the psychological occurrence. For many who do not agree with the GD diagnosis, there remained an argument to keep the diagnosis because the medical community contends that they cannot deem a treatment to be medically necessary without an actual diagnosis.

Regardless of where you stand as a mental health professional on this issue, it may help your clients to know that this has been the recent sequence of events and that controversy around the diagnosis remains. I tend to be on the more “liberal” end of the spectrum when it comes to assigning this diagnosis to trans individuals.

However, I believe that it is important for my clients to get the medical care that they need to improve their mental health. While I only have anecdotal clinical evidence to back up this assertion, it has been reported to me by many clients that it hurts the therapeutic relationship when their mental health professionals unquestionably provide the GD diagnosis. I suggest that mental health professionals directly and consistently improve the therapeutic relationship with their clients, while concurrently and critically considering how to assist their clients through their gender transition process.

Support before and after medical care

It will also be helpful to help prepare clients for the type of support they might need before and after engaging in medically necessary care. For example, hormone interventions often have many side effects (both desirable and undesirable) that can be very useful for clients to talk about with others who have been through the same process.

As well, preparing them for some of the emotional rollercoasters that occur during hormone interventions may assist clients in preparing their friends and loved ones for how to have conversations about supporting one another through emotional episodes. As well, after surgeries, clients may need help with transportation to and from the clinic/hospital and extra care immediately after the intervention. It will be useful to prepare clients for this process, as well as ensuring that they have the extra care required after major surgery.

Decisions about comorbid diagnoses

Mental health professionals may also have some difficulty making decisions about comorbid diagnoses. My first suggestion is to consult with another psychologist who has experience differentiating diagnoses from the dysphoria that results from gender identity incongruence. Sometimes it may be difficult to determine if diagnoses such as major depressive disorder or generalized anxiety disorder are organic to the individual, to other contextual factors (for example, financial trouble, or to gender incongruence. If you have determined, with your client, that they would like to move forward with a medical intervention, it is likely that some of their symptoms will decrease just with the hope and promise of being able to feel more gender congruent.

However, psychotherapy will still need to help trans clients in coping with minority stressors and also with any other stressors that may exist outside of the dysphoria.

It is common knowledge that there is not strong validity tied to the mental health diagnostic system, thus it may help mental health professionals to focus on symptom alleviation and improvement of quality of life—for the majority of clients, decreasing the stressors in their lives and learning healthier ways of coping with those stressors assists with improvement in mental health; trans clients are not any different from other clients in this regard.

Suggested Readings

Trans Men’s Positive emotions: The Interaction of Gender Identity and Emotion Labels

Anxiety and Depression in Transgender Individuals: The Roles of Transition Status, Loss, Social Support, and Coping

Coping and Psychological Distress Among Genderqueer Individuals: The Moderating Effect of Social Support

Interpersonal psychotherapy with transgender clients

Transgender Emotional and Coping Processes: Facilitative and Avoidant Coping Throughout Gender Transitioning

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Stephanie L. Budge, Ph.D.

Stephanie Budge (she/her) primarily works with Two-spirit, trans, and nonbinary people with regard to research and clinical work. She is an associate professor in the Department of Counseling Psychology and the director of the Advancing Health Equity and Diversity program in the School of Medicine and Public Health at the University of Wisconsin-Madison. She is the founding member of the Trans CARE Collaborative. Her research focuses on improving of medical and psychotherapy treatments (and access to care) for Two-spirit, trans, and nonbinary (2STNB) clients. She provides clinical trainings nationally and internationally related to LGBTQ issues, focusing on practitioners’ self-efficacy, knowledge, awareness, and skills. At the University of Wisconsin-Madison, she promotes 2STNB advocacy on campus by providing workshops to students, faculty, and staff related to navigating gender identity within a university environment. As a licensed psychologist, she provides pro-bono therapy to 2STNB youth and adults. Stephanie is currently an Associate Editor of two journals: Psychotherapy and Psychology of Sexual Orientation and Gender Diversity. She is also on the editorial board of the International Journal of Transgender Health. Stephanie enjoys going on hikes with her wife and toddler, cooking (especially anything with potatoes), and rappelling down waterfalls.