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Psychotherapists as Gatekeepers

An Evidence-Based Case Study Highlighting the Role and Process of Letter Writing for Transgender Clients


In order to receive medically necessary gender-affirming treatments, transgender individuals are required to provide evidence of their readiness for gender transitioning. Most often, this evidence includes 1 letter for hormone therapy and 2 letters for surgery. According to the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC), psychotherapists or other eligible health professionals are the only individuals qualified to write these letters. The present case study examined how psychotherapist gatekeeping and letter writing for a transgender client were intertwined with psychotherapy processes and outcomes. Over the course of 12 months of treatment, the client was assessed through 8 time points using multiple methods. Six of the assessments were conducted with validated outcome measures (baseline; Sessions 5, 10, 15, and 20; and termination); 1 of the assessments was conducted as a clinical interview for letter-writing purposes and additional outcome measures (Session 8); and evaluating the process of letter writing was an aspect of psychotherapy (Session 20). Symptom alleviation, improvement in psychological well-being, and increases in overall quality of life occurred from baseline to termination. Results indicate that psychotherapy assisted with the process of gender transitioning, which in turn improved client outcomes. Recommendations for writing letters for clients who desire a gender transition are included.

Keywords: psychotherapy, transgender, gatekeeping, outcomes, standards of care

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.

Cite This Article

Budge, S. L. (2015). Psychotherapists as gatekeepers: An evidence-based case study highlighting the role and process of letter writing for transgender clients. Psychotherapy, 52(3), 287-297. doi:



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