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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

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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