Social-Justice Oriented Treatment for Transgender Clients

Trans, nonbinary, and other non-cis populations across the country are increasingly under assault politically, physically, and socially. Suicide attempts occur in 40 percent of this population and suicide contemplation is over 80 percent (Austin et al., 2022). Suicidality seems, to me, like an understandable reaction to near-constant discrimination and painful dysphoria. I think I might feel the same, and possibly you would too.

Mental health providers can help reduce suicide rates and promote mental health in trans, nonbinary, and other non-cis populations. Working with this population and providing them with treatment letters when necessary, has become one of my niche specialties; I've done 13 to date. Here's a recent example from my practice.

Source: Psyche-Mask/Pixabay

Case Example

Mike is 17 years old. He was assigned female at birth but identifies as male.

Mike has a significant trauma history; his father abandoned him to raise another family and, at 5 years old, his mother left him with his grandmother. He began homeschooling in 2017 and has been largely isolated; virtually all his social contact has been online chatting with other trans youth. He voiced suicidal ideation in the initial meeting with me.

Early in treatment, Mike asked me for a letter in support of hormone therapy so his body would become more appropriately masculinized. Not infrequently, psychotherapists working with trans clients receive requests for documentation that a trans person has diagnosable gender dysphoria that has caused substantial mental health issues such as suicidal ideation and that they're “mentally fit” for hormone therapy and to make decisions about their own body.

Many insurance companies require this to ensure it meets "medical necessity" and to theoretically decrease the chance that the person will later regret the hormone treatment (which research has found happens very rarely). This also helps doctors and insurers be sure that hormone therapy and gender reassignment surgery can support, instead of hinder, a client’s mental health and overall functioning.

The problem is, most therapists don't get training for this in graduate school. Still, we're often thrust into this type of gatekeeping role with trans clients. Based on my 12 years of clinical experience working in agencies and supervising into the present, I've observed that therapists are sometimes encouraged to err on the side of caution by their agency or organization's management and/or supervisors—which often means they are told to require a certain number of sessions, questionnaires, and evaluations, in order to complete the letter. (Note: This is drawn from my own and my colleagues' experience, rather than research.)

Personally, I recommend therapists give their clients the letter sooner rather than later, because hormone therapy and psychotherapy together can (and usually do) promote mental health in trans, nonbinary, and non-cis clients (Budge, 2015).

It was clear from Mike's status exam that he was lucid and mature enough to make this decision, and I believed that his gender dysphoria worsened his symptoms. Thus, after safety planning (developing a plan to keep him safe in case suicidal thoughts arose [given they were reported initially]), I decided that it was both ethical and empowering to provide Mike with this letter by the end of the second session.

I believe that, as mental health professionals, we should not get to decide what clients can do with their bodies; we should support and honor their own bodily choices. I argue that as I health provider, I shouldn’t block Mike’s access to resources that a cis-person could access without a therapist’s permission.

Blocking Mike or other trans, nonbinary, or non-cis clients from having the body that best fits their sense of self is likely to worsen suicidality and other mental health issues like isolation and depression, not help manage them. If Mike were required to have more sessions before I'd write a treatment letter supporting his hormone therapy and future surgery, it would be stigmatizing the very condition of being trans. Being trans is not a pathology, but a healthy and valid component of some people's identity.

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After a mental health professional writes his letter, it is the role of the medical doctor to determine if the client is physically and medically able to start hormones, and the doctor’s job to monitor the client’s physical body.

Case Follow-Up and Development

Mike and I agreed that he is likely avoiding social situations because of chronic misgendering (being treated as a female—for example, via the use of "she" and "her" pronouns) he had endured—a common scenario for many of my trans clients—and the invisibility of his identity navigating the world as a trans-person who is not presenting nor is perceived the way he not only desires, but is. Mike is male despite having presented with female genitalia at birth and being assigned to a female.

Hormones turned out to be a key catalyst that helped Mike make friends in person once he started feeling comfortable in his own skin. Not accessing hormones would have very likely increased his depressive symptoms and suicidal ideation. This is true of many trans, nonbinary, and non-cis clients appropriately requesting a treatment letter.

After writing the letter, we continued safety planning and I provided Mike with community resources to connect with other trans youth in person. At this point, Mike is doing much better now—he's reporting no suicidality and a significant decrease in anxiety and depression symptoms, a lot of which he attributed to starting hormone therapy.

My role was to support Mike where he was at and with what he said he needed, not dictate where he should be. Since Mike was able to make sound decisions, I believed that there was no reason to limit or postpone when he started hormones. We also discussed the pros and cons of hormone therapy and transitional surgeries, all of which Mike had extensively researched prior to therapy.

Conclusion

Therapists writing supportive letters, especially earlier in treatment (after a clinical assessment) can help trans clients get the timely medical, hormonal, and surgical treatments they may need. This can not only powerfully promote their mental health (Budge, 2015) but may even save their life.

As mental health providers, what's more important than becoming a potent force for urgent and crucial healing?

Note: If you are a mental health professional and need a sample letter for a trans client, you are welcome to contact me for an example. For trainings and/or a list of providers I'm a fan of this national list: VanEthanLevy.com/providers.