Myths and Misconceptions about Therapy and the Transition Process

By Pete Franzen, Clinical Counselor (LCPC)

Note: Because my focus is adults (18+), this information is not accurate for minors.

I am a trans man who works as a therapist within the trans community. I have the amazing opportunity to spend most of my week talking with other transgender people. It is a joy for me to both receive and offer respite from the alienation that often comes with being "other" in this way.

In my conversations with trans people and mental health providers, I hear a lot of confusion about the role of therapy in pursuing gender-confirming medical care. We are all already working hard to manage other emotional, financial, and social challenges of transition. This lack of clarity creates additional anxiety and barriers in the gender transition process.

Here are some of the top misconceptions that I come across related to this process. I hope this helps you feel more empowered to get around unnecessary roadblocks on the path and get wherever you need to go!

Do I have to be in therapy for a long time to receive a recommendation for gender-confirming surgery?

People sometimes hear that they must be in therapy for “at least a year,” or another arbitrary length of time before the therapist would consider providing a letter of recommendation for gender-confirming surgery.

Sometimes, insurance companies or surgeons may want evidence of ongoing therapy. But more often, they will accept a letter based on a short-term assessment of 1-3 sessions. Please call your providers to confirm their requirements.

Therapists who set these timelines are positioning themselves as gatekeepers to gender transition. They seem to me to be more concerned about their liability than with the client’s rights and well-being.

Therapists who are comfortable working with the trans community will not require ongoing therapy if it is not wanted by the client. Instead, we will assess your capacity for giving informed consent. We will ensure that you understand the risks and benefits of your decision. We will make sure you have realistic expectations about the outcome and have a plan for recovery. Then we will focus on collecting basic background information for writing the letter.

Do I need therapy to begin Hormone Replacement Therapy (HRT)?

It is often not required to be in therapy to access hormone replacement therapy (HRT). Many healthcare providers, including Planned Parenthood, use the Informed Consent model. This means that they provide basic information about the risks and benefits of HRT. Then, if the client consents, they provide access to hormones. If there are no major concerns, this usually occurs without involvement of a therapist. Other clinics may have an assessment professional on staff who is also likely to use an informed consent approach. For adults, it is usually not required to be in therapy to access HRT.

Do I need to pass an assessment from a therapist to qualify for gender-confirming surgery?

There is no agreed upon official assessment to qualify for gender-confirming surgery. There is also no official assessment for diagnosing Gender Dysphoria.

Therapists diagnose Gender Dysphoria using a reference book called the DSM-5. You can search online for the term and "DSM-5"to see how the mental health field defines this. Therapists do not have the power to determine your gender. You are the only one who can. 

Therapists in earlier times have tried to use assessments to measure “gendered” traits. Or, they have used them to try to assess the severity of dysphoria. But none of these measures are in common use because they are not reliable or valid measures.

To access surgery using health insurance, you will need a letter from a therapist. Usually, the letter must state that you meet criteria for a diagnosis of Gender Dysphoria. It must also usually say the therapist believes surgery is “medically necessary.”

If someone is in my office seeking surgery, I already have evidence that the person is likely to be experiencing Gender Dysphoria. Many professionals comfortable working with trans people will be willing to write the letter that will be adequate for insurance companies and surgeons to approve your surgery.

Often, therapists working with the trans community use the WPATH Standards of Care. WPATH stands for World Professional Association for Transgender Health. They are an international organization that publish recommendations for gender-affirming medicine. Many people disagree about the ethics of these recommendations, especially their age requirements. But these standards are often used in health provider decision-making. So, it could come in handy for self-advocating with doctors or therapists. To learn more about the WPATH standards, download a free copy here: https://www.wpath.org/publications/soc. Some of the Standards of Care are often referenced in therapist letters. These include: the ability to give informed consent, persistent, well-documented Gender Dysphoria, living as your affirmed gender for more than one year, and being above the age of majority.” (18+).

Do I need to find a gender therapist to move forward in my transition?

Sometimes people refer to me as a “gender therapist” or ask me for referrals to “gender therapists.” They are often surprised to hear that, in fact, there is no such thing as a “gender therapist!" Some therapists indeed refer to themselves with this title for marketing purposes. They may use it as shorthand to communicate familiarity working with transgender people. But there is no specific training or certification to become a “gender therapist.” For these reasons, this term can often be misleading. Any licensed therapist can provide letter for surgery if they are willing.

How do I find a therapist who will provide the clinical documentation I need for surgery?

Check out this free online database, Psychology Today: https://www.psychologytoday.com/us

Start by searching for your insurance and location. Then search for people who list "transgender" as a specialty issue, or who are "allied" to the community. Or, search by identity to find people who are non-binary or transgender.

Or, you may already have a therapist you like, but they are unfamiliar with this process. In that case, you could refer them to the WPATH Standards. You could also provide them with example therapist letters of recommendation. You can find many samples online. Usually any licensed mental health professional can provide this documentation. But not all are willing.

Still hitting into barriers? The Gender Affirming Letter Access Project (GALAP): https://thegalap.org/ may help, too.

Conclusion

I believe in therapy, but for therapy to be effective, it must be a non-coercive dialogue. Clients in therapy choose to grow self-awareness for their own aims. The therapist's proper role is a collaborator and respectful witness. They should avoid at all costs taking authority on the life of another person.

It is inappropriate for therapists to take authority on our experience of gender. When they do this, they shatter the conditions of ethical and effective therapy. For therapy to be effective, clients must experience authentic vulnerability within the relationship. This is not possible if the relationship uses coercion or abuse of power.

Trans people deserve clear information about their rights when seeking support for transition. Mental health professionals must be educated about our proper roles in this process. We should offer therapy when clients want it. But we should never enforce it when they do not. Most of all, we should never use therapy requirements to block access to medical care.

Pete Franzen (he/him) is a queer trans man and mental health counselor serving the Southern Maine area. He is dedicated to promoting the emotional well-being of all people, but particularly the trans and gender non-conforming community.