There is no one-size-fits-all approach to the gender affirmation process, and when it comes to your journey, you are the expert of your needs, experiences, and body. In order to provide gender-affirming care, your therapist should support you in whichever combination of treatments is right for you—and sometimes, that includes surgery.
Over the years, treatment for gender dysphoria has become more individualized—while many individuals need both hormone therapy and surgery to alleviate their gender dysphoria, others need only one of these treatment options and some need neither. Some patients may need hormones, a possible change in gender role, but not surgery; others may need a change in gender role along with surgery, but not hormones. If you do choose to pursue surgery, there are some steps to take ahead of time, including getting a letter of readiness.
So what is a letter of readiness and how can your therapist help? In this post, MyWellbeing therapist Ashton Santo breaks down what a letter of readiness is and how a gender affirming therapist can support you.
While gender nonconformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex, gender dysphoria refers to the discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics).
Not all gender nonconforming people experience gender dysphoria at some point in their lives, but some do—when it becomes an extremely uncomfortable and confusing situation, a professional can diagnose this is as gender dysphoria.
"People experiencing gender dysphoria can feel anything from general discomfort to profound anguish regarding their assigned gender and/or sex characteristics," says Ashton. "If you're not sure what you're experiencing, a therapist can help you pinpoint the sources of your distress and map out ways to alleviate them, whether that includes surgery or not."
It is important to remember that transsexual, transgender, and gender nonconforming individuals are not inherently disordered. Rather, the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatment options are available. A diagnosis of dysphoria can facilitate access to healthcare and guide further research into effective treatments.
No. Gender affirming surgery is not for everyone; maybe surgery is too expensive or you’ve started or considered nonsurgical services to help you achieve your transition goals, such as hormone treatment, dermatology, and voice therapy. Maybe you don’t see surgery as being a part of your transition process at all. All of these feelings are valid!
"There is no one way to transition," says Ashton. "Deciding whether or how to pursue gender-affirming surgery is entirely up to you, for you are the expert on your life."
If you are ready to move forward with a gender affirming surgery, you will need to have a mental health surgical readiness letter.
This letter will be needed by the medical center performing the surgery as well as by your insurance company and it is also a requirement of the World Professional Association for Transgender Health (WPATH), a professional organization dedicated to the research and healthcare of transgender and gender diverse people. The WPATH’s Standards of Care were created by international agreement using the latest scientific research on transgender health so that doctors can best meet the unique health care needs of transgender and gender-nonconforming people (quick tip: if you’re considering surgery, ask your therapist about the Standards of Care and how familiar they are with the WPATH guidelines).
Certain surgical treatments for gender dysphoria can be initiated with a letter of readiness from a mental health professional who provides documentation of your personal and treatment history, progress, and eligibility for the surgery.
One letter of readiness is needed for breast/chest surgery such as a mastectomy, chest masculinization, or augmentation mammoplasty. One letter of readiness is recommended for facial surgery such as facial reconstruction and contouring. Two letters of readiness from two separate mental health professionals who have each independently assessed you are needed for genital surgery, such as hysterectomy/salpingo-oophorectomy, orchiectomy, and genital reconstructive surgeries.
Some surgeries require documentation of persistent gender dysphoria by a qualified mental health professional. For some surgeries, additional criteria include preparation and treatment consisting of feminizing/masculinizing hormone therapy and one year of continuous living in a gender role that is congruent with one’s gender identity.
"Insurance companies are often the ones that require letters of readiness before they'll agree to cover a procedure, which unfortunately has restricted access to care far more than facilitated it," says Ashton. "It can seem arbitrary that, for example, a transgender man has to undergo a psychosocial assessment to get a mastectomy, but not a cisgender woman—and that's because it is. When I collaborate with my clients on letters of readiness, I explain why it's needed while also recognizing how invalidating it can feel to need a letter that essentially says, 'Yes, I am really trans.'"
While they can be a barrier to care for many people, the letter or letters of readiness can help the surgical team understand your unique situation and ensure that you are as healthy as possible for surgery. It is also important to ensure that you have support from friends, family, and your healthcare providers before, during, and after your surgery.
No! However, your therapist can still play an important role in helping you make a fully informed decision about any procedures you might be considering as part of your social transition.
Mental health professionals with at least a master's degree can write the letters of readiness; this can include psychologists, psychiatrists, social workers, mental health counselors, marriage and family therapists, and doctors or nurses of family medicine with specific training in behavioral health and counseling.
Not all training programs teach therapists how to gain cultural competence with trans clients. Ask your therapist or letter-writer if they understand the letter-writing criteria required by your surgeon, insurance, or health care system, including what credentials are required for letter-writers.
"Not everyone pursuing gender-affirming surgery will want regular therapy, and that's okay," says Ashton. "That said, a therapist can provide crucial support, education, and advocacy as you pursue your most authentic self."
Regardless of whether or not you choose to have surgery, your therapist should affirm your gender identity, can help you explore different options for expression of your gender identity, and work with you to make decisions about any medical treatment options for helping you alleviate gender dysphoria, if that is what you are experiencing.
If you do choose surgery, it can be a daunting process, and your therapist should support you every step of the way. You’ll work together to ensure that you meet the readiness and eligibility requirements for your particular gender-affirming treatment or procedure. If you haven’t already done so, talk to people who have undergone gender affirmation surgeries or read first-hand accounts, but keep in mind that not everything you read will apply to your unique experience and situation.
Your therapist can also explore the negative impact of gender dysphoria and social stigma on your mental health, support you with your body image or body positivity, help build your resilience and coping mechanisms, and work with you to identify or create a social support system.
Whichever path you choose, you deserve respect, support, and care throughout your gender affirmation journey and beyond. Above all, you deserve to live your truth and surround yourself with people who affirm who you are.
Ready to find a gender affirming therapist? Book a free consultation with Ashton or use our matching form to find the right therapist for you.
Caitlin is MyWellbeing's Content Lead, a writer, speaker, communication coach, and the founder of Commcoterie, a communication consultancy. She teaches teams how to use professional coaching communication techniques in their everyday conversations, helps leaders engage their teams with effective and inclusive communication, and partners with service providers to activate their programs and offerings with their own clients through inspiring communication strategies. Find out more, including how to work with her, at www.commcoterie.com.