Trans Affirming Letter Writing: Best Practices and Challenges for BHP. Justin Wheeler, LISW-S Michelle Pride, Ph.D.

Transcription

1 Trans Affirming Letter Writing: Best Practices and Challenges for BHP Justin Wheeler, LISW-S Michelle Pride, Ph.D.

2 Disclosures The speakers and members of the planning committee do not have a conflict of interest in this topic. There is no commercial support for this program.

3 Objectives: Greater familiarity with the criteria for letters Knowledge of the elements of a WPATHconsistent letter for surgery Greater understanding of the role of the mental health professional in this process

4 Assumptions You have a basic, working knowledge of trans/gender diverse/gender expansive language You have some familiarity with the WPATH standards You are a stakeholder in this process: Consumer/client Therapist/qualified mental health provider Medical provider

5 WPATH: publications/soc

6 Purposes of the Standards of Care Promote evidenced-based care, education, research, advocacy, public policy, and respect in transsexual and transgender health Promote the highest standards of care based on the best available science and expert professional consensus Provide guidance for health professionals to assist transsexual, transgender, and gender non-conforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment.

7 Core Principles Exhibit respect for patients with nonconforming gender identities Provide care (or refer to a knowledgeable colleague) that affirms patients gender identity and reduces the distress of gender dysphoria Become knowledgeable about the health care needs of transsexual, transgender, and gender-nonconforming/gender diverse people, including the benefits and risks of treatment

8 Core Principles cont d Match the treatment approach to the specific needs of the patients, particularly their goals for gender expression Facilitate access to appropriate care Seek patients informed consent Offer continuity of care Be prepared to support and advocate for patients within their families and communities

9 Gender Dysphoria Diagnosis: The Basics Marked difference between an individual s expressed or experienced gender and the gender assigned to them Persists for at least 6 months Causes clinically significant distress in social, occupational, or other important areas of functioning

10 Role of Mental Health Practitioner Minimum credentials: Master s degree in a clinical behavioral science field, granted by an accredited institution Competence with the DSM-5/ICD Differential diagnostic skills Documented, supervised training and competence in counseling Knowledge about gender diverse identities and expressions Continuing education in the assessment and treatment of gender dysphoria Awareness of values and biases Do you see yourself as a gatekeeper? Are you providing an assessment for the client s competency and ability to give consent?

11 REMEMBER!!!! It is not your job to make the decision to initiate hormone treatment or surgical procedures. It is the client s decision to pursue these treatments. Your role is to: Support their decision Assess for competence/ability to give consent Make sure they are prepared Provide appropriate documentation Address any mental health concerns You do not need to: Determine if the person is really trans

12 Hormones: Informed consent Individuals must be able to legally provide informed consent for treatment Mental health concerns do not preclude someone from receiving treatment Individuals do not need to be in counseling and are not required by the SOC to provide a letter from a therapist to receive hormone therapy, IF they have a health professional who is trained in behavioral health and competent in the assessment of GD. You should have some understanding of the changes that occur when people choose to take hormones

13 Referrals for Surgery Top Surgery One letter form a qualified mental health professional is required for chest surgery. Procedures: breast augmentation, mastectomy Bottom Surgery Two letters from qualified mental health professionals who have independently assessed the patient are required for genital surgery. One letter should be from a primary therapist and the second should be from someone who has done a thorough eval. Letters should cover the same information. If both clinicians are in the same practice, one letter signed by both may suffice. Procedures: hysterectomy, salpingooophorectomy, orchiectomy, metoidioplasty, phalloplasty, vaginoplasty

14 Things your clients should be aware of In compliance with WPATH standards, in order for their surgeon and insurance company to approve the surgery, a diagnosis of Gender Dysphoria must be assigned The interview will potentially be emotionally intense and may even create some dysphoria as many personal questions will be asked Clients must have an identified surgeon to whom the letter will be directly sent, clients can not take letters with them for later use Clients must complete a ROI prior to leaving the meeting Surgeons may not consider clients good candidates for surgery if the client has attempted suicide in the preceding year It is not recommended to write letters for previous clients who have not had an updated assessment

15 Questions to ask during the assessment/interview Ask about gender identity and sexual orientation. How do they identify? What words do they use? If they are asking for on-going therapy, are they seeking therapy related to their gender identity? Or is there something else going on? Age at which they first began to identify an incongruence between how they thought about themselves and how other people saw them What is their experience of being able to freely express their gender? Are they able to live full time consistent with their identity? Where are they in their process? What is their social, familial, relational support like? Intersectional considerations What is their experience with minority stress? Have they made any decisions regarding family planning/fertility?

16 What are they hoping to get from therapy? What role can you play in helping them to identify options and facilitate connection to other resources? Are they currently on hormones? Are they getting the hormones legally? Have they ever used illegal hormones? Have they had any surgical procedures? Are they planning on pursing these options? What is their knowledge/understanding of the WPATH standards? What is their understanding of the short/long term benefits of the procedure? What is their understanding of the potential risks of the procedure? Do they understand that the surgical procedures are not reversible? Do they understand that the outcomes of hormone therapy are not necessarily predictable and are affected by their unique genetic makeup? Some of the outcomes of hormone therapy are permanent and can not be changed even after going off hormones. What is their plan for work/school/life interruption and aftercare following procedures?

17 Elements to include in a good letter: 1. Your relationship to the client 2. Use the client s name (if they have not legally changed their name, note this) and pronouns, do not dead name or misgender your clients 3. Duration/frequency of contact 4. Biopsychosocial assessment, which should specifically include the following: Ways client is affirming/inhabiting their gender: have they legally changed their name, degree to which they are out, social transition, Experience of dysphoria Stability/instability in academic/professional/career/financial/relational realms 5. Any DSM diagnoses, history of mental health treatment and medications 6. Must state that the person meets criteria for gender dysphoria 7. Ability to give consent and make decisions 8. The client s understanding of costs/benefits, not reversible, risks of infection, rejections, complications 9. The adequacy of the client s aftercare plan 10. That the therapist is available for consultation and coordination

18 Billing Questions we don t have answers to.. If you work in a fee-for-service environment and your client s insurance coverage or ability to pay allows you to bill an assessment session (90791), this is the ideal route. If their coverage or ability to pay precludes an additional assessment session beyond your initial intake, consult with your billing specialist. You may be able to bill the session as psychotherapy (eg, 90837) assuming gender dysphoria is reflected in your diagnosis and treatment plan. Suggested documentation is in your handouts. Locating providers for procedures What to do when the situation changes between writing the letter and the surgery How to navigate meeting WPATH SOC, the needs of the client, requirements of providers, and insurance company demands

19 Final thoughts We always learn from our clients, AND we do not rely solely on them to teach us. Consult! Find partners in your agency/community who are committed to this work and willing to journey with you. Read WPATH standards and other resources, such as those available from the Center of Excellence for Transgender Health ( and practice guidelines published by behavioral health professional organizations (eg, APA). Questions?

20 Thanks, y all