Transgender Children and Youth

THERE ARE CERTAIN SITUATIONS IN WHICH A TRANSGENDER young person will need or benefit from a letter from a licensed mental health professional. Carry Letters can be useful for trans youth who present in their affirmed gender, but whose identity documents still reflect their birth-assigned sex as their gender marker. If youth are questioned by legal authorities, these letters from their medical doctor or licensed mental health professional are sometimes helpful in “explaining” the difference between the young person’s gender presentation and the gender marker on their identity document, such as their driver’s license. As the samples reflect, these letters do not generally need to be lengthy.

A letter from a medical provider or licensed mental health professional is often required when a transgender young person wants to change the gender marker on their driver’s permit or license. While a sample letter is provided, specific requirements vary from state to state. Parents and/or professionals need to contact the Department of Motor Vehicles to find out the exact content and wording required within their state.

The recommended content of letters required for medical transition (hormone blockers, gender-affirming hormone therapy, and surgeries) can be found on pages 26-28 of the WPATH Standards of Care (2012). These letters need to set out detailed facts that support the diagnosis and recommendations. The Standards of Care indicate that hormone therapy and top surgery require one letter from a licensed mental health professional. Lower surgery requires two letters from licensed mental health professionals, one of whom must have an M.D or Ph.D. These letters must state that the client meets the DSM-V criteria for gender dysphoria.

With health insurance coverage increasingly covering transgender-related healthcare, including medical transition, it is important to cite the WPATH Standards of Care (2012) guideline specifying that hormone therapy (including hormone blockers) and both top and bottom surgeries are “appropriate and essential medical treatment” for gender dysphoria. This guideline is reinforced by noting that these treatments are considered medically necessary by all major United States medical and psychiatric organizations. I have provided sample text below and you will see this text in each of the sample letters addressing medical interventions:

It is my diagnosis that [full name] fully meets the criteria for Gender Dysphoria (302.85, DSM V). The appropriate and essential medical treatment for Gender Dysphoria includes both hormonal treatments and gender-confirming surgeries. These treatments are considered medically necessary by all major United States medical and psychiatric organizations and are recommended by The World Professional Association for Transgender Health (WPATH) Standards of Care.

The sample letters provided in this appendix describe hypothetical composites and offer suggested text. They are not in any way guaranteed to achieve their goals. All medical providers and licensed mental health professionals providing letters like these need to ensure that the content meets federal and state requirements, as well as those specified by individual health insurance carriers.

[Mental health professional’s name, credentials]

[Office address]

[Telephone and email]

[Date]

To Whom It May Concern:

This letter serves to confirm that FULL LEGAL NAME (can place preferred name here) is a transgender person/man/woman (whichever applies) and is in treatment with me for Gender Dysphoria (DSM 302.85; ICD-10-CM, F64.1). XX’s appearance and gender expression may vary from that expected from ID gender markers. (In other words, he/she/they may not look the way you might think a man or woman would/should.) This is not for the purpose of deception but is part of their treatment for gender dysphoria.

As a New York State clinical social worker, I have worked with many transgender and gender-nonconforming clients over the past 20 years—first as the director of adolescent and adult mental health services at the LGBT Community Center in New York City and then, for the past 12 years, in my private clinical practice. I am a social work professor at the University of Saint Joseph, West Hartford, CT. I provide training for medical and mental health professionals throughout the tri-state area on best practices for work with transgender and gender-nonconforming persons. I have been a member of the World Professional Association for Transgender Health (WPATH) for 12 years.

If you have any questions, please feel free to contact me.

Sincerely,

[Mental health professional’s name, credentials]

[Office address]

[Telephone and email]

[Date]

Department of Motor Vehicles

[Mental health professional’s state]

As a New York State clinical social worker, I have worked with many transgender and gender-nonconforming clients over the past 20 years—first as the director of adolescent and adult mental health services at the LGBT Community Center in NYC and then, for the past 12 years, in private clinical practice. I teach gender identity/expression and transgender care at Columbia University School of Social Work and offer postgraduate clinical training in work with transgender clients at the Institute for Contemporary Psychotherapy in New York City. I have been a member of the World Professional Association for Transgender Health (WPATH) for the past 12 years and participate in the Gender Working Group at Columbia Presbyterian Psychiatric Institute in New York City.

This letter serves to confirm that [client’s full name] is in treatment with me for Gender Dysphoria (302.85). [Client’s name] is a transgender man/woman and has been living full time as a man/woman for the past two years. He/She has legally changed his/her name and should be considered male/female in all legal jurisdictions. Please update all legal gender markers to read “male”/”female”.

Thank you for your assistance with this matter. If you have any further questions, please feel free to contact me.

Sincerely,

[Mental health professional’s name, credentials]

(This sample is for a young trans man, adapt as appropriate for young trans women)

[Mental health professional’s name, credentials]

[Office address]

[Telephone and email]

[Date]

Dr. [doctor’s name]

[Doctor’s address]

RE: [Client’s preferred first/last name] (legal name: [first/last]), DOB [client’s date of birth]

Dear Dr. [doctor’s name]:

I am writing on behalf of my client, [preferred name], a 13-year-old trans-masculine-identified individual (natal female) who has been seeing me for regular individual psychotherapy since [date]. I have also seen him several times in conjunction with his mother, [name]. [Client’s name] resides with his mother and younger brother in [town, state] and is completing eighth grade in school. [Client’s name]’s parents are separated, but both are involved in their children’s lives.

As a NYS clinical social worker, I have worked with many transgender and gender-nonconforming clients, both adolescents and adults, over the past 20 years—first as the director of adolescent and adult mental health services at the LGBT Community Center in NYC and then, for the past 12 years, in private clinical practice. I teach on LGBT issues, including gender identity/expression at Columbia University School of Social Work, and offer postgraduate clinical training in work with transgender individuals at several psychotherapy institutes. I have been a member of WPATH for the past 12 years and am a member of an ongoing peer consultation group for work with trans and gender-variant children and adolescents.

[Client’s name] and his mother report that he has experienced cross-gender identification since early childhood. From the ages of three to five years, [client’s name] never liked dresses and preferred to wear boys’ clothes. By the first grade, his mother reports, [client’s name]’s best friends were always boys. [Client’s name] reports that as a child, he always wished he was a boy but never knew it was possible to transition. [Client’s name]’s gender dysphoria increased with the onset of puberty. There was a brief period during the fifth grade when [client’s name] reports he tried to fit in better at school by dressing more like a girl, but he says it never “felt right.” His mom reports conversations with her husband while [client’s name] was young in which she discussed [client’s name]’s consistent masculine gender presentation/expression.

In [month year)], [client’s name] came out to his parents about being transgender and began socially transitioning within his family and at school. He cut his hair, bought more masculine clothes, and began binding his chest. His mother met with his school guidance counselor, and the school began using his preferred name, [client’s name], and male pronouns. His transition at school at school this year has gone very well. [Client’s name] reports positive relationships with peers. He knows several other transgender youth at his school. [Client’s name] is a bright young man with a great sense of humor and makes friends easily (though he was rather shy as a young child).

[Client’s name]’s mother brought him to see me this past March because she felt he needed someone to talk to about his trans identity and his experiences transitioning as an adolescent male. The family has begun coming out about [client’s name]’s transition with close friends and family. Both parents are supportive of [client’s name] and his transition.

In meeting with [client’s name] and his mother over the past three months, it is my diagnosis that [client’s name] meets the DSM-5 criteria for Gender Dysphoria (302.85). He reports significant gender dysphoria in relation to living as a transgender male in a body that does not match his internal gender identity. He experiences particularly acute gender dysphoria (self-hatred, depression, anxiety) in relation to his monthly menses. [Client’s name] strongly wants to proceed with hormone blockers at this time. There are no current psychiatric concerns that would preclude moving forward.

I believe hormone blockers now would alleviate some of [client’s name]’s gender dysphoria, thus lessening risks for depression and anxiety. His parents fully support this decision. As outlined in the WPATH Standards of Care for gender dysphoria, hormone blockers are medically necessary for transgender youth. I believe beginning hormone blockers will enhance [client’s name]’s mental and emotional well-being, both in terms of his comfort within his body and in his ability to move more comfortably in the world. It is my recommendation that [client’s name] be allowed to proceed at this time. Please feel free to contact me if you have any further questions.

Sincerely,

[Mental health professional’s name]

(This sample is for a young trans woman, adapt as appropriate for young trans man)

[Begin letter; format as appropriate]

[Mental health professional’s name, credentials]

[Office address]

[Telephone and email]

[Date]

Dr. [doctor’s name]

[Doctor’s address]

RE: [Client’s preferred first/last name] (legal name: [first/last]), DOB [client’s date of birth]

Dear Dr. [doctor’s name]:

I am writing on behalf of my client, [client’s name], a 16-year-old trans-feminine-identified individual (natal male) who wants to begin feminizing hormone therapy. [Client’s name] first saw me on [date]. I have seen her on a weekly basis since then for continued gender assessment and supportive psychotherapy. I also regularly meet with [client’s name]’s father, [name], and with both of them together. While the father has experienced some of the emotions many parents of transgender youth struggle with, he clearly supports [client’s name] in moving forward with her gender transition.

[Client’s name]’s father is a single parent. Her biological mother was ill and unable to care for her. At that time, they lived in Montana and were part of a very supportive community.

In [year], when [client’s name] was eight years old, her father relocated them to the New York City area in [year]. Initially, [client’s name] attended a private school, but that proved to be a negative experience. [Client’s name] and her father then moved to [town], where she attended school for one year. After this, they moved to their current home in [town], where [client’s name] has been attending high school.

[Client’s name]’s gender presentation has always been more feminine. Her father reports that when she was three years old, she would wrap a bath towel around her head and pretend it was long, flowing hair. Her favorite clothing at seven years old was a princess dress.

[Client’s name] reports “always feeling like a girl.” She presents with profound gender dysphoria that causes significant distress and interferes with her ability to engage productively in other areas of her life. She has extreme difficulty navigating men’s restrooms and feels tremendous dis-ease about her male body, especially when showering or looking at herself in the mirror. She reports feeling very angry when peers call her “bro” or “dude.”

In [month year], [client’s name] came out as transgender to her father and a few friends. Since then, she has come out widely at school with teachers and classmates. She has begun to use “[client’s name]” consistently as well as to dress and do her hair more femininely. Her goal is to begin school this coming fall fully presenting as a young woman. This includes obtaining a legal name change and beginning feminizing hormone treatment.

One area of concern is the ongoing conflict between the father and [client’s name]—often centered around [client’s name]’s failure to follow through on chores, not completing homework and sometimes refusing to attend school, and frequent angry outbursts toward her father.

We have discussed these areas in my work with [client’s name] and her father. These struggles seem partly related to [client’s name]’s gender dysphoria as well as to the stressors accompanying moving repeatedly, the loss of their family/community supports in Montana, and the challenges for [client’s name] of establishing new peer relationships in several different schools. When we first began meeting together, we attempted to focus on the family conflicts and [client’s name]’s failing school performance before moving forward with hormone therapy. While there has been some improvement in these areas, both remain critical areas of concern.

It is my assessment at this time that withholding feminizing hormone treatment has become psychologically harmful for [client’s name] and is leading to more severe gender dysphoria. While we will continue to focus on these other areas in therapy, my hope is that beginning hormone treatment may diminish her gender dysphoria and thus lead to enhanced self-esteem, fewer emotional outbursts and less anger, and improved ability to focus on school work.

As a NYS clinical social worker, I have worked with many transgender and gender-nonconforming clients, both adolescents and adults, over the past 20 years—first as the director of adolescent and adult mental health services at the LGBT Community Center in New York City and then, for the past 12 years, in private clinical practice in Manhattan and Westchester County, New York. I teach on LGBT issues, including gender identity/expression at Columbia University School of Social Work, and offer postgraduate clinical training in work with transgender clients at several psychotherapy institutes. I have been a member of WPATH for the past 12 years.

In meeting with [client’s name] over the past several months, it is my diagnosis that she meets the DSM-5 criteria for Gender Dysphoria (302.85). [Client’s name] believes that beginning feminizing hormone therapy is the next step in her transition. There are no current psychiatric concerns that would preclude beginning estrogen. She does not report current depression except occasionally in relation to her struggles in living as a transgender female in a body that does not match her internal gender identity.

As outlined in the WPATH Standards of Care for gender dysphoria, hormone therapy is medically necessary for transgender youth and can begin in adolescence. I believe this step will enhance [client’s name]’s life in terms of both her emotional comfort within herself and her ability to move more comfortably in the world as a young woman. Her father supports initiating feminizing hormone therapy. It is my recommendation that [client’s name] be allowed to begin treatment with estrogen at this time. Please feel free to contact me if you have any further questions.

Sincerely,

[Mental health professional’s name, credentials]

(This sample is for a young trans woman, adapt as appropriate for young trans man. In the final paragraph, you would generally state the specific surgery, e.g., vaginoplasty, chest reconstruction, phalloplasty.)

[Mental health professional’s name, credentials]

[Office address]

[Telephone and email]

[Date]

Dr. [doctor’s name]

[Doctor’s address]

RE: [Client’s preferred first/last name] (legal name: [first/last]), DOB [client’s date of birth]

Dear Dr. [doctor’s name]:

As a New York State clinical social worker, I have worked with many transgender and gender-nonconforming clients over the past 20 years—first as the director of adolescent and adult mental health services at the LGBT Community Center in NYC and then, for the past 12 years, in private clinical practice. I teach gender identity/expression and transgender care at Columbia University School of Social Work and offer postgraduate clinical training in work with transgender clients at several institutes. I have been a member of the World Professional Association for Transgender Health (WPATH) for the past 12 years.

From [date] to [date], I met weekly with [client’s name] for gender evaluation and assessment as well as supportive psychotherapy. She was referred to me by a clinical colleague after disclosing to that colleague that she wanted to begin to gender transition.

[Client’s name] is a nearly 21-year-old transgender woman (natal male) who according to her report “always felt female.” This gender dysphoria intensified during adolescence. [Client’s name] was born and raised in Manhattan with her parents, [names], and one sibling. I have met with [client’s name]’s family on several occasions, and they are very supportive of her gender transition.

During the year we worked together in New York City, [client’s name] came out as transgender with her friends, socially transitioned, and developed a supportive intimate personal relationship. She attended a weekly transgender women’s support group and participated in a weekend transgender conference that spring. She began hormone therapy in June [year].

In the fall of [year], [client’s name] began her undergraduate studies at College X as an out transgender woman. She has done well both academically and socially. She returned this fall as a sophomore and is looking to transfer schools for the next year. She is a math major who also has extensive musical interests. [Client’s name] and I continue to meet for psychotherapy when she is home for weekends in New York City and during college breaks, including numerous times this past summer.

It is my diagnosis that [client’s name] fully meets the criteria for Gender Dysphoria (302.85, DSM-5). The appropriate and essential medical treatment for Gender Dysphoria includes both hormonal treatments and gender-confirming surgeries. These treatments are considered medically necessary by all major United States medical and psychiatric organizations and are recommended by the World Professional Association for Transgender Health (WPATH).

Given [client’s name]’s current level of gender dysphoria (mental and emotional distress), it is my belief that the gender-confirming surgeries [specify exact surgery] scheduled with Dr. [name] are medically necessary and essential for [client’s name]’s mental and emotional well-being. Given her diagnosis, the surgery should be completed as soon as possible. If you have any questions, please feel free to contact me at the above phone or email. Thank you very much.

Sincerely,

[Mental health professional’s name, credentials]