Ethical Considerations For Two Referral Letters Questioned

[VickySGV]

Good discussion on the need for two letters for SRS, and a recommendation to WPATH.

http://www.theatlantic.com/health/archive/2014/12/transgender-people-face-outsized-barriers-to-genital-surgery/383788/2/

[Guest Ky_Ki]

Well a revision to WPATH in 2015 sounds like good news!

[Charlize]

I certainly have no trouble with the requirements for two letters. At the time of getting them it is a bit of a nuisance but the idea is valid. I do wonder how much the second 'evaluating therapist' gets to know you in a visit or two. I'm also glad to read again about the slow movement towards insurance coverage. I wish it would speed up as there are too many of us in debt or working 3 jobs simply to handle a situation we would love to have avoided at birth.

Hugs,

Charlize

[Guest]

Here's for hoping for the elimination of the second assessment.

Some of us have an almost impossible time to get one assessment done in a timely fashion. Never mind two of them.

Huggs,

Joann

[Carolyn Marie]

You can bet that insurance companies will seize on any requirement, even if only a guideline, to make getting surgery that much harder. I don't know if having two recommendations is better than one, but if one of them comes from a therapist/psychologist that is just doing a pro forma evaluation, then what is the point?

Carolyn Marie

[VickySGV]

In my case I paid out of pocket for my surgery (opportune time for a home mortgage refinance) so insurance paying for the surgery was not an issue. Where insurance came into play for me, was the Errors & Omissions (aka Malpractice) insurance of the hospital. They had an exclusion for covering them if I did not have the boiler plated level of screening. During a meeting with my surgeon before the actual surgery date, even she was nonchalant about her professional conscience's need for more than a single letter. As it was, I actually did get away with a single letter signed by a therapist and his supervising physician in the Behavioral Health Clinic at my HMO's regional center. A year after I had my surgery, my HMO would have covered the surgery, but not with my preferred surgeon. SIGH.

[Guest LizMarie]

I've always been bothered by the need for a second letter from someone who sees you once or twice then rubberstamps what the first therapist says. The first letter seems fine to me. Your therapist works with you, gets to know you, and can have a reasonable evaluation of you. But one visit?

[Drea]

Why bother with even one letter?

Time and again I am told how therapy is only something for those who aren't well adjusted (in other words someone else by them) and how such requirements are archaic.

[Guest Leah1026]

Why bother with even one letter?

Time and again I am told how therapy is only something for those who aren't well adjusted (in other words someone else by them) and how such requirements are archaic.

IMO everyone could benefit from at least some therapy. The letters of recommendation also provide legal cover for the surgeon. Without that all surgeons would be wide open to lawsuits and they may decide it's not worth doing anymore.

I have no issues with the current version of the Standards of Care. People may have issues with how certain doctors or national healthcare services interpret them, but the problem isn't the SOC in and of themselves.

[Guest LizMarie]

I concur with Leah. Well stated!

[Guest Jenny_W]

Yes, very well said Leah. Personally, I didn't have an issue at all with getting approval from 2 psychiatrists prior to my surgery. I believe there needs to be some checks and balances around this type of surgery because it's not like you can change your mind later. I also believe the 12 months RLT was beneficial because it ensured that I experienced a range of situations living as a woman prior to making the next big step.

After GRS, my outlook has changed which I didn't fully expect. I no longer feel that I have anything to prove to anyone - almost as if I was trying to justify my transition prior to surgery. Now, I feel more right than I ever have in my life and it's a significant shift from how I felt prior to GRS.

Maybe people should look at getting 2 letters as mandatory support rather than viewing this requirement as negative? GRS is a big deal and shouldn't be entered into lightly. Even marriage you can out of if you realise you've made a mistake.

Jen

[Charlize]

Leah brought up an important thought. The doctors who care for us are on the edge of what many of their colleagues feel to be ethical. They are examined and have to live to a higher standard than surgeons doing more accepted work. My surgeon is very careful for that reason and i can't regret the care she takes.

As C just noted as we face the knife and changes that it suddenly brings it is best to have talked it out with others. It is a nuisance and the mountain ahead of me seemed huge when i first saw it but now that a date has been set i'm glad for the help i've gotten.

Hugs,

Charlize

[Guest MsPerseveres]

Why bother with even one letter?

Time and again I am told how therapy is only something for those who aren't well adjusted (in other words someone else by them) and how such requirements are archaic.

I can think of at least one situation where an individual faked their letters of referral, and expressed suicidal levels of regret after having the surgery done. I think that the due diligence provided by a psychiatric evaluation that includes an assessment of the individual's understanding of the impacts of what they are getting themselves into is invaluable.

I also completely agree with the one year RLE - I had a very rapid transition, and without that year, I would have faced far too many situations after the surgery that would have been unexpected, and unwelcome. I know of one woman who went with the reduced 6 month requirement, but spent the first two or three months of her RLE receiving FFS, recovering from FFS and being off for Christmas vacations - I believe that she spent one week at work in her first 3 months of RLE. She never really started living "real life" as a woman until after the surgery, and her expectations were unrealistic on how it should be, and put her into a depressed state as well.

It no longer affects me, but I think that managing the expectations of the cis world, particularly the insurers and medical community, is important to those following behind. Making this something that one can rush into over a weekend inspiration, and regret for the rest of their life, isn't a good idea.

[Guest Ky_Ki]

I find the one year RLE more problematic because it seems completely superfluous and irrational. What does a year as living socially as a woman/man have anything to do with a new set of physical genitals? It doesn't seem like one could possibly prepare you for the other. They're do completely different things. And frankly one should be able to do one without the other. Social transition is not a great option for many people. At least psychiatric evaluations make sense

[Guest Carla_Davis]

My preferred GCS surgeon normally requires 2 letters, unless I can document living Full-Time as a female for 5 or more years, in which case I only need 1 letter.

My HMO, requires 2 letters if I decide to go through them which is highly unlikely, because I do not believe the doctor is an In-network provider.

I DO agree, that insurance companies will make it difficult for patents to get surgery covered by them, as away of trying to discourage individuals.

New York State Health Insurance Companies were just ordered by Gov. Cuomo to cover transgender transitioning care, including surgery if the patient is receiving mental health care for GD

NYS Medcare was also ordered to provide transitioning care, including surgery, if the patient is receiving mental health care for GD.

It was also pointed out that the number of transgender individuals that this would effect would be so small that it would unlikely cause any increase in health premiums to cover transgender care and surgery.

It would be helpful if the WPATH was updated in 2015, even though it is only a "Guideline", some medical professionals accept it as a "Requirement".

Lets hope for change in 2015

Hugs,

Carla

[Drea]

Why bother with even one letter?

Time and again I am told how therapy is only something for those who aren't well adjusted (in other words someone else by them) and how such requirements are archaic.

I can think of at least one situation where an individual faked their letters of referral, and expressed suicidal levels of regret after having the surgery done. I think that the due diligence provided by a psychiatric evaluation that includes an assessment of the individual's understanding of the impacts of what they are getting themselves into is invaluable.

My quote you address is rhetorical in nature as some of the arguments against the second referral tend to match the arguments about any need of a therapist in the first place. People who are "well adjusted" which 90% of the time is their own self declaration while at the same time, when they have had a therapist, decrying their therapist for wanting to discuss things the trans person is unwilling.

I also completely agree with the one year RLE - I had a very rapid transition, and without that year, I would have faced far too many situations after the surgery that would have been unexpected, and unwelcome. I know of one woman who went with the reduced 6 month requirement, but spent the first two or three months of her RLE receiving FFS, recovering from FFS and being off for Christmas vacations - I believe that she spent one week at work in her first 3 months of RLE. She never really started living "real life" as a woman until after the surgery, and her expectations were unrealistic on how it should be, and put her into a depressed state as well.

I don't have any issue with RLT, and I've seen lots seek to avoid it or at least the spirit of it. For example the faux retirement where the person has enough money to carry them for a year or few years but certainly not enough to permanently retire. The stop work to avoid dealing with employment and get thru whatever period, have SRS, then start to look for work. Being post-op of course solves all employment issues right? (another area of faulty logic I often see)

I find the one year RLE more problematic because it seems completely superfluous and irrational. What does a year as living socially as a woman/man have anything to do with a new set of physical genitals? It doesn't seem like one could possibly prepare you for the other. They're do completely different things. And frankly one should be able to do one without the other. Social transition is not a great option for many people. At least psychiatric evaluations make sense

You are correct, living in the new gender role has very little relevance on readiness for genital surgery nor does it prepare one for surgery.

That of course begs the question, why does the standard exist in the first place? The professionals largely understand that living in social role itself doesn't prepare one for surgery.

Many trans people will argue that it is necessary for one to be sure.

In my opinion the requirement exists because:

1) It fits the do no harm medical model that promotes least invasive most reversible treatments first progressing thru the more invasive, least reversible. The idea being the person only need to avail themselves of the treatment options they need to find comfort rather than jumping to the most invasive first.

2) Many transitioners dysphoria is rooted in social gender role and surgery is little more than "part of the package", "confirmation", "icing on the cake". That if they didn't change social role there would be no point in surgery. Thus RLT gives them opportunity to develop comfort and assurance in the new gender role as well as demonstrate their adjustment before having surgery.

3) There are trans people who mistakenly see surgery as resolving social role issues and thus, while really interested in social role latch onto the idea of having surgery first. I have encountered quite a few thru the years who said surgery was the most important to them until they started living full time. After living full time they found their interest in surgery significantly wane. In some cases they decided there was no point in surgery.

4) There trans people who have both physical and social dysphoria and RLT gives opportunity to address the relative magnitudes by dealing with the social first (least invasive/more reversible) to give opportunity to evaluate need for surgery without the social dysphoria.

5) It is a speed bump. Especially for the do-it-yourselfers who reject therapy and just seek to check off boxes. In fact there are many "gender therpists" out there that cater to this sort of thing, point at the standards and say have at it, collect a few bucks from infrequent sessions (once every month or three) and write referrals.

RLT essentially gives folks opportunity to decide if social role is right for them and to put their need for surgery into perspective after addressing social issues.

In my opinion, the first year RLE/RLT is a time of significant growth that is very valuable in and of itself.

I have found that most people who argue against RLE/RLT express desire to live full time, but balk at the key element of that which is, well...living full time. This is rational is that it is unreasonable to do so before surgery (e.g. item 3 above). I don't really understand this objection to RLT cause living in new social role is what they state they want most. Going full time isn't that difficult. I think this is more an idea of angst about doing so and like I said above the mistaken belief that surgery magically solves the going full time issues or somehow would magically make them pass.

On the flip side, there are some trans people for whom their dysphoria is rooted in the physical Who would have surgery even if they didn't change social gender roles. This is something many trans people can't comprehend because it isn't like them. RLT can become an obstacle because it offers little to no relief for their dysphoria to counteract the normal anxieties related to going full time. In fact it can end up adding additional focus to the physical dysphoria. This is where the therapist experience pays off and the standards allow for circumstances like this.

[Charlize]

So many of the requirements are due to the medical profession and it's extremely conservative bias. Any doctor who works with us has to prove as Drea mentions above that they will "do no harm". It is not only pressure from a disgruntled patient that may sue but from others in the medical profession. From where we sit it seems almost normal. Others see any procedure to be dangerous and unnecessary at best. I think we must remember that at this point, even though the climate is improving, those who treat us are acting on the fringe of "acceptability" in their profession. I feel they are heroes and heroines and will do what they require to protect themselves and us as necessary even though it sometimes seems foolish and without grounds.

Hugs,

Charlize