Transgender Teen Survival Guide

Lee says:

Hi everyone! I'm posting today to specifically point out an awesome resource that more people should be aware of.

The Gender Affirming Letter Access Project (GALAP) is an organization of independent clinicians who help transgender people access gender-affirming medical treatment like hormone replacement therapy and surgery by providing free letters using the informed-consent system.

The providers listed in the GALAP directory have pledged to complete at least one free informed-consent session and subsequently write at least one free letter per month.

This is super important because many people aren't able to get insurance coverage for the treatment they need without getting a WPATH-compliant letter, and that can make it difficult for someone to be able to start their transition.

For example, many low-income trans people aren't able to afford multiple therapy sessions which makes getting the WPATH-compliant letter difficult for them.

Similarly, trans people living in rural areas face more barriers in being able to find therapists near them who are trans-friendly and currently accepting new patients.

In my own personal transition, I've needed to get...

For anyone keeping a tally, I needed to get 10 mental health letters saying that I am trans and need to transition before I could get the medical care I needed, not including the “proof of HRT” letters.

It’s ridiculous— If I had needed treatment for any other reason, I wouldn’t have needed to jump through so many gatekeeping hoops where cisgender medical professionals were the arbiters if I was trans enough and deserve care.

For example, my stage 3 phalloplasty surgery is just having an erectile implant placed because I have erectile dysfunction. This is true of all post-phalloplasty patients as a result of the way our penis is structured.

If I were a cisgender man getting the same surgery for erectile dysfunction and having the same device implanted, I would not need to see two mental health professionals first who would judge me on my gender identity before deciding whether I should be allowed get the implant.

The urologist would just use their best medical judgement in determining whether the surgery would be a good idea and then explain the risks and benefits of the procedure and let me decide if I wanted to go ahead and do it. Then the doc would send the insurance the preauthorization info and codes for the procedure based on the diagnosis, and no required mental health evaluation or therapist letter would be involved at all.

But because my surgery is a “gender affirming surgery” for “treatment of gender dysphoria,” I have to see two therapists first and they will judge if I’m “trans enough” and then they have to write a letter saying that I need the surgery because I’m mentally ill (aka diagnosed with “gender dysphoria”) before my insurance will cover the surgery that’ll let me have an erection.

In my opinion, that’s paternalistic, demeaning, unnecessary and a waste of everyone’s time. And it isn’t just weird, invasive, and annoying— it can determine whether you’re able to access necessary medical care.

The GALAP also addresses how requiring a letter is a form of gatekeeping which can negatively impact multiply marginalized minorities, stating, "We are aware that people who do not fit a certain narrative about what it means to be 'transgender' often receive subpar care and face more barriers to receiving the care they need. We acknowledge that this greatly impacts people of color and indigenous communities, nonbinary people, and neurodivergent people."

The provider will have an interview session with you, using the informed consent approach in their interviewing, and then will write a letter, again using the informed consent approach in their letter writing process.

The interview session, the letter (and any additional copies of the letter) are all supposed to be pro-bono, which just means it's free. They aren't supposed to charge you for anything, like additional time on letter writing outside the therapy session, any clinical consultation they need to perform, or any communication with your surgeons and medical staff.

I believe that majority (or possibly all) of the providers in the directory will only provide informed consent letters for legal adults as the wesbite says "writing letters for youth brings up complexities since minors may assent but not consent without parent/guardian support to move forward with any medical interventions," so it's a resource that is more useful for those who are 18 or older.

You'll also need to discuss with your letter writer if they are comfortable officially diagnosing you with gender dysphoria if your medical provider/s and/or insurance company requires a formal a diagnosis of Gender Dysphoria to access gender-affirming medical services.

You should also check whether your letter writer needs particular credentials.

My insurance said:

“One of these letters must be from a psychiatrist, psychologist, nurse practitioner, psychiatric nurse practitioner, or licensed clinical social worker with whom the member has an established and ongoing relationship.

The other letter may be from a psychiatrist, psychologist, nurse practitioner, physician, psychiatric nurse practitioner, or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the member.”

Your insurance company may have more rigid requirements and need a letter from a medical doctor or doctor of osteopathic for example, and may not accept a licensed clinical social worker, or they may allow any mental health practitioner.

So it’s good to double-check that the person you’re contacting in the directory has the license you need for your requirements.

The GALAP site says:

The (current as of 04/2022) list of states that currently have a provider who has agreed to write free letters is below:

Most providers can only provide a letter to people residing in their state(s) of licensure, and there are some states that don't have any providers listed at all, so hopefully more providers will sign the pledge and get listed in the directory in the future.

But even as it is today, this is a super-useful resource for trans people who are looking to medically transition, and hopefully more people become aware of it and are able to make use of it going forward!

Our post on how to start HRT in the USA has linked to the GALAP website so this isn't the first time I've mentioned their directory, but I felt like the GALAP directory deserved its own post, so here it is!