Approval Letter model

Some trans and gender diverse people want to see a mental health professional for endorsement prior to starting hormones, and that’s okay. We are all about self-determination, and celebrate trans people making informed and autonomous choices about how we access gender affirming healthcare.

Trans people who prefer to access hormones in this way will do so for a variety of reasons.

For some, engaging with multiple clinicians over a longer period of time sits better with how they see their trans experience and medical gender affirmation. Having time and space to explore and unpack the reasons to start (or not start) hormones can be an important and therapeutic process.

Additionally, for those seeking surgical interventions, surgeons will generally require at least one referral (or two for genital surgeries) from a mental health professional and so establishing a relationship with a clinician from the start may be helpful.

The Approval Letter Model was once one of the only ways to learn about the effects, risks and protective factors associated with masculinising and feminising hormones, and up until the 7th edition of the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People (SoC7), this model was also one of the only ways to start hormonal therapy. The SoC7 opened up the possibility of informed consent, also known as ‘affirmation enablement’, to the wider community.

So even as the Approval Letter Model is beginning to fade from standard clinical practice in favour of the Informed Consent Model, with such a long history, it makes sense that some of us would prefer to start medically affirming our gender this way.

The process usually involves undertaking a mental health assessment and deep-dive into your history of gender incongruence and any gender dysphoria with a psychiatrist or psychologist who has experience working with trans people. When preparing a hormone-readiness endorsement referral to your GP, the mental health professional will provide some key insights, which will include:

1. Your gender and any other identifying characteristics;

2. The results of their psychosocial assessment of you, including any diagnoses;

3. How long you’ve been seeing each other, including the type of evaluation and therapy or counselling provided;

4. An outline confirming that the criteria for hormone therapy have been met, and a statement in support of your request for hormone therapy;

5. That you are making informed consent; and

6. Contact details for coordination of care, if sought

Additionally, you may be referred to an Endocrinologist who will assess your physical health and history, including family history, and arrange blood tests to establish base line levels of estrogen, testosterone and a range of other indicators such as liver function, thyroid levels, cholesterol, full blood count, electrolytes, glucose, lipids, and if applicable, pregnancy.

A genital exam is not required and is against recommendations1.

If you have complicated science-y questions about your particular hormone profile, or you’d like to work through your latest theory about the application gender affirming hormonal care, an Endocrinologist is a great specialist to build a relationship with. You may also need to see an Endocrinologist if a more standard hormone regime isn’t reaching the target levels, or you have some complex physical health issues going on that could benefit from a specialist assessment.

It is important that no part of this process, including seeing a mental health professional, Endocrinologist, or other medical professional feels forced upon you. Being forced to undergo a compulsory mental health assessment and evaluation, without adequate clinical reason and without your consent, is called gatekeeping. You can read more about on this page.