How to ask for a recommendation for HRT?

[missmacyrose]

I have had one therapy session so far, but he only did my intake assessment form and did not have time to do the full "gender assessment". He was not available for a long time so he scheduled me an appointment with another therapist with experience with gender dysphoria. He told me that she is the one who will do my "gender assessment" (I use air quotes because the notion that my gender needs assessing is laughable to me, but I digress). I want to know, from any trans people who have personal experience with this type of matter, what is the best way to ensure that she writes me my letter? This is through Kaiser Permanente and they are very trans friendly. I have heard stories of people with Kaiser getting their letters super easily. Do I just come straight out and ask for it? How to I make sure that it is VERY clear to her that I am ready to start as soon as possible, and hopefully get her to write me my letter right then? Please tell me how you personally went about getting your letters, especially if you have Kaiser.

[missmacyrose]

Sidenote- At my first therapy session, my depression was very very bad and I was feeling suicidal. My therapist told me that they would most likely not write me a recommendation until there was some stabilization in my depression, and he recommended I talk to my doctor about antidepressants. I plan to mark my depression much lower at this next session (there is a little quiz you take before each and every session where you rank your depression and things on a scale) and also tell them that I am actively seeking help with my depression, that I scheduled an appointment with my primary to discuss meds with him... do you guys think that the fact I am seeking help with the depression help my case getting my letter?

[Michelle_P]

Hi, Macy!  I'm with Kaiser NorCal.  They use a modified informed consent model, often putting a patient on HRT after just a couple sessions with a gender therapist.

My experience was a little different, partly because of my own actions in delaying HRT.

I had an initial contact with a generalist therapist, for suicidal depression and anxiety.  I came out in my first session, and he mentioned the gender specialists.  We did a few more sessions to help me with coping with the depression and anxiety.  In my particular case, I was not put on antidepressants or antianxiety drugs as he felt the cause was likely external (that is, my gender dysphoria and the stress from being in hiding, rather than organic and being amenible to medications).

I was referred to the gender therapist, and during my intake with her I mentioned that I would be interested in HRT eventually, but wanted to wait at least a few months and make sure that I was really being driven by gender dysphoria and not something else. At this point my wife had already put limits on me, including 'no HRT.'  She dropped that constraint after my second run at suicide a few months later.

After that, I thought that perhaps I should try HRT, as I had understood that it often helped with the depression and anxiety.   I went so far as to write my own 'referral letter' to try and demonstrate that I knew what was involved.  I went into my next appointment with the gender specialist, and after the 'check in' ritual, said I wanted to ask about something.  She immediately said:

"Oh, do you want to start HRT?"
"Yes, please!"
"Just a sec..." She turned to her computer and typed for a second.  "Do you prefer morning or afternoon appointments?" 
"Um... Morning?"
"How does tomorrow at 10 AM sound?  Dr. Che is a good endocrinologist here."
"Um... Yes, please!"

That's about as close as I've gotten to formal letters.

The approval process for FFS and GCS was simlar.  I met with a psychologist who went over my record, and was put on the queue to meet with the appropriate surgeons.  I've already had the FFS meeting and am now in the queue to have FFS scheduled.  I will be meeting with the GCS surgeon in a few months.

Everything is in the electronic records system.  I'm sure they could produce a formal letter if needed, but in their system, I've never seen one.

[Anne Blake]

Hello Macy,

You have already heard from Michelle and her experiences with Kaiser. I can attest that she is well worth listening to.

I have another point to suggest about therapy and getting hrt recommendations. A therapist can be either a useful agent in helping you understand how to grow into who you need to be or they can just be a gate keeper in constraining your access from what you feel you need. The difference lies in both their capabilities and your openness and willingness in pursuing growth. I have learned some good things about me in the process of working with my therapist. As to your point of how to get "The Letter", be open at the beginning of your engagement, tell them your goals; and be totally honest.

[DawnOday]

Hi, Macy!  I'm with Kaiser NorCal.  They use a modified informed consent model, often putting a patient on HRT after just a couple sessions with a gender therapist.

My experience was a little different, partly because of my own actions in delaying HRT.

I had an initial contact with a generalist therapist, for suicidal depression and anxiety.  I came out in my first session, and he mentioned the gender specialists.  We did a few more sessions to help me with coping with the depression and anxiety.  In my particular case, I was not put on antidepressants or antianxiety drugs as he felt the cause was likely external (that is, my gender dysphoria and the stress from being in hiding, rather than organic and being amenible to medications).

I was referred to the gender therapist, and during my intake with her I mentioned that I would be interested in HRT eventually, but wanted to wait at least a few months and make sure that I was really being driven by gender dysphoria and not something else. At this point my wife had already put limits on me, including 'no HRT.'  She dropped that constraint after my second run at suicide a few months later.

After that, I thought that perhaps I should try HRT, as I had understood that it often helped with the depression and anxiety.   I went so far as to write my own 'referral letter' to try and demonstrate that I knew what was involved.  I went into my next appointment with the gender specialist, and after the 'check in' ritual, said I wanted to ask about something.  She immediately said:

"Oh, do you want to start HRT?"
"Yes, please!"
"Just a sec..." She turned to her computer and typed for a second.  "Do you prefer morning or afternoon appointments?" 
"Um... Morning?"
"How does tomorrow at 10 AM sound?  Dr. Che is a good endocrinologist here."
"Um... Yes, please!"

That's about as close as I've gotten to formal letters.

The approval process for FFS and GCS was simlar.  I met with a psychologist who went over my record, and was put on the queue to meet with the appropriate surgeons.  I've already had the FFS meeting and am now in the queue to have FFS scheduled.  I will be meeting with the GCS surgeon in a few months.

Everything is in the electronic records system.  I'm sure they could produce a formal letter if needed, but in their system, I've never seen one.

Now that you mention it, I too never received a formal letter From GHC now Kaiser. I do know Misty, my therapist did input information in the computer and set me up with Dr. Lightbody. This was on my third visit. I also remember her asking if I wanted to use my female name so now every time I sign in I am identified as DAWN  and the description Transgender is also visible. I have since been referred to a speech therapist who is also a change mentor so I get not just voice lessons, but instruction on make up. Non verbal communication, how to dress age appropriately. I have recently been invited to come to counseling en femme. Last visit was my first conscious reveal to anyone. Tomorrow she wants me to sit in the lobby to expose myself (not literally) to the public.

[Michelle_P]

I have recently been invited to come to counseling en femme. Last visit was my first conscious reveal to anyone. Tomorrow she wants me to sit in the lobby to expose myself (not literally) to the public.

And you very likely won't even get a second glance from anybody.  Just try to relax, check in, and have a seat like everyone else. 

I love the Kaiser system and the electronic record keeping.  When I did my official name change, that was entered  one time by the 'member advocate' who was helping me, and presto! Every office, every employee saw my corrected name and gender, no issues anywhere.

Macy, I think you'll find the 'paperwork' side of Kaiser will be very easy to deal with.

[LexiDreamer]

I don't have experience from the place you're going to, but I'll share my experience for anyone else out there wondering the same thing.

I dropped my family GP for a (not so) local Trans friendly Medical Center, that was founded by the LGBT center of the city nearest to me.

I was taking herbal E at the time and my new GP told me that I should drop the herbals in favor of pharmaceutical HRT. On my next visit I told her I was ready for prescribed HRT. She told me, "OK, but you need to be evaluated by our mental health department". 
I argued a little bit and told her "Well I already have a therapist and I can have her send you a letter of recommendation" She insisted that I need to be evaluated by their people, regardless of my therapist's opinion.

So, after my appointment I went 2 floors up to sign up for my evaluation.
They took my name and number and then told me there was a waiting list for "Transgender Evaluation" and I was 11th on the list! My thought was cool that there are that many people looking to transition, but bummer that I have to wait.

A month or so passes and I go to my new GP for a follow up appointment. Before my appointment I check upstairs to get an estimate on how long before I can begin my evaluation. They tell me that they've frozen the waiting list, and I'm still in 11th place on the list! WTF!

I go to downstairs to my GP for my follow up and tell her how disappointed I am about the debacle happening upstairs and I don't want to wait indefinitely. She gave me a list of endos that they work with and says try one of these doctors then.

I took the the list home and started calling. All of the names I called were not currently taking new patients except one...and they could get me an appointment in about 4 months! WTF! There was no way I was gonna wait 4 months!

So I called up my GP and told her, "This list is useless and I'm not waiting 4 months just to talk to an endo. I'm just going to go ahead and order what I need from the internet. But I need you to order blood tests for me so we can monitor my health and progress!"

Of course she gave me the standard "I advise against doing this yourself... yada yada yada."

About an hour later I get a phone call from the Mental Health division... "We have an opening for you, can you come in this Thursday?" Whaddya know! What happened to the waiting list? I don't know, and nor did I ask!

I went into the appointment, sat down and in the most friendly tone I could muster, I told the therapist "This whole evaluation is only a formality for me. I'm proceeding with my transition one way or another."
He explained there was a standard questionnaire that we would be going through together and it would require 2 more appointments.
"Let's get started then!"
He was able to schedule me in for 2 more appointments within the next two weeks to finish it up in a timely fashion.

On my last appointment, I should up completely dressed as "Lexi" and that sealed the deal! We finished and told me he was recommending me to start HRT!

I'm sorry for the wordy post... but the moral of the story is, just don't take "no" for an answer.
It's my experience that we have to drive our own health care. Otherwise, you won't be happy with the results and doctors tend to not really listen to you.

Just recently I had to argue with my GP to get her to prescribe me progesterone. I tried it her way (she wanted to lower my Spiro to increase my T a bit) and it didn't work. I had to push back and say "this isn't working and I don't like the results!"
She sent in the script for the progesterone after that. I've been on it for a month now and the results are great!

They may be the gatekeepers, but sometimes you have to threaten to jump the fence before they'll let you in!

Anyway, good luck and enjoy the ride!

[KathyLauren]

The folks here pretty much stick to the WPATH guidelines, since that is what our health system requires.  On my first appointment with my therapist, we started out with the standard "Why are you here?" question.  I told her straight out that I was pretty sure I was transgender and that I wanted a hormone readiness assessment.  We did three hour-long sessions (including that first one) which together made up the assessment.

She asked me some personal history questions, like how far back I remember wanting to be a woman, what I did about it, etc..  Part of the assessment is that the therapist needs to determine if you suffer from any delusions that make you think you are trans when you aren't really.  (I don't think that's terribly common, but they have to check.)  Part of it is also the "informed consent" part, where they make sure you know what effect the hormones will have on you, what the risks are, etc..

After the three sessions, she wrote my letter and referred me to the clinic where the doctor checks my levels and writes my prescriptions.  It was all pretty painless.

[missmacyrose]

Wow, thank you all, this is very useful information. My session is in 4 days and I'm going to take the advice about just being honest and open, telling her exactly how my Dysphoria affects my every day life and how I feel like I am 100% ready to start HRT. Hopefully she says okay and sets it up! So far, Kaiser has been amazing. My therapist asked me at my first session if I'd like my preferred name changed to Macy, I said yes, he clicked a few keys and BAM! 2 days later at my preliminary consult with my endo, everyone there referred to me as Macy no questions asked!