The Sanity Clause

This is the recommendation letter for top surgery that I wrote but didn’t send. Disclosure – my therapist reads my blog because I am not a big talker.

Jamie is an adult and is mature enough to decide to get top surgery. If Jamie wanted breast augmentation I wouldn’t be writing a permission letter, you’d just ask what cup size and take the money. 

As confused as Jamie has been about being trans, and as long as it took to get to this point, I don’t think anyone can talk Jamie out of this. It is her their body and I am honestly tired of listening to her them complain about wearing a binder and being a boy. Enough already. Please schedule this ASAP. Maybe then she they will deal with the remaining issues so that she they can finally finish therapy.

Grouch Marx and Chico Marx discuss the "Sanity Clause" in A Night at the Opera.

Grouch Marx and Chico Marx discuss the “Sanity Clause” in A Night at the Opera.

I’ve written my own recommendation letters before. A letter from a professor for a job, one from a friend for a co-op apartment purchase package, and my annual performance review at work. I always knew what to say.

Lo, those many years ago when I started therapy, I told my therapist that I had three issues I needed to work on: compulsive eating, my Dad’s death, and “gender stuff.” I spent many years avoiding talking. It’s been an expensive game of chess. One move and then a lot of silence. Then another move. When she questioned me I clammed up. Session after session. She waited me out.

I’m slow to trust and make personal connections. I expect people to judge me.

I look like an old-fashioned butch lesbian. Masculine attire, short hair, sensible shoes. A long-term relationship, a cute dog, and a dented green Subaru Outback. I thought I was keeping “it” under control. No one questioned whether I was butch enough; no one asked me if I was transgender. When there was an opening to talk about it I teetered on the precipice, but regained my balance.

I’ve known the truth since nursery school. I coveted anything associated with boys (clothes, toys, mannerisms). I still think I’m a boy. I never gave it up. I just drove it underground into fantasy. Where it festered. Until recently.

WPATH (World Professional Association for Transgender Health) recommends that patients get a referral for surgery from a qualified mental health professional; the letter proves that you are sane enough and trans enough to undergo surgery. My surgeon follows the WPATH protocols. My therapist is not a gender specialist; I am her first trans identified client. When I began to talk about being transgender she was not comfortable with the idea of me getting top surgery. But she came around.

I’d already researched the requirements for my insurance, the diagnostic criteria for Gender Identity Disorder, and the points WPATH suggests to make in the letter. It made sense for me to write a draft. I fruitlessly looked for sample letters online, then I wrote the letter in my head.

It didn’t want to go on paper. I got stuck on the pronouns.

When my therapist and I talk, we use each other’s first names, or use the gender-neutral second person you/your/yours. I wrote the letter using they/them/their and realized she probably thinks of me in she/her/hers terms. I cringed and re-wrote the draft using female pronouns.

The letter states that she supports my decision, that I have experienced persistent gender dysphoria, and that it causes me pain and suffering. It details my gender expression, my name change, my decision to not go on hormones, and that the next step in my transition should be chest reconstruction. It states that I am in psychotherapy, meet the Gender Dysphoria/Gender Identity Disorder criteria, and that I am not taking medication. It explains that I am aware of the risks, that I understand the surgery is not reversible, and that she is available to coordinate care.

She said it was a good letter, made a minor change, and she signed it. I sent it off to the surgeon. My guess is that it will go into my file, unread, an archaic holdover from a time when the gatekeepers still tried to limit access to surgery.

Note: You can view the  “Contract Scene” from The Marx Brother’s film A Night at the Opera here. It includes Chico’s classic line “You can’t fool me. There ain’t no Sanity Clause.” The WPATH criteria are on page 28 of this document.

33 thoughts on “The Sanity Clause

    1. Jamie Ray Post author

      Thanks for letting me know I was unclear. I updated the post to include the sentence that I sent the letter to the surgeon. He has a file on me with my medical history, mammogram report, and now my psych assessment. All he needs now is the deposit for surgery (which I promise will not merit it’s own post, although my interactions with my insurance company might).

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    1. lostinthelakes

      Version 1 is exactly what I think so many of us want to say! I’ve said the “if I wanted an augmentation,” line to my partner so often that now, post surgery, I think she’d throw something at me if I ever said it again. I’m excited that you are one step closer!

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      1. gok9go

        This is so true–people can get augmentations with no question. No one ever questions if there will be regrets. No one asks how someone feels about the surgery being non-reversible. Today is 3 months post op for me, and I enjoy *my* chest every day–it’s the chest that should have always been there. Like lostinthelakes, I too am excited that you are one step closer!!!

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      2. Jamie Ray Post author

        Informed consent is a much better process than the pysch/medical permission model. There are only a handful of surgeons who don’t require a letter, and I would have gone to Dr. Steinwald in Chicago (informed consent) if it wasn’t for Donna and Gracie (I’d rather board Donna while I have surgery and take Gracie but that is another story). I think my only regret will be having waited so long.

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      3. Jamie Ray Post author

        That’s why I write a blog. At least here everyone understands what I am saying, and I try to only say it once (although I do repeat myself by accident every so often). It is incredibly frustrating and infantilizing to get your therapist’s permission to get surgery (or go to a different therapist to ask for it).

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  1. RonaFraser

    I love this: “Enough already. Please schedule this ASAP. Maybe then she they will deal with the remaining issues so that she they can finally finish therapy.” 🙂
    I also have to share that, although I am quite a talker, when I did my perhaps 6 therapy sessions, I never felt comfortable enough to discuss my main issue (men, and how my inner voice tells me I am so unwanted by them that I can barely even make eye contact and likely send out “leave me alone!” signals). She was too brusque (used to be a therapist in a prison!) and I felt so fragile… We dealt with my over-volunteering issue, which was helpful, but… So congrats on hitting the big issues with your therapist! It ain’t easy.

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    1. Jamie Ray Post author

      I’m not done yet, but I am almost there. I have a hard time complying with orders, so I really would have liked to have been able to write an assessment letter dripping with sarcasm, but, the surgeon really can refuse to operate if they don’t have a letter from a therapist that contains something like the phrase “chest reconstruction is the next logical step in so-and-so’s transition”. And, my therapist is trying to do the right thing by me and wouldn’t sign anything she thought was not in my best interest.

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  2. janitorqueer

    I seriously thought version 1 (when you stated you didn’t write it) WAS written by your therapist haha. I was really excited that maybe a therapist wrote that and it’d be given to a surgeon. I can be a little bit dense at times. Congrats on getting closer!

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    1. Jamie Ray Post author

      Always better to read a post all the way to the end! I didn’t realize how much I resented having to get a permission letter until I started to write it and had to get my anger out of the way. I don’t think I’ve had to get a permission letter to do something since a high school field trip to Albany.

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      1. micah

        I think I also resented writing one, for reasons even today I can’t explain fully. That’s why it was important for me to find an Informed Consent surgeon, which were much rarer “back in the day” (of 3 years ago).

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      2. Jamie Ray Post author

        I did some searching on-line and there are still only a handful who don’t require a letter, even if just to CYA. I think it is easier for them to say “I follow the WPATH V7” than to do informed consent.
        People do things they regret all the time (marriage is a big one) and they learn to live with the consequences.
        I was seriously considering going to Steinwald both for nipple issues and informed consent, but Donna preferred a surgeon who was in the NYC tri-state area so that I could recuperate at home and she could get support from our friends.

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    2. Jamie Ray Post author

      In the interests of being even clearer, for anyone who doesn’t read all the way, I changed the first sentence to read “…the letter that I wrote but didn’t send…” like everything else about being trans, i knew what I meant, but I confused a few people…

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  3. PlainT

    Let’s not forget that it’s not just augmentations, but breast reductions that don’t require a therapist note, or mastectomies for health reasons. But voluntary breast removal? Suddenly “this person must be crazy!”

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    1. Jamie Ray Post author

      You are right – stereotypically we all think about breast enhancements/augmentation because it is sold to women so that they will look “sexier”. But reduction is not questioned until you attach the words chest or male to it. No psych letters required for liposuction, botox, or gastric bypass either.

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  4. Lesboi

    I’m looking forward to the day when we don’t need the gate keepers to do what we need to do for our lives. I finally got my letter the other night and I’m still not satisfied with it but since it’s the 3rd one I’m done messing around about it. My therapist had the nerve to charge me $80 (it was supposed to be $160 but she was lazy and didn’t write a long letter so she gave me a break :/ ). I’m done with her and therapists in general for quite a while I think. I didn’t even consider writing my own letter since my therapist told me she was going to go into detail about all of the psychological aspects of my gender and it sounded very technical. In the end, I could have written the letter she wrote. Good for you for taking the initiative and, like others here, I prefer the letter you didn’t write. It’s the one we should all give our surgeons.

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    1. Jamie Ray Post author

      I offered to write the letter because I’d done the research – I wanted to be honest about taking it one step at a time (not taking hormones first and not going for a gender marker change) and not presenting myself as a trans man, but as trans-masculine (not that most people have a clue as to what the difference might be). It is a slam dunk if you say the exact right things (the surgeon just wants to cover his own butt) but I don’t want to lie to get it if I don’t have to.

      I’m also a control freak, but I remembered that part about writing the letter that you want to send and then ripping it up.

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  5. Mara Migraineur

    I remember when that one strain of breast cancer was discovered to be hereditary and the best way to deal with it was breast removal. I got all excited – “oh! breast cancer runs in my family! I’ll have to check that out! (yes, I get that being excited about cancer is twisted) Breast removal paid for by insurance!” My OB freaked out on me. “They’re a part of you’re identity!” Ummm, yeah…that I’d happily get rid of, thanks. I hadn’t realized people would be so concerned with my dislike of my breasts.

    LOVE Version 1.

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    1. Jamie Ray Post author

      I’m amazed by how many people are grossed out by the concept of top surgery and I have trouble turning the clock back four years to when it would have bothered me too.

      I also prefer version 1, but I doubt that my therapist would have signed it. But maybe I underestimate her.

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  6. Pingback: An open letter to the gatekeepers | Watch your fingers

  7. DogDharma

    In the days when I transitioned, both a letter from a therapist who specialized in gender issues AND a letter from a psychiatrist was required. I’d easily gotten both, had started T, had had top surgery, and had scheduled bottom surgery AND paid the deposit. As I was waiting for the bottom surgery date, I started seeing a therapist for other reasons, completely NOT trans-related. But of course, I disclosed my overall situation in therapy.

    As the date of my bottom surgery approached, my therapist said, “I think we need to think about this. I don’t want you to make an irreversible mistake.” !!! She’d never had a trans client and it certainly wasn’t her specialty. I refused to “talk about it” because it was MY decision, and I’d already jumped through the necessary hoops. The therapist “declined” to see me for therapy any more because I was “going against her professional advice” by “not talking it through with her.” !!!

    12+ years later, and I don’t regret a single thing. It still pisses me off, even though things have improved, the hoops we have to go through just to be who we ARE. Love the “augmentation” line!

    Maybe you should start a side business of writing letter (of various kinds) for people. 🙂

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    1. Jamie Ray Post author

      In those olden days, and it is still true in some areas, you had to give the standard trans narrative and present as a heteronormative man/woman to get past the gatekeeper. If that was my only choice, I’d probably lie my way through it by any means necessary. Fortunately, things are changing, but their is still the lingering sense that being transgender is a mental illness. Even my anger at the gatekeeping system could be read as being non compliant, immature, and needing to be worked out before approval for sugery could be granted.

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      1. DogDharma

        Yes, but you are a breath of fresh air because you resist the binary gender notion. In my day, even too many transitioned FTMs were guilty of ostracizing and bashing anyone who didn’t want to be / become a MAN. It ain’t that simple, not even for those of us who have fully transitioned, and are comfortable with where we are. There’s room for ALL of us. It’s not a competition. 🙂

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  8. The Final Rinse

    I remember needing my second letter for surgery. The first letter was from the therapist who only saw patients on the trans* spectrum. She got it. She didn’t push me to be things that I wasn’t. She considered herself to be informed consent, and her letter to the surgeon was probably something like your letter #1, although it may have consisted of just a phone call.
    For letter #2, I found someone in my own town. It turns out that she had never written a letter for surgery before, and that her knowledge of trans issues was largely from the old school book. But, I had already made a thousand dollar deposit, and surgery was scheduled in a few of months. I really resented having to endure those sessions, and I really resented that she held it against me that I wasn’t coming to the sessions in a dress. In the end, she relented, and “allowed” me to have surgery.
    I was curious about what she would write, so I asked for a copy. It was a multi-page manifesto, which obviously had not been proof-read. There were spelling errors, factual errors, and grammatical errors, as well as shifting pronouns. I could never have turned this in as a paper in college. The pronouns offended me most.
    So, I called her and asked if she maybe wanted me to proof it and send it back.
    Later, I realized how my resentment of the entire experience manifested itself in a resentment of her.
    I am sure that I hurt her feelings.
    But her letter really did suck.

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    1. Jamie Ray Post author

      I think my therapist would have written an OK letter, and her intent would have been good, but I have a better sense of what is required and how I want it presented. She was not insulted by my writing it (it saved her a lot of time and energy). Fortunately, I don’t have to find a psychiatrist and I don’t need the “year real life experience” as if the rest of my life was just pretend.

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