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.
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.