Getting a HRT Referral Letter

Getting a HRT Referral Letter

Getting an HRT Referral Letter

Once you decide to take the step to begin medically supervised HRT, getting an HRT referral letter is necessary. The Standards of Care is the primary guide for professionals working with transsexual, transgender, and gender nonconforming people. The standards are self-described as providing “safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment.”To begin HRT, you will first need to have an assessment by a mental health professional, which is someone with a master’s degree in a clinical behavioral science (such as a licensed MSW, a clinical sexologist, a licensed counselor or a psychologist) with specific expertise and knowledge about gender dysphoria. If you are currently working with a therapist and you do not feel like he or she is knowledgeable about gender care, here are some important questions to ask – even if (especially if) you have already been working with them for a while. If they are not able to answer these questions effectively, you may wish to seek alternative care.



  • Persistent, well-documented gender dysphoria;
  • Capacity to make a fully informed decision and to consent to treatment;
  • Age of majority in a given country (if younger, follow the Standards of Care outlined in section VI);
  • If significant medical or mental health concerns are present, they must be reasonably well- controlled


In requirement one listed above, it is essential to meet the criteria outlined in the Diagnostic and Statistical Manual (DSM5an. Getting an HRT referral letter requires that you are experiencing at least two of the following conditions for at least the last six consecutive months or longer (American Psychiatric Association, 2013):

  • Noticeable incongruence between the how you see your gender, and the gender you were classified at birth
  • An intense need to do away with your primary (breasts and genitals) or secondary (hair, voice, body fat distribution, etc). sex features
  • An intense desire to have the primary or secondary sex features of the other gender, and to be of the other gender
  • A profound need for society to treat and view you as another gender (or some alternative gender different from the one you were assigned at birth)
  • A feeling that you have the typical feelings and reactions of another gender
  • These experiences cause you clinical distress and affect you socially, at work, and/or in other important life areas

How many sessions does it take to get a referral for HRT?



In some cases, you may find that you meet all of the criteria outlined above, yet there are still obstacles preventing you from getting an HRT referral letter. Once you start HRT it is not advisable to discontinue use. Therefore, it is important that you are in a life situation that will support the continuation of HRT use once you begin. Therefore, if you are dependent on others financially and they are not aware of your usage of HRT, you are at risk of having your financial support withheld if they respond poorly to this discovery.  In this case, you can either do the work of coming out to those on whom you depend financially, or you can make choices to be financially independent of others. Another similar concern is if you are married and your spouse is unaware of your desire to pursue HRT. If your relationship is important to you, it is essential to communicate your intent to start HRT before starting so that you are not faced with a relationship crisis once it is revealed that you are on HRT.



A typical assessment process for me will range from one to three sessions. Rarely does an assessment, or getting an HRT referral letter more than two sessions. As long as you meet the criteria outlined above, and you are capable of affording HRT, and you have sufficiently made peace with your decision to feminize or masculinize your body, you are likely to have no obstacles getting a letter.  If you are already living full-time in your desired gender, or you have done a lot of work toward coming out and integrating your gender prior to getting an HRT referral letter, you will likely qualify for a one-session quick-assess where the assessment and letter are provided in the same day. To get an estimate of how long it will take for you to get a letter of referral for HRT, simply complete this form and I will give you a very accurate estimate of what to expect when working with me.



Join others who are experiencing gender dysphoria in a weekly video support meeting. More information here.

Gender Pronouns:  It’s good to ask.

Gender Pronouns: It’s good to ask.

What are your preferred gender pronouns?

As a gender therapist, I am aware that use of gender pronouns (he, him, her, she, his, hers, etc.) are critically important all of us, not just gender variant folks.  If you are reading this, and you identify as a male and look like a male, would you be uncomfortable if I referred to you as “ma’am,” or “miss?”  Say for example, I’m working at the local Starbucks and you are next in line, but you are not paying attention, and I start saying “miss,” “excuse me ma’am,” louder and louder, asking the person next to you, “can you let her know she’s next?” – and then you are tapped on the shoulder by a stranger, who is looking you in the eye and says to you, “ma’am, she’s ready for your order,” – and everyone around is observing this.  How would you feel?

Typically, it is an embarrassing thing to get gender pronouns wrong, for both the person being misgendered, as well as the person who is doing the misgendering. It is awkward and uncomfortable. The same is true for folks with gender dysphoria who are not yet at a point in their lives where their gender presentation matches their gender identity. Now, imagine a female-identified person who was born male, who is 6’5,” and is who is struggling to feminize her appearance in a way that the world can immediately associate as “female.”  In her mind, no matter how she looks, she will feel no different than the man in line at the local coffee shop, if she is misgendered.

Our mind identifies our gender in such a way that it is an uncomfortable experience for many transgender persons to be referred to with incorrect gender pronouns (misgendered) even when they are not out to the world, and they are not asking for or expecting correct pronouns.  Their discomfort is simply private; no one knows – except the female-identified person inside the male body who cringes with embarrassment with each misgendering. While she may not be ready to expose her true gender to the world yet (likely for fear of rejection and disconnection from loved ones and associations), she still suffers the pain of misgendering.

What can we do to help her, and other’s like her?  We can work to make our world a more gender-friendly place.

Advocating with Gender Pronouns

It’s uncomfortable to not know what a person’s gender is.  What do you do when you don’t know which gender pronouns to use?  If in doubt, don’t use a gender.  If in doubt, and you feel brave, or interested in participating in making the world a more gender-friendly place, the kindest thing, believe it or not, is to ask, “Which pronouns do you prefer?”

There is a common belief that it is rude to ask someone a question like this. However, if you are a person that embraces the diversity in the world, and you have a non-judgmental acceptance of the answer, it is actually quite kind to not assume that you know.  For example, I would never be offended if someone asked me, “Do you prefer men or women (gay or heterosexual)?”  The question itself suggests the the one asking realizes that not everyone is heterosexual!  What a concept!  To think it’s offensive to ask this question suggests that you consider it someone offense to be gay (or to be heterosexual, though I’m doubting that’s the case).  If you are comfortable asking someone if they are married, what is the difference between a question like that, and a question like, “are you bisexual, gay or heterosexual?”

Ask:  “Which gender pronouns do you prefer?”

Inquiring about a person’s gender is the same.  If you are comfortable and confident in your gender, having someone ask you which pronouns you prefer is not likely to offend you; you’re more likely to be curious about the question.  If you are uncomfortable with your gender, perhaps the question will bring you comfort – having the opportunity to clarify.

If you operate a business, or work with people on a regular basis – particularly those of us in “helping professions,” you can actually get into the habit of asking the question, “which pronouns do you prefer,” to everyone, so that it becomes common-place.

Gender pronouns on Email Signature Line

Another way to help make our world a more gender-friendly place is with your signature line on emails. On the signature line of my email, I not only include my name, address, website information and phone number, I also have a very simple line that says:  “she/her pronouns.”  I recommend you do the same, particularly if you are in the human service industry.  Some people will ask you about this.  You can educate.  Others will be comforted, and they will know you are a gender-safe person for them to be honest with.  This is a simple way to extend greater support, acceptance, and advocacy for non-binary, gender fluid, and transgender folks. I learned this from Dr. Gallagher’s Transgender Surgical Program Advocate, Nicole Jackson, who said she learned it from someone else… so see how this works… pass it along.

Gender Friendly Office Environments

A final strategy I’ll share about how to make your office a more gender friendly space comes from a fellow sexologist in one of my professional news lists.  He shared that his office is posting this information for all to see:

Our office is attempting to be more gender inclusive.

The staff will be asking about your pronoun preferences (Male, Female, Gender Neutral).

You may also hear us call patients Mx. (pronounced Mix) rather than Mr., Mrs., Miss, or Ms.
Of course, we will refer to you however your prefer.

This is a work in progress, please excuse our errors.

If you intend to be inclusive, kind and compassionate to all, regardless of their gender presentation and gender identity, these are ways to bring your intentions to life.

What are some other ways to be more gender friendly – please share in the comments.

MTF Bottom Surgery Options:  Q & A With Dr. Gallagher

MTF Bottom Surgery Options: Q & A With Dr. Gallagher

Q & A with Dr. Gallagher

Deciding on mtf bottom surgery is an overwhelming process for many transgender women.  There are so many factors to consider when deciding which surgeon to choose for surgery:  location, cost, comfortability, outcomes, aesthetics, experience, rate of complications, surgery style, willingness to work on higher BMI or other potential health complications, aftercare availability, and your overall comfort with his or her personality and bedside manner.  Once you’ve decided on a surgeon, you must also consider your surgical options.  Most people think of vaginoplasty when they think of MTF bottom surgery.

There are also three other options that are less commonly talked about when considering gender affirming surgery.  Some women are not interested in penetration, or the dilating and maintenance that accompanies vaginoplasty.  In particular, older ladies may be more interested in these  less invasive options for surgical affirmation.

MTF bottom surgery

I asked Dr. Gallagher to share her thoughts on the following four questions related to choosing the right MTF Bottom Surgery.

What are the different options for MTF bottom surgery?

What factors are important to consider for each one?


An orchiectomy is the most affordable and least invasive procedure available for MTF bottom surgery.  For some women, this is the only bottom surgery necessary. The orchiectomy  allows women to eliminate testosterone blockers, and estrogen doses may also be reduced. For those hoping to have vaginoplasty later on, this will not prevent you from pursuing additional surgery when you are ready.

Scrotoplasty and orchiectomy

This procedure removes the testicles and the scrotal skin. This is only recommended for patients who will not be undergoing vaginoplasty in the future. Because the wound is slightly bigger, it is a little more invasive than an orchiectomy.  Surgery is completed in one hour, and recovery time before returning to work is typically 1-2 weeks or less.

Zero depth procedure

Zero depth procedure is less invasive and much less likely to cause rectal injury or other complications. This surgery includes all of the steps involved in vaginoplasty (removal of testicles, scrotoplasty, labia pasty, clitoroplasty, shortening of the urethra), except for the creation of a new vagina between the bladder and rectum. This is ideal for women who are not interested in penetration, and wish to avoid the upkeep involved with a new vagina.

What is the most common mtf bottom procedure you do?

Orchiectomy is the most common procedure I do. This is often because many of our patients still sadly don’t have insurance coverage for their full bottom surgery. Orchiectomy is much more affordable for these folks and doesn’t take away any options.

What else is important to know about the various bottom procedures?

It is important to remember that with every surgery there are risks, downtime and in some cases a lot of care required. In order to have a happy vagina that will serve you well, it must be taken care of properly.  You must be able to commit the time necessary to do the dilation, take the time off to recover, and have a good support system of friends and family to get you through this demanding surgery.

For folks who are not at a point in their lives where they can commit to this level of post-surgery-self-care, the other options described above may be more appropriate.


TG FAQ:  Transgender Depression after Surgery

TG FAQ: Transgender Depression after Surgery

FREQUENTLY ASKED QUESTIONS about all things Transgender:  Depression after Surgery

  Answers to your questions about the medical and emotional aspects of transgender life by Sidhbh Gallagher, MD and Michele O’Mara, PhD

Why is it common to get the post surgery blues?

Depression after surgery is a common experience for patients of most major surgical procedures.  However, when the surgery is designed to positively impacts your social presentation and gender identity, and you have spent most of your life waiting for this day to arrive, it can be very surprising to then experience post surgery depression.

depression after surgery

According to Dr. Sidhbh Gallagher, many of her patients experience sadness and anxiety after any surgery.  When asked why, she said, “There are many reasons for this, and it is completely normal.”

  1.  CHANGE IN ROUTINE.  One of the most basic reasons for post-surgery depression and anxiety is the basic change in your normal routine.  When you are admitted to the hospital, you become temporarily displaced and while you may have the support of friends and family, it is unlikely that you have the same kind or quality of contact with them during this time.  Routines provide comfort, structure, and predictability to our day.  Whether you turn to a morning cup of joe, a hearty workout or yoga class, or a Mc-breakfast to start your day, your body will notice this change in routine.
  2. PERMANENCE ANXIETY.  In the weeks following surgery,  it is very typical for a transgender patient to think, “What have I done to myself?!” Not only is it common to feel depression after surgery,  feeling anxiety is also common.  Even when you know that you have taken the right step in aligning your body with your true gender, it is common to question yourself.  When you progress through a gender transition, it is common to forget the pain that drove you to make the choices to start HRT, to pursue surgeries, and to transition in the first place. Each step you take toward a gender transition brings relief.  From this place of feeling better, it is easy to question if you really needed to make these changes at all.  Think about the messages you have received throughout your life about who and how you “should” be.  It is a monumental task to counter everything you were told and taught that you are supposed to be, that you were born a boy/girl, and that your body is that of a boy/girl, and you are expected to behave, dress, think, and socialize as a boy/girl.
  3. HORMONAL CHANGES:  Adding insult to this already complicated surgical scenario, is the fact that many transgender patients will need to stop taking their hormones for a period of time before and through the surgery process, to reduce medical risks for blood clotting and other concerns. This, alone, contributes to a low mood and lack of energy.
  4. GRIEF. It’s a bit counter-intuitive to think we would grieve something that we’ve desired for so long.  However, from an emotional perspective, surgery is often the last item on your list of “todo’s” as you journey toward your truest self and authentic gender expression.  Consider the time, energy and resources that you invest throughout your gender transition.  It is all-consuming.  For many, transitioning is the most dominate focus in life.  When you complete this list of todo’s there is a feeling of “now what?”  To feel depression after surgery is natural.  The process of transitioning involves a roller-coaster of emotions.  From the lows of fearing the loss of (and sometimes not just fearing, but actually losing) relationships, supports, jobs, and more – to the highs of feeling aligned with your true self, is an exhilarating ride.  After surgery, the roller coaster begins to slow and you are faced with having to adjust to a new normal.
  5. WHAT IF’S? Gender-related surgeries invite a lot of “firsts.” While for many this is a wonderful adventure, it can also be very anxiety provoking. Whenever we do not know what to expect, it is natural to feel anxious.  When you go through a gender surgery, there are a lot of “what if” questions.  What if I don’t like how my _____looks?  What if I never orgasm again?  What if my swelling never goes down?  What if I still don’t feel happy even after having surgery?  What if this does not take away my dysphoria? And, on and on….

Some Helpful Tips To Deal with Depression after Surgery:

  • Focus on the here and now.  If you are seeking information about how to deal with your post surgery blues, know that in this moment, as you are reading these words, all is well.  Focus on right now; not what used to be, not what you are afraid will be, but what is.  When you stay grounded in this moment, you can also stay connected to the reality that you are okay, that all is well.
  • Remember the pain will go, the wounds will heal, and the numbness or itching all gets better! Your body knows what its doing just give it time.  Put down the mirror! Many patients will not see their final results for up to a year.
  • Surround yourself with supportive folks as much as possible and talk it through.
  • Be aware that bad habits like smoking can be very hard to avoid after going through the stress of surgery. Have a plan for when temptation sneaks up on you.
  • Remember to ask for help if you need it. Some patients experience real episodes of anxiety and depression after their surgery. Your mental health professional is available to you and can be incredibly helpful during these times reach out if you need help.
MTF Vaginoplasty (GRS):  Before and After Photos of SRS with Dr. Gallagher

MTF Vaginoplasty (GRS): Before and After Photos of SRS with Dr. Gallagher

MTF Vaginoplasty (GRS) Before and After Photos of SRS with Dr. Gallagher (10 weeks post op)

In a series of articles I wrote about Dr. Gallagher, I provided one post on vaginoplasty and at the time I was unable to include before and after pictures of the GRS.

Recently Dr. Gallagher sent me the following before and after photos of a recent MTF vaginoplasty (SRS) she performed.  With the consent of her patient, I am providing these here so that you can view the early results of her surgery.

The before photo:

before and after photos

The following after photos are taken at 10 weeks.  These do not reflect the final results, as this patient is still healing from surgery.


GRS / SRS before and after

mtf vaginoplasty


HRT MTF (Male to Female Hormones): MTF HRT Effects

HRT MTF (Male to Female Hormones): MTF HRT Effects

Effects of Male to Female Hormones – HRT MTF Hormone Effects  

hrt mtf

MTF HRT Effects 

The impact of male to female hormones (HRT MTF) varies from person to person.  However, there are some typical responses that are reasonable to expect from feminizing hormones for male-to-female persons (MTF HRT) which will be discussed here.

ONE THING MTF Hormones (HRT MTF) DOES NOT HELP IS YOUR VOICE.  Here is a resource to consider TO ASSIST YOU WITH feminizing your VOICE.

Common Effects of Male to Female Hormones / HRT MTF Hormones

Breast development – This will vary greatly, as it does with the genetic female population.  The breast tissue growth typically takes at least two years to reach maximum size.  MTF HRT effects on breast development rarely and it is rare for breast development to exceed a B cup size.

Within the first couple months of hormone therapy, a nodule-like formation behind the nipple develops and along with this is significant tenderness/sensitivity in the area, much as it does in adolescent females. These changes are induced by an increase in the ductal system behind the nipple and it is a part of the transition process that will typically normalize in a matter of months.

Body Hair – Depending on the amount of body hair to begin with, there is a significant decrease in hair over the course of time and after several years and may diminish entirely over a period of several years.  Arm and leg hair as well as hair on the abdomen, chest, and shoulders will greatly lessen and in some instances disappear completely.  Hair growth in specific regions including that around the areola, armpits and pubic area will not lessen to the same extent.  Whatever beard hair is present at the start of HRT, will remain.  Electrolysis or laser hair removal will expedite the removal of this hair and it makes sense to begin with this facial hair that will not go away on it’s own, and save hair removal treatments for chest and shoulders until later to see if HRT does reduce or eliminate it.


How many sessions does it take to get a referral for MTF HRT?


Skin – With HRT MTF hormones, your skin will change greatly, becoming softer, more translucent, and less coarse.

Fat Distribution – Over a period of time (1 to 2 years time), a change in the subcutaneous fat (located just beneath the skin) will occur.  The hips, thighs and buttocks will collect the majority of this distribution, and the tendency for fat to centralize in the stomach will diminish somewhat. The resulting redistribution will result in a smaller waistline and larger hips.

mtf hormones, mtf hormones, male to female hormones, mtf hrt effects, hrt mtf

Muscle Mass – Through the process of feminization, the MTF HRT effects much of the upper body bulk.  Over time there is a slow decline in this bulky appearance, depending on the amount of muscle mass an individual starts with.

Genitals – Testes will lessen quite significantly in size.  The production of testosterone and sperm is also greatly reduced.  Penile size will also likely diminish.  Sexual function will decrease, but the extent to which performance is affected is unpredictable. Erections may still continue, but will probably be less frequent, and not last as long, and in some cases may not be possible. Ejaculate will lessen, probably to the point of only producing a very small, clear discharge as a result of the prostate and the associated structures responsible for semen production being impeded.  It is important to note, however, that the ability to orgasm is not dependent on either an erection, nor ejaculate.  Anecdotally speaking, many transgender females report greater satisfaction with their orgasms after these changes occur in their genitals.

Prostate Gland – The MTF HRT effects the prostate.  Over time, the prostate will diminish in size due to the effects of estrogen and finasteride (Proscar), the latter being administered as an anti-androgen. Beside from the feminizing effect of these medications, both drugs are helpful in the treatment of benign prostatic enlargement.  This condition is often responsible for the difficulty with urination experienced by many older individuals.

Cardiovascular – Coronary heart disease is the leading cause of death in the United States. Due to various lifestyle and hereditary factors, cardiovascular conditions may pose additional risks to those undertaking elective medical therapies, such as the variety of drug treatments engaged in the feminization process.

Infertility/Impotence – One of the MTF HRT effects of long term use of  may result in infertility, with permanent infertility being a distinct possibility.  Sexual responsiveness will likely diminish over the course of hormonal therapy, potentially resulting in the inability to achieve or maintain an erection.  These effects are the basis for feminizing hormone therapy being termed chemical castration.

Voice is UNCHANGED by male to female hormones (MTF hormones).   However, inflection and manner of speech are very well suited to change.  Additionally, pitch can be raised through persistent vocal practice.  Given the importance of a gender congruent voice, surgical options have been explored in an attempt to alter pitch, but this most delicate of instruments is not likely to be properly retuned through surgery.   (For more information about how to improve your voice click here.)

On a related note, it is important (especially for younger transferals) to consider your wish for biological offspring BEFORE you begin MTF hormones.

* Sperm-Banking / Cryopreservation – If you have any concern or desire to have genetic offspring in the future, it is imperative if you are seeking male to female hormones, you choose the option of sperm banking prior to starting HRT MTF.  This is the process of having samples of your sperm frozen (cryopreservation) and stored for later use – prior to beginning FTM  hormone therapy.

How many sessions does it take to get a referral for HRT MTF?