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.