Required Mental Health Evaluation Before Initiating Gender-Affirming Hormones: Trans and Nonbinary Perspectives

Purpose: Gender-affirming hormones (hormones)—the use of sex hormones to induce desired secondary sex characteristics in transgender and nonbinary (TGNB) individuals—are vital health care for many TGNB people. Some hormone providers require a letter from a mental health provider before hormone initiation. We explore the perspectives of TGNB individuals regarding the impact of the letter requirement on their experience of care. Methods: We conducted semistructured interviews with 21 TGNB individuals who have sought or are receiving hormones. We purposively sampled respondents who were ( n =12) and were not ( n =8) required to provide a letter. An Advisory Board of transgender individuals guided the methodology. Interviews were transcribed verbatim and coded both inductively and deductively. Results: We identified three themes related to the letter requirement: (1) Mental health: While participants appreciated the importance of therapy, the letter requirement did not serve this purpose; (2) Trans identity: The process of obtaining a letter created doubt in participants' own transness, along with a resistance to the pathologization and conflation of mental illness with transness; and (3) Care relationships: The letter requirement negatively impacted the patient-provider relationship. Participants felt the need to self-censor or to perform a version of transness they thought the provider expected; this process decreased their trust in care professionals. Conclusion: A letter requirement did not improve mental health and had several negative consequences. Removal of this requirement will improve access to hormones and may paradoxically improve mental health.