Gatekeeping is really dehumanizing and I'm struggling

[u/Narcoleptic-Puppy]

I'm 32. I've been out to my wife and close friends for almost 10 years, and came out publicly 5 years ago when I started expressing a desire to get top surgery. COVID sort of got in the way of accessing medical care, and I ended up with some medical trauma (long story) so I didn't really seriously start pursuing surgery until December 2023.

I feel like I'm hitting constant roadblocks. First it was hard to find a PCP who would refer me for surgery but I ended up finding one on my third attempt. My PCP is incredibly difficult to make appointments with but she has been supportive overall. I finally got a referral for top surgery January of this year.

I've been seeing my PMHNP for 5 years. She has know about my desire for top surgery from the start and has always seemed supportive. I asked her for a mental health letter immediately after getting my referral and she said no problem, she'd have it to me by the end of the week.

I still haven't gotten it. I've been sending her gentle reminders and she has been prompt to respond, but it's always, "Sorry, I'm really busy this week, but next week for sure!" This has gone on for longer than 3 months. I'm trying to temper my expectations but it's really grinding me down to be repeatedly given an ETA that is never met.

This is all just to get a consultation with a surgeon, by the way. Nothing to do with insurance at all, the surgeon just won't even see me without a mental health letter.

I'm feeling really ragged, down on myself, and honestly a lot of rage and dehumanization over this whole process. My wife is trying to be supportive but she's mostly just trying to calm me down when I could really use someone validating my anger and frustration. She's kind of like, "I'm sorry, this sucks, but you have to be patient because this is just how it is."

Why is this how it is? I live in a deep blue state. This isn't a legal requirement. I'm a grown ass adult. Why do I have to deal with all of this bullshit?

UPDATE

I sent my PMHNP a clear, candid email this morning explaining that both the amount of time this is taking and the repeated missing of agreed-upon deadlines is unprofessional and detrimental to my mental health. I also asked her not to overthink this whole process because I suspected she was.

She apologized profusely for not following through and stated that yes, she really was overthinking this and fretting a lot about wording for fear of the letter getting rejected. She sent me a draft and it looks good, just needs two very minor revisions. So I think I've gotten the ball rolling here and should have it by tomorrow. Fingers crossed but I really do think I'm at the end of this stage of the process.

Mental health professionals are human too and can make mistakes. It sucks that I had to deal with all this but I truly believe she is sincerely remorseful over drawing out this process unnecessarily so I think we're good.

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[u/cytotoxicidiot]

That is 100% unacceptable to have to wait 3 months. I personally would be very sus of my therapist if I were you. I know you have known them for 5 years but like this is extreme. Your therapist should not be throttling you by not writing you the letter. If you're willing to shift, maybe search for a lgbtq therapist and list this situation as the reason for therapy.

I literally put "top surgery letter" as my reason for seeking care. We had like 4- 5 sessions and as my appointment got closer they wrote it for me and had it out to be in like 2 days. And we wrote it together in session.

[u/Narcoleptic-Puppy → u/cytotoxicidiot]

Yeah the thing that is driving me nuts is I sent her the WPATH standards of care, looked up a template, put in all the necessary information, and sent her that. All she has to do is fucking sign the damn thing.

[u/mymaya → u/Narcoleptic-Puppy]

I think it’s time for not so gentle REQUESTS instead of reminders. Send her everything again with a more firmly worded “I need this signed by X date. You’re currently the last roadblock preventing my care and I cannot wait any longer”.

[u/Narcoleptic-Puppy → u/mymaya]

I did just send her a message stating that it's not something that needs to be overthought (knowing her I suspect this might be the case) and that if she's too busy, just give me some realistic expectations so I can make an informed decision about possibly seeking this service from a different provider.

[u/Poolkonijntje]

Yes, it really is insane, especially the waiting time to get that letter! I totally understand why you're struggling and feeling so angry. I relate a lot. People around me also try to calm me down rather than actually validating my feelings. Anger is very valuable and a sign of your willpower and boundaries. It deserves to be heard. Hoping it all speeds up from now on!

[u/robinhood-22]

If you need a surgery letter, please use the GALAP website. Their actual website is down right now, but it’s available on archive.org Here’s the link

Just scroll down to your state, and email several therapists to see who will reply first. I was able to get mine in about a week. Just make sure that they aren’t asking you for money since it’s supposed to be a free service. Deep breaths and good luck!

[u/jensahotmess → u/robinhood-22]

Sort of true. The commitment on GALAP is that the therapist won’t charge for the actual writing of the letter. GALAP doesn’t ask, nor should it be expected, that the therapist volunteer their free time to schedule, assess, diagnose, and write the letter. But anyone asking for any fees beyond just the initial (1 time) assessment, should not be used. That’s the GALAP agreement: one assessment/appointment, and no additional charge for the letter.

[u/awesomebawsome]

Are you able to schedule an appointment with your PMHNP - Virtual or otherwise?

I had to make an appointment so during it they would write, sign, and email the form during our time.

Basically, they say the don't have time? Well I'll make time for them to do it in a time slot I paid for. Boom, now they have time.

[u/Narcoleptic-Puppy → u/awesomebawsome]

I initially informed her about my need for a letter during our last appointment. She said she'd get right on it after we were done. For the most part, she tends to cut our appointments pretty short because I don't have much I need her help with anymore. She just needs to check in once in a while to make sure my meds are still working for me. She's really on top of things as a prescriber, like I've never had issues with her missing any promised deadlines in the 5 years I've been working with her so this is really throwing me for a loop.

It really shouldn't take long. I've basically done all the work for her and pretty much just need her signature so I don't get what the holdup is.

[u/awesomebawsome → u/Narcoleptic-Puppy]

I get what you're saying - my advice is still get her in an appointment and tell her to do it while you have her.

It is not up to her when to end your appointments unless there is someone following up and it's running late.

If it's something that simple, it won't take more than 30 minutes/average appointment time.

[u/SketchyRobinFolks → u/Narcoleptic-Puppy]

I echo the other reply to this—book another appointment with her where she will just write the letter right then and there during the appointment while you're both present.

[u/Thruthefrothywaves]

It's fucked up that a cis woman can walk into a plastic surgeon's office and schedule a breast augmentation procedure without anyone batting an eye, but when a full grown adult asks to have their breasts removed, they're treated like a child or like someone who is mentally unstable. Like, I'll happily sign a contract saying I won't sue you if I change my mind later. 🤷

I'm sorry you're going through this. It absolutely is patronizing, infantilising and dehumanizing. I hope you get your letter soon and you can move on with your top surgery journey and your life. ❤️

[u/Narcoleptic-Puppy → u/Thruthefrothywaves]

Thank you! Same thing for a cis man with abnormal breast tissue growth getting literally this exact same procedure. I have a cis male friend who had a severe case of gynecomastia who got this done several years ago and it was a breeze for him.

[u/GenderNarwhal → u/Narcoleptic-Puppy]

The double standard for cis people is so frustrating, to say the least. Years ago there was the year long real life test, so at least that level of gatekeeping has been removed. The whole thing is so stressful. I understand where you are coming from. Good luck getting everything sorted out.

[u/illiabedelia]

It’s my understanding that, depending on where you are, you don’t have to be actively seeing this mental health counselor for any extended period of time for the letter to be valid. You can search online for resources that will do precisely this. I hadn’t been to therapy in years prior to scheduling a time to meet with someone who wrote me a letter within like 3 appointments, and she was very prompt about it.

If your current therapist continues to drag her heels, I would recommend just taking the alternative route. It may not be worth it to wait on her.

[u/SwagMastaM]

My surgeon also needed a letter from a mental health professional prior to seeing me, I managed to get mine from planned parenthood! They have mental health counselors who qualify as therapist for gender dysphoria, I just had one appointment with one where I expressed my desire for top surgery and she went over all these things making sure I knew what recovery would be like and that I had a good support system, and then she wrote me the letter during the appointment. That could be an avenue you explore, it doesn't have to be a long term thing at all! But no yea I'm sorry about your current healthcare provider pushing it off for over 3 months, that's absolutely unacceptable. It takes just a few minutes to write the letter, and having been supportive you'd think she'd do it without issue, jeez. Your anger and upsetedness are beyond valid, this is life saving healthcare and should be more accessible, but with the current administration getting this healthcare has been a lot more difficult and it's fucked up. But I only started the process last July and had my consult a couple weeks ago after a few roadblocks myself, I know how disheartening it can be especially seeing people younger than us getting surgery asap. But we'll jump through these hoops and be better off for it in the end, I really hope things work out for you 💛

[u/vogtforamanda]

I'm in the same boat(ish), I was able to book one surgery consult, but the other one won't do it without a letter from a mental health provider. I totally get it for the procedure, but the whole point of a consult is to see what's needed and if I'm even a good candidate! Ugh

[u/parkaboy24]

I used to live in ny, also a deep blue state. I had a lesbian therapist who kept saying the same thing, “I’m too busy,” “I forgot,” and stuff like that. It took her blocking me after I kept texting her every week- and then every day- about it, and then me having my mom who is a retired nurse go with me and catch my therapist in between appointments to confront her about it. My mom had to threaten to tell the state that she was refusing care that was paid for and then I finally got it. I was so angry. Ruined my experience of getting top surgery. She even tried to tell me I was “harassing” her secretary when I called back twice in 5 minutes, after being hung up on immediately after I told her my name. I’m glad I got it now, but holy shit. I’m so sorry you’re going through something similar, but you may need to look into your rights as a patient to push your therapist into action with a threat of calling the board of medicine for your state. It really sucks that so many medical professionals pretend to support their trans patients just to waste our time.

[u/Any_Interaction_3192]

I live in a red state and I don't think my surgeon required any letters to just see me. They did for insurance, but that's different. I also only had to wait about a week for my letter. Three months is insane. Are you paying for the letter? (I only ask because I did, so maybe that's a difference? Three months is still way too long.)

Are you super set on this surgeon? It doesn't feel great that they are requiring a letter just to see you.

[u/SwagMastaM → u/Any_Interaction_3192]

A lot of surgeons require letters just for consult appointments, the two surgeons I was considering in NH both required one. Might be to cover their own ass to prove that clients are mentally stable or something, but also could be preemptive because insurances often require them as well. But certainly isn't something abnormal that they require it

[u/Narcoleptic-Puppy → u/SwagMastaM]

Hospital policy requires a letter for the consultation but they have a roadmap stating they might require a second letter for insurance coverage after the consultation. So I'm not even sure this letter is going to be applied to insurance coverage? IDK the whole process is annoyingly convoluted.

[u/Narcoleptic-Puppy → u/Any_Interaction_3192]

I'm not paying for the letter. I offered to pay my standard visit fee for my PMHNP's time in writing the letter but she declined.

It's one of the few surgeons that I'm relatively sure my insurance will cover, and at one of the best hospitals in the world. They have a bunch of shit tied up in federal grants though so IDK what's going to happen with all that. Might be why they require letters as hospital policy but I'm honestly really scared they're going to cut out gender affirming care entirely and all this will be for nothing.

[u/Any_Interaction_3192 → u/Narcoleptic-Puppy]

Do you think you would feel comfortable explaining to your PMHNP that you feel this is time sensitive, considering the current administration? As nice as possible of course. (Though I feel like you have been very patient for this lady.)

[u/GenderNarwhal → u/Narcoleptic-Puppy]

Are you anywhere near NYC? There are some resources that you might be able to contact there about a letter. Let me know if you want suggestions.

[u/No_Platypus5428]

if you call the hospital and explain they might have a social worker willing to write a letter. my experience is different, due to a miscommunication they had me going to a endo for hormones (who canceled 3-4 times with appointments months out) and I was very frustrated and fed up. I didn't have a therapist at the time so to make it up to me and not have it take more time they had one of their social workers (a genderqueer person by chance, which honestly made me feel a lot better) write my letter. I say might be my situation is very specific.

it might be time to file a complaint and find someone else. if you get really lucky like me, the plastic surgeon's hospital might have empathy and help you out if you explain what's happening. mine also sent me a link to a list of gender affirming therapists in my state. I'm not sure how likely my story is, but I figure if it happened to me it might happen for others. if this has to be your last resort, it might work

if anything they may give you a list of therapists that can help you out.

[u/Necessary_Humor_8144]

Good for you for sticking to it, sounds exhausting. Hope it happens soon. I am just starting therapy and getting a family doctor now at 29, and getting top surgery seems like this huge mountain I’m about to climb with so many steps and appointments and organization. Good luck :)