Guide for Client Evaluation and Interview - Gender Affirming Mental Health Assessments for GAS Referral Letters - Sarah Eley

Sep 16, 2026

Uploaded by Mabel

Guide for structuring client evaluation and interviews for gender-affirming surgery (GAS) referral letters, emphasizing readiness assessment rather than therapy. It outlines how to set visit expectations, adapt the number of sessions to the type of surgery, and frame the letter process as an extension of intake. The guide addresses power differentials, client vulnerability, and the systemic barrier created by WPATH SOC and insurance letter requirements. It provides an interview question set covering surgical understanding, support planning, recovery considerations, and emotional stability, then describes letter-writing next steps and feedback workflow.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Setting the frame of the visit/assessment

Helpful thinking

Important considerations related to power differential and vulnerability

Acknowledgment in the seat of power

How to begin the interview

What to ask in the interview

Surgery details and planning

Support and recovery planning

Imagining life with and without surgery

Next steps

Guide for Client Evaluation and Interview: Gender Affirming Mental Health Assessments for GAS (Gender Affirming Surgery) Referral Letters Sarah Eley, LICSW, Behavioral Health Specialist in Primary Care, Fenway Health Center, Boston MA Setting the frame of the visit/assessment: It can be helpful to start an assessment for readiness for gender affirming surgery referral letters by checking in with the ct about what their understanding is already about the process of an assessment, and then, filling in information about the process where there may be more information needed. The process will often look different for a ct who you are meeting with for an initial evaluation and letter assessment vs a ct who you’ve been working with for a while in therapy and are now doing an assessment for writing a letter. Setting the frame by informing the ct that an assessment can take sometimes more than one or two visits, helps to manage expectations. Doing an assessment for gender affirmation chest reconstructive or breast augmentation surgery can take at minimum 1-2 visits, and for gender affirmation genital reconstructive surgeries, an assessment can take at minimum 2-4 visits. I let cts know that this is dependent of course on what comes up during the intake so that we don’t set ourselves up, or the ctsup, if we need more or less time. Helpful thinking: The main thing that helps me think about doing a letter with someone I won’t be continuing with in therapy is to think of it as an extension of the intake---a further assessment focusing on their decision and readiness for having surger(ies), rather than as being a therapy session. Important considerations related to the power differential and vulnerability: By the time most clients come to us requesting a letter, they have often been thinking about their plan for surger(ies) for a long, long time, possibly as long as they’ve recognized their true gender identity. While the decision to have surgery is a choice, obtaining a letter from a therapist and medical provider before one can have surgery is not. Our health care system, the WPATH SOC, and insurance companies set these requirements. And, the systems which set this requirement are rooted in the oppressive history which pathologizes gender variant identity, transgender and gender non-binary people. As a result, some people who come to us for a letter may experience the process as a barrier to accessing the care they choose or need. Additionally, meeting with a therapist who may be gender conforming or nontransgender can add another layer of power to the dynamic. For some, being required to speak with a therapist about intimate and very personal things about their body and gender that they may not have spoken to anyone about before, may be experienced as very vulnerable, invasive and exposing. For others, it may be experienced as being brought a sense of relief, or feel empowering. Acknowledgment in the seat of power: Acknowledging the power differential and intersectional power dynamics can be a helpful for creating space for clients to share their experience around the process of getting letters itself and may help someone to develop a sense of trust and feel more empowered in their process. How to begin the interview: Inform the ct that the questions you’ll be asking are not about questioning their gender identity, but rather, the questions are specifically related to assessing their choice or need for surger(ies) and their emotional and practical readiness for the surger(ies) (about where they are now in their process) . So what do I actually ask in the interview? -What surgery are you having (specify type of upper and/or lower)? -Have you decided on a surgeon? -How long have you been considering surgery? -What do you understand, know, and have questions about the surgical procedure(s) itself, the expectations of the surgeon and insurance, the recovery guidelines and timelines? (Within this, I includ

FAQs

How should expectations be set for the number of assessment visits?

Explain that an assessment may take more than one or two visits and depends on what arises during intake. For chest reconstructive or breast augmentation, minimum is 1–2 visits; for genital reconstructive surgeries, minimum is 2–4 visits.

What is the recommended way to frame the letter process to clients who are not continuing therapy?

Treat the letter as an extension of intake—a further assessment focused on decision and readiness for surgery, not as a therapy session.

How can the interview address power differentials and client vulnerability?

Acknowledge power and intersectional dynamics, create space for clients to share experiences of the letter process, and recognize that some clients may feel invasive and exposing due to discussing intimate body and gender topics.

What key topics should be covered in the interview questions?

Include the surgery type, surgeon decision status, duration of consideration, understanding of procedures and expectations (including recovery timelines and hormone-related planning), available support before/during/after surgery, recovery planning logistics, and emotional considerations such as anticipated loss and emotional stability factors.

Sep 16, 2026

Uploaded by Mabel