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Hey y’all, welcome back to the Testing Psychologist Podcast.
My guest today is Dr. Addyson Tucker. Addyson uses they/them pronouns. They’re a queer, non-binary, and neurodivergent psychologist who thrives when working at the intersection of racial, gender, and body liberation. They specialize in supporting Two-Spirit Trans and [00:01:00] Non-binary adults to develop shame resilience through self-compassion through 1:1 therapy workshops, and a virtual community, as well as offering free gender-affirming surgery assessments and referrals.
Professionally, Addyson supports trans-affirming providers through advanced group and individual consultation, as well as training related to gender-affirming surgery referrals. So that’s the topic of our podcast today. Gender-affirming assessment or gender-affirming surgery referral specifically.
We get into many aspects of this practice. We talk about some of the philosophical aspects of this practice. We talk about the history of gender-affirming assessment. We get into specific strategies around breaking down the power differential between clinicians and clients during these assessments. And of course, we talk about the [00:02:00] actual process of the assessment or referral including components of the assessment, what the interview looks like, and what the resulting letter looks like as well. So this is, honestly a fantastic conversation. It’s been a long time coming for the podcast. I am super grateful that we got to dive into this together.
Before we get to the podcast, I invite any practice owners or aspiring practice owners to check out the Testing Psychologists Mastermind Groups. Those are group coaching and accountability experiences led by me at different levels of business development. So there’s beginner, intermediate, and advanced. Cohorts are continually enrolling. So if you’re looking to decrease that isolation and connect with others and build some [00:03:00] accountability to take your practice to another level, could be a good fit. You can check out thetestingpsychologist.com/consulting and schedule a pre-group call if you’re interested.
Now, a quick disclaimer before I jump to the episode. There are perhaps some pet noises in the background. I had to record from home today for a bunch of reasons I’m not going to bore you with, but I have a sleeping puppy in the background who occasionally sighs and stretches, and some of that may have made it onto the podcast. Please forgive me for that. Hopefully, you’re puppy friendly.
One other quick disclaimer. Even though there is the “E” for explicit content on all of my podcasts, it is still relatively rare, I suppose, that there’s any swearing, but today is one of those episodes and it’s just a little bit here and there, but if you have kids in the car and you [00:04:00] are concerned about that sort of thing just a little heads up. It’s mainly toward the end and pretty brief, but I wanted to throw that out there just in case anyone is mindful of that sort of thing.
All right. Without further ado, let’s get to my conversation with Dr. Addyson Tucker.
Hey Addyson, Welcome to the podcast.
Dr. Addyson: Hi. Thanks a lot for having me.
Dr. Sharp: Yeah. I’m excited to chat with you. We’re tackling a topic that has not come up, well, not come up, that we haven’t taken a deep dive into on the podcast before. And I’m always amazed at how many topics there are where that applies, but there is so much within the world of testing that we can get [00:05:00] into, and this is just one of them. So thanks for being here and I’m excited for our conversation.
Dr. Addyson: Me as well.
Dr. Sharp: As we get going, listeners typically know that I like to start with the question of why this is important. So, of all the things that you could focus on in the world of psychology or assessment, why this?
Dr. Addyson: Such an important question. I think what originally drew me to connecting with you was even from a place of uncertainty of how much is this related to that world of assessment versus not and how it turns things on its head a little bit from what folks might traditionally be trained in.
And in talking about my specialty of working with trans and non-binary adults, I think the process of helping folks [00:06:00] connect with medically affirming treatment and surgery, in particular, is something that a lot of people wouldn’t think that they have the ability to support someone with. So part of why this feels so important in the work that I do and the training that I offer for providers is helping it feel a little bit more demystified, and really helping people feel like they can develop the competence to support trans folks.
And I guess the other piece of importance is related to really allowing us to talk about some of the limitations in the assessment world around working with trans folks generally, looking at how is the assessment process, the standardization, etcetera, limited and just helping people to get curious about ways to make that process a little bit more affirming and I guess just more open to [00:07:00] considering some of the different nuances that they might not have been trained around.
Dr. Sharp: Sure. Just in that little intro, there is so much to unpack and I’m holding back lots of questions, but I’m going to trust that we’ll get there during our conversation. I appreciate you acknowledging that and maybe setting a tone right off the bat to say that we can support folks in many different ways and at the same time, just speaking for myself, it is hard to do that sometimes because I’m it’s like that classic thing. It’s like I’m going to say the wrong thing or I’m going to do the wrong thing, or I don’t know the research well enough, or I’m going to step into some minefield of something that I don’t even know about and I’m already feeling a little more at ease talking with you which translates to the audience too.
Dr. Addyson: I appreciate that. Another part of my specialty, a huge part of the work I do is around self-compassion and shame [00:08:00] resilience, and thinking about the ways that we… sometimes our defenses or the responses we have when we feel a sense of shame of messing up, that in itself can shut us down and stop a conversation. So I work a lot to try to help people lean into that discomfort.
Dr. Sharp: Mmm. Okay. Well, it sounds like I’m talking to the right person then. I think there’s lots of overlap there.
Well, let’s jump into it. I know there’s so much that we could cover during this conversation. Maybe we could start just with some background or history around this type of work. And you can start wherever you would like, but I think putting it in context is important. A lot of us, I don’t want to speak for everyone, but it seems like the need for, let’s say gender-affirming care or [00:09:00] letters and whatnot, it’s ramped up maybe over the last several years. I don’t know if that’s true or not but I would love to hear some history around it and why this is a thing that exists in our field, if that makes sense.
Dr. Addyson: Yeah, sure. I’m happy to provide a little bit of context and recognizing that I’m also a younger provider, so coming into this field, there are so many elders and ancestors who have been doing this for a really long time who probably have different perspectives.
When we pull on who writes the suggested guidelines for flexibility in the assessment process of helping provide trans-affirming care, the go to organization is the World Professional Association of Transgender Health or WPATH. [00:10:00] They were originally coined and referred to by a provider named Harry Benjamin. There was these Harry Benjamin Standards that were first released in 1979 and there have since been seven iterations as of 10 years ago, and actually, the eighth version just came out this year of these WPATH Standards of Care.
I think originally they were created with the intention of some sort of summarization of how do we provide care to this population that’s actually been around for a really long time, but where the medical field was starting to recognize, okay, these folks really need some guidance and care. How do we help other providers start to offer this through hormones or surgery or other types of affirming procedures?[00:11:00] So, the manual itself is… the most recent version I looked is 260 pages with all of the references. So it’s gotten bigger. And it covers everything from primary care to vocal affirmation to mental health care, and then of course the surgery assessment and referral process.
So while WPATH is the go-to guideline, there’s a lot of work that still needs to happen in this field. If we look at assessment, for example, and look at gender norms and how different measures are standardized, there’s often this very binary sex approach that can be really limiting. Or if we look at the fact that gender dysphoria is still coded in the diagnostic manual of [00:12:00] mental related conditions when actually it falls more into the medical experience of discomfort, that’s an area that we really still need to continue working on. And then I think regardless of these standards, the insurance companies, managed healthcare, the surgeons themselves really dictate how care is accessible or not.
So with this new Version 8 of the Standards of Care, for example, it could take years for insurance companies to adapt some of the recommendations that have changed to allow this to be a little bit more accessible for folks.
So my job as a mental health provider, which can be masters level and above, I happen to be a psychologist, some insurances require a doctoral [00:13:00] level provider to do these assessments. I get where that history comes from. And also it’s really a problematic element of this because masters levels folks can be just as competent at this. In my role doing the assessment as a mental health provider, the guidelines of the WPATH standards and how the insurance companies adopt them help me to have a conversation with someone who’s going to consider a type of procedure to affirm their body.
So that’s the history of where this has come from. There’s a whole other conversation that can happen around how this assessment process actually is a pretty significant barrier in a lot of ways or can be, and has historically created a lot of gatekeeping. And so there’s been a lot of movement to try to reduce that [00:14:00] or get rid of it entirely. But while we are still doing this process, while we are still part of helping folks get the care that they need, that’s where my role comes in.
Dr. Sharp: Yeah. I want to talk about this gatekeeping process. I think that’s super important. And before we jump into that, I was hoping to pull on two threads from what we just talked about.
One is just to reflect, and this may go without saying, but I’m going to say it anyway. I think we get wrapped up in this idea that there’s been a seemingly large increase in individuals identifying as trans or non-binary here over the last few years, right? But this stuff is dating back to, like you said, the ’70s, which is the first formal declaration of processes or whatever you [00:15:00] want to call it, right? It’s been around for a long time. I think that’s a good perspective to have which makes sense. Like folks have been around for a long time, of course, but we can get locked into this sometime. It’s like, is this some kind of like new phenomenon or something?
Dr. Addyson: Yeah. Well, and I think it’s also interesting to think about how even way long before these standards were even developed, how back in times of before colonization, when indigenous communities really celebrated transness. They didn’t call it that. I think transness in itself was coined as this word to try to help understand, but white supremacy played a role in coming into play of saying like, hey, you’re different. You don’t fit into this assigned way that we see you. And so we’re going to literally enact not only violence and [00:16:00] murder of these folks, but limit access to resources and care and respect as a human being in whatever ways we can. And so that’s actually been happening for a very long time.
Part of what I think we see more recently, why it feels a little bit like there’s been an increase or why gender’s more just a part of the landscape now is actually that I think we’ve been having more conversations about it. There is a reduction of some stigma around people being allowed to consider what gender looks like for them, whereas, for a lot of us growing up, you may not have realized you even had options to consider something different.
Dr. Sharp: Oh, sure.
Dr. Addyson: And I also think that there’s more fluidity around what gender looks like. Years ago, if you were a binary presenting person, like if you were [00:17:00] a trans man or a trans woman, for example, then your journey might have been a little bit more clear cut in terms of what you thought affirmation would look like. You would potentially socially affirm yourself. You might take hormones to help shift into a presentation that feels good and you might consider surgery, right?
I think especially in a lot of the younger generations and folks who have really been thinking outside of that box, those two boxes, the non-binary gender identities and any other type of gender diversity or fluidity around expression and identity and how we experience our bodies, that’s I think where it can feel like a challenge because if we really think outside of that box, the possibilities are endless. And I think that can feel overwhelming sometimes for providers especially for those of us who were raised with just [00:18:00] those two options. They weren’t always the only two options, but they were the two that were presented to us as acceptable.
Dr. Sharp: Sure. That makes a lot of sense. You’re just echoing conversations that we’re having within our practice as well around… I think a lot of us are struggling with this. It seems like our brains automatically try to categorize everything and people and binary and black and white is cognitively efficient and all that kind of stuff.
Dr. Addyson: Yes.
Dr. Sharp: You’re hitting the nail on the head, right? Like once you blow open that box, it’s like, what do I need to consider? How could I possibly I think.
Dr. Addyson: And it’s hard and it can feel overwhelming, like my pronouns are they/them. And I think a common experience that folks have is that [00:19:00] this is really hard to adapt to, or that’s not grammatically correct or what if I mess up or if I correct somebody there can be that shame experience of shutting down. But I think the way I approach it is really, language is constantly changing. We adapt to things all the time. We learn complicated things that are important to us. And if the people in our lives are important, and we want to respect them, we don’t need to understand every single part about what’s important to them. If we care about them, we work on it and we try to get better. And that’s the expectations around it that minimize harm.
Dr. Sharp: Well said. There’s so many directions we could go. I wanted to ask you since you brought it up and maybe to close the loop a little bit on the, I don’t know if prevalence is the right word, [00:20:00] but perceived increase, and like you said, more conversation around gender and so forth. I feel like this is maybe a similar conversation that people have had around diagnoses like autism, for example. It’s like this question of, are we really seeing more folks identifying as trans or non-binary or fluid or is it more permission to have those conversations and be more in the open or some combination of both. Do you have any thoughts or research around that?
Dr. Addyson: Yeah, I think that’s a great question. It is actually hard to tell one, because, especially in the terms of the number of trans or non-binary gender diverse identified people. A lot of times people weren’t even recording that in the first place. So [00:21:00] we don’t really know. And now that they are tracking it, there’s the whole other piece of how are we tracking it? Are we saying, do you identify as a transgender person? Not everyone does. Do you identify outside of the cisgender identity that you know? Does your gender that you identify with match the sex that you were assigned at birth- the genitals that somebody decided major sex? Then if you identify outside of that, that’s a much broader type of question.
In some of the recent research, they have shown a larger percentage of people who identify outside of the cisgender realm, who are gender diverse. The number of people who may identify specifically with that transgender label may be lower, but it’s hard to really distinguish [00:22:00] because then if we get into the assessment part of it, does that mean that non-binary people don’t also experience gender dysphoria? No, of course, they do. Non-binary people also pursue surgery or hormones or different forms of social affirmation.
Does that mean that all transgender people who believe that they are on the other side of the binary, that all of them want hormones, surgery to change their name and to present as the completely opposite gender? No. And I think that’s where the assessments get broken down over time as we learn more and try to offer a broader range of looking at this.
Dr. Sharp: Yes. I’m with you. Well, maybe we do talk more about this process and what that looks like. So as we get going, this is a very basic question and important I think, which is, [00:23:00]what is this process for? You’ve mentioned surgery and you’ve mentioned procedures and you mentioned hormones and that. So when we talk about gender trans-affirming care and our role as assessors, what is happening here?
Dr. Addyson: That is honestly the million-dollar question because I think what was being historically assessed is not actually what allows people the autonomy to make decisions for their bodies? So when I look at this process, the way that I see it, and I use the acronym GAS, Gender Affirming Surgery assessment that also refers to the letter writing process, which is part of the assessment.
So when someone reaches out to me, we’ll use an example [00:24:00] of a trans man who wants to have chest affirming surgery and we’ll say he/him pronouns for the sake of my conversation. So he reaches out to me and asks for an assessment because his insurance company says that he needs one letter of referral from a mental health provider to be able to see Dr. so and so in Boston for surgery.
So when I’m doing these assessments, my role is to support a few different things in support of these WPATH Standards of Care guidelines that most insurance companies have adapted. So usually there’s some indication of this person has gender dysphoria, some kind of incongruence with the sex that they were assigned at birth or the way that their gender role is perceived and expected. So that’s one piece.
Mostly it’s that the [00:25:00] person’s 18 and over. I specifically work with adults. There are a lot of really incredible clinicians who work with adolescents and kids. And it’s not that they can’t access surgery, it’s just a little bit of a different process because we want to be intentional around development and age of consent and working when you’re not the person in charge of everything in your own life. There’s the ability, the capacity to consent to make a decision about your body.
Dr. Sharp: There’s a capacity element there.
Dr. Addyson: Yeah. And it’s not even that… If someone had a limited cognitive capacity, for example, it’s not that they can’t still access that care, but we want to help make sure they have the information they need, that they can really understand the process of making a medical decision for their body that’s potentially permanent, irreversible.[00:26:00] It’s more that element.
And then the fourth piece is, of course, mental health. Are there any medical or mental health pieces that might be contraindicated or that might complicate this person moving forward?
So all of these, and I will actually say that those were based on Version 7. I was looking through Version 8 and I didn’t actually see that same explicit list. And so, I have to revisit it. I searched through. It’s a lot of papers, but it makes me wonder if there’s been a shift even in that language of really just supporting the autonomy of people to make decisions for their bodies.
So I’m assessing gender or I’m not like assessing gender, but I’m discussing like, how is this surgery going to help you? What do you really excited about in affirming your body? How is this going to help to support your [00:27:00] gender? And as minimally as invasive as I possibly can, I’m asking some of those really gentle questions and conversations with that person.
Dr. Sharp: Mm-hmm. Can you say more about being minimally invasive? And maybe this is also related to just doing this in an affirming way. Is there some overlap there?
Dr. Addyson: Yeah, that goes back to, you picked up on my use of the word gatekeeping, which if you talk to anybody who’s been doing this work for a long time, there’s sometimes this ruffling of feathers that happens when using that word, because there can be a defensiveness of like, no, we’re not trying to keep anyone from accessing this. We’re just trying to be collaborative and help them get support. And that may be the case now for most people. For some people, it was not always.
So when we think [00:28:00] about how did this historically restrict care for people, these assessments might have been perceived in the past as like a readiness assessment. I, as the assessor, if we think about like, okay, so if you’re doing an assessment, you’re taking a look at all these different measures and different parts of what this person’s experiencing, you’re coming up with a diagnosis and you have recommendations. That’s the typical way that an assessment happens from what I understand. It’s not what I do.
But here’s where the assessment is different. For gender-affirming surgery, it’s not me saying, yes, this person is ready and I approve them to do this thing that they want to do with their body. Instead, it’s me saying, yes, this person has gender dysphoria. They have considered the different risks and complications. They’re able to read into this and look and make an informed decision about their [00:29:00] body. If they have mental health-related stuff, they either have a plan to manage it or they have a team helping them manage it. And they are of the age of consent or can make a decision in combination with whoever else is supporting them.
I’m just basically suggesting that I’ve had a conversation with this person and that we’ve touched on these different pieces that might impact them moving through this procedure.
Dr. Sharp: Yeah. That’s a much different framework, an important shift.
Dr. Addyson: And I think a lot of providers get caught up in the worry about, is this within my area of specialty? Can I offer this? If you don’t have any experience or knowledge of working with trans folks, then probably you shouldn’t be, because you might need to do some of that basic work first. But at any point in your work with anyone, they [00:30:00] can come out to you as trans or you may have somebody come to you who is trans and you don’t even know that because they’re presenting in a way that you don’t realize or you’re not asking those questions on your intake forms or whatever.
I listened to your episode with the Multicultural Assessment Conference team because I actually went to school with Tanisha. I was really excited to see that this awesome work that they’ve been doing was featured, but I think in the same way that you approach the intentionality around somebody’s different lived experience, and you try to make your process as open and welcoming and inclusive as possible, the same thing should be happening when we’re working with folks who are trans, non-binary or even in the queer population, the LGBT population generally.
Dr. Sharp: Sure. [00:31:00] That’s a major shift from the way that I’ve heard it described in the past, which is just my own ignorance and not spending a lot of time in this area. But that shift of we’re not here to really certify individuals as being ready or like you said, just ready to go through the process. It’s more, hey, we have this conversation and I’m going to document all that stuff. There you go.
Dr. Addyson: Right. And I think that there’s pushback in the field. There are different ways of looking at this, because we could say, well, what if someone is housing insecure and they don’t have a place to stay for recovery? I can’t possibly refer them for surgery because they don’t have a place to be. And maybe a provider would say, I can’t write you a letter until you have housing, but what if that person never secures housing but even the fact that they are [00:32:00] housing insecure is stable for them? What if they can create a plan? What if they have supports? Have we considered other resources?
So to me, it’s more like, just because something seems like an additional barrier or it makes something a bit more complex, it doesn’t mean somebody can’t still access the care that they need.
Now, if somebody’s actively having a psychotic break for the first time and it’s not managed and it’s in this place of instability and we’re trying to regulate that, then maybe I’m not going to write your letter right now, but let’s continue to monitor this and help you get what you need.
Dr. Sharp: Yeah. You’re anticipating one of my questions, which is, are there any situations where it may not be the right time or it may not be appropriate, and how do you approach that? You said active psychotic break.
Dr. Addyson: Sure. Psychosis in itself, not. And honestly, even active [00:33:00] psychosis is not necessarily, it’s more when you’re making an assessment decision. And I will say honestly, even in these complicated situations where there’s additional questions, I consult. I’m making the best decision that I can. I’m talking to the team. I’m talking to the other providers who are supporting this person. And so you’re never really alone in doing this work. We do the best that we can to do an assessment that is thorough but also not creating additional barriers for somebody.
Dr. Sharp: Right. That seems like a fine line to walk. Even if we zoom out from this specific example of gender-affirming surgery, it’s a fine line to walk that balance of exercising. I’m just going to say [00:34:00] exercising caution and skepticism with balancing advocacy and affirming, do you see what I’m saying, awkwardly, because I think that’s such a part of our identity wrapped up in assessment.
For our practice, we do what we call strengths-based assessments. I really stand behind that. And there is some navigating, okay, how do we exercise also good judgment and make sure that we’re doing both?
Dr. Addyson: I think it’s okay for a letter to be more nuanced. It doesn’t have to be invasive about the details of every part of this person’s life. But let’s say that someone has a lot of suicidal [00:35:00] ideation and has attempted recently and has said that if they can’t access this procedure, then they don’t know how they would stay alive, right? That can be really scary. And that also doesn’t mean that we’re going to immediately refer that person because we’re so scared that they’re going to attempt to end their life. But at the same time, we recognize the importance of having a conversation around safety planning with this person in the event that, like during the Covid pandemic, procedures got canceled, rescheduled.
So if we think about how, let’s say you come out of your surgery and you have some unexpected complication and actually that is a visible thing for you, that’s going to really be upsetting, how are you going to navigate that? What does your support system look like?
And so it’s not to say that we don’t have those conversations, [00:36:00] but as in private practice, I will say, because this may be very different for folks who work in different healthcare centers, community mental health, etcetera, but in private practice, 98% of the people that I see are super straightforward. They know what they want. They’ve done their research. They’ve been thinking about this for a long time. They have at least some support and somebody who’s going to support them in in recovery and they don’t really have a lot of concerns. So we can have a conversation, but it’s not going to feel complex in that way.
For that other, like 2% of the assessments that I’ve done, it is a little bit more of a nuanced conversation, but it’s still not going to create barriers. We’re just going to think through, okay, how do we help you get what you need to feel supported for this process?
Dr. Sharp: I like that. Let’s talk about the process itself. What does this process look like as far as the [00:37:00] assessment, whatever?
Dr. Addyson: Yes. This is also something that may vary historically with providers who have been doing this a long time versus some of us who are a little bit, I guess, more recently trained or trying to reduce those barriers, right? And it’s not to say that folks who do this in different ways are trying to create barriers, but it has historically created barriers for some people.
For example, sometimes folks used to charge hundreds of dollars for this assessment, and that may actually be what somebody needs to do for their practice and their business. And that’s totally a part of a business decision.
But there’s a lot of us in the field who for example, we pledge an organization called thegalap.org The Galap actually was created for providers who [00:38:00] wanted to offer accessible assessments to trans folks with either not charging them at all or agreeing to take their insurance if they were in network. And so, there’s this whole entire community of providers who offers these assessments for free.
And the way that I’ve set it up in my business is I do at least one or two free assessments a month. If for some reason I can’t get someone in that month, I refer to another person who’s willing to do the same thing. So it helps to provide access.
So I will say, making decisions about what this process looks like is it’s both trying to make it as streamlined and accessible as possible, and also respecting your own comfort levels of how quickly can you do these assessments.
So I work with adults. In private practice, I don’t tend to see quite as much in terms of complexity [00:39:00] around folks who are pursuing this. So usually folks will reach out to me and almost always, I can do the assessment in a one time intake appointment, write up the letter, have them take a look at it and fax it out. Sometimes a second appointment. I don’t promise it within one time, just because I never really know 100%, but if somebody does need a second appointment and there’s things we want to talk a little more about, or we want to make a plan to help them get connected with care, I can do that for them.
I’m more likely to see somebody who’s not a current client for an assessment to refer them. There are providers who only really feel comfortable doing assessments for folks that they’re already seeing an individual care. But the assessment itself does not require counseling and cannot require counseling if someone doesn’t want [00:40:00] that. It can be recommended, but it’s not a requirement.
Dr. Sharp: I see. Yes.
Dr. Addyson: So in both situations, whether it’s my client or whether it’s somebody who’s just coming to me for the assessment, I have a conversation with them, quick phone screen beforehand, have them do the typical paperwork to onboard them into my practice with all the informed consent documents, etcetera.
I talk with them about the assessment having three main components. This is how I approach it. I don’t know how others do, but this is how I train people too. So there’s probably other people doing it like this. I tell them that we’re going to talk a little bit about gender history, nothing invasive. They don’t have to share anything that they’re uncomfortable with and I’m not going to ask them anything that I don’t need to know.
Like I don’t need to know at what age did you start feeling uncomfortable with your genitals or what have you done explicitly to try to affirm your gender? I might [00:41:00] want to know, when did this first come up for you? How did you notice it? When did it get to the point that you couldn’t wait to do something?
I want to know some of the general history so I can show in the letter mostly for the insurance company and support that history of gender dysphoria, but also say, this is something that’s been there for at least a few months or longer, depending on how long because not everyone has had this experience since the time they were born. That’s a common misconception.
Dr. Sharp: Sure. I appreciate that you gave examples of that. I was definitely going to ask, what’s an invasive question? This is good to know. Those two examples you gave, I would not necessarily think or know that [00:42:00] that would be invasive. That seems like basic info, but that subtle shift of how you rephrased, it’s like, when did this first come up for you versus the more explicit.
Dr. Addyson: Right. And I think that there’s a history of that too for trans folks where there’s a desire to prove transness. I always tell folks in the beginning, I don’t need you to prove yourself to me. If you tell me you’re trans, I believe that. Most likely I’m going to be able to write you a referral letter, but that’s not a part of you proving this to me. I don’t need you to feel like you have to like over-exaggerate or lie. The last thing I want somebody to do…
I usually will give a symptom measure just so that I can figure out if there’s mental health pieces that I want to touch on around coping, etcetera, but I really say to people like, I want you to be honest because I want us to be able to anticipate anything that might be a challenge.
So the second part of the assessment in addition to the gender history is [00:43:00] we’re going to talk about mental health stuff. We’re going to talk about coping support and just brainstorm if there are things that might be helpful for you.
For example, if we go back to the person who’s seeking chest surgery and let’s say he works as a professional painter, and after having chest surgery, your scars are healing and you’re not allowed to raise your hands above your head for a period of time, or you stretch the scars. Let’s say he wants to go back to work within 3 or 4 weeks, and he’s going to be painting ceilings.
No. We’re going to have to talk about the impact of that, not just practically, but what’s the impact going to be financially for you? What will it be like for you to not be able to work? What if you go back to work and you find that you’re not quite as recovered as you want to be and your energy is waxing and waning for a while, which it will be.[00:44:00]What’s the impact of that and how will you navigate it? And what if you have complications, what would that be like? So that’s where mental health combines with the gender affirmation piece.
Dr. Sharp: Sure. The way you framed that, it strikes me as like you’re almost doing a little bit of the lifting for informed consent for the surgery. Is that fair?
Dr. Addyson: Yes. I guess another piece that’s complicated is that the consultation for the surgery is, if anyone’s ever had a consult pre-surgery, they’re like 15 minutes. The surgeon’s in and out. It’s very, very quick. So much information. A lot of people are wicked anxious even before.
And so part of my role is to just get creative and think about what might be helpful for this [00:45:00] person to be thinking about going into their consultation. I don’t need to know all of the details of the surgery. I happen to know a lot because I do a lot of research so that I am informed when I’m training providers and anticipating these things. But someone can just as simply say, hey, I’m sure you’ve done your research. Are there any complications or risks that you feel worried about that you want to make sure to talk more to the surgeon about? Because if somebody can go in with a list of questions, they can make sure to advocate for themselves and ask for what they need rather than to feel overwhelmed later.
Dr. Sharp: Sure. So you’re doing a usually one-time appointment. It sounds like a lot of interviewing basically. You did mention a symptom measure. Can we dig into the details of what’s happening in that appointment or appointments?[00:46:00]
Dr. Addyson: Yes. So it’s essentially, I would say it’s actually pretty much like a regular psychosocial type of intake. I’m assessing mental health. I’m assessing identity and how surgery might be helpful. We’re talking a little bit about symptoms, symptom management, coping, and social support.
I might not go into as much detail with family stuff, but I want to know a little bit more about substance use. For example, smoking nicotine, smoking cigarettes can affect the healing process. So if someone smokes, a lot of surgeons require people to quit smoking before surgery. So if someone’s a smoker, I might say, hey, FYI, a lot of surgeons require this. What would it be like for you to try to quit? So things like that. I’m gathering information.
In terms of the surgery itself, there’s [00:47:00] the gender piece, there’s the mental health piece, and then there’s the surgery itself. My role is not to be a medical doctor, because I’m not, but I might help the person think about, what do you need to ask for in this consultation? Have you researched this surgeon? Have you seen before and after photos? Have you thought about location, travel, cost insurance coverage? I’m not necessarily going into all the specifics, but I’m helping someone to just be thinking through, what do they want for their body, right?
Dr. Sharp: Yeah.
Dr. Addyson: So for a trans guy who is having a chest mastectomy, I might say like, in terms of the aesthetic of what you want your chest to look like after surgery, do you envision it looking the way that you imagine a cis guy’s chest look? Do you know [00:48:00] know that it’s not always going to come out symmetrical? That there can be complications with the nipple grafting? Sometimes the tissue has a hard time healing. What would that be like for you?
Because a lot of guys, if I’m thinking of a trans guy in particular or someone who’s having a mastectomy and once that masculine outcome, they might just be like, I just want to be at the beach with my shirt off. And that’s the exciting thing for them, right? But what happens if the results don’t come out that great? Or what happens if it’s a newer surgeon who hasn’t been doing this for a really long time?
If the whole other conversation, whole other podcast would be like, what if somebody is in a body that is not within a certain BMI that the surgeon has indicated should be acceptable for [00:49:00] surgery, which is not actually the person’s fault at all. It’s that surgeons are not… there’s a really long history of medical fat phobia and people are not actually trained and willing to work on fat bodies. And that’s part of a bigger problem. But I might talk with somebody about how to advocate for themselves if the surgeon pushes back and tries to tell them that they need to lose weight.
Dr. Sharp: Yeah. I love all this info. It is reshaping the process, which admittedly I don’t know where my template for this process is coming from. Maybe just like snippets of conversation and little bits of reading here and there. And there’s a lot of conversation. It’s a lot of conversation and inoculating it sounds like and just talking through like, have you thought about this and what might this be like and so forth.
Dr. Addyson: And I think I’m trying [00:50:00] not to… I’m recognizing that this person is going to face barriers at different steps of the process, right? Whether the insurance is going to approve it, whether they’re going to have to wait a year for a consultation or maybe three months for a consultation, and then a year for surgery. Are they going to be required to quit smoking or have hair removal or something?
I learned these things through my work. Somebody coming into this fresh might say, Oh my goodness, Addyson’s talking about all these things and this is really overwhelming. I don’t know any of this. But that’s when we come back to the basics of does this person have gender incongruence and dysphoria. Is it creating some impairment where surgery could potentially be helpful? Can they make an informed decision about their body and do the research and ask the questions needed to navigate that? And then do they have an awareness [00:51:00] of how they would navigate different challenges and what does their support and coping look like, right? Because if you can come back to that grounding, that’s actually all you really need as a provider doing this assessment. The other stuff comes with time and experience. And honestly, anecdotally, I learn a lot of these things just from my assessments.
Dr. Sharp: Well, you certainly make it sound doable and less intimidating. So thanks for that.
Let me talk about, I know I keep drilling down on these details. I’m a very concrete person. So I’m curious, when you say symptom measure, you mentioned sometimes I do a symptom measure maybe all the time. What is that?
Dr. Addyson: Just a basic symptom. Like I might do like a DASS-21 or the PHQ-9 although I recently [00:52:00] went to a suicide conference and discovered that that’s not quite as good at catching the suicide indicators. So I might shift that. Or if somebody’s got a history of like PTSD or really severe depression, I might give a little bit more of an assessment, but not nothing like, I don’t want to say like, not true assessment, but you know what I mean, it’s not like full batteries or anything like that. It’s nothing that is an additional barrier.
I don’t need someone to fill out anything related to gender. But if someone, for example, was reporting a lot of trauma types of symptoms, I might want to have a conversation with them about what would happen if something got triggered in healing from the anesthesia, for [00:53:00] example. We don’t always know what that’s going to look like and helping somebody to think about a plan for coping and responding. So it’s more just the symptom measures help me to get a sense of what areas of struggle or mental health stuff do we want to at least have a plan for.
Dr. Sharp: That’s fair. And then what does the… Well actually, let me clarify. So you didn’t say anything about these, so I’m just assuming it doesn’t happen, but no collateral interviews, no personality measures, no cognitive stuff, none of that stuff?
Dr. Addyson: No, nothing as a rule. I would say that the only time where I step out of that initial me alone doing this gathering of information as a regular intake is if there are some more complicated personal life stressors, like one time I worked with someone where there was some housing [00:54:00] instability and some job insecurity. And the person also, my sense was that they might have been neurodivergent. And so I suggested and asked if they would be willing to have their partner who was going to be their caretaker, come into a conversation because I could tell that part of what we were talking about was a little overwhelming and there was a lot of uncertainty and change happening.
And this is an adult, so they could have said no, and I could have gone based on what I had, but it felt helpful for me to have that conversation with the partner, be able to go through some of the things to expect. And then I also always will collaborate with the other provider on the team. So if that’s a hormone prescriber, if that’s their primary care doc, or another therapist because sometimes someone is coming to me for a second letter, some [00:55:00] insurances require a second letter.
The new standards actually have removed that recommendation. They haven’t supported that in the research. They’ve actually been like, it’s a little bit redundant and generally not actually telling you anything new or different. But insurance companies probably will still continue to require that for some time. So someone come to me for a second letter or sometimes the provider isn’t comfortable or competent enough to be able to offer that. So they might come to me for a letter. So I’ll just usually coordinate care, reach out, get a release and say like, hey, I saw your client, the person you work with. Here’s my sense of things. I’m working on a letter for them. Here are some things that I’m concerned about or things that we discussed and recommended. Is there anything you want to talk more about? And it’s more of just an opportunity for me to collaborate and let that person know that I’m offering support.[00:56:00] Dr. Sharp: Sure. And then you’ve mentioned insurance a few times. I keep meaning to ask, does insurance actually cover this process as far as you know?
Dr. Addyson: The assessment or the surgery?
Dr. Sharp: The assessment.
Dr. Addyson: Yes. It’s actually a regular intake. Sarah Eley at Fenway Health in Boston presents on this. I think they actually do it as a progress note because they don’t do like a full psychosocial. So yes, but I think it is actually definitely billable, whether an intake or a follow-up. And I’m still doing the typical assessment that I would if I was onboarding any regular client. I would say that I’m just maybe a little bit less extensive in my collecting of information related to certain parts of history that aren’t as relevant to what we’re talking about. [00:57:00] But other than that, I am doing a full typical intake assessment.
Dr. Sharp: Mm-hmm. Sure. And then what does the letter look like?
Dr. Addyson: So there’s lots of templates for this. I’ll share my information for folks to reach out. I have providers who often will do my trainings or reach out for consultation, have me look at letters for them. But I try to keep mine to about a page.
And this is the thing that I need to look into a little closer with the new version of the standards of care, because they used to have seven things that were required in a letter or recommended, I guess, which was like, when did you meet with this person? Do they have a diagnosis? If so, what are they? Including the gender diagnosis. Are you willing to coordinate care? It was simple sorts of things that outlined those requirements that I mentioned earlier.
And [00:58:00] so my letter is very much in line with meeting those minimum standards, adding a little bit more to humanize the person and really trying to be explicit about any recommendations or considerations that might be helpful for the surgeons. So there’s obviously a demographic section, little bit about the person. Little tiny bit about their gender history and how the surgery might be helpful. There is a little bit that just says, here’s what’s going on mental health-wise and or medically from what they’ve reported, and here are there other providers that are supporting them. And then at the bottom, it’ll say, the person fulfills the criteria consistent with the WPATH Standards of Care. There’s no contraindications that I’m aware of and here’s my experience in training. Reach out if you need to with questions.[00:59:00] Dr. Sharp: All right. Seems pretty straightforward.
Dr. Addyson: Yeah.
Dr. Sharp: And you give that letter directly to the client?
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Dr. Addyson: No, they get a copy but I actually prefer to fax it directly to the surgeon and address it to them.
Dr. Sharp: Oh, I’m glad. Okay.
Dr. Addyson: And then if they need multiple letters, I just create multiple [01:00:00] versions of the same letter for them. I think if it goes straight through to the medical record, it helps get where it needs to be for a person, and then they still get the PDF copy of it to do with what they would like.
Dr. Sharp: Great. All right. I feel like we’ve covered a lot of ground and there’s always so much more that we could talk about. As we start to maybe land the plane a little bit here, there are a few things that I wanted to maybe go back to and just touch on before we wrap up.
One is the piece that you mentioned about standardization and norms on our measures. This is a huge topic of conversation and there’s a lot of variability in test publishers and authors and how folks are tackling this. I know we’re [01:01:00] stepping a little bit outside of this specific process, but do you have anything to say about that now? How to navigate that when we might be doing more standardized assessment, I suppose?
Dr. Addyson: Hmm. In terms of decision making around it? Honestly, I don’t, because I don’t do that assessment. So it’s not even really within my wheelhouse to speak to it, but in all of my years of doing this work, I can give two things that might be really helpful around the process of it and the acknowledgment.
So we talked about how, especially cis providers are going to fuck up. Oh wait, am I allowed to curse?
Dr. Sharp: Yeah, you’re good.
Dr. Addyson: Okay. So cis provider is like, you are allowed to fuck up and that’s going to happen. How we handle that is actually really important. So the assumptions we make, the lack of asking certain questions that might help make [01:02:00] certain decisions, or even just an acknowledgment, for example, that the norms you’re using are going to be based in XYZ history, right?
So I’ll talk with folks about like, hey, there’s not a lot of research of this assessment or any assessment measure really for trans people. And I recognize that I’m going to do my best to try to find a balance and looking at these norms and getting curious about how this specifically relates to your case, but that’s got to be frustrating because it makes it hard for you to get what you need. So to me, acknowledgment of the history, because it actually doesn’t even matter how affirming you are. People bring that history with them. It’s passed down.
I think the other piece is how do you respond when you fuck up? So, acknowledgment of the history and then being able to hold yourself [01:03:00] accountable with some gentleness. And I think inviting clients to give you feedback about the process. Being able to say, hey, in this measure, there’s a lot of gendered language heads up. Feel free to adapt it and interpret it in whatever way makes sense for you.
When you write the assessment, if someone uses they/them, I encourage people to comb through and make sure you have not accidentally misgendered somebody. Or let the person look at the assessment and read it themselves before you finalize it. And I don’t even know if that’s an option, but I guess, that’s why people get to read my letter before I finalize it because I don’t want to miss something that’s important. Sometimes it’s the wording. Sometimes I accidentally misspell a name or whatever. I’m so good at they/them right now that I very rarely mess that up. But a [01:04:00] lot of people do. And so having a conversation.
And then I think the third piece would probably be, what’s the best way to affirm this person? So if that testing report is going to their employer, are they out? What’s the impact of that? What’s the legal name? What’s the name on their insurance because that might be different. And if they are billing insurance, the sex that you have to assign to bill it may be different than how they might identify their sex because they typically only give you two options.
And so again, these are all just questions. It’s a conversation. It’s an opportunity to acknowledge the history and the limitations and be able to try to empower the person in whatever way you can, because I would rather ask somebody what they think and recognize those limitations rather than hurt somebody [01:05:00] and have them not feel like they can say something.
Dr. Sharp: Yeah. I appreciate you saying that and want to acknowledge, I suppose, that process for anybody else who’s wrestling with it. We wrestle with this a lot. We take a lot of insurance in our practice and we also see a fair number of trans and gender fluid, non-binary folks, and we’ve taken the stance around- you just got to ask about it and apologize and say like, hey, this is the system we’re working in. We have to know what sex is listed on your insurance. I hate that we even have to ask that but that’s the world we’re living in right now. And put it out there and then navigate what happens after that. And it’s just the reality at this point where things haven’t really caught up, right?[01:06:00] Dr. Addyson: Yeah.
Dr. Sharp: You mentioned pronouns. I wanted to ask you a question about pronouns if you are willing to dig into that, which is, we also run into a fair number of situations. Maybe you see this with adults too, I’m not sure, where adolescents are pretty well settled on certain pronouns and their parents are not. Writing that report, which pronouns do you use is always the question. Who are you going to upset?
Dr. Addyson: I don’t work with minors, so I recognize that this is probably pretty complicated in some ways of like, who’s paying the bills. But when I have worked with college students, there might be times [01:07:00] where a student will say, my parent is not going to use the right pronouns. They don’t understand or accept this about me. And I will continue to support and use the pronouns that that person wants me to use- that the student wants me to use. But if the student says, “My parents don’t know, I’m okay with you using the wrong pronouns for the purposes of this thing.” I will be wickedly uncomfortable while doing that, but I will do what the student asks of me.
So actually I think if a parent, I guess if a student is out at school and says that they are okay using their pronouns, I would use their pronouns. I don’t know. And I think the discomfort for the parents, it goes back to all of the research around what actually helps to reduce the risk of suicide, the risk of mental health struggles and trans kids, [01:08:00] the risk of eating disorders. All of those pieces, actually family support or family attempted acceptance, right?
Saying like, “I see that this is important for you. I don’t get it, but I love you.” That actually is one of the biggest mitigators of risk. So if we can say to a parent, actually, from what we’re aware of, this is really important and we can always change it later if your kid changes their mind and they later on decide that they want a report with different pronouns, but we actually choose to respect the autonomy of the kid when we’re talking about them.
Dr. Sharp: Yeah. It seems like we just keep coming back to this idea of more of a conversation, just affirming the individual and checking in with that adolescent. Like, what do you want to do here? How comfortable are you? Are we going [01:09:00] for it? Are we putting these pronouns in there or is there some reason not to?
Dr. Addyson: Yeah. And I will say like this sometimes is an issue. I don’t think that this happens for me. I’m in Massachusetts, Rhode Island area, and the insurances generally have been really good about this when I use non-binary pronouns, etcetera. But there are some parts of the country where it’s harder for folks who don’t use he/she to get access to the care that they need. There’s a lot more stigma, resistance, insurance will deny things.
So there are some folks who will say, “Actually I do prefer that you use she, even though I use they or whatever because I really just don’t want to have to deal with the risk of this getting rejected or denied.”. So I think like in that case, with those letters and assessments, sometimes we’ll have that conversation just to make sure somebody’s okay with it but for your assessment [01:10:00] purposes, if the insurance has the right information on file and you’ve got that legal indication of whatever their name and the sex assigned at birth when you file, then you have what you need.
Dr. Sharp: That’s it. I have one last random question for you.
Dr. Addyson: Go for it.
Dr. Sharp: You’re like, what’s coming now? Here’s the random question. You mentioned this process, the GAS process that we’ve been talking about- the affirming gender dysphoria is a part of that, right? That’s a part of that. What are your thoughts on other assessments where that may not be the focus? Like it’s not a GAS kind of situation. It’s more like, hey, this individual came in for an ADHD assessment or autism. [01:11:00] Where do we land with that in terms of mentioning or listing the gender dysphoria, how does that tend to sit?
Dr. Addyson: This is a great question and this is something that I think is evolving. If you do not need a diagnosis of gender dysphoria according to the DSM or the ICD to be able to access certain care, then the diagnosis itself is not necessary as long as there’s another diagnosis that explains the distress, right? Like if I’m seeing someone for treatment and they’re coming to me with PTSD and that also happens to be linked to gender violence, then like I’m going to diagnose the PTSD, not the gender dysphoria.
And so, that to me is a little bit more case by case because we don’t want to assume that just because someone is trans, that they have gender [01:12:00] dysphoria to a level of impairment or giving accessible care and affirmation. And also, sometimes I think, I don’t specialize in treating eating disorders, but I think eating disorders is a good example where gender stuff shows up differently for trans folks with eating disorders than it does for cis folks with eating disorders.
So if we think about body modification for example, why might a trans person be restricting what they eat in a way to modify their body to affirm their gender versus somebody with an eating disorder who’s restricting for other reasons? It is a little more nuanced. So we would still diagnose the eating disorder, but there’s a different understanding of it.
Dr. Sharp: Yeah, that’s a good way to think of it. Yes.
Dr. Addyson: Yeah. So basically, if the gender dysphoria is creating impairment and there’s a significant part of [01:13:00] the presentation, there’s not something else there, then you can definitely note it, but otherwise, it’s perfectly fine to just say in the demographic overview that this person is trans and this impacts the way that they are experienced socially or the way that people respond to them.
Dr. Sharp: Sure. That sounds great. Thank you for bearing with my random questions. So listen, as we wrap up, I know you mentioned earlier that you work with folks and do some consulting with people and help out in that regard. How can people get in touch with you if they want to do that? And are you open to people getting in touch with you? I should have asked that first.
Dr. Addyson: Yeah, no, thank you. I would say that the surgery-related support of providers helping providers feel more comfortable doing this. And then I think my other element of my work that I alluded to around self-compassion and [01:14:00] shame resilience with trans folks. Those are my two major specialty areas.
I do definitely offer consultation, training, etcetera. I do have a series of training options coming up, and I also have billions of resources that I can always share with folks at different price points depending on what your time and capacity, and accessibility is.
In two weeks, I’ll share the link with you for the show notes, but I have a Learn and Grow series that I do. This one’s going to be an hour-brief overview of surgery assessment just open to come and have a conversation, learn a little bit about the process and get a little bit of an overview, kind of like this today. And then on December 16th of the fall, I don’t know when this is coming out, so if this is a little bit late, that’s okay too. I’m doing a [01:15:00] 5 CE day on that Friday for folks who have a little bit more of a basic understanding.
So that’s why I’m offering a little bit of an overview first for anyone who needs that little bit of a prerequisite understanding. And then we’re really going to go into some of the deeper dives around the different surgeries, the most common surgeries that you’ll refer for. Some of the psychological considerations that I find really helpful to be aware of as a mental health provider. Talk about how do we help people talk about aftercare? And then really reducing the gatekeeping element- making it as accessible as possible while also doing your job and doing what you’re being asked to do by the insurance companies.
Dr. Sharp: Yeah, those sound great. Let’s definitely put them in the show notes for folks who are [01:16:00] interested. I imagine there will be some folks who are interested.
Dr. Addyson: Yeah.
Dr. Sharp: Well, I really can’t say thanks enough for having this conversation and letting me ask some silly questions, and just sharing all this knowledge with us. I really appreciate it.
Dr. Addyson: I’m really grateful. I didn’t anticipate that this would be such a helpful way for me to really talk about this part of my specialty because I think that nuance around what does it mean to say that we do assessment, and then where do we break down this traditional idea of what assessment is in the way that those power dynamics happen in the work that we do. So I’m really grateful I had a chance to reflect on that a bit.
Dr. Sharp: Yeah, I’m glad to hear that. So it’s got me thinking a lot about that particular aspect of our work and how we can continue to even the playing [01:17:00] field and just be more affirming. That’s a nice theme for today I think.
Dr. Addyson: Thanks.
Dr. Sharp: Well, thank you again.
All right, y’all, thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out.
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