Using The Companionship Model When Writing Referral Letters for Transgender and Nonbinary Adults

In October 2022, the World Professional Association for Transgender Health published updated international guidelines (Version 8) regarding Standards of Care for medical interventions for transgender and nonbinary (TNB) people. We encourage providers to use The Companionship Model when they are required to write referral letters for patients and clients. This model includes information regarding obtaining informed consent on the procedures from the client, collaborating with the client in navigating institutional gatekeeping, and utilizing the clinician's knowledge and resources to increase the client's access to critical resources. Clinicians are encouraged to use four actions to process gatekeeping with clients: validate (V), ask (A), share (S), and engage (E). The referral letter session includes the clinician validating (V) the client's assumptions, reactions, and normative mistrust of gatekeeping processes, asking (A) for the client's reactions to the letter-writing process, sharing (S) the clinician's critical understanding of the letter-writing session, and engaging (E) the client as a collaborative decision-maker in writing the letter. To illustrate The Companionship Model, we provide two case examples of clients from a community clinic. By using this model, we invite clinicians to shift their typical role from assessor to companion and to navigate gatekeeping with intentionality. We offer specific suggestions for mental health providers to improve their therapeutic relationships and to follow ethical guidelines for decreasing barriers for TNB people to access mental health resources. Finally, we provide sample letters in the cases where a referral letter is required by a clinic or provider.