Table 7 Additional illustrative quotes

Reasons for engaging in mental health care initially

“My story has not been seeking out a mental health care professional to get me approved with the letter. That is not at all … My story is, I need help for myself, for mental health, gender dysphoria, dysmorphia, these whole things that they’re here for” (Participant 11)

“Literally the only reason is the bureaucracy of the state requires me to see someone to get two different letters before I can have surgery. So I did that.” (Participant 1)

“I just was going there not so much for my own benefit, but to get the letters for surgery.” (Participant 3)

Diverse and opposing views of the pre-surgical process

“I couldn’t really expect it to be any better because I thought it was actually pretty easy. The hardest part was to get up enough nerve to seek help” (Participant 2)

“So it doesn’t sound that bad but hopefully today with all the stuff I said, you see it’s not like a series of soft blows. It is like a traumatizing violent, you’re talking about one of the most vulnerable of your population, who’s probably fired if they ever did get a job. To say that it isn’t violent. It’s all so sad.” (Participant 10)

Opinion on ideal number of letters

“Two letters? [Sigh.] I don’t understand that. I guess you could argue that it’s this need for making sure you don’t just have a therapist out there who’s just writing anybody who wants a letter a letter. But I personally feel like two letters feels like a step we don’t need. And a PhD holder also feels like a step, that’s just very, setting up a roadblock. Right, getting, being able to see a therapist is potentially, in at least our healthcare landscape, a luxury for folks.” (Participant 7)

“[Y]ou should not need any letters for this... They need to change it. It is so degrading... You needed no letters to get $100,000 of student loan debt. Zero letters. You need zero letters to sign up for the Army. Zero. So there’s no reason to have a letter.” (Participant 10)

Attitudes towards second letter writer

“The other one felt like much more of a formality. I had to track down someone who met those requirements, and then see them several times, until they [emphasis] were comfortable enough to say that they could write the letter. So that was much more of a formality, of like, rehashing of a lot of the things that I had organically talked about with my primary therapist over the last couple of years. And then I had to bring up [emphasis] this new therapist up to speed and then we could talk about things that mattered for this letter.” (Participant 7)

“I enjoyed that actually, it’s comforting. It’s definitely necessary because you personally need that outside opinion on, ‘how do you feel about this?’” (Participant 12)

Mental health providers inexperienced with caring for transgender patients

“I had an appointment with my psychiatrist, and I... asked him to write me a letter, and emailed him or forwarded him an email from the surgery team that went over what the requirements for the letter were—the WPATH requirements. He was like okay; I’ll look at this. And then I got an email a couple of days later where he said that he didn’t know how to write it.” (Participant 4)

“[S]he’s like I’ve actually never had a transgender patient before, which can’t be true, like statistically, if she’s been practicing for several years. Anyway, I’m like basically, all these people need your expert opinion on how trans I am, and this lady has never met a trans person before... And a few of the things she said were harmful and I had to address them once I got my therapist now.” (Participant 10)

Benefits of mental healthcare received

“It was just really good to have someone that really was first getting to know me as I was getting to know myself. So that was a really just affirming feeling, to have someone to talk to about some of my fears, some of my concerns and some of the challenges. And it was one of the first places where I started gradually coming out of my shell and presenting myself as myself. So, yeah, it was just … it was kind of like a little island. If my house was like a fortress of safety, it was a little safe island that I could go to away from that.” (Participant 6)

“It has always been helpful for me. Sometimes it’s frustrating, but I think seeking help for mental health in general is extremely important for most people, most everyone, and especially for me. It is a necessary part of my life. I very literally and figuratively, but most importantly literally, could not live without mental health support.” (Participant 11)