1) But what about getting paid for our work and our time?
We acknowledge that we all have to support ourselves and cover our practice expenses. However, we encourage you to consider writing a certain number of letters per month pro bono (e.g., one letter per month) and then using this network as a referral source to locate other providers who are able to provide pro bono letters. This is one of the reasons why we have chosen to advocate for free letters as a professional/practice community. Many of us belong to marginalized groups that cause our work to be devalued, so we understand the need to charge for services. As a community, we have decided this is an important cause/community to which we can provide the pro bono work suggested in our code of ethics.
2) What if the potential client has insurance that will pay for a mental health provider/assessment visit? Or what if they have the financial means to pay for meeting with us?
For people who do have access to insurance coverage for mental health visits, we opt to bill insurance for our services/time (or provide superbills/statements for clients who are able to get reimbursement). When clients have financial means to pay , we still encourage you to provide this service pro bono. We also understand that some clients will feel uncomfortable and state a strong preference to pay for your time/services. In these cases, we think it best to make it clear that the service is free, but they may opt to donate any amount they feel comfortable in order to increase the capacity to write letters for others who may not have financial resources.
3) I support this cause, but I don’t have adequate training to write letters (or don’t currently have a practice). What should I do?
The GALAP list is a resource meant to be shared with people who need letters and are looking for a provider. At this time we are asking providers to only sign on if they are actively able to provide at least one pro bono letter per month. We want people in the position of having to obtain letters to be able to meet with clinicians who understand informed consent. Many of us provide professional consultation, and if you are committed to providing letters under this model, we may be able to provide this training pro bono or at a reduced cost. We are especially committed to training other transgender and nonbinary therapists and therapists of color. In the future we plan to have formal training structures/opportunities so that we can build the capacity of our professional communities to provide care/services/letter to transgender and nonbinary people of all backgrounds. In the future, we may have a separate signature list for people who support this movement but cannot provide letters.
4) What if someone needs several visits? I can’t afford to offer services for free on an ongoing basis.
If a client is asking for ongoing care or would like support related to the gender-affirming medical care they are seeking, this falls under the category of counseling/psychotherapy. GALAP signees/members who have agreed to write a pro bono letter commit to either: 1) continuing to work with the client at their regular rates (or continue to accept their insurance, where applicable) or 2) referring the client to the wider network of gender affirming clinicians on this list who may be able to see them for psychotherapy, if their practice is full.
5) What about diagnosis? Do I have to diagnose people with Gender Dysphoria?
Some medical providers and systems requires a diagnosis of Gender Dysphoria in order for someone to access gender-affirming medical services. The WPATH Standards of Care for most procedures state a requirement of “persistent, well-documented gender dysphoria” but it does not specifically state that this must be an DSM or ICD diagnosis. There is some lack of clarity or agreement about what this means for our clients. Before writing a letter, it’s important to understand the letter writing criteria required by the client’s surgeon, insurance, or health care system, including what credentials are required for letter-writers.
6) What about working with children/youth?
At this time, we encourage people to apply the principles of the GALAP to working with adults. We think these ideas are relevant to young people and must be considered in the context of youth oppression (e.g. historical and current gate-keeping, limited/delayed access to medically necessary care like puberty blockers, gender-affirming hormones, and reconstructive surgeries). However, we acknowledge that writing letters for youth brings up complexities since youth may assent but not consent without parent/guardian support to move forward with any medical interventions. This may require additional visits that may involve family collateral visits to move towards family readiness aligning with youth readiness. As mental health providers, we serve as both supports and advocates for transgender and gender expansive youth who are susceptible to significant health disparities with lack of family acceptance and access to gender-affirming care.
7) Who started the GALAP? What inspired this movement?
We are a group of trans and nonbinary mental health providers based in the San Francisco Bay Area who have witnessed the highly unethical exploitation of trans people through the requirement of mental health “assessments” and letters. This practice has been defended by paternalistic, ableist, pathologizing groups of professionals. We have witnessed some providers charging anywhere from $100 to $800 dollars for letter writing. This causes a significant financial burden for people in trans communities who, as a whole, experience employment discrimination, poverty, and other barriers to financial resources at much higher rates than the general public. The outrage that we felt toward this injustice fueled this movement. The GALAP is not an organization, nor is it a source of income for any of us. We are not funded. The work we have done to create this resource and spread the word about it is a labor of love.
8) I don’t fully understand. Are you for or against writing letters?
The beliefs that underlie the GALAP movement are: 1) The current system is broken but is a reality for many people trying to access health care; 2) In the meantime, people still need gender-affirming and life-saving care; 3) Providers must be willing to work toward removing barriers to accessing care, as well as provide information/resources that can support positive outcomes. Removing the cost of letters is a concrete way of supporting trans clients/communities.