Author ORCID Identifier

Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation




Educational, School, and Counseling Psychology

First Advisor

Dr. Robert J. Reese

Second Advisor

Dr. Sharon Rostosky


Transgender and gender nonconforming (TGNC) people who pursue gender affirming medical interventions, such as hormone therapy and surgery, are required to supply their physicians with referral letters from mental health professionals (Coleman et al., 2012). The process by which TGNC people are required to obtain referral letters before accessing gender affirming care is often referred to as gatekeeping in the TGNC literature (Budge, 2015; Cavanaugh, Hopwood, & Lambert, 2016). Despite implications that the current gatekeeping system may have for the relationship between TGNC clients and their therapists, few studies have examined TGNC individuals’ experiences related to obtaining referral letters in therapy (Bess & Stabb, 2009; Elder, 2016). This study used semi-structured interviews and a grounded theory approach to qualitatively examine the experiences of 15 TGNC individuals who have obtained a referral letter for gender affirming medical intervention from their therapists. Thematic analysis revealed two core themes: (1) “blessings” that TGNC individuals experienced because of the referral letter requirement and (2) “bullsh*t” (or “BS”) participants endured due to this requirement. Implications for psychotherapy practice and training, as well as healthcare policy, are discussed.

Digital Object Identifier (DOI)

Funding Information

Research Grant Award from University of Kentucky Office of LGBTQ Resources.