Dear Laurie,

Read the letter and this is the classic example of how a letter of endorsement should not be written. This type of letter is in fact seen when a therapist feels a certain obligation to say something but in fact has deep seated reservations about making any written commitment. This is akin to a “letter of recommendation”  for an employee.   Miss so and so worked in my office from June 1st 1999 to September 5, 2001. (Start, period, end of letter).

This is a more a letter of detachment.

The standards for how a letter should be written if the Dr. is interested are posted on WPATH.   To wit:

The Mental Health Professional’s Documentation Letter for Hormone Therapy or Surgery

Should Succinctly Specify:

1. The patient’s general identifying characteristics;

2. The initial and evolving gender, sexual, and other psychiatric diagnoses;

3. The duration of their professional relationship including the type of psychotherapy or

evaluation that the patient underwent;

4. The eligibility criteria that have been met and the mental health professional’s rationale

for hormone therapy or surgery;

5. The degree to which the patient has followed the Standards of Care to date and the

likelihood of future compliance;

6. Whether the author of the report is part of a gender team;

7. That the sender welcomes a phone call to verify the fact that the mental health professional actually wrote the letter as described in this document.  

The organization and completeness of these letters provide the hormone-prescribing physician and the surgeon an important degree of assurance that mental health professional is knowledgeable and competent concerning gender identity disorders.

More or less in the first paragraph the therapist should introduce him/herself by virtue of their background and training and societal memberships. Next the therapist should endorse the client for transgender surgery (”I recommend, I endorse, or Miss so and so would be a good candidate for transgender surgery, etc”).

Next suicidal ideation or attempts (yes or no) should be mentioned, as well as any drug abuse history or ethanol dependency (yes or no).

Lastly the therapist should invite the recipient to call their office for further discussion should questions arise.

Look at Dr. Mora’s letter hopefully and you will see the difference.

Sincerely,

Harold M. Reed, M.D.
305-865-2000

I followed a GLBT advocate and counsellor. My talk on sexuality included as per syllabus from Dr. Clark…

Medical factors related to sexuality and sexual functioning

Objectives:

· Define the DSM sexual disorders, and discuss the following in relation to it: symptoms, factors increasing susceptibility, and prevention.
· Describe how surgical procedures, such as a hysterectomy, may affect a woman sexually, physically, and emotionally.
· Define hormone replacement therapy and explain its advantages and potential risks.
· Describe the incidence of, symptoms of, and treatment alternatives for penile cancer, testicular cancer, prostatitis, benign prostate hyperplasia, and prostate cancer. Describe tests for prostate cancer and treatment alternatives.
· Describe the reasons why women would choose to have or not have breast implants and controversies concerning the implants themselves.
· Learn how major disabilities my affect sexual function and expression. Learn coping and enhancement strategies for people with disabilities.

2 hours later with time for serious questions and answers, we were done. But aside from potty breaks their day was still going strong. Young therapists seeking their doctoral degrees, thirsty for knowledge. Commendable, Carol (who is a board certified sexologist with a doctoral degree, how many therapists can claim that!).   Dr. Carol L. Clark   (closest to our office)  305-757-6070 

Harold M. Reed, M.D.

305-865-2000

possible phalloplasty.

Dr. Reed,

 I have been on T since Jan 2008. I am looking into having a hestorectomy, but also want to have both top and bottom surgery as well.
Specific_Questions: I am on psychratric medications. Seroquel, Methylphenidate ER, Methylphenidate, and Lexapro. Would these medications be a complication?

 Armando

 Hi Armando, 

Thank you for your interest in what we do.

Hysterectomy is performed by others, but if you have this done, please go for a laparoscopically assisted vaginal hysterectomy and simultaneous oophorectomy (removal of ovaries) as well.  2 letters of therapy clearance should be obtained prior to this irreversible surgery.

We operate on patients taking your medications all the time, and this is not a contraindication.  A letter of clearance from your psychiatrist will be requested, and also we do advise your taking any AM medication on the morning of surgery with a sip of water. 

A word about methylphenidate…

Methylphenidate is the most commonly prescribed psychostimulant and is indicated in the treatment of attention-deficit hyperactivity disorder

Contraindications:

Methylphenidate should not be prescribed concomitantly with tricyclic antidepressants, such as desipramine, or monoamine oxidase inhibitors, such as phenelzine or tranylcypromine, as methylphenidate may dangerously increase plasma concentrations, leading to potential toxic reactions (mainly, cardiovascular effects). Methylphenidate should not be prescribed to patients who suffer from severe arrhythmia, hypertension or liver damage. It shouldn’t be prescribed to patients who demonstrate drug-seeking behaviour, pronounced agitation or nervousness. Care should be taken while prescribing methylphenidate to children with a family history of Paroxysmal Supraventricular Tachycardia (PSVT).

Special precautions:

Special precaution is recommended in individuals with epilepsy with additional caution in individuals with uncontrolled epilepsy due to the potential for methylphenidate to lower the seizure threshold.

All the best,

Harold M. Reed, M.D.
305-865-2000

Good morning Mariah,

We would not recommend any surgery be done until a patient is over 18 years of age, unless there is some very strong compelling reason, and then your parents would need to be a part of the decision making process.

Have a restful Sunday,

Harold M. Reed, M.D.
305-865-2000

To Tara at Tarareources.net 

Dear Tara, 

This is to advise you that we have not been able to offer grants, which had been solely based upon testicular donation,  for over 2 years. That project was concluded by the research lab.

We do offer individual consideration for needy people only. However, without any contingency funds to cover the unexpected, we cannot operate.  A financial statement may be requested. 

Thank you for referring the many nice patients who have made inquires, some of whom we have been able to assist.

As is, our fees run about 6000 below what other charge in North America if that is of any help. Unless you have an impulsive need for genital ablation, please select a doctor whose work is pleasing to you

and who may respond to your request for assistance (circumstances change for us all, for example some doctor may have a cancellation and be willing to fill that time slot for less).

All the best to your group.  Your good deeds will not go unnoticed.

Harold M. Reed, M.D. 

The periareolar approach is good for size A breast, and will inevitably produce some (hopefully transient) wrinkles as a larger circle is worked into a smaller circle.  The smaller circle being the down sized areolar or pigmented shield that surrounds the nipple.  A way of minimizing  wrinkling is the leave the areolar halfway in size between an ideal male areolar and the original female areolar.   This works well aesthetically only for very big FTM patients, but not so for smaller FTM patients who do not want any tell-tale vestiges of their feminity.

 We are getting excellent results with a free nipple areolar complex graft.  In other words, once removed, the graft is down sized and reapplied precisely in the correct anatomical position judged by when the patient is sat up during anesthesia and after the skin incisions are closed.  Some compression is required for 7 days and this is done with both dressing and a compression garment vest which is essential for all patients to minimize bruising and swelling.

Harold M. Reed, M.D.

Dear Friends and prospective patients.  This year we gave out 15 grants with a combined savings of about $50,000.   These funds were made possible by a testicular research program who paid for the specimens.   All gone.

However, however, we may still offer compassionate professional courtesy discounts to those who need feminizing vaginoplasty (MTF procedures) such as augmentation mammoplasty or FTM procedures such as male chest reconstruction and metoidioplasty and testicular implants.

Anne, our office coordinator, is the maker of deals and the brains behind Pa.

Please call her at 305-865-2000.

Merry Christmas and Happy Holidays to All,

Harold M. Reed, M.D.                                                                                                                 305-865-2000

Yes, we do male chest reconstruction surgery.

While we will endeavor to utilize the smallest incisions possible, and strive for reasons of concealment to make those incisions along anatomical skin folds or planes if at all possible, a consultation would be required to best advise you.

We cannot do breasts larger than a C in the office, unless your breasts are pendulous and the base or pedicle (coming off the chest wall) is narrow.

Fees to include anesthesia and use of the facility range from $5,000 to $8,500.  Scheduling for surgery requires a 50% deposit which is non-refundable.

The balance is due no later than the day before surgery and must be presented in cashier’s check or currency at that time.  Credit cards and personal checks are not accepted.

Consultation is $250 and there will be some out of pocket fees for a compressive chest garment, laboratory tests (which could be done in your home town) and a letter of medical clearance (if indicated).

Any special pre-operative instructions?Do initiate a telephone consultation before surgery so we can get to know you better and answer any questions you may have. A CBC should be performed 2 months before your scheduled procedure. If your blood count is low normal or below normal values, a hematology consult may be needed. Usually patients on testosterone have normal to high blood counts.Better to learn of this well in advance.

Within 10 days before surgery, all patients are required to have these blood tests: a CBC (again), PT, PTT, and platelet count. Our lab fee is $100, but you could have this done in your home town perhaps more reasonably.

All patients over 40 and those on diabetic, neurological or cardiovascular medications require a letter of medical clearance with reference minimally to an EKG and chest X-ray to be obtained within 1 week of your scheduled procedure.

You may wish to stop testosterone a good month before surgery, as testosterone is metabolized into estrogens and may predispose to thromboses or emboli (unwanted clotting). You may resume 10 days after surgery.

No aspirin or aspirin products, no anti-inflammatory drugs such as Motrin, Advil, Alleve, or Cox 2 inhibitors such as Celebrex or Vioxx for a week before surgery. No Vitamin E or excessive alcohol
or spices for a week before surgery as this may promote bruising. Bruising can be reduced (many believe) with Bromelain 500 mg 1 twice a day, Arnica montana (Boiron brand) dose 30C (take 4 small tablets sublingually, 4 times a day), vitamin C 500 mg (3 times a day) starting 1 week before surgery. Do take these medications unless there are specific reasons why you choose not to and let’s discuss it beforehand.

If for any reason, despite tight scheduling arrangements and eager anticipation of being converted, you have contracted an illness such as a flu like syndrome with coughing, sore throat, fever, or diarrhea, please reschedule allowing a good two weeks for recovery. These things happen and we are very sympathetic. Surely we do not want any patient with a very recent cold to have general anesthesia. If you have gained weight, please advise as we may have to postpone surgery.

If you are a smoker, you must stop completely for 2 months before surgery and please never again. Smoking causes vaso-spasm, impairs wound healing, produces excessive scarring, tissue necrosis, irritates and inflames pulmonary membranes and enhances anesthetic risk.

This goes also for any products containing nicotine or nicotine like agents including nicorette gum, nicotine patches, Nicotrol inhalers, and second hand smoke. Again not for 8 weeks before and not for 8 weeks afterward. Hopefully never again.

Obtain one pair of anti-embolism thigh high stockings. T.E.D. (by Futuro) or Jobst are common brand names. Yes, do try these on before you come here to be sure they fit comfortably. If you wash or dry them in a hot cycle, they may never fit properly again. So best not to wash them at all until after surgery.

As a courtesy to the hotel, please obtain and bring with you a bundle of “chucks” or disposable super absorbent pads with plastic liner on underside (typically 24 by 36 inches) to conserve hotel laundry and bedding.

Please keep up with a good fluid intake the day before surgery.

Nothing by mouth after midnight unless otherwise instructed. Do not shave yourself as we will do that for you.

We observe the guidelines of WPATH (World Professional Association for Transgender Health, formerly Harry Benjamin International
Gender Dysphoria Association)

Taken from the Standards of Care (SOC)
http://www.pfc.org.uk/files/medical/soc1998.pdf

1. legal age of majority in the patient’s nation
2. 12 months of continuous hormonal therapy for those without a medical contraindication
3. 12 months of successful continuous full time real-life experience. Periods of returning to the original gender may indicate ambivalence about proceeding and should not be used to fulfill this criterion
4. if required by the mental health professional, regular responsible participation in a psychotherapy throughout the real life experience at a frequency determined by the mental health professional. Psychotherapy, per se, is not an absolute eligibility criterion for surgery. In that removal of natural breast tissue is an irreversible procedure, two letters of therapy clearance, one written by a consultant with a doctoral degree (could be a psychiatrist, psychologist, or sociologist), and another with at least a master’s degree is required as mastectomy is irreversible surgery. You may already have such a letter(s).  If written in the past year this is acceptable, or simply have it updated, and co-endorsed by an independent therapist with an appropriate educational degree. For those unable to completely satisfy the SOC requirements, individual consideration may be given especially if there is a plausible explanation and concurrence of support from the therapists. Please also consider joining a very stimulating discussion group re: SRS procedures by logging in on http://groups.yahoo.com/group/MTF-SRS-FTM/.

We hope you’ll join us!

With kindest regards,

Harold M. Reed, M.D.
305-865-2000