Zak: Well, depending on where you live a lot of different people could prescribe hormones. Pretty much any general practitioner/family doctor/OGYN or endocrinologist (possibly any MD or DO, but I’m not positive) can prescribe hormones, and in some states even nurse practitioners can as well. These people all have their own guidelines, and may or may not follow the WPATH standards of care, which recently changed to support an informed consent model for obtaining HRT. Many places already have policies in place that require therapist’s letters and have no desire to change this. However, doctors who do not already have a firm policy in place may be more open to informed consent given these changes. It is certainly worth printing off a copy of the standards of care when pitching the idea of informed consent to a doctor that you want to work with, if you ever find yourself in such a situation.
Location-specific questions are tough for us to answer, and we generally do not respond to them. However in this case it seems worth mentioning that the Mazzoni center in Philadelphia offers informed consent for HRT for individuals over the age of 18. I know that is likely quite a drive for you, but it is a major resource for the entire area. I also know that the Howard Brown clinic in Chicago offers informed consent, and I’m sure there are many others across the United States. However they are much less common than those that require a letter.
As for your concern about being rejected for top surgery later, it certainly isn’t impossible to get top surgery without a letter from a therapist. At the top surgery show-and-tell at the Philadelphia Trans Health Conference we recently attended, there were many guys who mentioned that they went the informed consent route with their top surgery as well. Unfortunately I don’t remember the names of any surgeons off the top of my head, but there are definitely some out there who do not require a letter. Dr. Garramone, as you mentioned, is not one of them. While not having a letter may not keep you from getting surgery, it may limit your choices when it comes to surgeons. This is a con of informed consent that you need to weigh along with the pros. If you are having trouble with therapy, remember that you do not need to necessarily see a specific therapist (or even someone listed as a gender therapist) in order to get a letter for HRT or surgery. Any licensed therapist will do, and perhaps if you look some more you might be able to find someone who makes the experience more positive for you (if you decide you want to try again).
For more information about informed consent, check out Gendercast’s episode on informed consent for access to trans* health care.