原文为知乎首发。给需要做手术的同学参考。
鉴于被问了关于在推荐信过程中咨询到的一些内容，这里把从联系医师到拿推荐信的整个过程整理一篇文章出来。
Dr. Graham L Peveller, 称呼 Dr. Graham, 是WPATH（World Professional Association of Transgender care）的成员，同时也是American Counseling Association的一员。具有可开具全世界大部分医疗诊所可接受的手术推荐信。在业内认可度极高。通常是以网络文字聊天咨询的方式开推荐信证明。
预约SRS推荐信需要支付 320 USD （不含快递费）作为网络咨询费用，一般会安排5-6次session，全部结束并通过后方可拿到证明。一般是每周一个session，时间安排自由。
在拿到推荐信后会通过邮箱发送给你电子件，而原件需要通过邮寄的方式给你或者你所准备手术的医院，一般快递费各个国家的计件方式不同，在此不一一赘述。
以下是和 Dr. Graham 聊天时截取的部分关于跨性别知识的对话，仅供参考用：
Gender Dysphoria:
Male and female brains are structured and develop differently. This is chiefly to accommodate variations that exist between the sexes and hormonal difference.
The sex/genitalia of an individual and whether they develop bodily as male/female is defined by the chromosomes XX female/ XY male – this is linked to brain development, whereby the mothers early production of a large and excessive amount of hormone matching the defined sex of the child, in turn bombards the fetus.
The fetus shape together with the sex of the child is defined by chromosomes – XY male/XX female – whereas the brain is formed male/female through the mothers early detection of that fact and production of the large amount of the sex hormone of the particular child – estrogen for females and Testosterone for males
Males produce and receive the hormone Testosterone, which is predominant and produced in the testes (male characteristics, beard and aggression etc.). The female equivalent estrogen is produced in the ovaries (female characteristics, breast development and monthly cycle etc.)
At this stage it is important, to understand that we all start out and (default) to female – the mothers hormone rush (which we are about to discuss) in the case of a male initially de-feminize’s the fetus
Whereas, following conception the fetus has in the genital area of a mound with a lump either side
If the chromosome depicts an XY male child, the mound and two lumps grow outward to create the penis and testes
If the chromosome depicts a XX female the mound splits and lumps invert to create the vagina, vaginal canal and ovaries
It has further been discovered that there is a separate trigger for brain development, this is named the FOX 3 gene.
Experiments with mice have shown that at an early age if the gene is triggered the gender changes direction.
At the very early stages the mother recognizes the chromosome formation, for instance the presence of the male egg (XY male) and as a result, she produces and bombards an excessive amount of the hormone testosterone to stimulate the fetal brain to shape and develop into a male pattern structure.
This testosterone bombardment which is a large and excessive amount of hormone, is produced by the mother during her first 8 to 12 weeks of pregnancy and normally shapes the brain into a male or female pattern according to the hormone produced in high volumes
If all is normal this shaping, enables the brain to accept and take in a correct level of the required hormone (testosterone) which is predominantly produced by the healthy male body within the testes
However, problems can arise if the mother does not recognize and produce a high enough level of the required hormone or any at all to stimulate brain development to the correct gender. Therefore, If not excessively produced the brain structure simply blocks and rejects that particular hormone for the other (estrogen)
Again, With an XY male fetus during the early stages your brain needs to be bombarded by an excessive amount of testosterone so that the brain structure can shape and evolve as a male pattern – If this excess of testosterone does not occur or is halted/paused the child brain as a result, will reject the testosterone, the brain will then shape and develop further towards a female brain pattern and in turn only be able to intake an inadequate amount of estrogen that the male body produces.
The same is apparent if there is no Y chromosome in the male egg – the mother then should produce initially a large amount of estrogen if that does not take place correctly, you get the same result of the estrogen being blocked out and the Testosterone production of the body as being inadequate for a brain that has formed into a pattern structure of male.
The dysphoria experienced comes from the brain being “wired” to seek out estrogen, but getting confused because it is only receiving testosterone
In effect what you have is a body that is producing the dominant amount hormone at the correct level, but only producing a minimal level of the opposite hormone from the adrenal and hypothalamus glands for a +/- normal male/female patterned brain
Hence, with that a gender dysphoria develops (a sense of difference accompanied by anxiety and depression) which is the brain literally informing and questioning the body about what is going on.
It has been further suggested that the degree and intensity of the dysphoria much depend on the shortfall of the hormone originally required, the one which should be produced in the ovaries/testes – the one that takes the person closer to the opposite gender spectrum of male/female – this process and intensity can vary somewhat
Also a further part of the process is initially the gender brain development of a fetus depends on the amount of excessive hormone the mother produces during the first eight weeks to stimulate brain pattern shaping and development to the defined and appropriate gender
If this is not recognized or somehow goes awry, as a result not only does the brain develop incorrectly, a dysphoria is produced (a sense of something not quite right – a sense of anxiety and unhappiness) this carries on throughout one’s life at varying levels of intensity until the person receives the correct amount and hormone required
In summary, during the early stages of pregnancy as the mother was unable to produce the male hormone testosterone consistently – it was summarily blocked or rejected. As a result the brain shaped and developed into a female pattern brain – following that due to the body only naturally producing only a small amount of estrogen, it has since birth been inadequately supplied and nurtured.
As a consequence, the estrogen you take will naturally address that imbalance to your female brain and create a harmony and the effects will create some feminising features
Finally – the body produces both estrogen and testosterone – you produce the predominant hormone “testosterone ” through the testes and a small amount of estrogen through the adrenal, hypothalamus and pituitary glands, but your brain has rejected testosterone due to the lack of your mothers early and excessive production and bombardment following conception and therefore the brain only receives the minimum amount of the hormone estrogen it requires – as produced through the pituitary and adrenal glands
That is why when you start to take hormones you feel relieved as the brain is then receiving its correct amount – the dysphoria then gradually leaves, but as you are still the opposite gender in terms of brain shaping and development then you still have the desire to transition to your real/true self – without the dysphoria of course.
In conclusion and simply explained you have an imbalance of the hormone in your brain, plus a brain that was shaped and developed as female, one which operates to a greater or lesser degree depending on the amount of estrogen, it is fed and as a result is not in synch with your wholesome self and male body.
Here are a two definition which may also help.
Gender dysphoria is a condition in which a person feels there is a conflict between their biological gender and their gender identity. Biological sex means the sex that you were born with. It is defined by the presence of sex organs. These are: the penis and testes in males, vagina and ovaries in females
Gender dysphoria is a recognized medical condition. It can be complex and affects different people in different ways. It is not a mental illness. Gender dysphoria has no bearing on a person’s sexuality. Just like anyone else, a person with gender dysphoria may be heterosexual, homosexual, or bisexual.
Gender identity is your personal sense of the gender you belong to. For example, if a person views themselves as female, then their gender identity is female. For most people, their biological sex and gender identity are the same. However, some people experience a difference between them, this is now known as gender dysphoria.