RLE- Really!? Why requirement for “Real Life Experience” is/was detrimental

Recently in my quest for a doctor to provide hormones for a teenager outside of San Diego, the issue of “Real Life Experience” came up. The doctor made reference to the fact that this teen had “less than a year of Real Life Experience”. I wanted to respond, “Really!? This teen, who has minimal family support or advocacy, has socially transitioned and has tried to present as male for almost a year, with no medical assistance??”. I think that’s amazing. Another doctor told a (then future) client of mine he would need at least 3 months of RLE before getting any type of medical assistance with transitioning. This is an overwhelming concept for most, and I’m glad my client pursued a session with me even after that! I think asking someone to have “real life experience” as the gender with which they identify in order to receive hormones is like asking someone to earn a prosthetic leg by running a marathon!

For those of you who don’t know, “Real Life Experience” used to be a REQUIREMENT for those seeking gender transition. It is, thankfully, becoming an antiquated concept. In the Standards of Care Version 6 (2001), the Real Life Experience is defined this way:  “The act of fully adopting a new or evolving gender role or gender presentation in everyday life is known as the real-life experience. The real-life experience is essential to the transition to the gender role that is congruent with the patient’s gender identity. Since changing one’s gender presentation has immediate profound personal and social consequences, the decision to do so should be preceded by an awareness of what the familial, vocational, interpersonal, educational, economic, and legal consequences are likely to be. Professionals have a responsibility to discuss these predictable consequences with their patients. Change of gender role and presentation can be an important factor in employment discrimination, divorce, marital problems, and the restriction or loss of visitation rights with children. These represent external reality issues that must be confronted for success in the new gender presentation. These consequences may be quite different from what the patient imagined prior to undertaking the real-life experiences. However, not all changes are negative.”

Yes, there may be negative outcomes to transitioning. Transitioning can be one of the most (if not the most) stressful undertakings an individual ever experiences in his or her lifetime. However, these negative outcomes are not a reason not to do it, they are side effects of someone living true to one’s self.  Asking someone to transition without any assistance medically is quite simply a set-up for more discrimination, and decreases the chance of a positive outcome. The ability to present more as the gender with which someone identifies while transitioning increases the chance of being accepted and acknowledged as one’s asserted gender. This individual described it beautifully:

“Whilst individuals vary greatly, some people have considerably more difficulty being read as their gender prior to HRT [Hormone Replacement Therapy], and AMAB (Assigned Male at Birth) people are more likely to receive certain forms of harassment if people read them incorrectly. Forcing people into public facing roles to get the treatment they need puts them at direct risk of violence, harassment and discrimination.  What ‘real life’ is being experienced? From my own and others’ experience, I know that living full time as a woman pre HRT is vastly different to being full-time after a year on HRT. The near daily abuse and marginalization, with incumbent stress, is not the real life I’m experiencing now, but was a feature of living as a woman who was visibly trans*. The RLE required is entirely unrepresentative.”

In my opinion, the Real Life Experience requirement was a very tricky, if not dangerous, requirement for kids or adults to do before receiving hormone treatment. Being teased, rejected, and bullied can be more of a risk when one is trying to present as the “opposite” gender and not being able to pass due the presence of natal sex markers and the absence of traits of one’s asserted gender. I understand it feels riskier to prescribe quickly with a youth, but the decision-making should be based more on how consistent and persistent his male gender identity has been, his distress at being read as female, etc. Doctors seem to be just as resistant to prescribing hormones right away for adults who have decided to transition. So many people are worried about making certain the individual is “sure”. I can understand this, however- how many people do you think are going to decide to transition when they are unsure about their gender identity, really? The most common source of indecision is the choice about if/when to transition, not one’s gender identity. About that most people are sure, especially when they make the big decision to undergo gender transition.  Attempting to transition while struggling to “pass” may make someone more unsure about their decision to transition, but doesn’t change their gender identity.

I recently watched “TRANS”, a documentary feature film.  When speaking about Christine McGinn, a successful and eloquent doctor, they tell about the steps of her transition like this: “First, live life as a woman.”  Really?! That’s FIRST?? With no medical assistance of hormones to soften male facial structure, redistribute body fat, etc.? Just simply, “live life as a woman”? This seems completely backwards. It simply makes more sense to create physical changes first to assist in passing as one’s asserted gender (the gender identity in line with their brain).  Allowing a transgender individual to medically transition IS the way to allow them to get on with life- their real life. Making medical transition harder and less accessible is a sure way to increase stress, depression, and the risk of suicide in a population that already struggles with these issues far more than the general population.

Wondering what the current version (Version 7, 2011) of the Standards of Care says about “Real Life Experience”?  From a weblog written by Dr. Kelley Winters: “The tone and language of the SOC7 are more positive than in previous versions, with more emphasis on care and less emphasis on barriers to care. Some highlights include […] removal of the three month requirement for either “real life experience” (living in a congruent gender role) or psychotherapy before access to hormonal care.” Although this obstacle has been removed, “12 continuous months of living in a gender role that is congruent with their gender identity” is still recommended prior to “bottom surgery”.

Here’s to you, and living YOUR real life, whatever that may be.

Published in: on August 26, 2013 at 3:04 pm  Comments (13)  
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Helping Your Gender-Expansive Child With Teasing (Gender Spectrum Workshop)

Due to a family emergency, I was forced to cancel my presentation at Gender Spectrum this year. My workshop was titled, “Helping Your Gender-Expansive Child With Teasing”. I have been contacted by parents who had anticipated attending the workshop and who had been looking forward to gathering information on the topic. For that purpose, I’ve outlined and summarized what I was going to discuss. Please feel free to contact me if you have any questions! An important part of my workshop was going to be role playing, so if that makes you squirm, you got lucky… this time. 😉

My presentation was going to be based largely on this blog post: Your Gender Variant Child: Teasing.

Please read it before reading this blog post if you haven’t already.

One of the main points of my previous blog post was about the importance of parents avoiding warning a child about how their interests, way of dress, etc. may result in teasing. This increases anxiety and makes the child wary, rather than equipping them with coping skills.

Helping Your Gender Nonconforming Child With Teasing

Key concepts:

Gender Identity: How someone identifies in his or her brain; male or female.

Gender Expression: How a person may choose to dress or express gender; feminine or masculine.   May be in line with gender identity or may not; may be in line with assigned birth gender and may not.

Gender Nonconformity: Conform means to “behave according to socially acceptable conventions or standards”. Being gender nonconforming is not subscribing to society’s gender “rules”; what colors/dress/interests are for girls and which are for boys. These societal rules are always changing, and it’s my belief these gender rules won’t always be so rigid.

Coaching your child: It’s our job as parents to teach our kids how to behave, right? Remember, gender identity is not a behavior. It is simply a core characteristic of a person: whether they feel male or female. Gender expression, if it is a reflection of their gender identity, is not a behavior that should be molded or changed to prevent teasing. If your child has a behavior that is negatively impacting others, and is a behavior they can change, coach them about this. (Examples of this might be if they themselves are teasing peers, if they are physically aggressive, bossy in play, etc.) If it’s not a behavior they can change, teach them how to care for themselves in response to behavior from others.

Why do kids tease?

There are so many reasons why kids tease: because they themselves have been teased, they want to feel powerful, they want to impress other kids, etc.

Why does gender nonconformity elicit teasing? A gender variant child is even more susceptible to teasing given that they tend to behave or dress in a way that can be unexpected by other children or deemed by other children to be “different”. As most of us know, those that are “different” or in the minority are more likely to be teased, get teased more often, and often more severely than other children.

Also, kids are focused on rules. Since the day they begin exploring their world, they begin learning about rules. Don’t touch that, don’t do that, can’t go there, don’t eat that, etc. It’s how kids learn about the world around them and learn what works. Things fit into categories so that it makes the world make sense. The more one is able to categorize something, the less thinking one has to do about it, and the less discomfort it brings up. When something doesn’t follow the “rules” a child has been taught, there is discomfort, possible anxiety- and kids work to have their world make sense again. They have been taught specific rules, “pink is for girls, boys don’t cry, girls don’t like sports, boys can’t wear skirts, etc.” When a peer’s gender expression doesn’t fall in line with these “rules”, kids can compulsively make it their job to let them know they are not following the “rules”. Additionally, because kids are essentially being controlled much of the time, it is likely an outlet for them to try to be the one to control others occasionally.

Teasing vs. Bullying- what’s the difference?

Teasing: Can be done by friends or kids who are not friends, can be done in a friendly/fun way, or in a mean way. Typically mild by nature. Does not cause major distress on behalf of the child being teased.

Bullying: Greater intensity, more frequent, and can also be much more hurtful or damaging. Typically mean-spirited.

Important distinctions between the two: teasing is a behavior or an act that is temporary or occasional. Bullying may be ongoing, daily, etc. Most important clarification is how much distress it brings to your child. If child starts to have somatic complaints (headaches, stomachaches), wants to avoid school, etc. they may likely be getting bullied at school.

Responses by caregivers to both:

Teasing: Caregivers process incident (talk about feelings) with child and empower child to stand up for self, ignore, problem solve.

Bullying: Caregivers may need to intervene, get school (or other) authorities involve, advocate, make sure bullying is addressed.

Ways to support and empower your gender nonconforming child:

  • Stay connected. Ask the best and worst parts of day at bedtime/dinnertime. If your child seems to clam up under one-on-one questioning, as questions in the car. With your eyes on the road and not on the child, some children tend to open up more.
  • When your child reports teasing, ask questions; fight the impulse to just give “answers”. You will find out a lot more about your child’s feelings about and ability to handle the teasing if you avoid jumping in and trying to “fix”.
  • Again, don’t warn about the potential to be teased. If your child asks if you think they may be teased, be honest. “Maybe.” Ask questions. “What do you think?” Model confidence that even if you do think teasing may result, your child can handle it. (If you are nervous about the potential of your child being teased for an interest, toy, clothing choice, don’t show it. Fake it ‘till you make it! J)
  • If your child comes home and is sad or upset about teasing they encountered, ACT like it’s not upsetting to you. You can show compassion for your child without showing it is hurting you.  Your child may avoid telling you about being teased if they know it upsets you. See my first blog about teasing to read about ways to take care of your feelings.
  • Support your child’s true self at home.  Teach your child I AM AWESOME JUST THE WAY I AM, until they believe it and it is a part of their core self.  (This is important for ALL kids, not just gender nonconforming kids!)
  • Model appropriate responses to others if they question or mock your child’s gender expression or reflection of gender identity. Be it in response to a family friend or a stranger at the grocery store, don’t apologize for your child’s behavior, gender expression, etc. or act like you are sorry for how your child is making them feel.

Equipping Your Child

Work with your child on having a toolbox of responses (both verbal and behavioral) to teasing. You can write these down and put them in an actual box your child can revisit from time to time. Or, make a list you can review in the car on the way to school.

  • Verbal responses are best used in regards to children your child considers to be a friend. “That hurts my feelings”, “Please don’t say that”, “Please stop”, etc. (Saying these verbal responses to children who are not your child’s friend, or who are mean to your child on a consistent basis, may open your child up to more teasing.)
  • Practice assertiveness skills. Chin up, eye contact, shoulders back, looking strong. Facing the person they are talking to. Using a firm but kind voice.
  • First teasing is usually a “test”- help them pass. Explain the importance of “acting” like it doesn’t bother them. If a child senses the teasing has “gotten to” your child, it may fuel the fire. Teach your child to hold back emotion until they are in a safe place or speaking to an adult they trust. Also discuss the importance of not “fighting back” with their own mean words.
  • Ignore. Act as though the other child is invisible. Can’t see ‘em, can’t hear ‘em.
  • Walk away! Move to another area of the playground. Approach another group of kids or another kid who is typically friendly.
  • Stay in adult eyesight or earshot. Kids aren’t going to relentlessly tease or bully other kids who are near an adult. Talk with your child about what it might look like if they were “subtly” trying to stay near an adult.
  • Get adult help. If the teasing is getting to your child, your child is having difficulty ignoring, may act out in response to the teasing, or is in physical danger, teach your child to get adult help right away. Explain the importance of saying “I need help because ____________” rather than presenting it as “telling on” a peer.
  • Role play! I can’t stress the importance of role plays enough. If your child reports being teased, or is worried themselves about being teased, practice at home. Have your child tease you, and model appropriate responses. Then switch!

Dealing with teasing can be stressful for both the gender nonconforming child and their parent(s). I hope these tips make you and your child feel somewhat more equipped! Please feel free to comment about other specific topics you would like to see covered in this blog.

Published in: on August 1, 2013 at 5:56 pm  Comments (6)