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.

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12 CommentsLeave a comment

  1. Great supportive blog post Darlene. It seems very backwards to expect RLE without supportive medical transition, especially for our MTF sisters who already are marginalized and face dangerous situations. Dr Nick Gorton has written a wonderful guide for other providers supporting the Informed Consent mode of care.
    http://www.nickgorton.org.
    As well as one patients and loved ones thru Vancouver Health program.
    http://transhealth.vch.ca/resources/careguidelines.html
    Keep up the good work
    Den

  2. I love this post so much! This is typical practice in my home state of Virginia even for adults and it makes no sense to me for the reasons you describe. I am so very glad you are here educating — thank you!

  3. The new SOC v7 did remove RLE almost entirely (I think the exception is bottom surgeries), yet it is worded so that it’s inclusive of all genders, not “opposite sex” rather “target gender”

    I’m glad we have moved away from that.

  4. Dear Darlene,
    I’m Riley and I’m a pre-t and pre-op trans boy. I’m 17 yrs old and has been see a psychiatrist for almost 2 years. I totally agree with you about how real life experience is unnecessary and dangerous. My psychiatrist refused my request for any kind of HRT and surgeries because he thinks I do not wear like a typical boy. He also states that real life experience is the best way to know if you really want to live as the opposite gender. I find it frustrating cuz how am I supposed to live as the opposite gender if all my physical characteristics are still a girl? And if the transgender person is required to wear like the opposite gender, by which means we can tell a person’s clothing is of the opposite gender?? E.g. if a trans girl wears pants and a trans guy has long hair, does it mean they are not living as the opposite gender? The whole real life experience requirement is entirely subjective and gender stereotypical !! I’m really glad I find someone like you who shares the same view as mine! It’s a disgrace to see how doctors think real life experience is the golden rule to determine whether a person is suitable for transsexual surgeries.

  5. I am 44 transgender. MtF. I recently found the nerve to talk openly with my counselor at the Veterans Administration about my second life I have been living for several years. I expressed my feelings clearly and he was very supportive and told me that he was going to recommend me for HRT to my General Practitioner.
    2 weeks later when I came in for a counseling session he announced that there is a R.L.E. requirement of some sort. He was not sure the details but was going to get back to me.
    I am very frustrated. Do they tell FtM to go to work without a bra when they still have a 38DD? If a woman walks into the dr’s office without makeup, do they call her SIR?
    BUT They want me and my 6’1″ 220lbs frame to wear a dress and makeup like a custom and dance for them like a queen in order to unlock the door to HRT.
    Oh, by the way… I am actually still in the Guard so I can’t grow my hair out. Am I required to buy a $600 female uniform as well?
    I have been making changes over the last year. Small changes. Shaving whole body for 2 years, shaping eyebrows for a year. Very light makeup for 6 months. BUT there is no way I am prepared for full life walk as a female. I do not feel the need to be singled out as a crossdresser. I want to dress as a female as my body allows me and needs me to dress.
    Please forgive me if my wording is not the best. I could really use some help.
    Sophia

    • Sophia, this must be so frustrating for you! In what state and city do you live?

      • Portland OR

    • Sophia,
      That is also the situation I’m in. I’ve been seeing a psychiatrist for a few years but recently he just flat out rejected my request for HRT and SRS. He said I don’t look like a typical FTM transgender at all. My response was exactly like yours. It’s ridiculous to ask a pre-op and pre-HRT transgender to “live as the opposite sex” as putting on boy/girl’s clothes doesn’t make you a boy or girl – that’s why we are asking for the surgeries. It’s a simple logic my psychiatrist doesn’t understand.

      The whole real-life experience scheme is seriously flawed and impractical. If a man has long hair, you won’t call him a woman; but when a ftm transgender has long hair, I would be considered as “not having real-life experience as a male”. Am I supposed to wear a tuxedo every day and put on fake moustache to “prove” I’m a real transgender? Cisgender male can wear pink and tight jeans and cisgender woman can have short haircut and don’t like wearing dress. It’s really frustrating to know it is required that every trans man has to look like a butch lesbian and every trans woman has to look like a drag queen. I resonate your sentence saying “I want to dress as a female as my body allows me and needs me to dress”. It’s not that I don’t want to dress as a male, my body doesn’t allow me to. As for now, me wearing male clothing makes me nothing more than a tomboy or a butch lesbian.

      • Riley!! How frustrating! This makes me so mad for you. Where are YOU located??

    • Hi Sophia, I talked with someone who may be able to help you. Rather than post his email here, will you please email me so that that I can give you his contact info? tandotherapy@me.com


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