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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