The real-life experience (RLE), sometimes called the real-life test (RLT), is a period of time or process in which
transgender
A transgender (often abbreviated as trans) person is someone whose gender identity or gender expression does not correspond with their sex assigned at birth. Many transgender people experience dysphoria, which they seek to alleviate through tr ...
individuals live full-time in their
identified
''Identified'' is the second studio album by Vanessa Hudgens, released on July 1, 2008 in the U.S. June 24, 2008 in Japan, February 13, 2009 in most European countries and February 16, 2009 in the United Kingdom. The album re ...
gender role
A gender role, also known as a sex role, is a social role encompassing a range of behaviors and attitudes that are generally considered acceptable, appropriate, or desirable for a person based on that person's sex. Gender roles are usually cent ...
in order to be eligible to receive
gender-affirming treatment. The purpose of the RLE has been to confirm that a given transgender person could function successfully as a member of said gender in society, as well as to confirm that they are sure they want to live as said gender for the rest of their life. A documented RLE was previously a requirement of many
physician
A physician (American English), medical practitioner (Commonwealth English), medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through th ...
s before prescribing
gender-affirming hormone therapy, and a requirement of most
surgeon
In modern medicine, a surgeon is a medical professional who performs surgery. Although there are different traditions in different times and places, a modern surgeon usually is also a licensed physician or received the same medical training as ...
s before performing
gender-affirming surgery
Gender-affirming surgery (GAS) is a surgical procedure, or series of procedures, that alters a transgender or transsexual person's physical appearance and sexual characteristics to resemble those associated with their identified gender, and alle ...
.
In September 2022, the
World Professional Association for Transgender Health
The World Professional Association for Transgender Health (WPATH), formerly the Harry Benjamin International Gender Dysphoria Association (HBIGDA), is a professional organization devoted to the understanding and treatment of gender identity and g ...
(WPATH)
(SOC) Version 8 were released and removed the requirement of RLE for all gender-affirming treatments, including gender-affirming surgery.
Previous versions of the WPATH SOC had required completion of RLE for initiation of gender-affirming hormone therapy (3 months) and gender-affirming surgery (12 months).
Criteria
Standards of Care
Version 6
The sixth version of the
World Professional Association for Transgender Health
The World Professional Association for Transgender Health (WPATH), formerly the Harry Benjamin International Gender Dysphoria Association (HBIGDA), is a professional organization devoted to the understanding and treatment of gender identity and g ...
's (WPATH)
Standards of Care (SOC), published in 2001, listed the parameters of the RLE as follows:
Version 7
The seventh version of the SOC, which was published in 2011, was more ambiguous, and did not list any specific parameters for the RLE.
Instead, they merely stated that the individual should be living full-time in their preferred gender role continuously for the duration of the RLE. They also stated that documentation of a name and/or gender marker change can be presented as a way of providing proof that the RLE has been completed, but did not state that a name and/or gender marker change was a requirement for completion of the RLE.
These changes may have been signs of WPATH moving away from
gatekeeping
A gatekeeper is a person who controls access to something, for example via a city gate or bouncer, or more abstractly, controls who is granted access to a category or status. Gatekeepers assess who is "in or out", in the classic words of manage ...
, which the SOC had been criticized for.
The seventh version of the SOC state that medical professionals should clearly document a patient's RLE in their medical chart, including the start date of living full-time for those preparing for GRS.
Sometimes surgeons may require proof that the RLE has been completed.
The SOC state that, if applicable, proof may be provided in the form of communication with individuals who have related to the patient in a gender identity-congruent role (such as, presumably, the patient's physician, therapist, boss, or a teacher), or as documentation of a legal name and/or gender marker change.
Version 8
The eighth version of the SOC, published in 2022, removed all requirement of RLE for gender-affirming treatments, including gender-affirming surgery.
Necessity
The SOC are followed by most medical professionals who specialize in the care of transgender individuals, and are the most widely followed clinical guidelines for the treatment of transgender persons in use.
Hence, the SOC criteria for HRT and GRS, including completion of an RLE when applicable, must usually be met for one who seeks such treatments to receive them.
As of the seventh version of the SOC, a three-month minimum requirement of RLE is no longer part of WPATH's recommended criteria for HRT. A referral letter alone from a qualified mental health professional now suffices. The SOC state:
With respect to
mastectomy
Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operat ...
/
chest reconstruction and
breast augmentation
Breast augmentation and augmentation mammoplasty is a cosmetic surgery technique using breast-implants and fat-graft mammoplasty techniques to increase the size, change the shape, and alter the texture of the breasts. Augmentation mammoplasty is ...
, the seventh version of the SOC do not require an RLE for these procedures; nor is an RLE required for
hysterectomy
Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures.
Usually performed by a gynecologist, a hysterectomy may b ...
,
salpingo-oophorectomy
In medicine, salpingo-oophorectomy is the removal of an ovary and its Fallopian tube. This procedure is most frequently associated with prophylactic surgery in response to the discovery of a BRCA mutation, particularly those of the normally tumor ...
, or
orchiectomy
Orchiectomy (also named orchidectomy, and sometimes shortened as orchi or orchie) is a surgical procedure in which one or both testicles are removed. The surgery is performed as treatment for testicular cancer, as part of surgery for transgend ...
, or for other procedures such as
facial feminization surgery
Facial feminization surgery (FFS) is a set of reconstructive surgical procedures that alter typically male facial features to bring them closer in shape and size to typical female facial features. FFS can include various bony and soft tissue proced ...
and
voice feminization surgery
"Voice therapy" or "voice training" refers to any non-surgical technique used to improve or modify the human voice. Because voice is a social cue to a person's sex and gender, transgender people may frequently undertake voice training or therapy ...
. However, for GRS, including
metoidioplasty
Metoidioplasty, metaoidioplasty, or metaidoioplasty (informally called a meto or meta) is a female-to-male sex reassignment surgery.
Testosterone replacement therapy gradually enlarges the clitoris to a mean maximum size of (as the clitoris ...
,
phalloplasty
Phalloplasty is the construction or reconstruction of a penis or the artificial modification of the penis by surgery. The term is also occasionally used to refer to penis enlargement.
History
Russian surgeon Nikolaj Bogoraz performed the firs ...
, and
vaginoplasty
Vaginoplasty is any surgical procedure that results in the construction or reconstruction of the vagina. It is a type of genitoplasty. Pelvic organ prolapse is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplas ...
, one year of continuous RLE is a listed requirement.
Previous versions of the SOC stated that an RLE for GRS was an absolute requirement that could not be skipped or ignored.
However, the seventh version of the SOC appears to be less stringent, and does not contain any such statements. In addition, WPATH emphasizes that the SOC are merely clinical ''guidelines'', and are intended to be both flexible and modifiable to meet the circumstances of the patient and the preferences and judgement of the clinician.
Hence, the latest version of the SOC appear to allow for, in certain circumstances, the RLE to be skipped.
Clinical practice in many places may be more or less stringent. In the
United Kingdom
The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom (UK) or Britain, is a country in Europe, off the north-western coast of the continental mainland. It comprises England, Scotland, Wales and North ...
, most
National Health Service
The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948, they have been funded out of general taxation. There are three systems which are referred to using the " ...
trusts will require two years of RLE before surgery, whereas in countries such as
Thailand
Thailand ( ), historically known as Siam () and officially the Kingdom of Thailand, is a country in Southeast Asia, located at the centre of the Indochinese Peninsula, spanning , with a population of almost 70 million. The country is bo ...
and
Mexico
Mexico (Spanish: México), officially the United Mexican States, is a country in the southern portion of North America. It is bordered to the north by the United States; to the south and west by the Pacific Ocean; to the southeast by Guatema ...
, some surgeons may not require the completion of any RLE at all.
Criticism
Though the WPATH SOC's one-year RLE requirement prior to GRS has been widely followed by surgeons in the past, it has not gone without criticism. Like the previous three-month RLE requirement for hormone therapy, many transgender people have expressed displeasure with it and have declared that it is unnecessary. Alongside this, some private providers did not require RLE to prescribe hormone therapy. Supporting such claims, physician and sexologist
Anne Lawrence
Anne Alexandra Lawrence (born November 17, 1950) is an American psychologist, sexologist, and former anesthesiologist who has published extensively on transsexuality.
Work
Lawrence is a proponent of Ray Blanchard's transsexualism typology theo ...
, in a paper presented at the XVII Harry Benjamin International Symposium on Gender Dysphoria in 2001, stated that there is little scientific evidence that a one-year RLE is necessary or sufficient for favorable outcomes following GRS. In addition, she presented the results of a study she conducted on a group of trans women in which she showed that GRS without a prior one-year RLE could be undergone without the subsequent expression of regret. She concluded that her results did not support the SOC requirement of a one-year RLE as an absolute requirement for GRS.
Further in support of the idea that a one-year RLE requirement prior to GRS is unnecessary, regret, as well as suicide, appear to be very rare in post-operative transgender people in general. In another study conducted by Anne Lawrence and published in 2003, she found that in a group of 232 post-operative trans women, none expressed outright regret, and only a few expressed even occasional regret.
In addition, a 2002 review of the literature reported that there is less than a 1% rate of regret, and a little more than a 1% rate of suicide, among post-operative transgender people;
for comparison, the rate of suicide in the general population is only about 1%,
while the suicide attempt rate of the transgender population as a whole was around 41% per a 2013 publication.
Amnesty International
Amnesty International (also referred to as Amnesty or AI) is an international non-governmental organization focused on human rights, with its headquarters in the United Kingdom. The organization says it has more than ten million members and sup ...
emphasized in 2017 that the RLE has been criticized by the
Committee on the Elimination of Discrimination against Women for promoting stereotypical gender roles.
Perhaps in response to such criticisms, the WPATH SOC Version 8 removed the requirement of RLE for all gender-affirming treatments.
See also
*
Gender transitioning
Gender transition is the process of changing one's gender presentation or sex characteristics to accord with one's internal sense of gender identity – the idea of what it means to be a man or a woman,Brown, M. L. & Rounsley, C. A. (1996) ''True ...
*
List of transgender-related topics
The following outline offers an overview and guide to transgender topics.
The term "transgender" is multi-faceted and complex, especially where consensual and precise definitions have not yet been reached. While often the best way to find out ho ...
References
Further reading
Vancouver Coastal Health's Real Life Experience booklet
{{DEFAULTSORT:Real Life Experience (Transgender)
Gender transitioning and medicine