RLE before HRT?

[Dianne S]

A post on the Second Therapy Session (http://www.crossdressers.com/forums/showthread.php?219092-Second-Therapy-Session-First-Time-Out-Dressed&p=3600495&viewfull=1#post3600495) thread caught my eye:


Progress into living 24/7 for a year or two before making any major decisions about what path you need to follow.

I have gone out presenting as a woman, but I could not imagine going full-time before the body changes caused by HRT. Body-hair management and getting the right shape would take up too much time... so just wondering, what's the "typical" sequence? HRT and then RLE, or vice-versa? Interested in experiences from those who've done it either way and what they think the pros/cons of each are.

[Angela Campbell]

For me there was no question...HRT for a while and at least for me ffs before going full time. Going full time before you can get the look right would be much more difficult.

[Aimee20]

Agreed, starting hrt will not cause any immediate, drastic, or permanent changes in a short amount of time; going full time however will. Typically during your first year with hrt you are building up more and more to fulltime and during that period you will generally hit the brakes and go a different direction if a complete transition is not right for you.

[Jennifer-GWN]

Dianne;

Thanks for asking this question as this is one topic I have been struggling with as well. My impression is that the establishment would like us all to follow one particular path. There are good arguments given the medical and physical ramifications that come with HRT but which comes first should be a personal choice and one that works best for the individual and their particular situation.

I'll leave it at that at this point as I'm new here and want to ease in at this point and listen.

Cheers...Jennifer

[Jorja]

Back in 1980 when I transitioned, RLE was a requirement prior to issuing HRT. Over the years RLE has become looked at as a cruel and medically contra-indicated practice. It is not required these days. However, even if it was cruel, it helped thousands make the decision whether or not to continue down the path and did a damn good job of sorting out those who wanted to continue on or quit.

[LeaP]

Nothing like a bit of cruelty to separate the girls from the boys.

[Rachel Smith]

I didn't go RLE 24/7 pre-HRT and frankly don't know how you could go RLE 24/7 before you decide to transition and why would you start HRT if you are not going to transition. 24/7 to me means work and every where else. That means risking a lot before you have even decided if transition is right for you. So do I have this wrong Jorja? Did you decide transition then do RLE then start HRT?

What I did was live 2 years of RLE everywhere save work, there I was still the male me. I would go to work as Rachel save makeup, then change to Randy for work. After work I would change into Rachels' clothes and do my makeup for the drive and all stops on the way home. All days off were lived as Rachel. At this time I was also doing my due diligence with my therapist(s). The main question I kept asking myself during this time was "is it just the thrill or am I really TS. All 3 of my therapists had told me they thought I was but it took me 1 1/2 years to make MY decision which I didn't make until one attempt at ending it all. The pain I caused my family and friends by doing that told me what I needed to do. Then it was 6 months until I came out at work and to my family.

[Jorja]

Back in those days there was no decisions Rachel. If you wanted to transition you did it their way or no way at all. RLE for 2 years then HRT would be prescribed. If you were extremely lucky, your therapist could sign off after 1 year if they thought you were really really serious about it. Thank God I was really really serious about it. You girls complain about the gatekeepers. You don't know how good you have it.

[Kimberly Kael]

I chose to transition socially before anything else, so yes I started my RLE without HRT entirely voluntarily. I had done laser hair removal and had a fair bit of practical experience for brief periods of time. I had zero doubts about my path but I didn't want to believe that my womanhood was predicated on medical intervention. I wanted to approach any decisions on their own merits, not because I was afraid to live openly and honestly. Of course I don't pretend that what I thought was important for me applies to anyone else so take all of the above as a purely personal decision-making process.

After two years I finally took the jump for my own reasons and on my own schedule.

[Rianna Humble]

I began my social transition well before I got an appointment with the Gender Identity Clinic. I could not have continued living and having to present as male. In the end it was nearly 18 months before I got the prescription, but living an authentic life and becoming accepted for who I am simply could not wait.

The only place I ever see any suggestion of a rigid one-size-fits-all approach from the medical community is here, generally from people who don't like the fact that the doctors treating them actually have standards for giving you the best care that they can.

[whowhatwhen]

I started HRT before doing any "real" work towards social transition for one big reason.
I still look like a man.

IMHO I have to at least try to meet people half-way. Sure, I could probably get by if I wore makeup but I don't want to so my physical transition will take longer.
Sure I can say "my name is Corinne, please use she/her/hers" but if I still have beard shadow and masculine features it's asking too much of a society that is barely just coming around.

By the time it came to start HRT I was already looking fairly queer and I had stopped actively hiding and specifically putting forth a male image.

So if I had to do RLE first that would mean that I'd have to cake on the makeup to maybe not even pass and take more shit than necessary for over a year.
Actually I've gotten off light on the shit so far, that tells me that I'm so early I'm not even being read as trans that often.

[Nigella]

I think that it really is a case of what suits you, I cannot answer for the UK NHS requirements because I was 24/7 before even seeking any "professional" interaction. I do know that RLE is a requirement prior to SRS on the NHS route, however, not too sure about RLE prior to HRT.

[Deborah_UK]

Not sure if its the case now, but under the protocols in place with the UK NHS I had to be at least three months into RLE before I could be prescribed hormones. It was seen as a sign of "committment" !?! (This was in 2010) I then started on a low dose while my bloods were monitored. They were increased after the first blood tests showed good results.

To be honest, I was just finally happy to get on with my life and hormones were a welcome addition, but how long do some of yo expect to be on hormones before you start the RLE? Hormones do not do everything, your own postivie attitude to life helps.

Nigella, Kimberley & Rianna were living as their true selves long before they started on the "magic" pill. The hormones just help on the path.

[Angela Campbell]

Nothing like a bit of cruelty to separate the girls from the boys.

Yes but that is what the electrolysis is for not RLE.

I did start hrt well before I was full time but at least 7 months of that I was living as a woman everywhere but work. For me "full time" was when my name and ID was changed and I never again attempted to look or appear as a man for any reason.

I'm not sure if my therapist ever saw me as a man.

[Kathryn Martin]

Under the Standards of Care RLE is not required for hormone therapy. You have to have at least three assessment session over a minimum of three months with your psychologist.

RLE is required for SRS. The purpose is to demonstrate that you can live your life before making substantially irreversible alterations to you body. It used to be 2 years.

In the UK 2 years of RLE was required to do any intervention whatsoever. But you even had to be cleared for RLE to slot into the gove that the psychiatrists insisted on. I have seen some videos of therapy session in the 1970s. Let me tell you about gatekeeping, holy smokes. The psychiatrists completely controlled your life and were nasty about it too.

[Kaitlyn Michele]

I think your view of RLE is a bit more hopeful than realistic.. It can easily be an awkward time... body changes happen slowly and can be more subtle than meaningful and hair removal can go on for well into transition...

When I went full time I was much more weirdly androgynous than feminine... and there were some very awkward moments...remember it also takes time before you can change your name for example..
you just have to deal it...

HRT is best when you are simply ready to have HRT improve your quality of life...

[Dianne S]

Thanks for all the replies.

I'm about 8 months into laser hair removal and a month on spironolactone. My hair and skin are the perfect candidates for laser, so I'm going to keep going on laser until it makes no more difference; I'm hoping there won't be too much left for electrolysis.

I like to go out presenting as female, but the issue for me going full-time is simply the amount of time it takes me to look presentable. There's no way I could keep up a normal work schedule with all that preparation. :)

Here in Canada, there's no RLE requirement for hormones, but I believe you have to be one year full-time to qualify for SRS, which frankly isn't even on my radar yet... for various reasons, I think stopping at hormones and full-time presentation might suffice for me.

I'm starting to present female more and more on weekends and plan to progress to full-time-except-for-work like Angela did.

Thanks again to everyone for sharing their experiences.

[I Am Paula]

I went full time except for work before HRT. When I went full time, I was still kidding myself this wasn't going any further. Very quickly I decided I needed to transition fully. When my therapist gave me my HRT readiness letter, I said to make a note that I was officially starting RLE. She looked at me a bit strangely, and said 'Your RLE is done, call me when you need the letter'.

[Kathryn Martin]

I like to go out presenting as female, but the issue for me going full-time is simply the amount of time it takes me to look presentable. There's no way I could keep up a normal work schedule with all that preparation. :)

Seriously that is the weirdest reason for not going out I have ever read:D

When I started it took me 1.5 hours. Now, with shower, hair, makeup and dressing 30 minutes which is a normal morning routine. And I look fabulous as my friend Art keeps saying.

[Frances]

It will take less and less time, I am sure. Losing the beard will be the biggest difference, and noticing that most women do not look they are going to a ball everytime they step out of the house.

Starting any sentence with "here in Canada" can be problematic. Each province has its own thing going on in regards to standards of care and what is covered or not by health insurance. It's evolving continuously. For instance, SRS is no longer required by law for a gender marker change in Quebec, but it is by the agency that emits birth certificates and grants gender modification certificates (Bureau de l'état civil). So SRS is sill required until the agency changes its rules to follow the law.

[LeaP]

Seriously that is the weirdest reason for not going out I have ever read

:yt:

There are many ways of measuring intensity. One is apparently one's preparation horizon.

[I Am Paula]

Seriously that is the weirdest reason for not going out I have ever read:D

I really had to chuckle at this one. One half the world's population manages to get out the door in a timely manner.:doh:

[Dianne S]

Hi, Frances,

Yes, I know that in Canada it varies province-by-province. But I'm not aware of any provinces that require RLE before HRT.

From now on, I'll be more precise and say "Here in Ontario" :)

LeaP said: There are many ways of measuring intensity. One is apparently one's preparation horizon.

Well, true. I think going full-time when I'm not confident I'm ready may actually make things worse. I won't be deterred by negative reactions, but at the same time they're quite painful and I certainly do my best to avoid them. I feel that more hair removal and at least half a year on HRT is required to build my confidence.

[Kaitlyn Michele]

Its just the way it is that the people that have transitioned will arch a brow when we hear that you won't go full time because it takes too much time to get ready...

HRT is not going to make it take less time to get ready and I transitioned in 2009 and I still shave every other day. (after laser AND almost 300 hrs of electroylysis...I got screwed on that one)

[Kimberly Kael]

So true. Anyone holding out hope that HRT will do anything about facial hair hasn't done their homework. Laser / electro will do far more for being read as female than any of the subtle effects of hormones. Getting your morning routine down to the point where you can do it in your sleep makes a real difference, but between hair and fairly basic makeup that's still half an hour out of every single day that you have to appreciate isn't the unique province of a trans woman. Other women are under the same pressure to look like our society expects women to look.

[whowhatwhen]

What HRT could do though is begin to soften the more harsh male facial features while you get your affairs in order and build confidence.
For many people even the cost of estrogen is significant, let alone hair removal. So in regard to timelines there needs to be a fairly wide berth given.

e:
Hair removal cost is a huge barrier as well.
Soon I'll need to start electro and even only being able to afford 4 hours at $60/hr leaves me with just enough money to pay my bills and that's mostly it.

[Kaitlyn Michele]

I guess what i'm really trying to say is that you won't grow confidence by taking more HRT or removing more hair..

[Angela Campbell]

No, the confidence comes from being out there. Things like hair removal, ID that matches you, and a name change do a lot towards making it a bit less awkward, but you have to live the life and get out there.

[Dianne S]

I know HRT does nothing for facial hair... that's why I'm doing laser. But HRT does help with body hair.

I actually think my confidence will increase with HRT and less facial hair. The laser sessions I've had so far have done wonders for my confidence. A year ago, I never went out in public. Now it's no big deal. But still, we all have to reach a point when we're ready for full-time, and I have not yet reached that point... and I would hope that does not preclude my receiving HRT.

[Anne2345]

But still, we all have to reach a point when we're ready for full-time, and I have not yet reached that point... and I would hope that does not preclude my receiving HRT.

It does not preclude it. Of course, you already know this. No need to become defensive, though. What some here are advising (and rightfully so) is that one should not place such heavy emphasis and reliance on HRT to gain and acquire confidence and conviction. HRT is not magic, and it is not a substitute for the lessons that can only be learned through real world experience and getting out there and doing.

Regardless, this is not a race, and no one gets extra points for going faster. So proceed at whatever pace is reasonable for you, and that you are comfortable with. It's your life, and when you are ready to do with it what you must, whatever that may be, you'll do it then. Until such time, keep collecting data, and you'll figure it out. Just be careful not to assign too much importance or significance to any one thing related to this path, because that will not serve you well . . . .

[Barbara Ella]

Everyone's needs will be different as to when HRT is started, and even more to the point needed. Some need the HRT to alleviate the GD, as did I. and little thought being given to any RLE, given a life situation. For others, RLE is the must do element in one's development. As others have said, there is no need for one to be done before the other can begin. What is most important is that one feels comfortable with what one does, regardless. No one can tell you what is comfortable for you, just what worked for them.

Barbara

[Rogina B]

I guess what i'm really trying to say is that you won't grow confidence by taking more HRT or removing more hair..

There is also no way that "you can learn" without putting yourself out there and being female in the mainstream world. There is no "cutting that line"..

[DebbieL]

A post on the Second Therapy Session (http://www.crossdressers.com/forums/showthread.php?219092-Second-Therapy-Session-First-Time-Out-Dressed&p=3600495&viewfull=1#post3600495) thread caught my eye:

I have gone out presenting as a woman, but I could not imagine going full-time before the body changes caused by HRT

How much have you gone out? How often?

HRT is not a substitute for the important steps you have to take PRIOR to HRT.


Body-hair management and getting the right shape would take up too much time... so just wondering, what's the "typical" sequence?

Let's start with that. Have you been waxing or just shaving? To have the thinner lighter hair on your legs and arms, you have to wax them. Of course, your friends will notice that your arms are bare, and/or that you are wearing long sleeve shirts in the heat of july. If you are serious about HRT, then you need to be comfortable with wearing short sleeve shirts even a few days after waxing, and wearing shorts.

What about Facial hair? Have you started laser? Have you grown a beard and waxed it off? Have you started electrolysis? There are ways to reduce the cost and time involved, but you have to be willing to do some things that will be painful and difficult. I grew my beard to 2 inches long, then waxed it off. The process was bloody, painful, and for a few days during the work weeks, my face looked a bit like hamburger. I couldn't get the moustache to wax off, so I had to pluck it out with tweezers.

Are both of your ears pierced? If so, your friends and family are already aware of your gender dysphoria and waiting for you to tell them.

A huge portion of RLE is planning a successful disclosure. Before you can start HRT, you will need to tell friends, families, in-laws, employers, and everyone important in your life that you are transgender and planning to transition in the near future.

Normally, a therapist wants you to be living at least MOST of your time as female, with the exception of work, before you start HRT. Furthermore, your therapist will confirm that you have been in communication with your employer and that they will be prepared for the time when you are ready to start working full-time as female.

The key requirement, more than amount of time, is that the therapist needs to know that your life will work as you start to grow breasts. The therapist has to know that you are emotionally, psychologically, and financially able to accept and deal with any and all possible consequences. As you transition, you will be encouraged to look at new consequences as they present themselves.


HRT and then RLE, or vice-versa? Interested in experiences from those who've done it either way and what they think the pros/cons of each are.

Keep in mind that once they physical effects of HRT manifest themselves, there is no hiding and there is no going back. If you have C-cup breasts, it will require surgical breast reduction to go back to being male again. Conversely, if you are an FTM and you've taken enough testosterone to lower your voice, to grow hair everywhere you want it (and a few places you don't), it's a really big deal to try and get back to female mode.

By the time I started HRT, I had already taken steps that made it impossible to hide that I was transgender. The pierced ears, the manicured nails, the hairless arms and legs, and the hairless face, all led to questions that could only be answered honestly. When I told my manager I was now on HRT and would be ready to transition soon, he asked me to post a current picture of myself. I was presented to clients as "Her" and "She". On the next engagement, I had to work as "Rexxie" because I had not yet initiated my name change. By the titme I got my next engagement, I had filed for the name change, gotten the gender change letters from the doctor, and was working as Debbie from day one. My badge still said Rex, but I was allowed to wear it so that it would usually be covered by a coat. By then, I was good enough at blending that many people thought I was a woman. The only give-away was my e-mail which still had my male name.

A few co-workers started asking me more questions, and we were able to have informative and often amusing discussions. I was able to properly help them to feel more comfortable almost immediately. This is because I had done it dozens and later even a hundred times before. When Debbie came to Thanksgiving, the family liked her better than Rex and have Debbie all the Christmas presents, which made me so happy I cried. At church, the women knew I was going to start coming in a dress, and when Debbie did show up, about the only thing that gave away my prior nature as a boy was that I was singing in the Bass section of the choir. The main reason being that we had too many tenors and even though my voice was going up by over an octave, I still had baritone notes.

When one of the elderly gentlemen, a staunch conservative, and a key contributor asked me why I felt I needed to do this, I was able to explain everything he needed to know in less than 10 minutes, and he realized that I had always been Debbie, it was Rex who had been created to survive a world that was often brutal and painful. Others embraced me and accepted me even more quickly. A few were still uncomfortable, but I had learned to remove any sense of threat through my previous RLE before starting hormones.

In my particular case, I had the advantage of a previous RLE period. From 1989 to 1996, I was able to get lots of RLE, often living all but work hours as Debbie. When I met my wife, I had placed pictures of Debbie next to pictures of Rex in my profile. I knew that most (about 99%) of the women who saw it would just move on to the next candidate. The 10 out of 1000 women who did respond positively were rare treasures, and when Lee asked and I gave an explanation I had shared hundreds of times before with hundreds of different people, she was still interested. When she show my profile to her daughter, she said "well mom, at least you won't have to worry about shatterig his fragile male ego when you tell him your in charge of it". Lee told me that over the phone. I laughed and said "well, she's got that much right".

The only time I had a setback was when I wasn't able to see my previous therapist because of my business travel requirements. My wife realized that I wanted to transition and that I wanted to start hormones, and told me "I'm not OK with this". I hit the wall rather suddenly, but once I got with a new gender therapist, and went through the preliminary evaluations and process, she invited Lee to come to my sessions. Lee was just upset that I hadn't told her I wanted to transition. She also worried "I'm not a lesbian". Then the therapist asked about what we did together, including details. Then she asked if there were any other men in her experience who did things like that. Her eyes popped open and said "Oh my God, I must be bisexual". She's still attracted to men, but she also finds Debbie attractive as well, and she loves what we do together.

After that, Lee became very supportive, and insisted in doing a "What not to wear" session with me. We threw away about 90% of my clothes, along with the memories that went with them. We then went shopping for clothes that were age appropriate, size appropriate, and situation appropriate. I resisted at first, but when I realized that people were actually experiencing me as a woman, and I was NEVER getting read, I realized she was on to something. At one point, we were at a dinner, and one of the others at the table asked "how long have you been married?", when we indicated that we had been married since 2006, she said "how is that possible, gay marriage wasn't legal back then". Lee finally admitted "Debbie used to be my husband". Three of the people at the table dropped their forks and did goldfish impressions. Then the inquisitive one said "You were a GUY in 2006, I can't believe it". What really shocked her was that I had been working as a guy until mid 2013.

Thanks to Lee's coaching, I was able to "fly pretty", changing to Debbie as soon as I left work for my drive to the airpoirt, then going through TSA. I still had to show my proper legal Driver's license, but when the TSA worker looked at my old picture, looked at me, and did a triple take, then said "No way you were ever a guy", I knew I was ready to transition at work. A couple of months later, I went to the airport wearing shorts and a T-shirt. The TSA agent called out "MAAM, I CAN HELP YOU". I didn't realize she was addressing me because I wasn't trying to be "pretty". But I did have just barely a 38-B and is was a bit "pointy". When I got home, I wore the same T-shirt and Lee told me I had to wear a bra from now on. A Sports bra if I wanted to "pass" as a guy. By the end of summer, even my thick cotton L.L. Bean dress shirts, which I called "pup tents", couldn't hide the puppies anymore.

Since then, I haven' left the house or hotel room without wearing my wig, even to get ice. For any extended errand, it's wig, make-up, bra, and appropriate attire for a woman my size and age. I couldn't "pass" as a guy even if I wanted to.

Often, we think we want instant transition, to immediately go from full time male to full time female, complete with D-cups, hot legs, and long beautiful hair. We have fantasies of looking like our favorite pop singer, movie star, or television personality. We want to have that Cinderella experience. But the reality is something very different. Slow growth is good growth. It gives us a chance to test the waters, to see where our foundation might need shoring up, and who we can trust and who will be available as support as we transition. It also gives us time to make new friends as our feminine personalities, and to have friends who can know us in transition and support.

Trust the process. It will take time, and it will take trust, and it will require changes. Changes are hard. Some people we know and love will not accept us, and others won't even be surprised. My sister's reaction when I came out to her as Debbie back in 1989 was "yeah, you were ALWAYS my big sister, you knew how to brush out my hair without hurting me, you tought me how to do make-up, and we used to go shopping together and you loved to pick out outfits for me. I was just afraid you'd freak out if I asked you if you wanted to be a girl.

[Dianne S]

How much have you gone out? How often?

I spend about a day a week presenting as female in public, on average, plus a few evenings a week at home.

Have you been waxing or just shaving?

Epilating and shaving.

I too have varnished nails, long hair, earrings, and hairless face---well, as hairless as I can get it, given my genetics. I agree that slow growth is good growth, but the GD in me is impatient! :) Anyway, thanks for sharing your experience; it was interesting and hopeful.

Oh, and about the pierced ears: Times have changed. I know several guys who have both ears pierced and who are definitely not transgender.

[Angela Campbell]

Debbie brought up something that does need to be considered, that i experienced. After being on hormones a while it is more and more difficult to hide.
I was living as a woman but was still a man at work. I was often mistaken for a woman while trying to look like a man. Things were becoming more and more obvious and I did not look at all like my id. This was very difficult. It was such a relief to get the name change and go full time., but that followed a period of awkwardness that was months long. The in between time is difficult.

[Donna Joanne]

Debbie and Angela are correct, as time on HRT goes on it gets more difficult to conceal unless you are really trying to hide your transition. I was "reversed clocked" multiple times last week just wearing a pair of shorts, t shirt, and flip flops. No makeup, jewelry, or hair pulled back. Once I was even wearing a ball cap. After seven months of HRT and working hard to lose weight, between my growing bust (B cup and still growing) and shrinking waistline my physical attributes are getting harder and harder to conceal. I'm up to two t shirts under a button up shirt in order to pass as male now, but my biggest "oops" is not lowering my voice when I'm at work. I've be practicing my female voice for four months, and it's becoming second nature. Good luck and godspeed on your progress. Just remember to hang on as you enjoy the ride!

[LeaP]

?..
The only place I ever see any suggestion of a rigid one-size-fits-all approach from the medical community is here, generally from people who don't like the fact that the doctors treating them actually have standards for giving you the best care that they can.

+1 on that!


... body changes happen slowly and can be more subtle than meaningful and hair removal can go on for well into transition...



I guess what i'm really trying to say is that you won't grow confidence by taking more HRT or removing more hair..

I agree with the first,Kaitlyn, but not the second.

In my case the body changes are definitely subtle. I have had several people comment on them, knowledgeably in the case of my therapist, unknowingly from others. So I have a good idea where they are and what the effects are. But it isn't like I look like something different or anything like that. Were I to characterize the most often–commented changes it would be that they have taken a decade or more off my appearance.

I have been on HRT for just over two years. My body shape has shifted slightly. I can see and feel the difference, but I have plenty of male physical cues left that are permanent.

Breast development is by far the thing that has to be managed most, pre-transition. if it is significant enough, it will dictate both clothing choice and circumstances.

Facial hair removal is affirming and will obviously help your presentation. I don't think it matters at all beyond that. I also don't think body hair removal matters at all to others. Not even a little bit. (Well, okay, maybe to your SO.) My body hair has been gone for a long time. No one has ever blinked an eyelash.

So if the physical is subtle, manageable, etc., then why do I disagree with the second cite, above? Simple, and you caught the essence of it in another (un-cited) line when you said you're ready for HRT when you are ready to improve your quality of life. For me, although the physical changes are relieving and affirming, the huge benefit was psychological. But that's because I was a mess!

It is from this perspective that my comments about RLE without HRT being cruel come. I suppose it's plausible that others whose heads are on a little straighter than mine was may not have this need, but I wonder. The change for me from HRT is so profound, and my psychological state was so compromised prior to HRT, that I cannot imagine starting RLE or transitioning without it.

This is about more than comfort. Some of my worst difficulties were addressed when I started taking antidepressants, on which my therapist insisted prior to addressing gender further. Even then, I was in a highly ambiguous state. HRT took me from identity awareness to identity actualization. I stopped analyzing my psyche and started living it and making decisions normally and naturally.

[Cheryl123]

If estradiol can relieve the symptoms of gender dysphoria -- and it is well recognized in the medical community that it can with many transwomen -- then I fail to see the logic behind forcing someone to wait a year to received to receive a medically sound treatment for GDS. I have never seen any scientific study -- and if I am wrong then please someone correct me -- that a one year RLE makes a person more ready for HRT than someone with no RLE at all.

Current medical research shows that GDS is in part a result of a hormone imbalance that transwomen are born with -- too much testosterone and not enough estrogen. When that imbalance is corrected through HRT, the GDS symptoms are greatly reduced if not eliminated in many transwomen. If a medical professional forces someone into a year long RLE before prescribing HRT, he or she very often prolongs their patient's suffering. Moreover, many transwomen, for reasons of their own, prefer not to live full time as women and find that HRT alone is suitable for them. Making RLE a condition to receive HRT has the effect of denying these women HRT altogether.

Many doctors and gender clinics in the US -- included the most respected such as Callen/Lorde in New Work and Howard Brown in Chicago -- now prescribe estrogen immediately if initial screening indicates a person is suffering GDS. Therapy is seen not so much as a way of qualifying someone for HRT but as a way of helping the transwoman live a happy and successful life -- regardless of whether she decides to completely transition or not.

Does HRT help one undertake RLE? Many people won't receive enough physical change to help. But psychologically and emotionally HRT can make it a lot easier to venture out in the world as a woman. All of this is my opinion, of course.

[Kaitlyn Michele]

Makes sense Lea...

I was thinking very narrow... the idea of say making it a point to check out at the shoprite without using the self checkout..

somebody tell me they've gone to three different grocery stores for one trip so they could avoid a big checkout and a clerk..it will make me feel better about that fact that I did this regularly until one day I said "f' it"

It's a good thought to consider that anything you can do to improve your frame of mind will trickle down to more confidence and more personal growth..

[celeste26]

In my book anyone willing to endure the pain and cost of electro is qualified for SRS, it will force anyone questioning their motives to re-evaluate themselves. As one of the posters above noted, electro will help out tremendously in obtaining a more female facial look. Without electro it makes living as a female more difficult (not impossible just difficult.) I have basically gone 24/7 without HRT because I naturally have a very sparse beard. But I am also retired and have no job to go work at.

[Frances]

Do you mean qualified for HRT?

[LeaP]

In my book anyone willing to endure the pain and cost of electro ...

It's especially illuminating to counsel starting with the upper lip and directly under the nose.

(And Frances, that would make more sense!)

[stefan37]

I actually thought along the underside of the jaw to be most uncomfortable

[Kathryn Martin]

Just to set a little counterpoint here, not that I generally disagree with the comments made so far, but in my circumstance things were different.

I went out exactly three times before transitioning socially and professionally. Twice to shop for my wardrobe and once with friends to a restaurant. For me keeping things under wraps was more important than anything else. I had a reasonable sense of how I would look once I transitioned.

My timeline was transition decision, then three counseling sessions to get hormone clearance letter, 5 weeks later start of electrolysis, two weeks later hormone start. Five months later social and professional transition, 5 months after that begin SRS assessment, 3 months to first SRS assessment letter, 3 weeks after that booking for surgery confirmed, 3 months later second SRS assessment, 2 months later SRS. Start August 2010, end SRS May 2012. I am still going to electrolysis (although I am now weeks away from being done).

Now, two and a half years later I can say that totally worked for me.

I have no idea what earrings have to do with GD, or transitioning. I started with C cups (my first bra) and am now a D cup which is all about a woop di doo difference and doesn't help when your boobs are what they call in the industry flat and wide (which actually determines partially your cup size). So they can't really have all that much to do with transitioning either.

[whowhatwhen]

When would you say that "going out" counts?
I make no attempt to put forth a male image, or male anything for that matter yet I'm still read as male so I'm not sure if it counts as RLE or not.

It'd be different if I wanted to wear makeup and dresses and all those things but I'm more plain than a dehydrated cracker.
That's kinda what confuses me a bit, I've gotten off light in terms of getting shit so I assume that I'm being read as male enough to pass under the radar.

So far I've only been stared at and had people yell something unintelligible at me from a van.

(x)nthing Electrolysis as being a good indicator because holy crap I'd leave my appointments inches away from tears.

[Kathryn Martin]

The description for Real Life Experience means that you live 24/7, go to work, eat, sleep, socialize a woman. Going out is more or less the weekend warrior status, not RLE however, at least according to the standards of care.

[whowhatwhen]

That's what I don't get though, does that mean stereotypical woman stuff or people seeing you as a woman?

[Jorja]

You are in the minority Kathryn and probably pretty darn lucky that all went well both before and after.

[Frances]

That's what I don't get though, does that mean stereotypical woman stuff or people seeing you as a woman?

Neither. It means asserting yourself and your identity, using your chosen name all the time, correcting people who misgender you and not have "two voices." As far as appereance goes, there are a lot of options. Fortunately, jeans and a T-shirt is stereotypical these days.

In short, in means being one whole person. No more talk of your male self™.

[whowhatwhen]

Ahhhhh okay that makes sense :)

[Michelle789]

There is no right or wrong way to transition. There are standards of care, which are guidelines that doctors use to treat trans patients, not rigid do it this way or the highway. In fact, with the way real life goes, it is impossible for any two transitions to be exactly the same, and to follow any protocols 100% perfectly. Also good doctors aren't cookbook doctors. They don't follow recipes the same way for everyone. Good doctors use some common sense and make adjustments for any given patient's needs.

I think forcing someone to live 24/7 before getting hormones opens us up to the worst risk, and the one irreversible risk, of transition, coming out to people. To live 24/7 including work means you must come out to work, your S.O., all your friends, and family, risk losing your job and everyone in your life, only to find out that you might not transition after all. There seems to be no point in taking that risk unless you know for sure you're absolutely sure you're going to proceed with transition.

If you are certain you are going to transition and you're ready to go full time before you start hormones, then be my guest and out yourself to everyone and start living your authentic life.

If you're really uncertain of your gender identity, which many of us are because we fight this tooth and nail, you may need to try hormones first to get confirmation of gender identity. In that case maybe trying hormones before going full time and coming out to everyone would be better.

What I did was somewhere in the middle. I did neither 1-2 years RLE before starting hormones, nor took hormones for 1-2 years before going full time.

I first went out on a Friday night to a safe TG support group. I continued to go out only at support groups for a month. Then I took my first "solo" outing - without any friends or safe support group - I went on a scenic drive, to Starbucks, and a bookstore. I continued for two more months of safe support groups and more weekend outings.

Then I lived a full weekend as a woman, and then another one. Then I took a week off from work and lived a full week, well 9.5 days counting weekends, as a woman. After returning to work I knew that going full time was imminent and I was a miserable wreck having to go to work in male mode. By the grace of God, I lost my job and was given a freebie to go full-time. Actually I went 165, because I was still going to AA as a man. I continued that for two more months, and started hormones. I eventually got re-hired at my old job. Then I came out at AA and went full time. I still have plenty of work ahead of me, but I am living full-time now. This happened in a span of 7 months.

Everyone's story is different. Some of us may have no choice but to go full-time before starting hormones. Some of us need to try hormones to confirm our gender identity. Some of us because of our living circumstances need to do as much hair removal and be on hormones for a year before we can start living as a woman, because it's pass or die for some of us. Some of us might live as a woman outside of work (nights & weekends) and go to work as male for a few years before going full-time. Everyone's path is different.

[LeaP]

I'm not exactly an Anne Lawrence fan, but ...

http://www.annelawrence.com/2001hbigda2.html

Not much evidence for the concept, according to her.

[becky77]

I'm not exactly an Anne Lawrence fan, but ...

http://www.annelawrence.com/2001hbigda2.html

Not much evidence for the concept, according to her.

Isn't that RLE before SRS rather than HRT? RLE before SRS is pretty sound practise it's just about how much RLE is deemed necessary. You know in yourself when you are ready so it can be a massive frustration someone telling you that you have to pass their test first first, which could be years.
But RLE before hormones? I think making someone go fulltime before hormones is risky, going on hormones took away most of those doubts in my head. But what if it turned out not to be for me and I had already told the world?
I'm playing devils advocate on this, for that percentage of people that transition for the wrong reasons. If I look at my own circumstances I never needed someone to tell me I need RLE before hormones, I just knew that's who I needed to be, I told my family and friends before I was on hormones, I just knew in myself that hormones would help and transition was what I had to do.

[Kathryn Martin]

I'm not exactly an Anne Lawrence fan, but ...

http://www.annelawrence.com/2001hbigda2.html

Not much evidence for the concept, according to her.

I have huge reservation about the work of Anne Lawrence. But this quote is central I think:


For some gender dysphoric persons, the desire for surgery may center on the sexed body, and may have little to do with the desire to enact a specific gender role. Recall that in DSM-IV, gender identity disorder can involve either:
"Persistent discomfort with his or her sex, or a sense of inappropriateness in the gender role of that sex."
Either somatic discomfort or gender role discomfort qualifies one for the diagnosis. And for persons whose dysphoria is primarily somatic, the real-life experience may be little more than an irrelevant barrier to care. Here is what one of my respondents wrote:
"My incongruity was with my anatomy exclusively, so...RLT...did nothing to alleviate my anxiety. I know it is popular to say it is the role that is important, and SRS is [just] 'the icing on the cake,' but for me that [was] simply not true. SRS was the whole enchilada."
The comments of this patient are consistent with Jay Prosser's analysis in his book, Second Skins: Body Narratives of Transsexuality. Prosser's study of over 50 transsexual autobiographies led him to conclude that the essence of transsexuality was a profound sense of "wrong embodiment," which went beyond concerns about enacting a particular gender role. It may be that in the case of transsexuals, we have paid too much attention to gender role, and too little attention to the dysphoria associated with the sexed body. Anne Lawrence, M.D. PhD, SRS without one year RLE: Still no regrets, 2001 Galveston Texas

I think the important point though is that if RLE is either reduced or abolished before SRS, then the psychological assessment becomes even more important. It underlines the need for exclusion of co-morbidity issues and ascertainment of stability of the persons life circumstances both psychologically and otherwise.

RLE before hormones makes no sense whatsoever. Hormones are and should be a common sense precursor for transition. And transition is what RLE essentially means. Many people will re-transition during RLE which is what RLE is for: Can you manage before you do something that cannot be undone? Most people after their first year following transition will just keep on gathering more real life experience like any other ordinary human being:D

[LeaP]

Isn't that RLE before SRS rather than HRT? RLE before SRS is pretty sound practise it's just about how much RLE is deemed necessary.


I think we are using terms too loosely. The concept of RLE (or RLT) in modern usage pertains only to SRS. All RLE is experience in life, but not all experience in life is RLE, which is why some confuse their part time experience with RLE. Part time, full time, whatever - if it isn't the qualification period prior to SRS, it isn't "RLE." Sorry for the semantics diversion, but this is a source of constant back and forth about "experience."

If RLE before SRS is sound practice, there is apparently no evidence for it. If it is sound practice because of irreversible changes, then the same has to be admitted for hormones.


RLE before hormones makes no sense whatsoever. Hormones are and should be a common sense precursor for transition. And transition is what RLE essentially means.

I agree. I would also agree with the need for more careful evaluation if RLE periods are shortened or eliminated. And they are being shortened in practice, if Lawrence is correct (e.g., Meltzer).

[Marleena]

The WPATH group has advocated for real life experience for at least 3 months prior to surgical
intervention.v This step was developed to establish coping mechanisms for the above mentioned social stressors, and it requires people to live in the gender role of their internally-experienced gender, with or without hormone administration. This step can be problematic for clients if it requires them to adopt a role prior to having any physical changes commensurate with that gender. The real life experience will certainly be valuable to evaluate the client’s ability to cope with the stressors associated with expressing gender, but we do not consider it a necessary step prior to hormone administration.


link: http://sherbourne.on.ca/lgbt-health/guidelines-protocols-for-trans-care/

[Frances]

Regardless of WPATH's recommendations, and this is just my opinion, the RLE should be much longer than 3 months prior to surgery. I am a big proponent of long observation periods and so-called gatekeeping style therapy.

[Marleena]

I agree Frances but thought I'd share that paragraph. They go on to state that it does not change the statistics of the regretters at all. They make it sound like they are far more concerned with helping people that are suffering from GD. I find it worrisome because sometimes we see people rushing towards SRS after getting a diagnosis.

[Kali]

Perhaps this is the only “advantage” to being 6’5” and trans. I have been living almost full-time as a woman for the last two years. When my therapist asked me if/when I planned to transition, I didn’t have an answer for her. Nor did I decide to start HRT. But one of the things we did discuss was that no matter how much surgery/cosmetic work/etc. I decided upon, I would always stick out in a crowd. Nothing will ever change my frame and bone structure. But if nothing else, I know that I don’t obviously look like a man in a dress and that the additions to my daily grooming requirements have been minimal, despite being fairly hirsute.

When I first made the choice to live as myself my daily process was more complex. I was trying to make sure that I was removing whatever trace of the male me I could. Now, my daily routine is no longer than my wife’s preparation for work, though I do like longer showers. I’ve discovered the fact that a light touch with makeup is often much better, for example. I use a light touch with foundation, some lipstick, and I go about my day. People in the real world treat me as a woman 90% of the time without any issue. Nothing I can do will change the reactions of the other 10 percent.

I am a very shy, private person. I hate being the center of attention or doing anything to draw attention to myself. If nothing else, that demonstrates to me, my family, and my therapist the depth of my need to be who I am.

Disclaimer: These are my experiences and apply to me. Your mileage WILL vary.

[Kathryn Martin]

I find it worrisome because quite often we see people rushing recklessly towards SRS after getting a diagnosis.

where do you see any evidence of that? I have never met anyone who "recklessly rushed towards SRS

[Marleena]

Let me fix that to say "sometimes"...

I was agreeing with Frances that one year RLE made sense and can be a cooling off period and reality check on socializing as a female.

[LeaP]

...the RLE should be much longer than 3 months prior to surgery. ...

Maybe. It seems that one can usefully distinguish learning to live well from avoiding regret, however. I'm not suggesting that one is less important than the other, either.

[Kathryn Martin]

Isn't the measure of readiness really the point where no doubts remain, for hormones, for transition and for SRS. I mean why would anyone go down that road unless they were 100% sure. The "waiting" period Frances proposes is really more about checking your motivations because that is where the whole things falls off the cliff.

[Frances]

What most people don't understand about so-called gatekeeping programs is they don't actually exclude people. Patients/clients self-exclude themselves because they cannot play by the rules, which are to explore the motivation for a set period of time. I can't even count anymore the amount of people who left the program I went through and that now complain about it's unfairness. The funny thing is that they give letters to just about anyone who will go through weekly sessions for the the mandatory length. If you stay, you get the letters, if you leave, you don't. It's that simple.

I know some people who gave up on transition, because the program's length and wait period was too long. How trans can you be if you give up on transition because it's not "soon enough™.

This is in regards to SRS. They don't ask for a RLE period before HRT, only about 8 months of weekly individual and group therapy.

[JohnH]

All I can say is thank goodness one does not have to do RLE before HRT. In fact in Texas you can find clinics that work on the informed consent model. If you go on M2F HRT you certainly need to be aware of the effects. Right now I have C cup breasts soon to be D cup and yet I have caught absolutely no flack of having them in spite of presenting myself as primarily male (male clothing however with my past shoulder length hair, lipstick and eye makeup, and carrying a purse).

Now I think SRS is a completely different situation. You had better be DARNED SURE you want the operation before proceeding. In my case at this time I have ABSOLUTELY no desire to have that procedure done. I however do not absolutely rule it out in the future.

Johanna Anna

[LeaP]

What most people don't understand about so-called gatekeeping programs is they don't actually exclude people. ...

I know some people who gave up on transition, because the program's length and wait period was too long. How trans can you be if you give up on transition because it's not "soon enough™.


The point is valid, though it only covers one scenario, even for transsexuals. Others include those without access to the system, those who transition sooner outside it, and those who object for a variety of reasons. There are discussions to be had on the merits and details in these cases and others.

Nonetheless, it does seem the objections come most often from non-transsexuals who want streamlined access. The issues this creates for me are those of medical ethics, which in turn conflict with my philosophical and political ideals. More and more I come down to deciding the conflict on the basis of evidence-based care. This has two components: care regimens and standards based on evidence (which also addresses needs of different types and levels), and evidence of individual need. The existence of need does not obviate or replace the need to evidence it, much as some would wish otherwise.

I'm persuaded to set aside my socio-political ideals for one simple reason. And that is because it is obvious to me that most people simply have no idea what they are talking about. Interestingly, that's even more true of the effects and risks of hormone administration and androgen blockades than it is surgeries (please excuse the MTF orientation here). It undermines much of the foundation underlying the freer variations of informed consent. That position might open me to some sort of elitism-based counter argument. My response would be that this would carry more weight in times past, when standards were heavy-handed indeed and unjustifiably exclusionary. We live in a time when some standards (at least) have been loosened and more flexibility in regards to practice against standards is allowed and justified.

A further comment on informed consent: Although I focused above on the "informed" part of informed consent, the medical ethics around consent are complex. An issue that plays in the trans community – and has to be given some recognition in its own right – is the prevalence of self administered HRT. A valid harm reduction argument has been made for a streamlined process to bring care for this population into the medical community. I dislike such considerations being conflated with the ethics of consent, however. A useful analogy harmoniously bringing together aspects of medical ethics, consent, and personal freedoms is voluntary sterilization. A more useful analogy to the self-administered hormones situation is methadone administration to replace heroin usage. I don't mean that to include the negative aspects of addiction, but in the sense of the ethics decisions involved.

[Kathryn Martin]

Patients/clients self-exclude themselves because they cannot play by the rules, which are to explore the motivation for a set period of time. I can't even count anymore the amount of people who left the program I went through and that now complain about it's unfairness.

I think this hinges on the purpose for which people go to see a counselor. If your purpose is to explore "feelings" when you go to see a counselor then the rules are to explore those feelings until the patient is satisfied that they know where they stand and can make an informed decision to go down the hormone road or not. It is incredible to me that you would take hormones without having first sorted out your feelings about who you are. Hormones have a massive impact physiologically and on peoples mental disposition. It is always the patient who sets the timelines because good counselors will not offer unless asked.

If your purpose is to be cleared for hormones then state so. The assessment is completely different because the standards require that a recommendation should be based on the exclusion of co-morbidity issues and a diagnosis from which the recommendation for hormones follows. These assessments will go for as long (or as short) as it takes for the therapist to complete the assessment but under the care standards should at least include three visits over three months.

I have great trouble with the informed consent model. It conflicts significantly with the Hippocratic oath doctors have to take to practice. The highest maxim is "do no harm". That sometimes involves weighing one harm against another. It is an objective process. The informed consent model removes all objectivity from the process.

[Frances]

Other than financial means to access care, there seems to be culture gap in how medical healthcare is viewed in this thread and accross the countries represented on this forum. There is also a disparity between want and need. In a public system where everyone chips in for everyone's medical care, the onus is on the trans person. I know some people on this site view transition as some sort of body modification process that should be commercially available, but I don't... yet. WPATH and CPATH and all the other PATH's are relaxing requirements. They must know something. They have access to statistics and case studies.

The requirements for HRT are not set by the government in my province and in any other province. Those decisions are made by medical associations. Governments (like insurance companies in the States) decide what get's paid for. They do, however, decide who has authority to make decisions regarding medical treatment. Quebec used to have a single gender clinic who could give letters for paid surgery. They require a minimum of 8 months of therapy before HRT and 2 years before SRS (with one year of RLE). The government decided to allow other medical professionals to approve HRT and SRS. They mostly follow the current WPATH guidelines, and some are even more liberal. One psychologist will write a recommendation letter for HRT after one session, never mind pre-HRT RLE.

All that said, is it better to facilitate access and let people ruin their lives or to proceed with caution and have people wait for stuff? I know someone who gave up on transition because his appointment to see a psychologist for HRT was 6 months. He told me that it had to be "now or never." In a body modification paradigm I get it. In the context of transsexuality as a medical condition, I find it outrageous. Was he not going to be trans in six months? I am glad that person was "gatekept" out of it.

[Kaitlyn Michele]

In all medical things, we are our own best "advocates" For TS people its more important than most issues.

one of the unfortunate outcomes of letting people ruin their lives is that it implicates people that don't....

No matter your view on standards, rules, ethics, morals, or even what constitutes good judgement...
controversy and bad outcomes are not in our best interests as people that want transition to be more understood and accepted..

it is a fact of life that one bad apple spoiling things is a real thing.. and its really tough to take when its actually an orange in with the apples...

thats why its in ts people's best interest to allow a system to be in place that can vet people...
we want a system that helps everyone and pays for every one...i had to pay ...i hope in the future nobody does

this system will be (is) imperfect but persistence will be rewarded if you receive poor treatment..and persistence will be rewarded the more transsexuals transition well..

and btw...that is a part of the "system" that shouldn't be ignored... if you are motivated and open to it, you can learn a lot and make a very difficult thing easier and give yourself a better chance to have a great outcome

[whowhatwhen]

No, things don't need to be more stringent than they already are.
Younger transpeople are already finding it hard enough to get care let alone adding even more gatekeepers.

You've got a system in place set up by people who have the numbers and know their **** and that seems to be working well enough for the time being.
There are people transitioning when they shouldn't, but that number is very small and not worth making things harder for everyone else.

A good example of "bad apples" are the guys who go naked at pride, people bitch about them every year yet it's only a handful of people out of thousands.

I'm not saying to dispense HRT like candy but we don't need anymore barriers in the way of those who need it.
IIRC The HRT regret rate is pretty low and those unsuitable stop before any irreversible effects happen.

I read /r/asktransgender every now and then and it's saddening to read that people still have trouble finding care, let alone making them go through more hoops because someone wanted DD tits in 3 weeks.

[LeaP]

No, things don't need to be more stringent than they already are. ...
Younger transpeople are already finding it hard enough to get care let alone adding even more gatekeepers. ...
IIRC The HRT regret rate is pretty low and those unsuitable stop before any irreversible effects happen.


What HRT regret rate? I've never seen a single reference to such a rate and doubt that any statistics exist. Are you aware of any?

Access to care and standards of care are different issues.

[Frances]

I don't think there is much regret about HRT and hence no need for RLE before that part of the treatment. HRT can, however, cause great harm. I have two friends who almost died from clots. So while RLE is not necessary, a strong intent on transitioning is, in my opinion. This stuff can kill you.

[Nigella]

Frances has highlighted why the members of this side of the forum do not to advocate self medication :)

[whowhatwhen]

What HRT regret rate? I've never seen a single reference to such a rate and doubt that any statistics exist. Are you aware of any?

Access to care and standards of care are different issues.

I'm not sure, I guess I mostly go by transition regret rate in general.
I suppose most that stop HRT aren't vocal about regretting it and just stop when it's no longer right for them.

Frances, you're right about HRT being serious business which of course the patient needs to be aware of the risks as well as having regular checkups.
I'm sure if you're doing the informed consent route they have to make sure you're aware of the potential risks, it gets a bit hairier if you're going DIY though but it seems that most seem to manage from what I've read.

[Frances]

Frances has highlighted why the members of this side of the forum do not to advocate self medication :)

And they weren't even self-medicating! Even with supervised care, phlebitis and pulmonary emobolism are a possibility.

[whowhatwhen]

Of course being a hypochondriac helps too ;)

[Rianna Humble]

in Texas you can find clinics that work on the informed consent model.

I am always amused when someone opposes "Informed consent" to Standards of Care

WPATH and the other standards bodies of which I am aware advocate informed consent within a set of minimum standards for the care of the individual.

It is not either/or, although "informed consent" can sometimes be a euphemism for buying your way past ethical standards.

[Frances]

Especially to us non-Americans who have a very different relationship with the medical establishment.

[Kathryn Martin]

It is not either/or, although "informed consent" can sometimes be a euphemism for buying your way past ethical standards.

As far as trans health care is concerned "informed consent" as a standard is always a euphemism for buying your way to a result. Informed consent is a legal term that is used in the analysis of treatment gone wrong. For this reason courts have insisted that before every operation the patient or the guardian of a patient must be informed about the risks and benefits of the procedure and must consent to the procedure being performed.

In trans health care this term is used that once you waive all liability of the treating physician they are obliged to give you what you want, without any needs of benefits assessment. Those that advocate for this model are usually those that might fail in the WPATH assessment model which is considered a gate watching or gate keeping model to ensure that diagnosis, benefits and risks are balanced.

Historically, the wait times advocated by WPATH, surgeons etc. did not exists. They were instituted by psychiatrists doing assessments to better get a grasp on the need and intensity factor which is part of the diagnosis.

[LeaP]

...
All that said, is it better to facilitate access and let people ruin their lives or to proceed with caution and have people wait for stuff? ...

I would not facilitate access through any kind of insurance system or national healthcare system. These exist to fund treatment of medically-necessary conditions, address certain social concerns on which there is sufficiently broad public health agreement (e.g., birth control), fund services related to medically necessary care, etc. Funding for increasing the capacity of the healthcare system itself and reducing wait times is a separate issue. I understand that extended waits result in pressure to open access elsewhere, but that doesn't justify opening funded access for non-medically necessary services.

Some procedures can be and are treated as both medically necessary or elective, depending on circumstances. Elective access to these appears to be based on lack of harm relative to those which are more consequential or dangerous. We allow aspirin. We don't allow narcotics. (Please don't counter with culture-laden examples like alcohol.) BAs can be cosmetic or reconstructive. I would put SRS way of the range of elective acceptability. Hormones? For me, the answer is still no elective access and again, a major reason is the demonstrated inability of most people to offer truly informed consent.

Over the counter access is out of the question. Not only are these drugs powerful and potentially dangerous, as Frances rightfully points out, their use is properly monitored (blood tests) and a regimen personalized by a knowledgeable professional as well. I.e., administration needs to be regulated (in the medical sense). That situation is not amenable to open purchase and self-administration.

That leaves the last frontier as free access to elective (in the strict sense of not being medically indicated) hormones through medical providers. But the thing is, WE ARE ALREADY THERE in a practical sense. You want them, you can get them. Period! The complaint is more a matter of having your cake and eating it too. People want them the way they want them, i.e., as if they are entitled to medical services as if doctors were beauty salons or something. And you cannot demand elective services in this way. There are two sides to the elective coin, and the providers have as much right to impose their own procedures, and accept or refuse patients as you have a right to ask.

[whowhatwhen]

Here's the thing though.
Some people are having to choose between medication, food, or rent.

It's easy for some people to say that transpeople should pay out of pocket but usually they are the ones that are more or less financially stable.
The world is still unkind to us and many are unable to find a job let alone finding one while being visibly trans, perhaps leading some into sex work or living on the street.

SRS Is a medical necessity in the same way as penile reconstruction would be for an 18 year old who loses his penis somehow, it's the right thing to do to improve a person's quality of life.
How many do you know that could cough up $10,000 to go overseas?
That's even if one is comfortable going overseas in the first place.

[Frances]

Who is saying that anyone should pay for anything out of pocket? SRS is paid for where I live. Since that money comes from our taxes (pooled resources), it seems all the more fair to make sure it's not a whim or that the patient is not simply tired of living up to perceived expectations of what a man should be in today's society, hence the need for prolonged observation and RLE protocols.

[whowhatwhen]

That's what I got from Lea's first paragraph, but then again I could just be interpreting it wrong.

[Kimberly Kael]

That's what I got from Lea's first paragraph, but then again I could just be interpreting it wrong.

I believe she was referring to merely meeting the "informed consent" bar. The point of getting medical professionals involved is to determine whether something is medically necessary, and at that point they're gatekeepers by design and for good reasons.

[Rogina B]

Here's the thing though.
Some people are having to choose between medication, food, or rent.

It's easy for some people to say that transpeople should pay out of pocket but usually they are the ones that are more or less financially stable.
The world is still unkind to us and many are unable to find a job let alone finding one while being visibly trans, perhaps leading some into sex work or living on the street.

A person of any age that is wanting to transition has to have a realistic and workable plan.Usually the older transitioners have more financial assets but a whole lot more baggage as well. Young people are often free of obligations,but lacking a plan that will ultimately bring them a "good life" has them rudderless. Occupation selection and the education and skills leading to them is a critical choice..But everyone here knows this stuff. If all medical help [to do with transitioning] were free,fast and easy,I still don't think everyone would be better for it. A person has to first have a plan on how they are going to be "successful in their new life"and then make that happen. My viewpoint anyway..

[LeaP]

I can see that I wasn't clear enough.

I was differentiating the patterns of practice for elective, self-paid medical care from those provided in connection with 3rd-party payers. Third-party payer systems do not cover elective medical care, with very few exceptions, as I pointed out in my earlier response. Nor should they. Because of this, there is always a determination of need. Elective care does not usually interpose the need condition – though some providers may introduce their own requirements. The unrestrained access to hormones that is being discussed here is trying to have it both ways. That is, addressing hormones need and having 3rd-party pay - but without process around or evidence of need. It's simply an unreasonable thing to demand.

Having staked a position there, I turned my attention to whether hormones should reasonably be provided in the elective care model, need or no need. And my answer there is still no.

[whowhatwhen]

If all medical help [to do with transitioning] were free,fast and easy,I still don't think everyone would be better for it..

Why?
There are people who can't afford therapy, let alone hormones or hair removal.

I've read a lot more about financial concerns coming from young people than older ones.
Hell, for most FFS isn't even in dream territory.

I view all forms of mental health issues as important and needing coverage, gender issues are no different.
Even poor people deserve to be healthy.

[LeaP]

I have no problem personally with free, fast and easy healthcare. Medically necessary healthcare, that is.

Fast can be as fast as capacity allows and determination of need can be made with the proper differential diagnosis and physical screens.

What's free? If you mean covered, then yes, medically necessary hormones should be covered. I don't know about you, but I pay thousands of dollars annually for my health plan. Other people pay through their taxes. Nothing free about any of that!

As far as I am concerned, meeting the two criteria above constitutes easy.

[whowhatwhen]

We do pay higher taxes, but that also means that the less fortunate can get decent quality care.
It's "free" in that everyone shares the pain and the care is there when you need it rather than when you can afford it.

From what I've read DIY is a lot more common in the US where people either cannot afford all the gatekeeping or there are no therapists or endocrinologists within a reasonable distance.
Now if someone ends up severely hurt due to physical issues then you're going to be paying way more through emergency care than you would if everyone shelled out for therapy and proper medical treatment in the first place.

Gatekeeping only works if everyone who has to go through it can afford it.

[Kathryn Martin]

BAs can be cosmetic or reconstructive

In Nova Scotia both cosmetic and reconstructive breast augmentation is considered "cosmetic" and therefore not eligible for funding.


I would put SRS way of the range of elective acceptability. In my province SRS has recently been recognized as a medically necessary procedure (it was considered cosmetic before). Interesting statistics though, the Department of Health and Wellness anticipates covering no more that 8 such surgeries per annum out of a total population of 940,000. This is based on statistics of all provinces covering SRS and amounts to 1:117000 of population.


Hormones? For me, the answer is still no elective access and again, a major reason is the demonstrated inability of most people to offer truly informed consent.


Under the Guidelines for treatment of adult transsexuals doctors are required to go through a 15 page questionaire which the patient and the doctor has to sign. The patient must demonstrate that they understand fully the risks and consequences of embarking on hormones. To even be allowed to sign the questionaire you require a recommendation from a clinical psychologist that hormones are medically indicated. Then you have to go through the weird exercise of having your pharmacist tell you at excruciating length why you should not take them, in hushed up tones, sort of keeping his hand in front of his mouth, with twirling hand motions when indicating, you know, "down there" - it was so funny and both my spouse and I burst out laughing ......

[becky77]

Then you have to go through the weird exercise of having your pharmacist tell you at excruciating length why you should not take them, in hushed up tones, sort of keeping his hand in front of his mouth, with twirling hand motions when indicating, you know, "down there" - it was so funny and both my spouse and I burst out laughing ......
The first and last time I went to my Pharmacist as a guy, he did something very similar then warned me they where for woman and things might change, it's a bit worrying he thought someone wouldn't know what they were taking.

[Rogina B]

I view all forms of mental health issues as important and needing coverage, gender issues are no different.
Even poor people deserve to be healthy.

I agree with you. I just feel [from observation] that many people have no plan as to how they are going to live happily ever after in today's mainstream world even if their transition was completely free.

[LeaP]

In Nova Scotia both cosmetic and reconstructive breast augmentation is considered "cosmetic" and therefore not eligible for funding.

Under the Guidelines for treatment of adult transsexuals doctors are required to go through a 15 page questionaire which the patient and the doctor has to sign. ... Then you have to go through the weird exercise of having your pharmacist tell you at excruciating length why you should not take them, ...

There is an interesting correlation between reconstructive breast surgery and SRS in that both are regarded as critical to mental health. I'm really surprised that reconstruction isn't covered.

My consent form was a one-pager. The general approach was "you agree you've been warned ... sign here ..." But then, in the US it's not considered necessary to warn people that they will wind up shooting the puck like a girl. (obligatory Canadian hockey joke)

The most common reaction I get from a pharmacist is a quizzical look, perched on the edge of saying something. One did ask "have you taken this before?" Estradiol is still occasionally prescribed for prostate problems, so I'm sure it's the dosages that trigger the reaction.

I love the statistic! It's another tangle in the thicket of incidence, and it's a real outlier.

[whowhatwhen]

Then you have to go through the weird exercise of having your pharmacist tell you at excruciating length why you should not take them, in hushed up tones, sort of keeping his hand in front of his mouth, with twirling hand motions when indicating, you know, "down there" - it was so funny and both my spouse and I burst out laughing ......

That makes me appreciate my pharmacists even more, I've been with them my whole life and I've gotten nothing but excellent service.
One of the older ladies working there filled my first prescription of spiro and said she had noticed the changes, she then wished me luck :)

[Kaitlyn Michele]

Yesterday I went to the movies

I went to movie called Tusk... I was late and I was meeting two old horror movie buff friends so I went in alone (btw...it was a silly bad movie...!!)...

I asked for my ticket and the guy looked at me funny at the desk...he asked "....you do know this is a horror movie, maam????".........

[Angela Campbell]

My pharmacist only asked me if I had any questions the first time I had the prescription filled. I said no and that was that.

of course I was dressed as a woman, but the scrip was for Michael.

[Cheryl123]

My pharmacy tech asked me if I had any questions. I said no, and then she asked me where I got nails done. (This is the clinic pharmacy where they are used to customers such as I). The estradiol does come with a large sheet of warnings written in fine print which is there for me to read, along with an invitation to call the pharmacy if I had questions

[LeaP]

...along with an invitation to call the pharmacy if I had questions

You know, I hate that line. It's like the tv ads - "Talk with your doctor ..."

The problem being that most doctors don't have much time to talk and even fewer of them have any particular expertise in this area anyway. In my experience, pharmacists are very helpful and very willing! But they don't know anything about this practice area, either.

[Cheryl123]

You know, I hate that line. It's like the tv ads - "Talk with your doctor ..." Not the case in my clinic. My doctor will do a phone consultation within a day or two of my request, and answers my emails promptly. She consults with the hospital's transgender team which supervises the treatment of about 100 patients a year. Hawaii is very accepting of the transgender community for the most part and medical care in this respect is probably a little ahead of the rest of the country. I'm very happy with it.

[Janelle_C]

First I struggled with this for 52 years then went to a gender therapist for a year and half. Then I decided to transition and go on HRT. Started laser on my facial hair. But I did not have a lot of RLE. But three months after it became harder and harder to go back and fourth, then one morning I got up and could no longer be the person I was not. After a lot of crying I got went full time and never looked back! It's been almost a year and half and I'm on track for my surgery next year and I've never been happier in my life! There is no one way to do this, listen to your hart it will tell you what you need to do.
Janelle

[DebbieL]

We live in a culture where we can get frozen meals we can stick in the microwave and be ready to eat in less than 3 minutes, we can get the answers to almost any question via the internet in a few seconds, and even if you can't get it in the store, you can buy it online and have it the next day.

If you want a pair of 'instant breasts" buy some really good breast forms and wear them at night for at least 3 hours a day, with a bra that's about 2 inches too tight around your chest. While your at it, wear some 4 inch heels with pants and a sweater for the same period. HRT is not access to "Instant Boobs".

When your therapist starts talking to you about HRT, he or she wants to know that you are a good candidate. Have you told family and friends? Or will you end up losing wife, kids, job, friends, and home because you haven't told anybody at all? Part of RLE is designed so that little things like the pierced ears, the clear nail polish, the bit of make-up left over from last night, and the feminine mannerisms that come from spending hours as a girl WILL spill over into your "regular life". It's a necessary part of the process. It takes a lot of courage to face people you really care about and tell them about your most treasured secret, and having to face the possibility that they may not be able to accept the REAL YOU! Do you think it's going to be any easier if you show up at your next family reunion with C-Cups and no other warning or indicator?

How much RLE do you actually need? That has changed over the last 40 years. At one time, most programs were absolutely strict that you had to live 24/7 as a female with no reversions to male ever before you could even START on hormones. Unfortunately, because it was easy to revert to male, many patients did under social or marital pressure and the results were catastrophic, including suicides or self destructive behavior.

More of the modern programs want to see evidence that you have been living evenings and week-ends as female and that you've had discussions with family, friends, and employer prior to starting hormones. This is often called "120" mode. There are 168 hours in a week, if you spend 40 at work, and 8 hours in commutes, that leaves about 120 hours/week including sleeping for you to dress and act like a girl.

Normally, the therapist will ease you into it, giving you assignments that may start with something like going for a drive at night for less than an hour and coming right back home, maybe even only 2 or 3 nights. Then longer drives, a trip to a store to buy a soda, a trip to a dark nightclub that's friendly to LGBT, and attending support groups that may include transgender support groups, or groups like AA, NA, or Weight Watchers - as a girl.

How quickly you get up to 120 hours/week depends on you. When I started, it took several weeks to be comfortable with going to a candlelight AA meeting. About 3 months before I was comfortable in a restaurant that had drag queens as patrons. it took about a year to reach the point where I was able to do 120 hours a week. There were many changes along the way, I DID have to give up my wife and let her and her new husband have primary physical custody of my kids, I DID have to leave my job. I DID have to move to a city that was more LGBT friendly. I DID have to get a new job with an employer who not only knew I was transgendered, but would support my transition. I DID fall in love with a girl who loved Debbie and supported my transition.

Your therapist also needs to know that you will be able to handle the biological changes. Will you start freaking out because you can't lift a suitcase anymore, or you don't have upper body strength? Will you freak out when you have erectile dysfunction? Will you start freaking out when you cry at a movie, or for no reason at all? She may want to discuss your sex life, does your sexual satisfaction depend on intercourse? At one time in my life, I was told I wouldn't get hormones because I wasn't gay. I had to explain in detail exactly what I did with my girlfriend before she realized that I really WAS a lesbian and almost NEVER relied on intercourse.

Often, the doctor will start with the testosterone blocker first. The effects of no testosterone can be easily reversed by eliminating the blocker. The OTHER reason is that some men who are inter-sexed will actually begin producing higher estrogen levels on their own once the T levels are blocked. Important to know so you don't overdose the patient, and may indicate acceleration of the transition process. About 1 in 300 male babies are born "gender ambiguity" which could range from a very small penis to a uterus and vagina as well as the penis. Often these facts are discretely NOT noted in the record because cisgender male patients can get really upset about it when their chart suddenly says they have "girl parts". Granted, the number of adult men with a functioning uterus is more like 1 in 5,000, but even this is uncertain because the records are not kept publicly.

Often, the doctor will provide the T-blocker with a placebo instead of estrogen. This helps the doctor and therapist determine whether the patient will respond well to the feminization. Most transsexuals will be more calm, relaxed, Their partners (who the therapist usually wants to be seeing regularly by then) will notice they are more affectionate and "cuddly". They also want to see how the patient responds to male impotence. if the transgender isn't a good candidate (at this time), they are likely to slip into depression, isolate, and even avoid sex, romance, and intimacy entirely. They may become more irritable at work, they may even change their mind. They may be transsexual, but they aren't emotionally ready to transition - yet.. Others are cross-dressers and will decide that the RLE is fun, but the side effects of the hormones (actually the feminizing effects) are to unpleasant to deal with.

Once the estrogen is started, the doctor will start with a low dose for a few months to see how the patient handles it. There will be emotional swings, jags, and even physical symptoms, but there will also be more calmness and lightness. The doctor will also be alert for any indications of clotting, pain or swelling in legs or veins. One of the great dangers of self-medicated estrogen is some nasty side effects like blood clots, heart attacks, stroke, even kidney or liver failure. For patients like this, an alternate form of delivery may be needed, and lower doses. Slow growth is good growth, but it can be very frustrating.

By this time, the breasts will begin growing. They will be small and lumpy at first, and very sensitive. If there are situations where male presentation is required, a sports bra is needed because it's too uncomfortable to wear a shirt directly over the sensitive breasts. The therapist will want to see how the patient is responding to the new sensations. If breast play is becoming part of arousal, this is usually a good sign.the neurology is changing and the client is responding positively to the changes. If on the other hand, stimulation is avoided, resisted, and rejected, this could be a sign that the client is not handling the neurological changes well. Wearing a bra for a few hours might be exciting to a cross-dresser, but wearing one for 8-10 hours a day, 7 days a week will either become just "Normal", or a bit irritating. if the client is upset that it's no longer exciting, this could be an indicator to stop.

By this time, with breasts beginning to form, 24/7 is almost unavoidable. Working and living 24/7 is no longer an option, it's necessary. It's not practical to try and hide anything, and usually by then, so much of the feminine has bled over to every area that "coming out" doesn't even surprise anybody. By this point, the ground work has been done, the foundation is solid, and it's just normal to be living 24/7 as female. Passing is not an issue, because the client has learned to blend so effectively that someone will look at her for 5-10 seconds, then move on to the next person. People with whom she has long and regular interactions may even have a hard time believing they were once men even though they may know it. The bathroom isn't an issue anymore because no one sees "a guy in a dress", they see another woman, doing her business and leaving. Nothing is unusual.

At his point, the main question is whether to finish "the bottom work". More often than not, the main barrier is financial. if there isn't a romantic need or a partner who is pushing for the final touches, some girls will continue for months or even years without the "bottom work". One of the big issues was that most insurance companies didn't cover vaginoplasty. Many barely cover HRT, even though the AMA and APA have now declared that for transsexuals, treatment is necessary and refusing treatment is unethical. In some countries, national health plans have realized that HRT and SRS are as essential to a transsexual as insulin is to a diabetic. Recent studies of transsexual mortality and morbidity of both non-transitioned and transitioned transsexuals has made the need even more apparently acute. If you had a disease with a 30% mortality rate and 85% morbidity rate with a 95% recovery rate when relatively inexpensive treatment is given, no insurance company would be ALLOWED to prevent such treatments. But because the treatment involves removing male anatomy, the insurance companies seem to thing this is "elective surgery" rather than necessary treatment for a deadly disease. (Off the soapbox now)

Most transsexuals, including myself, by the time they have completed a year or two on hormones, will want SRS, and will want to find the means to make that possible. Some have even turned to prostitution, many older men have used part of their 401K funds, others have taken out home equity loans to pay for the procedures. Some people with highly prized technical or professional skills will only consider companies who provide SRS coverage.

Hard to imagine at this moment, just struggling with the prospect of having to get even 40 hours a week of Real Life Experience, that you will reach a point where you are completely happy living as a woman inside and out, on a 24/7 basis without even the possibility of presenting as a man. If that prospect excites you and makes you feel like life is worth living but only on those terms, then you will breeze through RLE and the time spent between the start of RLE and HRT will just seem like time well spent.

There are hundreds of other reasons why you want to do RLE, many too subtle to describe here, but even this posting only touches the surface - even as long as it is.
Sorry about the length.

[Angela Campbell]

Wow! I am glad my therapist went by the current WPATH guidelines, rather than put me through that. In this area once the person gets the letter they often start a half or a full Dose of spiro, estrogen, and progesterone , followed by regular checkups.

[whowhatwhen]

Yeah, I'm just happy that all you need is a letter saying you're not crazy.
Or if you are that it's not something that interferes with your ability to make the decision.