Does RLE Make Sense When ...

[Kittie]

The purpose of it is to make sure you can function fully as a member of society in the gender role - socially, career wise. They are trying to ensure your safety and well-being, not end up ruining your life making snap decisions about irreversible changes. I tend to agree with Melissa in her last post - RLE by definition means living, working even sleeping in the gender role you're transitioning to - going out and actually pursuing that which you seek, not shying away from the challenge or staying in the closet at home playing a fantasy out in your mind. I started mine myself before even approaching my GP - my name was changed long before my first appointment at a gender clinic.

There is a lot more to living as a man or a woman than just how your external features look - you might be sure of what you need, but the people that can help are not going to take such drastic measures unless they are certain, that you are certain and capable of living.

[sandra-leigh]

How can one be living full time as a woman and yet not be out is beyond me, but I guess my idea of what a Real Life Experience is may be different than others.

Other than my mother and sister (who am I out to), I have not seen any of my relatives since my grandmother (mother's mother) died 5 or so years ago. The ones on my mother's side, I have not heard anything about since then. I am FB friends with some of my relatives on my father's side, but my cousins and I just don't seem to have anything to say to one another (not tension, just too little in common.) I am not in any regard "close" to anyone short of some of my second cousins: two of them and one or two third cousins are the only ones likely to care about me personally rather than thinking first about the "spectacle" or about how I am affecting the family name.

It is true that going through the... drama... associated with revealing yourself to your more distant relatives is one of the aspects of RLE. On the other hand, some here talk about "controlling the message" and not letting people know until necessary.

I already went through a time where I was cut off for 20 years by my father's side of the family, so it is not a big deal. The only one of them that I really missed, I am pretty sure will not cut me off.

Locally, everyone I am in touch with already knows me as Sandra, with the exception of my dentist (who has seen me dressed and has my meds list, but just hasn't been given the name.) I might also notify two ex-co-workers, one more for courtesy than anything else. My co-workers saw me with everything short of skirt or dress (and I never hid my bust from them.)

[Badtranny]

but do you understand that RLE is supposed to be about LIVING full time in ALL aspects of your life, with NO partitions?

Otherwise what would you be proving?

Note: I'm not judging your life, or transition, or your choices, I just don't want to see RLE redefined like we've redefined transition.

[emma5410]

I have a brother who cut himself off from the family 20 years ago. I have a sister who I loath (with very good reason but I will not go into that) who I have not spoken to in 10 years. They do not know about my RLE nor do the many distant relatives in the UK and Ireland. Not to mention any number of ex-co-workers. I have no intention of telling any of them because they are not important in my day to day life. I have no objection to them knowing. My list seems worse than Sandra-leigh's. As far as I am concerned I am doing RLE because I live as a woman 24/7.
I certainly agree with your point about redefining words.

[Angela Campbell]

My RLE will begin sometime after the first of the year when I can get the legal name change and gender markers all changed. At that point there will be no one I know who will not be aware that I am no longer going to ever appear to be a man again.

I will be Angela in looks, at work, at the bank, to friends, family, coworkers, enemies, the IRS, and Santa. There will be no hiding nor going back. Nothing less is full time and nothing that is temporary can be a RLE. It has to be all or nothing.

I am now preparing and working towards that point with a very detailed plan and no illusions.

[LeaP]

I'm not questioning the value of RLE, and I fully understand its purpose. My point is that the point has been lost - largely, if not completely - when the RLE that's to be used to validate your readiness for irreversible procedures is started with ... Yup, irreversible procedures! Doesn't anyone other than Misty see the irony in this?

Now you CAN make an argument on the basis of differences between SRS and, say, FFS, but you cannot do so without imposing a value judgement about the nature of the changes. Trying to differentiate them on the basis of permanence isn't very credible.

[Angela Campbell]

But the whole thing is irreversible. The act of going full time is the most irreversible of all. Once you come out and everybody knows there is no way to return to the before anyway. So the RLE is in itself what they are trying to protect you from.

[GirlieAmanda]

One can change every part of their body to look more feminine, but if they don't integrate into society well and have issues going through daily activities, it doesn't matter how much surgery one has. RLE is about LIVING in your new gender. RLE is supposed to make you get used to the idea of being you. Being trans doesn't happen in a doctor's office, it happens inside YOU. You have to be OK with it. I know a girl who got fairly big implants and then still presented as a guy for painfully too long. Some are on hormones for so long and look so obviously feminine, but still, they remain scared to integrate into society as their new gender. Living full time is a huge deal. It really means FULL TIME!. It's where the rubber meets the road.

[Angela Campbell]

Exactly!!

So to protect you from making a choice and get surgery no one is likely to see and can be hidden easily.......you first have to make a totally irreversible step and make sure the whole world knows, (even after taking on multiple non reversable procedures) which if you are not ready is much more damaging and life changing, to a person than SRS will ever be.

In other words, to make sure you do not get a vagina but still live as a man or somewhere in the middle of the spectrum, it is ok to add breasts - totally obvious not easily hidden - get FFS - same thing - and you must show the world what you are doing for a year. Do they check on you after the SRS and make sure you are still living your life the way they insist you do? Is living as a woman and integrating into society absolutely necessary if you have a vagina? I know some transmen who might disagree.

Reminds me of the laws requiring a waiting period before an abortion, or purchasing things we are not allowed to mention here. Big brother needs to make sure you do not make a "rash" decision....or is it because someone doesn't want you to do those things anyway?

Don't get me wrong, I intend to go by the book and do the RLE as specified, but I can also see the benefits and the uselessness of it. It is a good idea to me just because being on hormones for a year seems like a pre requisite.

Just playing devils advocate here.

[Kaitlyn Michele]

It is ironic Lea
Its just something on the long list of things that are messy about our situation. there is no perfect answer for something so destructive and risky (and so validating and life saving!!)

FWIW...my RLE started 2 months before my FFS.. I always felt in my mind that FFS (and my ensuing life being gendered correctly w/o question) was the conforming surgery... my penis was just there..
I took advantage of the rules at the time. I had no issue waiting the year (although I only waited the 12 months)

It's interesting to me that if person A has FFS and person B has GRS ...and they both realize it was a mistake... Person A, with the unmistakably female face and a penis could easily have a tougher time...i'm not saying Person B would not miss his penis, but no one would ever guess it was gone.. It could easily be argued that FFS should carry a requirement of RLE if your belief is that access to these surgeries should be subject to rule such as this one..

I simply do not believe in the idea of protecting people against themselves with rules and regulations except in extreme circumstances.. (like a psychotic person)
...I'm all for good support networks and being challenged by friends and therapists...but a one year rule? meh.. is one year even enough? and the whole idea of protecting ourselves against ourselves puts us in the same boat as the psychotic person.
we are viewed as someone that can't simply decide for ourselves.

I'll put it another way.. you either can or can't integrate well into society. its that simple, and its independent of your sexual organs. and if you can't integrate well into society as a woman, perhaps getting GRS to conform your body (regardless of the their gender role in the world) is the absolute best treatment for you...

how dare anyone lay claim to the idea that because they integrate well they are "allowed" to have this life saving surgery, and because you can't integrate this surgery is denied to you..

[bas1985]

This of course if we say that the person is able to decide for herself and able to PAY for herself.

I speak from a "social" view point, in the sense that a "normal" person could understand that the State will pay SRS (and maybe BA, FFS)
for a "real" TS who wants really to live as a woman, and not for a undecided person who simply does not want the penis but is unable
to decide to live in the gender role of people without a penis (generically speaking women... but of course there are FtM etc... but
I am speaking in general).

So... if the person pays SRS than it's OK, but in this case

a) we are perceived as a "strange" community, of people who mutilate ourselves without not a clear view of transition (some time ago there was a post of a person who was NOT a TS and wanted SRS. He was treated "badly" here, just for this point of view)

b) "poor people are not allowed to transition"... this is a title of a current thread. RLE is useful in countries, like Italy, where SRS is
payed by the state, in this case the state obliges to live as the target gender and I think that this is a sensitive requirement, in this
case only people who live as a woman get in the "free" waiting list. Others... well, maybe will pay for a psychiatric evaluation of GID
and fly to Thailand.

[Michelle.M]

You've had FFS, BA, orchie, and possibly additional plastic procedures performed?

So, in such a circumstance, what is the point of RLE?

I see your point and I love the question! But the rationale for RLE is spelled out in detail in Section XI in the WPATH SOC Version 7 (page 61 in the download I got from the WPATH website). In fact, Real Life Experience is a phrase we use; it's not even a WPATH term.

RLE and pre-surgery requirements are not necessarily the same thing. If one has FFS and backs out of transition, what's the worst that happens? He's an androgynous-looking man.

Using myself as an example, I started RLE with boobs and FFS. Which is Lea's point. Why should I wait a whole year to get the 'final cut".

Why indeed? Who says that you have to wait at all? There's only a 12 month RLE requirement if you're following the WPATH protocol. If you choose to follow the ICATH protocol you can have any hormones, procedures, surgeries or whatever as soon as you can find a provider who is willing to help you out. No referrals needed. But you'll have to find your own consenting medical providers, and good luck with that.

I don't actually advocate that, but for those who say that "the system" is holding them back or that they "have to" wait for this or that, well, it's just not true.

Now, if you're dependent on a payment system where someone else (or the government) calls the financial shots, then there's your answer. It's a financial (if not also a medical) gatekeeping system. Kinda goes with the territory, unless you're willing to write the check yourself.

How can one be living full time as a woman and yet not be out is beyond me, but I guess my idea of what a Real Life Experience is may be different than others.

I'm starting to think your idea is different. If by being "out" you mean living openly, completely and always as a woman, then that's just RLE. If you mean that RLE must include revealing one's transition and previous male existence to others, then I really can't see how that has anything to do with RLE.

I was RLE for a year before I came out to anyone, and even then it was only because I wanted to become more involved in effecting change in trans issues in my community and I felt that this would be better done if I came out from the shadows. But my RLE was quite successful up until then.

My point is that the point has been lost - largely, if not completely - when the RLE that's to be used to validate your readiness for irreversible procedures is started with ... Yup, irreversible procedures! Doesn't anyone other than Misty see the irony in this?

RLE is not necessarily an evaluation for one's readiness for irreversible procedures. It's to evaluate one's readiness to change gender roles. You can have all of those surgeries and still live as a man; you'd just be a man with some feminine features.

[Kaitlyn Michele]

....your last line Michelle......one of those feminine features could be no penis!!

I don't think RLE includes telling people you lived as a man in the past unless that's what you desire to do......only by leaving your prior life can you avoid this issue anyway...

as far as the gov't or the insurance paying Bas I hear you...

here in the united states I wonder as this becomes more medically accepted and insurable whether the standards for getting SRS will rise... it would probably still be worth it for people that can't afford it to wait longer..
and people that want it faster can just pay for it... that seems to make sense to me...

[Michelle.M]

....your last line Michelle......one of those feminine features could be no penis!!

Yeah, but . . . who would know, or even care? Sure, I wouldn't CHOOSE to be a man with no penis, but one could still live as a man regardless. Trans men do it all the time.

as far as the gov't or the insurance paying Bas I hear you...

here in the united states I wonder as this becomes more medically accepted and insurable whether the standards for getting SRS will rise...

That's kinda where I was going with that thought.

In the not-too-distant past we had a rigorous gatekeeping system for gender transition in the US that required that very strict social and gender norms be met before surgery. Although the SOC exists the gatekeeping paradigm is history, and as far as I can see everyone's glad for that. But that little bit of progress will likely be overcome by even stricter standards if GRS ever gets paid for by any kind of government benefit.

[LeaP]

I'll put it another way.. you either can or can't integrate well into society. its that simple, and its independent of your sexual organs. and if you can't integrate well into society as a woman, perhaps getting GRS to conform your body (regardless of the their gender role in the world) is the absolute best treatment for you...

how dare anyone lay claim to the idea that because they integrate well they are "allowed" to have this life saving surgery, and because you can't integrate this surgery is denied to you..

This is a good example of the kind of value judgement that is involved.

Michelle, RLE is for both purposes. From the SOC v7:

The criterion noted above for some types of genital surgeries—i.e., that patients engage in 12 continuous months of living in a gender role that is congruent with their gender identity—is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery.

(The above is in the section entitled "Criteria For Surgeries" by the way.)

So the concern is surgery. The SOC essentially institutionalizes the value judgement that Kaitlyn describes so well. This despite the fact that WPATH, in the same document, ALSO recognizes that:

Surgery – particularly genital surgery – is often the last and the most considered step in the treatment process for gender dysphoria. While many transsexual, transgender, and gender-nonconforming individuals find comfort with their gender identity, role, and expression without surgery, for many others surgery is essential and medically necessary to alleviate their gender dysphoria (Hage & Karim, 2000). For the latter group, relief from gender dysphoria cannot be achieved without modification of their primary and/or secondary sex characteristics to establish greater congruence with their gender identity.

So by their own admission, WPATH "imposes" a requirement of a non medically-essential (if important) process for a medically-necessary procedure. It does so even though there is recognition of other risks associated with that delay for some.

... surgery can help patients feel more at ease in the presence of sex partners or in venues such as physicians’ offices, swimming pools, or health clubs. In some settings, surgery might reduce risk of harm in the event of arrest or search by police or other authorities.

I wonder if, from the perspective of SRS, RLE induces more issues than it prevents? Or whether anyone has even examined the question?

[Michelle.M]

. . . the concern is surgery. The SOC essentially institutionalizes the value judgement that Kaitlyn describes so well.

I don't think so. I don't want to sound like I'm splitting hairs, but IMO you put the emphasis in the wrong place:

This is the "why" -

"The criterion . . . that patients engage in 12 continuous months of living in a gender role that is congruent with their gender identity . . . that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role"

and this is the "when" -

" . . . before undergoing irreversible surgery."

And I agree that there's extreme concern about surgery, but it's from a doctor's professional perspective. It matters not a bit to any doctor if anyone has a successful RLE. The issue here is their own professional ethics (also addressed in SOC) and having an agreed-upon professional standard for care. In the ICATH protocol the professional and ethical requirement is met not by RLE but by informed consent. No RLE is involved, so RLE addresses no patient's surgical issues.

RLE is all about US, and the concern there is our own ability to adjust to and deal with living in our target gender.

So by their own admission, WPATH "imposes" a requirement of a non medically-essential (if important) process for a medically-necessary procedure.

Sure they do! Any professional (doctor, lawyer, accountant, whatever) won't put his or her professional reputation (and license to practice) on the line if the patient or client isn't willing to participate in the program. And WPATH seems to think this protocol is a pretty good one, and since there's quite a bit of agreement (or at least cooperation) among most, although not all, potential patients then they might be right.

. . . It does so even though there is recognition of other risks associated with that delay for some.

I wonder if, from the perspective of SRS, RLE induces more issues than it prevents? Or whether anyone has even examined the question?

Interesting question. What are your thoughts on this?

[LeaP]

I think there is logically some subset of the TS population who incurs some harm as a result of the requirement

Here are a few scenarios that come to mind:

The first is one where someone whose reluctance (or fear) to transition without SRS leads to them not transitioning at all or significantly delayed transition. Worst case, that could result in their suicide. One reason I think this is a real possibility is that, despite transsexualism being a lifelong condition, at the point which someone is finally addressing and resolving it, they are often either in crisis, or only shortly past one. Once the transition path has been started, many of us can testify to the spike in anxiety and dysphoria symptoms that crop up when we hit opposition, delays, and roadblocks.

Another is the arrest scenario mentioned in the SOC doc. The examples of being mistreated by police are legion. Many are roughly handled when discovered. Things get worse – far worse – with incarceration. I can see where this kind of concern might loom large for someone with a record and who is at a greater relative risk of arrest and incarceration.

Denial of emergency care is a real possibility. In one highly publicized case, the trans woman (Tyra Hunter) died when the responder refused to treat her after cutting open her pants and discovering her pre-op genitalia. The general issue of medical discrimination is huge. Have a look at this Huffington Post article: http://www.huffingtonpost.com/sunny-...b_3415304.html.

I am sure there are many other possible scenarios, but even these few suggest that the requirement causes some issues. The question is whether relatively more people are helped by the twelve-month requirement than are harmed by it.

There's another possible twist to this, though. It seems that most people who start transition actually do transition permanently. From the social transition perspective, then, you might infer that the twelve-month requirement for SRS simply doesn't matter.

But consider one alternative: What if the availability of SRS before going full-time reduced the percentage of transitioners? Would that be good or bad? Got me …

[Michelle.M]

But consider one alternative: What if the availability of SRS before going full-time reduced the percentage of transitioners? Would that be good or bad? Got me …

I tend to believe that this would directly contribute to a very high number of "regretters". But of course, there's no way we could possibly know.

[stefan37]

While RLE at first glance appears to be a roadblock, it will go fast. Changing your name and all your ids can take a couple months. In that time expect a tremendous amount of confusion and angst. Finances have to be arranged unless you are wealthy and can plop down at least 40k. Not even including electrolysis which takes forever, seems to never end and costs a small fortune. I could get my letters tomorrow if needed for srs. FFS is initially more important to me at this time. I would benefit from that more than srs. So in the meantime I have to deal with what I have. I would schedule ffs tomorrow, however I lack the funds, so I must continue saving until I can afford it. The major limiting factors to my physical transition are sufficient funds and timing. Due to the nature of my work I can only schedule operations early winter. In the meantime I have lots to work through as I shed my male persona and allow the inner me to emerge.

Having SRS now will not allow me to integrate any faster than I am already. Awful lot of theory-crafting floating around. Just do it and let it flow. Transition has to happen naturally and in its own time. Rush it and the consequences can be disastrous. There is much to unlearn and much to learn to integrate successfully. The awkward in between period develops the thick skin needed to successfully transition.

[Rianna Humble]

I think there is logically some subset of the TS population who incurs some harm as a result of the requirement

I'm sorry, Lea, I just don't buy your argument. If the requirement to live as a woman full time is too much for some people, what makes you think that it will be less arduous after they have had major surgery?

Yes there are always examples of discrimination but no they do not always depend on the other party looking at someone's genitalia.

The case that you mention of a medic or paramedic refusing aid based on their prejudice is a prima facie example of gross professional misconduct, but we should beware of saying that Transwomen don't need to live as women in case someone commits Gross Professional Misconduct.

I'm not sure what problem is making you argue so vehemently against the requirement for a woman to live full-time as a woman, perhaps we could be more productive examining what support we can offer with that problem.

[Michelle.M]

Having SRS now will not allow me to integrate any faster than I am already. Awful lot of theory-crafting floating around. Just do it and let it flow. Transition has to happen naturally and in its own time. Rush it and the consequences can be disastrous. There is much to unlearn and much to learn to integrate successfully. The awkward in between period develops the thick skin needed to successfully transition.

That's it! You've got it sussed. This is probably the best way to look at RLE and what it will do for you that I've ever heard.

[Kathryn Martin]

how dare anyone lay claim to the idea that because they integrate well they are "allowed" to have this life saving surgery, and because you can't integrate this surgery is denied to you..

There are two issues involved in making the RLE requirement necessary.

Firstly, The medical community operates under the maxim of "do no harm" which is interpreted substantially as meaning that the least invasive procedure while preserving patient life is the preferred one.

The first requirement to meet this medical requirement is to ensure that the surgery is being sought for the obvious reasons, sex change and is not influenced by significant mental health issues of the Axis 1 and 2 variety. Since depression is an Axis 1 illness and therefore gender dysphoria as well the surgeon requires assurances that the depression is circumstantially connected with the need for a sex change and the difficulties in attaining it.

The second requirement is to ensure that any improvement following surgery is in fact sustained. Part of that ( but not all of it) is tested by requiring the patient to transition before surgery and to demonstrate that the patient is capable of working, earning a living, interacting in their social environment and sustaining a life. In some countries which pay for surgery this can be up to two years, with clearance for hormones after one year. This has, albeit deficient, been attempted through RLE. In many cases this can be torturous especially when the transitioner is younger and wants to get on with their life. Another aspect of RLE is to see an actua;l improvement in the Axis 1 issues, for instance flushing out underlying problems in the event that the pateint has simply recited a learned narrative and thus manipulated the system.

This is a good example of the kind of value judgement that is involved.

I wonder if, from the perspective of SRS, RLE induces more issues than it prevents? Or whether anyone has even examined the question?

All of these questions including this one are central to developing eligibility requirements for publicly or insurance funded surgery. There are radical advocates for so called "informed consent model". This however does ot sit well with the medical service providers for the above mentioned reasons.

[LeaP]

I'm sorry, Lea, I just don't buy your argument. If the requirement to live as a woman full time is too much for some people, what makes you think that it will be less arduous after they have had major surgery?

...

The case that you mention of a medic or paramedic refusing aid based on their prejudice is a prima facie example of gross professional misconduct, but we should beware of saying that Transwomen don't need to live as women in case someone commits Gross Professional Misconduct.

I'm not sure what problem is making you argue so vehemently against the requirement for a woman to live full-time as a woman, perhaps we could be more productive examining what support we can offer with that problem.

Rianna, you are assuming way too much! I have no issue personally with RLE, and have every every intention of doing exactly that. That I don't have the kinds of issues I listed doesn't mean that they do not exist for others. They do. They have, in fact, cost some people their lives. Another way of looking at it for myself is simply that because I intend to transition anyway, it simply doesn't matter much to me. Different approaches to the same end, so to speak (pun intended).

Your own value judgment is contained within the quote above. It is the presumption that someone intends to live in the target gender and in the assumption that it might be "too much" for someone (as opposed to simply preferable). If someone does not intend to live in the target gender, then RLE forces them into doing something they would not, and should not do in order to obtain SRS.

Now believe me, I fully understand that this involves another kind of discussion. We have had debates over whether someone who does not intend to transition is truly transsexual. But putting that aside for the moment, if the need is to treat gender dysphoria with SRS, then transition might not be warranted in every case.

You are correct in stating there is a professional misconduct issue. You are incorrect in suggesting it is only a misconduct issue. The circumstances create the conditions under which the misconduct occurs. If you want to argue that that is necessary and unavoidable, that's fine, but don't dismiss such a deep and widespread reality. The circumstances (full-time and pre-OP) can be a problem trigger in many scenarios, so ignoring it as a potential problem in its own right makes no sense.

Its kind of funny that the topic raises concerns for me, when I am simply making observations. But I appreciate the goodwill, including your offer of support, Rianna.

There are two issues involved in making the RLE requirement necessary.

Firstly, The medical community operates under the maxim of "do no harm" which is interpreted substantially as meaning that the least invasive procedure while preserving patient life is the preferred one.

They do. Or at least they pretend to, and invoke this maxim when their own prejudices are in play. In a world of clean ethics and pure motives, RLE can be viewed as a less invasive first step. But when the medical community – even the very same surgeon – will do very invasive, irreversible procedures upfront? In that circumstance, I don't buy "less invasive" at all, and "do no harm" becomes highly suspect.

Steph, being dismissive by calling something theoretical is uncalled for. I raised a topic which by its nature is theoretical. The entire set of care standards is based in theory, the criteria for SRS most of all.

[stefan37]

It was not my intention to be dismissive, but if it was taken that way so be it. The criteria for SRS may be theory, but it seems to work in actuality. If one does not intend to live in their target gender, why even go through RLE or have SRS. I don't get this.

Could woulda shoulda. Sorry I am a contractor, I don't get bogged down thinking of all contingencies or scenarios. I will leave that to the beancounters. I formulate a strategy, develop a plan and execute it. Transition is not that much different. If one has no intention of transitioning all of this makes no sense to me. Permitting an individual to have srs when they plan to live as a male is a concept that is so bizarre to me. You need to transition? Then transition. Waiting a year for srs is hardly a handicap and if someone does not have the patience to wait as they are making progress, then they will have a difficult transition. Transition as you know is no game. Lives are at stake and many lose the battle. You want to discuss funding and the lack of that throws real roadblocks in front of many. That is a major anxiety stressor and Not having funds for procedure can lead to heavy depression and serious consequences. In many cases it will take a year between consults and scheduling surgery. There is much groundwork to be laid in that time. How comfortable are you using the woman's room constantly? There is a dynamic going on there that srs will not resolve. FFS is a much more valuable surgery to help an individual integrate while waiting for srs and that does not require a wait time other than the surgeons schedule.

Aetna's policy for instance if they do not specifically exclude transgender care will cover the surgery as a medically necessary procedure. However they require a 2 year RLE period. Want it faster find a therapist to sign off and pay for it out of pocket which most of us will have to do anyway.

[Kathryn Martin]

They do. Or at least they pretend to, and invoke this maxim when their own prejudices are in play. In a world of clean ethics and pure motives, RLE can be viewed as a less invasive first step. But when the medical community – even the very same surgeon – will do very invasive, irreversible procedures upfront? In that circumstance, I don't buy "less invasive" at all, and "do no harm" becomes highly suspect.

If you talk to serious endocrinologists, serious surgeons they all subscribe to some gate keeping. Plastic surgeons just cover their ass as far as SRS is concerned because it is standard practice and would net them too many law suits. You should have seen the waivers and caveats I had to sign. Anyone who has plastic surgery should have their heads examined (I mean that literally) before engaging in these types of procedures unless it is reconstructive after a major medical event or accident.