Does RLE Make Sense When ...

[Angela Campbell]

then it is a good thing I have had my head examined.

[sandra-leigh]

Which leads us back to the question of why natal women can get breast augmentation (any standard size) routinely, but a transsexual should (no exceptions provided for) need to "have their head examined"

[Kimberly Kael]

Which leads us back to the question of why natal women can get breast augmentation (any standard size) routinely, but a transsexual should (no exceptions provided for) need to "have their head examined"

There is a legitimate argument to be made that BA can create unique social issues for someone raised male who may or may not have practical experience living as a woman, don't you think? Then again, I tend to think the double-standard you cite is more of an oversight on the cisgender side of the equation than a gross disservice on the trans side, but that may just be me.

[Michelle.M]

Which leads us back to the question of why natal women can get breast augmentation (any standard size) routinely, but a transsexual should (no exceptions provided for) need to "have their head examined"

Huh? I didn't need any referral or therapist's letter for my BA. Nor for my FFS. Why would anyone need to have their head examined for wanting to improve their appearance?

[Kathryn Martin]

Sandra you just assumes I was speaking of trans people only. I think everyone should.....

[sandra-leigh]

Michelle: Kathryn had posted,

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.

and has now clarified the point to be clear that her "Anyone" includes everyone, trans or not.

I do not seem to follow Kathryn's reasoning on this matter, so I do not know why (etc.) "for wanting to improve their appearance". Perhaps because of the medical risks and the way that the medical industry requires that responsibility for faults be signed away??

[LeaP]

I can think of any number of arguments for why it might be a good idea. But I also think that line of thinking feeds the mentality of accepting and living with what you were born with. It's difficult to argue congruence for SRS but exclude FFS when it is clearly so affirming to some, for example.

Back on topic, let me ask a question, speaking to the topic in another way:

The premise - FFS is highly invasive and effectively permanent. Hormones, taken long enough, result in permanent changes. Social transition results in permanent effects to life, even if unwound. As an invasive process with permanent effects, SRS is in he same general class as the others. So much so, in fact, that the original gatekeeping approach allowed none of the above until completion of RLE.

Nonetheless, people do go ahead with much of this at (or near) the start of social transition these days.

The question - Given the above, if the notion of RLE had never been invented by the gatekeepers, would it occur to you to impose it? Or would you simply approve going ahead with transition?

[Michelle.M]

The question - Given the above, if the notion of RLE had never been invented by the gatekeepers, would it occur to you to impose it? Or would you simply approve going ahead with transition?

Oh, now THAT's an interesting idea! Good question!

I think we've all been conditioned to accept RLE as the standard (and for the record, I endorse it). But if we had never known this as a standard then why would anyone impose it? The paradigm would be the reverse - immediate transition would be the norm and RLE would be seen as a delaying tactic. Instead of a chorus of "What's your hurry?" we'd all be asking "What's holding you back?"

If that were the transition standard I think we might actually see fewer regretters who wouldn't transition for fear of the suddenness of the change.

I tend to think regretters have a variety of life skills issues, indecision being one of them and the willingness to tackle the real issues in their lives being another. Rather than arrive at surgery over a period of time, unprepared for not having done their gender transition homework they might not even begin for fear of having to make a decisive move.

And the lack of roadblocks would encourage others who really needed to make a gender transition to decisively and deliberately do so.

[Kimberly Kael]

The question - Given the above, if the notion of RLE had never been invented by the gatekeepers, would it occur to you to impose it?

If there aren't gatekeepers then by definition it isn't being imposed. In practice, as many have pointed out, it's not hard to bypass the guidelines. Particularly if you're well off. Would I still advise RLE? Absolutely. I'm sure I had other options and I never once seriously considered them as a starting point.

I tend to think regretters have a variety of life skills issues, indecision being one of them and the willingness to tackle the real issues in their lives being another. Rather than arrive at surgery over a period of time, unprepared for not having done their gender transition homework they might not even begin for fear of having to make a decisive move.

And the lack of roadblocks would encourage others who really needed to make a gender transition to decisively and deliberately do so.

... successfully? That I'm much less convinced about. I suspect many regretters' life skill deficits have more to do with setting realistic expectations of what surgery will do for them. It's not a magic wand that addresses everything that feels unfair about life, and honestly I've seen more than a few who seem to believe otherwise.

[LeaP]

I am so happy that you mentioned the aspect of following an existing standard, Michelle. I had that in mind but did not want to suggest it myself, biasing a response.

What ever you think of its value, the standard does carry some implications. One is seen in our constant debates about real versus fantasy transsexuals. The issue here is not knowing who really is transitioning, who intends to, who might, when they might do it, etc. A point in time transition decision removes a lot of ambiguity.

I think the aspect of defending the standard is also manifest in the magical quality that is sometimes granted the one year mark. How so? By questioning people as time goes by. Not 12 months yet? No problem. Hit 12 months? "So, when do you plan on…?" Two or three years go by and the judgment is "oh, she's stuck." Yessiree, there is a lot of potency in that twelve-month standard.

Would there be more regretters or fewer? I don't know. There are some many ways of looking at that question. Some talk about the slippery slope biasing toward transition when hormones are started. The suggestion underlying the comment is that perhaps the person should not be taking the hormones because they are not a transition candidate. To the extent that is true and such people transition, that is certainly one potential source of regret. If all-in-one transition were to become the norm, on the other hand, I can easily see where it would require a different approval regimen – and that might incur more delay anyway. I think most of us, with the exception of the radical types Kathryn mentions, would not recommend an informed consent-only model.

[Michelle.M]

I suspect many regretters' life skill deficits have more to do with setting realistic expectations of what surgery will do for them. It's not a magic wand that addresses everything that feels unfair about life, and honestly I've seen more than a few who seem to believe otherwise.

I've never heard of a regretter who was actually trans to begin with. In other words, they didn't go into GRS to achieve gender congruence but rather they were looking for something to fix a problem they couldn't (or wouldn't) identify or to fulfill a fantasy. So in that sense, you're probably right.

I think most of us, with the exception of the radical types Kathryn mentions, would not recommend an informed consent-only model.

I don't know if informed consent is radical; it's just different. Remember, this site is heavily geared towards the WPATH protocol, and anyone who wanders in here who endorses informed consent usually gets run out of [virtual] town.

Yeah, it happens.

Informed consent is fine for some who have very well-defined goals and few, if any, concurrent issues. But that also assumes the transitioner can find a surgeon who is on board, and that alone makes the informed consent protocol hard to follow.

[Kathryn Martin]

Before I can answer this question I would have to know who is asking it. But no matter who is asking it there is an analysis and it goes like this:

I am a girl. My body is not a girls body. I am a freak, it's all in my head, oh my god how can I fix my head. I find out there is no head fix. Everyone sees my body but no one sees inside my head. WTF do I do now. So am I a girl or am I a boy what trumps here? Body or brain?

Brain makes me see the world in a particular way, so maybe I need to fix my body. I find out there is a body fix. Hormones and surgery.

I go to see a doctor, who says: I can't see inside your head but your body tells me you are a boy. Let's do some bloodwork. Bloodwork comes back normal, doctor says it's all in your head, sorry. I insist I am a girl. Doctor says well I can't test if you are just making it up. So show me, because I am not going to give you drugs willy nilly and cut of body parts just because you say so. So show! you show me that you are a girl and I will consider it. I say, ok, I'll show you. And there is RLE freshly minted awesome RLE because if I show him he will believe that the inside of my head looks the way I say it is.

Yup, I would have come up with that one .....

[LeaP]

But you didn't, Kathryn. You started hormones before RLE. So from YOUR perspective, there was no issue. What the doctor wants for reassurance is a different question.

Should I take your point about knowing who is asking to indicate that what was good for you might not be good for another?

[sandra-leigh]

I do not have any personal experiences with the topic, but please have a look at this recent article in transadvocate on the topic of transitioning back:

I had an appointment with my own therapist, Patricia Wojdowski, L.C.S.W., on Wednesday. While at the appointment, I asked her some questions regarding detransitioning, and asked if I could post her responses at Pam’s House Blend.

I actually was kind of surprised at Patricia’s answers. Basically, in her long practice with trans clients (she’s been involved with studying and treating transsexuals and other gender variant people since the mid-seventies), the single commonality for all of her detransitioning clients has been that external pressures were the impetus. All of her clients who have detransitioned still considered themselves as having a gender identity that didn’t match their natal sex, but external pressures — issues such as inability to find employment, biases and discrimination in the workplace, an inability to find appropriate housing, conflict with friends and/or family, etc. — are why the RLE is evaluated by the client as unsuccessful, and the client decides to detransition.

I know there are other reasons than the ones my therapist cites. Sometimes the reason is relating to faith, where one becomes an “ex-transsexual” or “ex-transgender” (the trans equivalents to “ex-gay”). Sometimes it’s because the person really isn’t a transsexual, and an unsuccessful RLE catches them before they experience transsexual regret. Since my therapist doesn’t practice conversion (or reparative) therapy, she wouldn’t see those who are detransitioning for reasons of faith. But, it is interesting that in all the years of her practice, she’s never seen a transsexual who has detransitioned due to because the detransitioner has figured out that he or she really wasn’t transsexual — all of her detransitioners have detransitioned due to external pressures.

The article also has some relevant information about what RLE is:

Page 17 of the Harry Benjamin Standards Of Care For Gender Identity Disorders says this about the RLE (emphasis added):

The act of fully adopting a new or evolving gender role or gender presentation in everyday life is known as the real-life experience. The real-life experience is essential to the transition to the gender role that is congruent with the patient’s gender identity. Since changing one’s gender presentation has immediate profound personal and social consequences, the decision to do so should be preceded by an awareness of what the familial, vocational, interpersonal, educational, economic, and legal consequences are likely to be. [...]

Real-Life Experience versus Real-Life Test. Although professionals may recommend living in the desired gender, the decision as to when and how to begin the real-life experience remains the person’s responsibility. Some begin the real-life experience and decide that this often imagined life direction is not in their best interest. Professionals sometimes construe the real-life experience as the real-life test of the ultimate diagnosis. If patients prosper in the preferred gender, they are confirmed as “transsexual,” but if they decided against continuing, they “must not have been.” This reasoning is a confusion of the forces that enable successful adaptation with the presence of a gender identity disorder. The real-life experience tests the person’s resolve, the capacity to function in the preferred gender, and the adequacy of social, economic, and psychological supports. It assists both the patient and the mental health professional in their judgments about how to proceed. Diagnosis, although always open for reconsideration, precedes a recommendation for patients to embark on the real-life experience. When the patient is successful in the real-life experience, both the mental health professional and the patient gain confidence about undertaking further steps. [...]

With regards to some points that were raised earlier in this thread: notice the HB talks about "adopting a new or evolving gender role or gender presentation in everyday life". My relatives that are not in my immediate family are not part of my "everyday life": I have seen them only twice in more than 20 years. My friends Back Home are not either; I see them at about 2-3 year intervals now. My friends where I live now all know me as Sandra, as do my doctors and all my regular appointments.

Changing my name legally will make a difference, but the difference will be mostly for myself; that and my mother and sister and spouse. And those are important people, to be sure. But even without a legal name change, I am effectively RLE already.

[LeaP]

I've never heard of a regretter who was actually trans to begin with. In other words, they didn't go into GRS to achieve gender congruence but rather they were looking for something to fix a problem they couldn't (or wouldn't) identify or to fulfill a fantasy.

There have been examples of this in the forum. One described the failure of SRS to achieve the desired change. I.e., the procedure "failed."

Topic note - it's hard to talk about procedures, particularly SRS, as separate from RLE. But they ultimately ARE separable. It's possible to conceive of surgical approval protocols that make no mention of social transition (experience, test, or anything else) whatsoever, leaving that as a matter solely between patient and therapist, for example.

Consider that some maintain that the state of your genitals is irrelevant. Is that consistent with a position of imposing RLE before SRS? Or is it more a matter of buying into the almighty penis - that it doesn't matter as long as the genitalia are male?

[Kathryn Martin]

I don't know if we are speaking of the same person but with reputable surgeons there are no failures of the procedure. There are failures of the aftercare, usually not during the supervised recovery period but rather when things are not done by the book. Such simple things as not properly dilating etc. can very well lead to a non-functioning vagina. Of course people love to blame those that "should have provided the care" but really. Health is, after all first the patients responsibility. The funny thing (and somewhat crude) is that even a perfectly working vagina does not get you a partner. So what is the desired change occasioned by the surgery? A well functioning, fully orgasmic vagina. It's not going to make you a woman, it doesn't get you a sex partner, but it makes you whole. Oh and a surgically constructed vagina does not make you a woman.

Damn, you edited while I was typing. Not sure buying into the AP? Can you clarify?

[Michelle.M]

With regards to some points that were raised earlier in this thread: notice the HB talks about "adopting a new or evolving gender role or gender presentation in everyday life".

OK, then! This is very helpful. Thanks for broadening my perspective on this.

[mary something]

I don't know if we are speaking of the same person but with reputable surgeons there are no failures of the procedure.

really ?

[Kathryn Martin]

really ?

Yes quite literally. Most surgeons will not undertake the surgery of there are organic deficiencies etc. They will tell you up front. I looked around and tried to find "botched surgeries" that resulted from a skills deficiency by surgeons. Some obscure names came up. The actual procedure is pretty straight forward.

The trouble always comes in the aftercare and most often after the patient is released home.

[LeaP]

Strictly from the perspective of medical risk and results, that would argue for SRS to be relatively less regulated than FFS and BA. Cosmetic procedures are performed by a very large number of surgeons. They vary widely in skill and experience. There is more opportunity for unpredictable or unsatisfactory results. There are many stories in the news about botched procedures, loss of function and sensation, tissue damage and loss, infections, scarring, disfigurement, and much, much more.

[Angela Campbell]

So....if RLE is so important then why is there no mention of the standards of what RLE is? The therapist and psychologist will write a letter after a year of RLE, but how do they know other than what you tell them? There is no mention in the WPATH SOC about the requirement to change your name and gender legally, just to live as a woman for a year. No proof required, no rules which constitute what is required to be considered RLE.

So if you sit in your house and never leave it except for the occasional trip to the therapist is it just a game of waiting until a year has passed since you met the therapist and stated you were living as a woman? Do they hire a private detective to follow you and report? Is it really just saying that at least a year ago you told a therapist you were a woman and wanted SRS, and a year later you still want it?

Yes most of us will gladly be living as a woman as fast as they can but how do they know?

[LeaP]

It's an interesting point, Angela. Especially since the standards of care recommend, but do not require ongoing therapist visits. Theoretically, the therapist (and the surgeon) are on the liability hook. But the reality is that actual verification would be difficult under the current approach.

[Angela Campbell]

So that means there is no real RLE required just a waiting period, making it pointless as a requirement. No better than a suggestion.

[Frances]

So people want to transition without living in the target gender? I don't get that.

So-called gatekeepers do no more than observe people over a period of time. Not by following them, but by listening to them. Do people make up stories about going to a non-existant workplace or meeting non-existant friends? What's the point? The transitioner has to report his or her real life experience to a therapist who makes decisions based on the patient/client's ability to cope with real life. Having facial surgery does not count has real life experience. Lots of men look like women.

[Angela Campbell]

The point is that a person is either going to live as the preferred gender or they will not and the therapist has to take their word for it just the same as taking their word for being a woman inside. Why does a year of the same insistence make any difference other than waiting or testing resolve?

Well you can have SRS but you reallllllyyy have to want it!

All it means is someone is stubborn not actually a transsexual. A RLE does nothing to determine that..

Do people want to get SRS without living as their target gender??? I doubt it but RLE is designed on the assumption that they do.

Keep in mind I am playing devils advocate here and I do intend to live a RLE. As soon as my name is changed I will do RLE for the rest of my life.

There was a time when you must be attracted to only men and had never been sexually excited by wearing womens clothing in order to be approved for SRS. This was in order to keep anyone who is not really a transsexual from having the surgery. It didn't take long for many to learn this and tell the therapist what they were expecting to hear so the practice was changed.