RLE before HRT?

[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

[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/...or-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.