RLE is a Civil Rights Issue

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Transgender LogoCisnormative.

For those unfamiliar, the word refers to the viewpoint that being cisgender is “normal” and that being transgender is special, unusual, or out of the mainstream. Any policy that makes it hard for transgender people to have their identities respected (on official documentation, for example), while cisgender people don’t have similar difficulties, is cisnormative.

Among transgender circles, cisnormative has a deservedly negative connotation. As long as attitudes and assumptions are cisnormative, our world will not be friendly to trans people.

Gate keeping is cisnormative. A healthcare provider requires some condition we need to satisfy to be ourselves and to be whole, while cisgender people have no such requirement.

When cisnormativity impacts treatment of transgender people, it becomes a civil rights issue. We have a right to be ourselves. Some countries are enshrining this into law, but even elsewhere, compassionate, humane people recognize that those in authority have no right to force women to live as men or men to live as women. That goes for cis and trans alike.

If a doctor forced a cisgender woman whose body did not produce a healthy level of female hormones to prove she was really a woman before prescribing supplements, outrage would result. No such requirement should be placed on transgender women simply because there are fewer of us. Transgender people have the same right to our identities and to healthy bodies. Anything else is cisnormative.

Which brings me to RLE, or Real Life Experience, the year we must spend demonstrating our worthiness for Sex Reassignment Surgery. Many transgender people appropriately call it the “real life test”, because it feels like one. A cisgender women has a right to female genitals, having been born with them. A cisgender man has a right to a male chest, having been born with one. No one demands that cisgender men prove their gender or submit to breast augmentation, or that cisgender women forcibly be given a phalloplasty unless they prove they are women.

We deserve the same rights.

It is a violation of our rights to demand we prove our gender, by a real life test or any other way, before we are permitted to make our bodies whole. However, I will give the medical community latitude if RLE is saving or improving transgender lives.

It’s not.

At least, no one seems able to prove it. I recently embarked upon a quest for research scientifically validating RLE. I came across no data that indicate better outcomes by forcing transgender people to wait before our bodies are made whole. In fact, the data I came across indicated exactly the opposite. Every study seemed to show that the existence or duration of RLE had no effect at all on the outcome. According to a study posted by NIH, “Compliance with minimum eligibility requirements for SRS … was not associated with more favorable subjective outcomes.”

Granted there is little research, but no one with a scientifically discerning eye would declare it a verified fact that RLE before surgery saves or improves lives. In the vast bibliography accompanying the latest version of the WPATH Standards of Care, no study is cited as justification for RLE.

The best that can be said, the very best, is that it has the potential to improve lives. Someone, somewhere, sometime, may find out during their RLE that SRS is not for them, and will be saved from a dismal existence of surgical regret. If we stopped requiring RLE, the logic goes, we might harm that hypothetical person, that person whose existence science is unable to verify, but who nonetheless might be out there.

Another line of thought says RLE makes common sense. If someone waits a year, they’ll make a better decision. Under that logic, forcing a yearlong wait is a favor to us. Otherwise, in our inability to understand our own readiness to decide, we’re prone to undue haste..

I’m not sure why we wouldn’t know when we’re ready to decide, but I’ll accept that thinking for the moment. Based on that, one might conclude living for a year as our true gender does no harm and might help. Therefore RLE makes sense.

However, that logic assumes RLE is otherwise a neutral requirement. It isn’t. An abundance of problems and difficulties easily come easily to mind:

  1. It is patronizing and paternalistic. It assumes transgender people are incompetent to make decisions and cisgender people are competent to make those decisions for us.
  2. It is a violation of our right to control our bodies. In Roe v. Wade, the Supreme Court declared more than 40 years ago that women in the U.S. have a constitutional sovereignty over their own bodies. We deserve nothing less.
  3. It is enforced by cisgender people who have no clue what it feels like to be trans.
  4. It was devised by …, well actually no one is sure who came up with it. One article published on the trans-health.com website attributes it possibly to a doctor named James Lorio, who does not appear to have credentials either in transgender health care or research. The wealthy founder of a research foundation he mentioned it to, however, thought it made sense.
  5. It is based on, and perpetuates the ridiculous notion that living as a woman/man tells you something about what it will be like to have a the genitals/chest of a woman/man.
  6. It assumes everyone who wants to alter their body also wants to live as a different gender. This is utterly untrue. There are multiple types of dysphoria. Some people have body dysphoria without social dysphoria (i.e. need to change their bodies but are comfortable living in their gender assigned at birth), while others have social dysphoria without body dysphoria and are comfortable living with a body that doesn’t match their gender presentation post-transition.
  7. It provides hardship for those who literally cannot stand life in a body that doesn’t match their gender.
  8. It requires us to pay mental health professionals to document that we have satisfied our RLE. One doctor charged me $190 for telling me he wasn’t ready to qualify me for surgery, and that I needed to see him again for another $190 before he would write me a letter.
  9. It puts transgender people at the mercy of mental health providers who often have a profit motive that conflicts with our needs.
  10. It is cisnormative. It puts requirements on transgender people who want our bodies to be whole, while similar requirements do not exist for cisgender people.
  11. RLE has an economic impact that may further delay surgery by eroding earning power.
  12. RLE without surgery can itself be traumatic. Consider the case of a man required to hide the bulge of a large chest.
  13. It asks all patients to endure difficulty for the very small percentage of outliers who experience regret.

So, to recap, in order to get surgery to make us whole, we are forced to endure a yearlong wait. We’re not sure who came up this idea, and no one can prove it is useful. It violates our right to control over our own bodies, contributes to financial hardship, and seems predicated on the notion that transgender people are not competent to make decisions about our health. It is based on outdated understanding of gender dysphoria and confuses gender expression with body sex.

To me, the most baffling question is why the transgender community allows it to persist. If a policy required cisgender people to do something similar when seeking elective surgery (especially were it aimed exclusively at women or some oppressed minority that has found its voice), there would be an outcry. However Trans people meekly accept our fate as meted out by the collective wills of cisgender (and a few trans) health care providers.

When I was 13, I read a story by Shirley Jackson called “the Lottery” about a town that randomly killed one of its residents each year. No one there thought it was a good idea or knew why they originally started doing it, but no one dared stop. It had gone on so long, there must have been a good reason. It’s an absurd example, but a lesson on the way people continue as they always have even in the absence of any evidence of good.

It’s a lesson providers of transition-related care and transgender activists don’t seemed to have learned.

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About Author

Suzi Chase writes about transgender issues through both fiction and non-fiction. She has had careers in teaching and software engineering and has raised two children.

7 Comments

  1. I suppose I was lucky because everything about my transition 24 years ago was done by informed consent. My daughter wasn’t so lucky and had to play the gatekeeper lottery with therapists before she could start HRT. There is one particularly notorious therapist here in New Zealand who claims to be a gender specialist who is known for milking transgender clients of their money without results and then abandoning them once the money has run out . Fortunately my daughter escaped her clutches and found a much more genuine therapist who charged much lower fees.
    I hate everything about RLE. The only doctor I struck who wanted to play the RLE game with me also came on to me sexually and was dumped like a hot potato. My next doctor was more sensible, treated me like an adult and everything was done with informed consent.

  2. Don’t you have to be on HRT for a minimum amount of time anyway?

    I don’t really get the big deal about the discontent with RLE. I guess it’s because SRS for me isn’t the ultimate goal. I could be perfectly happy as a non-op, except that it poses some challenges, especially when it comes to a romantic partner.

    I do think that RLE without HRT is pure torture, and unnecessary and thankfully that practice has largely gone by the wayside.

  3. The standard wait for HRT here is officially three months of RLE, except that it takes a year to get an appointment with the shrink who approves it. In my case it took another 13 weeks for them to type the letter.

    The required RLE before surgery is two years, but as I found that is two years before being put on a waiting list to see the surgeon. When I was waiting it was another year but I understand it is now several years.

    I was told they have had someone back out after 18 months of RLE, but isn’t the figure we want to compare the number of us who have taken their own lives after giving up hope of ever reaching the head of the queue?

  4. Great article as usual Suzi! I agree that we should have the right to our own bodies and such treatment is cisgender discrimination. I read that the regret rate for SRS was just 2.2% in a Swedish study, while plastic surgery procedures, at least in a study of British people, have a 65% regret rate. So why does society let people easily have plastic surgery with its very high regret rate, but not SRS with its extremely low regret rate?

    Links for the studies mentioned:

    http://www.medicaldaily.com/becoming-transsexual-getting-facts-sex-reassignment-surgery-309584
    http://www.dailymail.co.uk/femail/article-2640543/Two-thirds-Britons-REGRET-having-cosmetic-surgery.html

    We should assume that all adults bear responsibility for their own decisions (after all, the law and society assumes this.) The vast majority of transgender people should not have to suffer for the few people that make decisions too hastily. Such procedures are expensive enough and big enough that most people wouldn’t undergo it unless it was absolutely needed for their well being. The medical community should not be treating us like children in this regard. Even with RLE, it seems that the impulsive people still find a way to get through anyway. It didn’t stop noted de-transitioners like Sam Hashimi / Charles Kane from getting SRS.

    The idea of RLE is simply an idea that seems to make sense for cisgender people, because from a cisgender person’s perspective: “This is a dramatic thing to do to one’s body, so it shouldn’t be easy for someone to do so unless they can prove that they are transgender”, but it totally disregards the point of view of a transgender person, and the well-being of transgender people, and that is wrong. We have to fight for equal and fair treatment on this issue.

  5. I love this article, Suzi. I completely agree on all accounts. I, too, have always felt like my rights were being violated. I’m trans, but don’t think I need to live life like a binary gendered woman, to be one. I never understood how surgeons continue to enforce the WPATH standards, when they clearly violate medical ethics (about violating the autonomy of a patient). I learned very early that the WPATH isn’t my ally as they claimed, but the hurdle that must be overcome, which is tragic. If they were truly interested in the well-being of a transgender patient, their S.O.C. should be two guidelines and two guidelines only:

    1) Is the patient autonomous?
    2) Is the patient making an informed decision?

    If yes to both, allow the procedure.

    Suzi, since you are well-versed and well-vocalized, you should start a change.org or a white house petition to prevent this continued violation of our civil rights and force the WPATH to change their S.O.C. I’d sign in a heartbeat. And with the recent momentum of the trans movement, I’d think this petition would get incredible support.

  6. Since “gender clinics” are few and far between and largely unnecessary, and estrogen is only $4 a month from Walmart, I went to a family doctor and started HRT using informed consent. I had to wait several weeks for an appointment and then several days for blood test results showing my health was good enough to undergo HRT. I didn’t transition until after over a year of HRT and laser hair removal, then started the day my name was legally changed. My family doctor wrote letters for my Social Security record and passport, and she signed the form for my driver license. I did, however, have to see a psychiatrist for an hour as well, so that he could fulfill the legal requirement that someone with a doctorate who specializes in mental health write a letter to change the sex on my birth certificate.

    I now see a transsexual therapist who is recently post-op herself, for the sole purpose of providing one of the two letters required to get SRS and to confirm for Medicaid the medical necessity of my top surgery and facial reconstruction. The psychologist in her office will see me for an hour or two to write the second letter.

    If the federal government weren’t prohibiting all Obamacare insurers, Medicare, Medicaid, and federal employee plans from excluding transition coverage, I could never afford surgery. Once my coverage is confirmed, I’ll still have to wait up to 18-20 months for SRS because surgeons have such a backlog of patients waiting. At least the top and facial surgeries will be obtainable within a few months.

    Informed consent is a godsend, as is letting patients start HRT long before their RLE, and individualizing the RLE, even if one year is still seen as optimal. These latest WPATH standards need to be observed everywhere; I see from others’ comments this is sadly not the case in some countries. Also, in the next decade perhaps, the standards need to be updated away from the patriarchal gatekeeper approach entirely.

  7. Most srs surgeon’s require you to have been on hrt for a year anyway , I actually agree with the RLE , not that it should be mandatory , but I do think a year or more living in your preferred gender is sensible , I am glad I made sure I passed well before srs asI knew for me that it would bug me if I had a vagina but didn’t pass well.

    That may make me sound superficial , but it’s about quality of life , I didn’t want to go from living as a deeply unhappy gender dysphoric guy , to an even more unhappy woman , who was post op but who was afraid to leave the house , I know a few girls who are lost op and who don’t leave the house and that’s worse than not transitioning in the first place, so maybe not everyone should skip the RLE.

    I am sure some women will disagree , that’s fine but be nice if you do, I didn’t post to get into an argument.

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