Poll: Should the medical community require RLE for SRS or should it be optional?

[Cindy]

Suzi, I have kept my opinions on RLE to myself. I was trying to answer the question logically and not emotionally.

Patients going for allo cardiac vein transplants to correct blocked veins in their heart now go onto a treadmill for a few weeks prior to the removal of the leg vein for transplantation into their heart. It has dramatically improved life outcome.
It use to be thought a dumb idea to force patients who had a cardiac arrest to do exercise. It is now standard.

As for knee surgery, if the ligaments have been severed there is no use in compounding the injury. I'm unsure if I can see a relationship between the issues I posted in regards to a clinical trial and the scenario you posted.

I am happy to walk away from the discussion.

[kira21 ♡♡♡]

well to take a broad view and not to be sexist or anti woman or anything considered demeaning whitch I have absolutely no intention to do. Usually  one approaches living as a woman on the most basic and benign level as dressing as other woman dress which in and of itself leaves a lot of leeway . I mean on the most basic level any clothes whether be jeans or slacks that other woman purchase would suffice to fulfill any requirement as be perceive as dressing as the female as opposed to being dressed as a male even though many women blend clothing so in reality it really doesn't matter how one dresses to fulfill any clothing requirement . As far as other issues such as name change on documents and other legal means of existing within the framework of a specific gender if that's your purpose it seems only common sense if you want to be perceive by others as a specific gender .in which case what's the big deal of being perceive as that specific gender in order for the medical professional that's going to rearrange your genitals in order  for you to be perceived as that gender to try in the least offensive and least demeaning way to feel comfortable in surgically rearranging an organ that obviously plays an important individual and social role in your mental well being.

Now I have female Tom boyish friends who don't fit this. The whole notion of there being a female way of dressing is very much at odds with how society views women and very poor from a feminist perspective.

I'll define living as a woman, when you have to make a choice that says am I a man or a woman , you pick woman.

It doesn't need to be any more complicated than that.

Now this is a better definition, but how does a year spent ticking the 'f'  box have anything to do with preparing for surgery? How can ticking the 'f'  box be equated to having a real life experience?

Really there is no way of adequately defining rle.

The nearest I can come is with regards to HRT and there is no requirement for that.

[stephaniec]

Now I have female Tom boyish friends who don't fit this. The whole notion of there being a female way of dressing is very much at odds with how society views women and very poor from a feminist perspective.

Now this is a better definition, but how does a year spent ticking the 'f'  box have anything to do with preparing for surgery? How can ticking the 'f'  box be equated to having a real life experience?

Really there is no way of adequately defining rle.

The nearest I can come is with regards to HRT and there is no requirement for that.

well, the point being change the laws so the medical profession isn't held liable in any way for a person to walk into the operating room off the street and announce they want to change their sex organs to better fit an individuals perception of them selves no matter how vague their concept of gender is and how vague their understanding of the reason they need surgery to feel that can fit better into some vague notion of some undefined  notion of gender presentation. As it is now the medical community seems it necessary so people don't find themselves in the horrific state of having made a mistake. I'm not a doctor obviously , but if I was I sure as heck would not want to be responsible for not taking at least the most minimal precaution to ensure someone's continued mental well being.

[kira21 ♡♡♡]

Oh I would want to make sure I was doing to right thing too and an assessment like for other surgeries makes sense,  but rle doesn't exist unless you have strict definitions of how a woman should act and dress, which you shouldn't.

For me,  its a non issue,  I have a very femme appearance and I am post op,  but the concept of rle is a fallacy, as far as I am concerned.

[stephaniec]

Oh I would want to make sure I was doing to right thing too and an assessment like for other surgeries makes sense,  but rle doesn't exist unless you have strict definitions of how a woman should act and dress, which you shouldn't.

For me,  its a non issue,  I have a very femme appearance and I am post op,  but the concept of rle is a fallacy, as far as I am concerned.

Well, It's good your healthy and everything worked out.

[diane 2606]

I was confused by those saying a femme appearance was required for MtF surgery. It turns out WPATH SoC says nothing about that in Appendix C — Criteria for Genital Surgery.

Metoidioplasty or phalloplasty in FtM patients and vaginoplasty in MtF patients:
1. Persistent, well documented gender dysphoria;
2. Capacity to make a fully informed decision and to consent for treatment;
3. Age of majority in a given country;
4. If signi cant medical or mental health concerns are present, they must be well controlled;
5. 12 continuous months of hormone therapy as appropriate to the patient's gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones);
6. 12 continuous months of living in a gender role that is congruent with their gender identity.

Although not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional.

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.

Here's the link http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf to the SoC</a>

The relevant portion is on page 104.

According to the Standards of Care, there's nothing preventing you from "butching it up" if you're so inclined.

[JLT1]

Hi,

I backtracked through WAPATH to the published literature source for the RLE requirement. 

Bockting, W.O. Psychotherapy and the real-life experience: from gender dichotomy to gender diversity, Sexologies, 17(4), 2008, 211-224......who, in turn, keeps referencing further back.....

However, there is little scientific rigor in the one-year cutoff.  However, the reasoning is better than I anticipated.  Below is the guts of the justification form the paper. 

Finding a comfortable gender role and expression The second phase of transgender-specific psychotherapy is more behavioral. The client is encouraged to connect with peers and find community on the Internet and in real life and
to experiment with various options of transgender expression. The goal is to explore to eventually find a gender role and expression that is most comfortable. Oftentimes, this phase involves giving adult clients permission to be a ''kid'' again and engage in adolescent developmental tasks (i.e., developing a sense of competence and  attractiveness in a more authentic gender role), yet not without losing sight of adult responsibilities (work, family) and appropriate interpersonal boundaries (Bockting and Coleman, 2007).

After a period of exploration and experimentation, most clients are ready to make a decision about a possible
gender—role transition and the available options of hormone therapy and/or surgery. Making a full-time gender—role transition is in essence the start of the RLE. Taking this step is terrifying for most clients. The goal of the RLE
remains to test the client's resolve and to prepare him or her for the implications of irreversible body modification
through surgery. Although the RLE no longer has to conform to a binary conceptualization of gender, clients
need to express their transgender identity in a way that is consistent with their long-term gender identification and
goals for expression. Hence, the therapist needs to help the client distinguish between gender ambiguity (e.g., bigender or gender-queer identity) and attempts to ''back into'' a gender—role transition out of fear of rejection (by family, friends, community, school or workplace). Making incremental changes without a thought—through plan, or assuming an ambiguous gender—role when the client's ultimate goal is a complete transition, may unnecessarily prolong anxiety. Rather, the client should take responsibility for the transition by planning it carefully in consultation with the therapist and peers (e.g., in group therapy). Appendices A, B and C provide examples of guidelines based on the WPATH standards of care for gender-identity disorders to evaluate the client's eligibility and readiness for hormone therapy and/or surgery (see also Bockting and Goldberg, 2006).

Hugs,

Jen

[cindianna_jones]

But shouldn't they be required to prove that RLE somehow contributes to that high rate of success?

So far, I've seen no such proof. On the contrary, all the evidence I've seen is that RLE has no relation to post-surgical satisfaction.

Proof would be so nice wouldn't it? But you know what? There is little to no proof that statins actually help prevent heart disease and how many decades have we been taking them to lower cholesterol? Wow, three questions in a row to answer a question. That must be a record for me.

Of course it would be a better argument if there were proof. We make it mainstream first and then the studies will come in from research students getting their thesis in med school. That's how it generally works. No one is going to pay to  have a study done like this.

Cindi

[stephaniec]

I don't know my brain could be damaged in some way for it to be like it is , but honestly I don't see the harm in it and it just makes sense. I might be delusional , but I honestly can't see why this is even an issue.

[Emileeeee]

I always thought I would have to fit a certain mold to qualify for this RLE thing, but as it turned out I didn't even have to present as female. I just had to tell them I was. I guess it helped to have a sympathetic therapist that was cis female and dressed like a guy though.

I have mixed feelings on the requirement. Prior to starting the RLE, I thought it was the most ridiculous requirement ever. I thought it was a way of putting my life in danger for a year.

Now that I've started it, I feel like it really was a necessary step. There are so many things that I have to deal with that never even crossed my mind prior to starting it. I wanted HRT and surgery without the RLE because I was too afraid of what would happen if people knew I was trans. It never occurred to me that I'd have to go to a doctor's office and explain why I'm male with a vagina. Or that the hormones would change the way my face looked. Or that if I had to pee in a public location, that I would have to decide which bathroom to use on the spot. There are a lot of things I would have been blindsided by without the RLE. With it, I've been able to face each obstacle mostly one at a time.

That's not to say that I believe it should be a requirement because I still believe that it's my body, so it should be my decision. I just think it should be strongly suggested as a way to be sure, but not required.

[JLT1]

I don't really know.  My mind says it's necessary and helps so many people.  I do know there has to be flexibility and a year is arbitrary. 

However....I had full FFS - brows, eyes, nose, jaw, Adams apple, cheek implants, lips and anything else needed to look like a woman.  (I was still swollen in my picture.) then, I went full time.  No way I will ever again look the way I did. 

Given the extent of FFS, would GCS have been that much different?  I asked in another topic.  The answer was about 50/50 yes and no.

I also know they waived RLE for me.  Psychs (three of them), surgeon (two) and insurance.  I just can't seem to get it done.  Something always blows up.

Be yourself, dress they way you want and have the genitals that fit you (as much as possible).  The rest is nothing. 

(Except where they still require RLE to get HRT - that's inhuman)   

Hugs,

Jen

[Serenation]

Now I have female Tom boyish friends who don't fit this. The whole notion of there being a female way of dressing is very much at odds with how society views women and very poor from a feminist perspective.

Now this is a better definition, but how does a year spent ticking the 'f'  box have anything to do with preparing for surgery? How can ticking the 'f'  box be equated to having a real life experience?

Really there is no way of adequately defining rle.

The nearest I can come is with regards to HRT and there is no requirement for that.

I lived full time (voluntary) for a very long time before having SRS, I don't think RLE prepares you for surgery at all but I don't personally think it was intended to. That does not mean I think RLE is a bad thing.

Most people who have SRS will integrate into the pre-established laws and rules of a binary gender society. Why shouldn't people make an educated choice on that.

[Serenation]

Divorce and career/money to name two.

We all wish transitioning had no negatives. Losing all of those things is something no one should have to go through, yet for so many of us it does.

For the sake of us all we need to make it so in the future families do not reject us, employee's do not reject us. Get rid of the stigma associated with being trans.

[diane 2606]

Since RLE has had good outcomes it would be unethical to set up a blind trial of X people in each group and see which ones had the 'best' outcomes

And that, my friends, is why RLE will be a requirement for all eternity. You may not like it, but it's not going away.

We've been fighting all our lives, internally anyway, at the injustice of having incongruent brains and genitals. We're hard wired/spring loaded (pick your favorite) to resist when gatekeepers place requirements on us that don't match our personal agenda, but RLE is part of the price of admission. We can rail against the tyranny, or we can take the less stressful path. Fighting it will only extend the time it takes to achieve congruence.

Rebellion feels good. Fighting for the cause that will set our sisters and brothers free is euphoric. But this isn't Star Wars and the Rebel Alliance ain't gonna destroy the Death Star.

[Endless Rain]

I have severe body dysphoria, but no social dysphoria. Forcing me to do RLE makes no sense; it does nothing for me and delays the medical care I actually need. If they made, say, cancer patients do useless stuff for a year before getting medical care, there would be an uproar. I am horrified that nearly half of you support this.

Furthermore, I have extremely strong views against gender roles, I don't want to change my name, I don't care about what gender people perceive me as, and I won't even view myself as female until I finish transitioning. For me, being forced to do RLE would basically force me to pretend to be a vastly different person than I would be pre or post transition. It would be like having to volunteer for the Donald Trump campaign, and I hate Donald Trump.

[cheryl reeves]

The main thing I been reading is wanting to be a woman but live like the man you used to be..why bulk if you want to be a woman then rle should be a cakewalk..Rle was put in place for you to get comfortable in the role your going too live in for the remainder of your life. I'm a rarity for I need no hormones or surgery to look fem and it would be easy for me to go fulltime with no problems, my real rle is trying to be male which is much harder too do.

[kira21 ♡♡♡]

So if rle can mean presenting as anything, having experience of presenting as anything, what on earth does it actually mean and what could it's value possibly be?

I was confused by those saying a femme appearance was required for MtF surgery. It turns out WPATH SoC says nothing about that in Appendix C — Criteria for Genital Surgery.

Here's the link http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf to the SoC</a>

The relevant portion is on page 104.

According to the Standards of Care, there's nothing preventing you from "butching it up" if you're so inclined.

In actuality though, it is in many places and by many therapists, used as a mechanism to force somebody to present as feminine, even if they are a tomboy, just to receive the go ahead.

[suzifrommd]

So if rle can mean presenting as anything, having experience of presenting as anything, what on earth does it actually mean and what could it's value possibly be?

Based on all that I've seen and read, it is nothing more than an excuse for making trans people WAIT.

We're assumed not to know what shape our bodies should be, so the cisgender medical establishment demands we take a year to think about it so we won't make an awful mistake.

If cisgender people had to wait a year before their body could be made whole, I suspect the RLE requirement would be gone pretty quickly.

[XKimX]

My problem with RLE is that it is not real at all.  Especially for the young, the basic reason for wanting to have the sexual organs of a different gender is to experience sex in that gender.  RLE, as now done, is demanding that you live life as a cross-dresser, not as a member of your chosen gender.  Demanding a year or more of enforced celibacy hardly seems ethical unless you are in a nunnery voluntarily.  Every choice that you make along the way in transition -- HRT, FFS, BA -- has lifelong consequences.  SRS has lifelong consequences also, but why should it be so different in terms of making an informed choice about it?

Half of the planet lives with one sex organ and half with the other.  Sure, some people might not be happy with their new organs, but they were not happy with their old organ either.  They are stuck and will be unhappy, but no worse off than someone who desperately wants to have that other sex organ.  At least they had the chance to give it a chance.  We all accept that every year after 14 reduces the chance of a good outcome with HRT.  Is it ethical to make someone wait a year or more for SRS, knowing that the eventual outcome will be worse as a result of that wait, as the unwanted hormones continue to do their work on your body?  No one is forcing anyone not to do RLE (if you think it as real life), and wait as long as you may wish for SRS, if at all.  But those who do wish to change their sex organs now should be able to do it now.  If they are legal age, and if not with parental per mission.  While HRT before SRS makes some sense, SRS followed by HRT will produce even better results with no need for blockers.  You are only young once.

As other have said, this is not personal; I already have mine.  But for the next generation, do we really want to extend the angst of their gender dysphoria by forcing them to wait for the medical procedures that will end it?  That sounds like cruel punishment to me.

If 95 percent are happy with their new gender choice and five percent are not, why should to dissatisfied five percent get to veto the joy of the other 95 percent?

[diane 2606]

the basic reason for wanting to have the sexual organs of a different gender is to experience sex in that gender.

Your assertion that the ability to have sex is the prime reason for surgery doesn't mesh with what I've heard from every transperson I've ever known, and I've known a few. The standards of care, which have always included a period of RLE, have existed since the dawn of medicalized transsexualism. Sex reassignment is about more than fornication; it's about living a lifetime.

You can rage against the system, but the only thing that will eliminate the requirement is overwhelming clinical data saying RLE is unnecessary. Good luck with that.