Wonderful transition without any RLE

[rmaddy]

It's ok for those who want RLE but to force it on a person, of age, to do RLE,  is cruel and takes away our rights as human beings.

I disagree. 

I don't believe that the ability to self-direct complex medical care is among our fundamental rights.  I certainly think our input needs to be given heavy weight, and those who are philosophically opposed to transition should not be allowed to function as gatekeepers. 

That being said, I am a physician and I occasionally encounter individuals who press for irrational, potentially harmful tests and procedures based on a variety of factors which do not typically drive quality medical care:  obsession, poor education, confirmation bias, etc.

Please understand that I do not work in transgender care and do not have a dog in the fight in terms of acting as a medical gatekeeper.  I want patients to get the care they need and support their ability to obtain proven therapy with a minimum of hassle.  When it comes to transgender medicine though, the therapies which have been proven have specifically been proven under the precondition of adherence to the WPATH/Benjamin standards.  There is no evidence of which I am aware to suggest that transitional medicine/surgery outside of these guidelines is equally efficacious.

[warlockmaker]

Rmaddy :Thank you for stating you are not a physician that works in TG care. I have been an advocate against RLE and advise my country office of the United Nations on TGs. Wapath has modified its RLE requirements and can be intrepreted as up to the medical caretaker.  It is cruel and barbaric to require RLE from a person of age. In my original post I did require therapy. Many are forced to dress up as a female looking still like a male, causing lack of confidence from ridicule and agression. This can scars them mentally. SRS is not the cure all for the mental health, many of TGs living in countries that have archaic laws have many other issues  mentally that face the general population. There is NO medical study that compares those with or without RLE as being better.

Complete: Yes those were the dark ages, dinasour age. I fully understand that many who HAD to do RLE want others to go thru it also, its just human nature.

[rmaddy]

Rmaddy :Thank you for stating you are not a physician that works in TG care. I have been an advocate against RLE and advise my country office of the United Nations on TGs. Wapath has modified its RLE requirements and can be intrepreted as up to the medical caretaker.  It is cruel and barbaric to require RLE from a person of age. In my original post I did require therapy. Many are forced to dress up as a female looking still like a male, causing lack of confidence from ridicule and agression. This can scars them mentally. SRS is not the cure all for the mental health, many of TGs living in countries that have archaic laws have many other issues  mentally that face the general population. There is NO medical study that compares those with or without RLE as being better.

Complete: Yes those were the dark ages, dinasour age. I fully understand that many who HAD to do RLE want others to go thru it also, its just human nature.

I don't think it is either cruel or barbaric, particularly since there is wide latitude to interpret what constitutes a successful real life test.  The RLE and stepwise progression is the best way to ensure that those who transition are likely to benefit from it.  Again, there is no good evidence to evaluate the efficacy of transition outside of the WPATH guidelines--they have been with us from very early on.

To your suggestion that because I had to do RLE, I want everyone else to do so, I suppose that there may be a kernel of truth to that, but let's turn that around.  Is it possible that because you didn't do a RLE you think that no one else should have to either?  Before you say, "Well it worked for me", please remember that I would say exactly the same thing, and the overwhelming load of gathered evidence that says that it works out for those who followed the guidelines.

I've watched your videos (nicely done!).  You are a charming free spirit who has the world by its tail and makes your own rules.  I totally get why having to follow someone else's guidelines might be odious to you.  Nevertheless, most of us have neither your means nor opportunities and are somewhat more used to functioning within guidelines set by others.  I doubt the RLE is going away, and I think casting it as barbaric is a bit hyperbolic.

Think of it this way:  I am having BA/FFS next week.  I have to have my potassium drawn within 10 days of surgery.  My potassium has been checked every three months since starting on spironolactone.  It has never once been abnormal over the course of multiple years.  Nevertheless, the anesthetist insists on the tests:

My options:

1.  Make the case that the odds of my potassium being off next week are vanishingly small and that there has been no previous history of cardiac or renal failure.  Argue that testing is irrational, excessive and impinges on my freedom to choose what care I do or do not want.
2.  Get the flipping test.

I'm going with #2 personally, even though I might be factually correct in pursuing #1.  The potassium level is a safeguard to help the anesthetist identify potential train wrecks.  It costs me little, puts her/him at ease, and...this is important...picks up on something really vital once in a blue moon.

I'll admit that I don't really see the merit of the libertarian argument.  If someone is dedicated to transition, what is the harm in having them try it out before undergoing invasive medical procedures?

[Lisa_K]

The original rational for RLE was to determine whether one is actually a good candidate for transition including hrt/grs...or not. There seems to be a tendency to blow off RLE as a hurdle or just some Cis conspiracy to make it hard to transition.

There are a lot of things people don't know about or don't understand about the "dark ages" and the so called gatekeeping of the past. In many, if not most medical circles outside of a few places of research, knowledge of the treatment for transsexualism by changing the body to fit the mind was limited or considered experimental. There was certainly no widespread consensus among professionals and those that did have some understanding of the phenomenon were conservative and tentative in their approach. They didn't want to make mistakes or have patients filled with regret or get sued, etc.

The world was a lot more binary back then too. Why would doctors want to help someone that could never fit into their new gender role? What would they be unleashing on the world if they created male/female chimeras that couldn't pass or could never successfully assimilate in their new life? This was socially and ethically unacceptable.

Let's face it, transition tends to bring occasionally significant levels of instability and turmoil to a person's life and anyone that's experienced severe gender dysphoria and strong drive to have things taken care of right now knows the potential is there to rush headlong into things without a full comprehension of the consequences long term. Will they be able to get a job and support themselves? Will they eternally be on the fringe of society, be marginalized and suffer minority stress? Will the frequent loss of family, friends and livelihood upset an already tenacious balance in a person's life and will the emotional/psychological baggage be too much to bear? Will the "cure" create more problems than it will solve? There was a lot of caution because the roadmap was ill defined and not entirely proven and accepted. Even today I think certain caution is still warranted in the industrialized, seemingly on demand sex change industry it seems there is now (almost).

These were the reasons for the real life test and back in the day, if you weren't on a surgical track as your ultimate need and objective, then you were something other than transsexual, namely, just a paraphilic transvestite or whatever and good luck with getting help for that. Remember, there was no transgender, no in-between and no non-binary or gender queer/fluid, being gay was considered a mental illness and if you couldn't assimilate fully into your new gender role, then you were pretty much out of luck. In order to insure their patients were going to do well, the guidelines and gatekeeping were pretty strict. You had to demonstrate that you new life was going to be an improvement or at least that post social transition you could take care of yourself and were mentally stable. SRS was considered "the icing on the cake" for the new life you had made for yourself that only came at the end of a long road. One can only imagine the fate of those that washed out of programs or were deemed otherwise unsuitable. I know what I would have done and I wouldn't be here nearly 45 years later writing this had that happened to me.

Over time, it became obvious the one size fits all approach wasn't working and that many of those that failed to meet all the rigid standards could still be helped to varying degrees. Some of this was due to a better understanding of the relationship and distinctions between sex and gender, some of it from changing social attitudes, some of it from the de-pathologization of homosexuality and increased public and medical awareness that trans people were a real thing. All that leads to somewhere near where we are today.

Here's my opinion on the RLE/RLT thing and I think some of it does has to do with age and a person's station in life but exceptions should be rare. I don't  think proving you can live as your new gender should have anything to do with getting hormones, feminizing procedures and therapy. That's just stupid. However, if someone is taking the irreversible steps of having SRS, I'd be concerned if the person hadn't lived fully day to day as the person they're going to be after surgery for at least a year or two. In fact if asked, I would have to offer my opinion that the one year of RLE guideline before having SRS is there for a good reason at least here in North American culture. Remember, it's the "icing on the cake" for the life you've made, not a magic bullet to fix things outside of your relationship with you and your body. I strongly feel the inside you and the outside you need to congeal for a while as a whole person in the real world to make sure it works for you. If you've got unresolved external issues be they be family or relationship problems, problems getting work, housing or domestic issues, SRS isn't going to change them or automatically make them better. RLE is when you show you can work these things out

I fully understand that many who HAD to do RLE want others to go thru it also, its just human nature.

Now wait a minute. That's hooey. What you're promoting may be fine and work well in your country, in your culture and in your medical community but I think it's almost dangerous information to instill the notion to those in this part of the world that RLE is superfluous and invasive gatekeeping intending to hold them back. There's a reason for it I fully support and it's not just because WPATH says so but because I know what it really takes to be successful and don't want to see others make mistakes. Doesn't matter if you are invisibly stealthy, aren't passable or are comfortable outside the gender binary - live it for at least a year or more before having SRS because that surgery isn't going to fix other stuff and many seem to think it will which the medical term for that is "wishful thinking".

Sorry for the long post. I thought some may find the info, the history I had to throw in from before time was invented might be interesting?

[AnonyMs]

There's been plenty of discussions here about taking hrt and not transitioning and it seems generally accepted. I can't see any difference between doing that and having SRS. I'm all for doing whatever makes you happy, and fully agree with warlockmaker.

As far as WPATH goes, it's obvious that there's plenty of medical "professionals" that gatekeep rather than follow it. Whats not so obvious is that there's plenty that respect their patients and provide them the freedom to do as they choose. WPATH is not what it appears to be.

[xFreya]

I think forced RLE(except for minors) is potentially harmful and meaningless, especially before HRT/FFS. The psychiatrist surely will feel more comfortable before giving the referral for HRT(mine made me wait like 8 months and it was terrible) but beyond that they don't care much. They don't care about our distress not getting our treatment, or discrimination/harassment we might get from doing RLE before passing as cis. -I tried to explain that to my psychiatrist ok naturally you want to make absolutely sure it will be ok to give me HRT but making me wait this long has negative effects on my life too. She took that as me threatening her with suicide and threatened having me put into a mental institution or something. I was never suicidal in my life and I didn't imply such a thing.-

Everybody will have different circumstances and have more or less succesful transitions, psychiatrist might  help the patient be aware of potential negative stuff and all their options but in the end it should be up to the patient.

Like maybe a patient will lose their job, lose some family, not fully blend in as their gender and cis gender psychiatrist might see that as a disaster and want to "save" the patient from that fate. But that might be still better than not transitioning for the patient? It's not like we have other treatment options for a person who definitely wants to medically transition, we can't say "oh it appears you won't have the most succesful transition so take these pills and you should be ok living as your AAB gender". For SRS it might be better to be more cautious but again professionals should be open minded to people's different circumstances. Some people take hormones and get surgeries but not socially transition. If that is the best solution for them why should they be prevented?

And RLE can be meaningless before HRT and FFS because without at least HRT you may not be able blend in your gender , not that you have to but it might not reflect what your life will be like after HRT and whatever treatments you want.
Oh and if the gatekeeping is too strict people will just lie to psychiatrists. If therapists expect you to be a certain way a lot of people will say them what they want to hear. A lot of psychiatrists expected a trans woman to be very feminine and they acted like that to get treatment, and(from what I read) then they would make deductions like TS women are overly feminine when in their own lives they are more like cis women on average.

Last edit: I think if the patient is adult and mentally fit to make their decisions, if they know about these issues and treatments they should be able to make their final decisions. It is impossible to make sure no body ever regrets any decision. People will take all kinds of risks in their lives.

[warlockmaker]

Society fear change, but its up to us to think out of the box and look at the rules that the next generation will face in the west. In Thailand TGs are identified by parents at a very youg age, normally between 5 to 12 yrs old. They dress as their preferred gender at a young age because there is no major taboo nor discrimination. Because of this most dont even understand this rule of RLE. They are lobbying so that they can officially marry and change their birth id so that they can travel abroad easier. We are referred to as the third generation and a natural part of nature and no difference from cis men and women. All these rules the demean us to 3rd  class citizens from those in power who want just the keep things as they are. Who suffers from this view? Time to look at change.

[xFreya]

Society fear change, but its up to us to think out of the box and look at the rules that the next generation will face in the west. In Thailand TGs are identified by parents at a very youg age, normally between 5 to 12 yrs old. They dress as their preferred gender at a young age because there is no major taboo nor discrimination. Because of this most dont even understand this rule of RLE. They are lobbying so that they can officially marry and change their birth id so that they can travel abroad easier. We are referred to as the third generation and a natural part of nature and no difference from cis men and women. All these rules the demean us to 3rd  class citizens from those in power who want just the keep things as they are. Who suffers from this view? Time to look at change.

Hey may I ask you a question  When we were in Thailand my mother saw a group of students and all the boys had very short hair, and someone we asked said it was a dress code. She was wondering what if one kid is trans wouldn't that be really tough emotionally? I said I don't know maybe they make an exception in that case but we were still curious. If 5-12 yrs old kids can present as their identified gender, do you know what do they do at school?

[rmaddy]

One more thought to add:  I think the perception that there is a mental health establishment hostile to transgender rights eager seeking to snuff out transition despite and against the will of their patients is paranoid hogwash.  The APA, AMA, and dozens of massive international organizations are in our corner, seeking to promote WPATH not to thwart transition, but to see that it is done consistently and well.

[staciM]

I believe there needs to be some middle ground.  A year of RLE seems a little much but I agree that some is important.  What if changes on HRT aren't as "magical" as you expected (hoped)?  What if funds for FFS dry-up and you're stuck in some middle ground with your male bone structure?  Would you reverse your life and go back to live as a man or should you learn to have confidence as you are?   Are you mentally prepared for that possibility?  RLE will help with that....it's a dose of valuable reality.  Even with extensive HRT and 100k worth of FFS, some girls will always be seen as trans...are you ready for that?  RLE will help.

Also, there's lots of agreement about therapy and RLE related to GCS/SRS, but not as much about HRT.  I would say HRT is easily as life altering as GCS/SRS and therefore should be treated similarly.  The attitude that you can dabble in HRT or "give it a try" is dangerous.  My opinion is you need to be "all in" and if you are, RLE should be no big deal.  As for RLE goes, it's different for everyone.  Nobody is saying that you need to wear an evening gown and stilettos to the grocery store.....that's ridiculous and not realistic. 

[warlockmaker]

xFreya: Its up to the parents to decide if they go as a female or male in school and dress accordingly. There is no discrimination and tgs naturally grow up to act like females/males. Life has the buddhist philosophy of "live and let live".

[xFreya]

Also, there's lots of agreement about therapy and RLE related to GCS/SRS, but not as much about HRT.  I would say HRT is easily as life altering as GCS/SRS and therefore should be treated similarly.  The attitude that you can dabble in HRT or "give it a try" is dangerous.  My opinion is you need to be "all in" and if you are, RLE should be no big deal.  As for RLE goes, it's different for everyone.  Nobody is saying that you need to wear an evening gown and stilettos to the grocery store.....that's ridiculous and not realistic.

If my gender/gender identity is certainly binary female, naturally I want female hormone levels and secondary sex characteristics. Even if I face other problems living as a trans woman, this won't change. So why should a trans person in this situation not just advised to but have to wait, while cis people simply can get their hormones right if necessary? Cis people get all kinds of elective procedures too.

Btw I don't think WPATH and those organizations are hostile to trans rights, but we live in different places and just debate how things should/shouldn't be

[xFreya]

xFreya: Its up to the parents to decide if they go as a female or male in school and dress accordingly. There is no discrimination and tgs naturally grow up to act like females/males. Life has the buddhist philosophy of "live and let live".

Oh okay, that's cool, thank you

[staciM]

If my gender/gender identity is certainly binary female, naturally I want female hormone levels and secondary sex characteristics. Even if I face other problems living as a trans woman, this won't change. So why should a trans person in this situation not just advised to but have to wait, while cis people simply can get their hormones right if necessary? Cis people get all kinds of elective procedures too.

Btw I don't think WPATH and those organizations are hostile to trans rights, but we live in different places and just debate how things should/shouldn't be

CIS gendered individuals have the advantage of clear data showing that their hormone levels are outside specific ranges and can be appropriately corrected.  Whether we like it or not, at the moment, and until they can find another appropriate method, much of the transgender identify is mentally perceived.  Since this is the case, and before dangerous cross-sex hormones are prescribed there should be some checks and balances to verify that what we "feel" is indeed correct and not something else going on....and that we know what to expect realistically long term. 

Ask a CIS gender individual to go to the Dr. and ask for hormones because they "feel" they're not right and see what traction they get without a battery of tests and verification. 

I'm just as confident as you in my identity, but I also feel that even with this confidence, jumping into something without some feel for RLE is like marrying a mate without a first date.  Even if your head says it's exciting, they are attractive, and on paper they are compatible...do you think that's a good idea?  Do people do that?  Yes.  However, I bet the chances of that being the correct decision is decidedly low.  Also, some of us are plenty capable of mentally calculating the future...relationships, finances, society etc.... but I also have been exposed to individuals that are just as confident and desperate as you and I but are just as likely to think they are a chicken tomorrow.....i.e. not ready for such an important decision without a dose of reality.

[xFreya]

CIS gendered individuals have the advantage of clear data showing that their hormone levels are outside specific ranges and can be appropriately corrected.  Whether we like it or not, at the moment, and until they can find another appropriate method, much of the transgender identify is mentally perceived.  Since this is the case, and before dangerous cross-sex hormones are prescribed there should be some checks and balances to verify that what we "feel" is indeed correct and not something else going on....and that we know what to expect realistically long term. 

Ask a CIS gender individual to go to the Dr. and ask for hormones because they "feel" they're not right and see what traction they get without a battery of tests and verification. 

I'm just as confident as you in my identity, but I also feel that even with this confidence, jumping into something without some feel for RLE is like marrying a mate without a first date.  Even if your head says it's exciting, they are attractive, and on paper they are compatible...do you think that's a good idea?  Do people do that?  Yes.  However, I bet the chances of that being the correct decision is decidedly low.  Also, some of us are plenty capable of mentally calculating the future...relationships, finances, society etc.... but I also have been exposed to individuals that are just as confident and desperate as you and I but are just as likely to think they are a chicken tomorrow.....i.e. not ready for such an important decision without a dose of reality.

Of course gender identity is perceived, it is something perceived by each person trans or cis, even if cis people are often unaware they have a gender identity. Can a psychiatrist tell whether a patient trans or not? Until we can figure out a way to do brain scans or something to consistently diagnose it, they can only help the patient figure it out, educate them on their options and try to help them with problems they may face transitioning. They shouldn't use strict RLE rules for people who certainly want HRT. Or maybe endos shouldn't require it for adults, Idk. Doing RLE isn't really a simulation of HRT's physical and mental effects anyway.

Hormones aren't even that dangerous when they are done with an endo. I wish I wasn't that scared of HRT when I was in my teenage years.

I am not desperate at the moment by the way, I've been on HRT for 15 months and post SRS for almost 4 months.

[misschievous]

Is there actually a country where one has to do RLE pre-HRT?

Not sure about whole country, but my therapist would not refer me to HRT without going out in Full fem. I told her that I have went out with Makeup, nails done, hosiery, ladies t shirt, and heels. But with men's jeans on. She said that wasn't good enough.

[SadieBlake]

Not sure about whole country, but my therapist would not refer me to HRT without going out in Full fem. I told her that I have went out with Makeup, nails done, hosiery, ladies t shirt, and heels. But with men's jeans on. She said that wasn't good enough.

r

Not knowing where you are I don't know about practice there but WPATH v7 doesn't require RLE or a therapist referral at all for HRT. All that should be required is a diagnosis of gender dysphoria without any psychiatric contraindications. Your physician ought to be able to refer you for HRT - that's what mine did.

Version 6 of WPATH did have an RLE requirement and just as not all mental health professionals choose to follow new versions of the DSM, physicians may choose to observe an older protocol.

[Complete]

So it seems there are more than a few trains of thought running through this thread. One is that a responsible approach to hrt is for the patient to fully understand the effects and the ultimate result of long term use. Another seems to be that any adult should be entitled to these drugs without any responsibility for the consequences or even to pay for them. Some seem to think that these powerful drugs should be dispensed for whatever reason that someone might want. There are many on this forum who want or use these drugs for simple feminization, while still wanting to maintain their virility.
Is this not a misuse of these drugs? Is it the right of these people to have these drugs and make the rest of us to pay for them? Personally, l don't think so.

[SadieBlake]

So it seems there are more than a few trains of thought running through this thread. One is that a responsible approach to hrt is for the patient to fully understand the effects and the ultimate result of long term use. Another seems to be that any adult should be entitled to these drugs without any responsibility for the consequences or even to pay for them. Some seem to think that these powerful drugs should be dispensed for whatever reason that someone might want. There are many on this forum who want or use these drugs for simple feminization, while still wanting to maintain their virility.
Is this not a misuse of these drugs? Is it the right of these people to have these drugs and make the rest of us to pay for them? Personally, l don't think so.
&WRT gcs:
Nowadays it seems that anyone who wants it, or thinks they want it, should get it at taxpayers expense.

Addressing your last point first, nobody I know that's been on HRT or for GCS has spent a dime of taxpayer money on either, they've all done it out of pocket or by employer health insurance. In the case of the latter it was friends who worked for IBM and John Hancock insurance company respectively and it was covered as medical expenses because those are companies that appreciate that the value they derive from their employees dwarfs what they pay out in healthcare costs. Both of these women had their transition medical fees covered including BA and electrolysis in the early '90s and early '00s respectively.

My coverage isn't quite as complete as theirs but I'd bet if I wanted to pursue BA and full hair removal, I could get it covered, moot point, as I don't want these things. And if my insurance were government funded, so what? We pay into Medicare all of our working lives, like any insurance, that's how it works. The key is "medically necessary", if that bar is met then it's correctly covered by insurance.

As for "misuse", by definition if the 'drugs' are prescribed by a licensed MD then it's not misuse. I would also argue that hrt isn't a drug, it's a normal and essential part of our bodies that are absolutely essential for metabolic and mental health (hormones are an essential to the body's healing systems as well as for production of neurotransmitters). In terms of those fundamentals testosterone and estrogen serve the same purposes so it's simply a matter of having the correct one in place.

I can't really fathom what you intend by "want or use these drugs for simple feminization, while still wanting to maintain their virility."

If you mean to say that one should not be permitted to transition as far as HRT will allow unless also proceeding to GCS, I say bollocks! First off, one hardly remains virile just because there's still a penis in place. In my own case I determined that I'd be happier on HRT and foregoing vaginoplasty than doing nothing and I weighed this exhaustively with my psychiatrist and my gf. Ultimately I decided I needed GCS as well and so far hindsight says the decision was far more correct and necessary than I'd imagined.

[Complete]

I am happy things worked out so we'll for you and that you benefit from your employer's health plan. Others are not so fortunate. I still think the purpose of RLE is to at least try to make sure the person about to embark on a profound life change understands what to expect. That is all. If someone is in a position to pay their own way, then  of course they can do what they want. If however the are not and someone else,  be it an insurance plan or gov't., then  the decision is in the hands of others. If you were putting up the money for someone else, would you not want some assurances that  your money was being well spent?