RLE is a Civil Rights Issue

By Suzi Chase 8/3/15

https://www.susans.org/2015/08/03/rle-civil-rights-issue/

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 It is based on outdated understanding of gender dysphoria and confuses gender expression with body sex.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.

The way I see it, RLE is nothing more than a BS CYA standard made arbitrarily by the WPATH (don't get me started) so that if something goes awry and there are regrets for any reason, the doctors and therapists can testify in court that they went "by the book" if they indeed recommended SRS for someone who was misdiagnosed with GD and ended up being sued.

Since there are as many ways to be trans or deal with being trans as there are transpeople, maybe we should take a more enlightened approach and toss the book altogether.

Then there's the matter of getting your insurance to pay for it without "gotchas" and endless hoops to jump through...

This probably isnt a popular opinion here but I think the RLE for surgery is a good thing. Its a life changing surgery and there is no going back. I know someone who was all gung ho about the surgery and ended up transitioning a few months after going full time. For hrt on the other hand, I think it should be informed consent.

I don't see it as a big deal. I've been full time for maybe 6months and been seeing my therapist for as long as me it seems really not a big deal at least for me. I'm in no hurry on the operation so I just live as me. I could see if someone wanted the operation immediately it would bother them, but for me there is just too much to consider that I never thought of before . I have to worry about the few months I'll have a hard time taking care of my self while I heal. I'm totally alone so I have to plan how I'd get food and clean my apartment and shop and get to places I'd need to go. Its more complicated than I once thought if your alone. I'd be up the creek if I just one day decided to do it and then got home and couldn't move. I had a hip replacement a few years back and had no one to help and it wasn't fun. I just think you really need to seriously think about what your doing unless you've got a lot of money to pay for help or family to help out. Its really not something to do after a night drinking and the thought comes in to your head , yea that would be cool.

I guess RLE is still a prerequisite in the UK and Europe? The clinic I go to for HRT just relied on informed consent, although I did jump through a few hoops (lab work, interviews, a questionnaire etc.). Because of the plethora of medical stuff I've been taking care of with doctors I know and trust, I don't really need a therapist to write the SRS letter. Although I bet that isn't the golden standard for Californians, just the new one since I started a few years ago.
The big concern for WPATH, is to make sure doctors "do no harm." It does have something to do with malpractice insurance, but only obliquely. SRS isn't something surgeons learn in med-school. They have to apprentice with someone already performing those surgeries, and it takes quite a bit of extra dedication to serve the trans community in that way. It seems to me like they wouldn't bother unless they had empathy for our community.
That being said, no one is going to hire a detective to make sure you are living as a woman 24/7 with heels and dresses and makeup for your year of RLE. And by the time your able to get the NIH appointments you need, the standard route I last heard takes like 3-5 years. I doubt you'll want to live as a guy through all of that.


     Hugs,
- Katie
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It is a requirement for most surgeons.  One that they don't wave lightly.  However, they will wave it....

However, I wanted that year to be sure that it was the correct decision. 

Jen

I wish it wasn't a year's wait but am glad there is some wait time. I have taken my sweet time with everything because I want to know I am sure. I didn't begin electrolysis on my facial hair until about a month ago, I needed to fully explore my feelings on that specifically. Now I have my mind on voice, adam's apple and srs. If I could sign up for srs tomorrow I am not sure I would. I have always wanted that thing gone from down there but a surgery of any kind is a big thing to think about.

However, when I first reached out for medical help I was offered a fast path to hrt. I decided to hold off. Two days later I changed my mind and it was the best decision I ever made. The hrt has made being me a good thing and I don't want to do anything big if it has ceased to be a problem thanks to the therapy. My voice comes to mind, I have hated my voice since puberty but I am getting more comfortable with it.

Perhaps, just as with informed consent for hrt a similar process could be in place for srs. A careful encouragement to consider things and let estrogen work its magic. Then the leap of faithers could take their leaps and the pondering types could do their thinking. It should not be in the hands of doctors and especially should not be in the hands of insurance folk. It is a most personal need and the process leading to it should be nurtured and supported at whatever speed the patient requires.

This is an important topic for me.

I am transgender and I have chosen not to transition for personal reasons that are fundamentally important to me. Things that I'll risk my sanity over. I'd like to socially transition, but I can live without it for now.

I'm doing everything I can not to transition. It's a losing battle, but social transition is the very last thing on my list. I'll do it, but only after I've exhausted every other option because that one step has the potential to seriously screw up my life. SRS won't do that, and it might help me stay sane longer. Full strength HRT has certainly helped a lot.

Requiring RLE is essentially saying I have to get divorced to get keep my sanity. That's not right.

RLE should be informed consent, with a psychiatrist determining if someone is informed and mentally capable of consent. The rest is gatekeeping.

When it comes right down to it I'm having SRS with no RLE before or afterwards, and I really don't care if anyone else thinks its a good idea.

Here's a question - what do call an RLE where no GRS follows? What is an RLE where the trans person either cannot or chooses not to have any surgeries at all?

I see the point of the article, but this seems to assume that trans people normally have surgical interventions, and that isn't necessarily so. For these people, RLE isn't RLE - it's just finally living life in your true gender.

Why isn't that the same for those of us who are on the way to surgery? If we see RLE merely as a cisnormatively-mandated burden and an unnecessary delay on the way to GRS then we're missing the whole point of RLE. Life does not begin after GRS.

By inextricably linking GRS to RLE we trans folks are establishing another cisnormative standard, one that says we must transition into a known value in the gender binary and that a proper transition is becoming as "complete" as possible through surgery. GRS is not the pinnacle event of our trans experience. It's just one of the things we do (or not) to achieve gender congruence.

I don't see RLE as a burden so much as a gift. It's an opportunity to explore a path to my real self with the added feature of being able to hit the reset button and try another path if I discover that this one isn't the right one. Cisgender people generally don't get the opportunity to do anything like that.

Quote from: Michelle-G on August 04, 2015, 08:01:27 AM
I don't see RLE as a burden so much as a gift.

Isn't a gift something that is received voluntarily? I.e. you're free to accept or turn down. Can something be a gift if you're required to receive it whether you want it or not because the person giving it has the power to impose it upon you?

For example, if I gave you a gift of a trip to Alaska, it'd be up to you whether you actually went, based on whether you wanted to go. But if I said "you MUST go to Alaska or I will remove some important body part", am I giving you a gift or imposing my will on you?

I don't think it is irresponsible  to advocate proceeding with an irreversible life altering surgery without some kind of assurance that the candidate is fully aware of their choice.  So, if RLE was off the table, what would you suggest as an alternative safeguard.

Having to obtain quite significant amount of money (if paying out of Your pocket) seems to be significant deterrent time-wise which will slow You down anyway - like You wont be able to decide that "hell, yeah, I wanna have that surgery and let's do it tomorrow!".
I have read countless stories about those who wanted to have that surgery and had it, despite of having skipped on RLE and other requirements. IMO, if I wanted, I could probably skip those too. Besides, I keep getting more and more confused on those terms - RLE, full-time, part-time... I never went full-time, I have not changed my name and gender (because the procedure is eff-ed up) - I just go on with my daily life and society treats me as female. Would that qualify as RLE? No idea, but since for me that surgery is till 4-5 years away, I dont effin' care .

Hi Michelle-G,

I'm not really sure I understand what you are saying. If it were in the dictionary I think RLE would be defined as the test you do to before you are granted permission to have GRS, although in less direct terms. It's also called RLT, or Real Life Test, and I think Test describes it quite accurately. It's a test you have to pass before you are granted permission to have SRS.

The article assumes trans people have surgicial interventions because its about RLE, and RLE itself assumes surgical interventions. I don't think its saying anything with respect to GRS in the process of transitioning.

There's plenty of people who are non-op and living as women, but its not RLE as far as I understand the term. Perhaps it's just RL?

I believe I understand what you mean about transgender being gift, but I have to say its a very painful one. However I don't see RLE as a gift because its not a choice. You can't refuse, or at least its very difficult. It's certainly a gift I don't want.

I guess I'm responding to your post as I see it saying that RLE is good in general (I think that's what you saying) while the others are saying how it helped them. I can see how it helps many people, and I'd expect that to be the case. No ones ever going to stop you from doing it.

I personally spent almost exactly 1 year talking to a therapist about starting HRT, and I could have started anytime. It was my choice though, and I started when I was ready.

This entire thing bothers me because its infringing on my rights, and has been causing me a great deal of mental anguish as well. I've wasted a lot of time and effort working out how to deal with this.

I think I forgot to say, I liked the article.

Obviously RLEIs a problem for some and not others. I'm one who actually enjoyed RLE as it was a time that during my journey I had close access to good therapists who helped me in my life changes, but others are not fortunate.

As for alternative models Argentina brought what is basically transition on demand model. You can get any surgery etc whenever and just go for it (I'm not sure of how it is financed as to whether there is free or subsidised health care). Unfortunately this seems to have lead to a greater number of post op regret people than in other models. There has to be a happy medium but I'm not sure what it would be.

Certainly if you go to the other extreme of some Scandinavian countries where transition is strictly controlled to a horrible cruel level there are very few people who have regret, but large numbers of men and women who suffer greatly waiting for their journey to even begin.

Where I am which runs a pretty standard informed consent model nowadays, there are long waiting lists, but for transwomen who eventually get to therapy after undergoing RLE before reaching the therapist, treatment and HRT access is then a rubber stamp.

We are seeking to make that even easier by getting GPs to prescribe HRT, but sadly too many feel they are inadequately trained or experienced enough to do so with confidence.

Quote from: kittenpower on August 04, 2015, 08:58:01 AM
I don't think it is responsible to advocate proceeding with an irreversible life altering surgery without some kind of assurance that the candidate is fully aware of their choice.  So, if RLE was off the table, what would you suggest as an alternative safeguard.

I'd suggest a psychiatrist evaluate people to make sure they are sane, apart from being transgender (it gets a bit gray if they have any other problems, but lets not get distracted by that for now). They should also evaluate that people have a good understanding of the implications of what they are doing.

If you're not crazy and you know what you are doing, whats the problem?

I think it would be called informed consent.

In the UK it is currently the case that RLE is not strictly required for HRT but shrinks do like to see it. For GRS then RLE is required if you get GRS publicly funded, I am not sure if it is required if privately funded but two of my friends went private and I recall that they had RLE for GRS.

One thing that the discussion here has not focused on is the responsibility of surgeons. Doctors and other medical staff have a philosophy of "do not harm" and they need to be convinced that they are doing no harm.

I have seen stories about cis people asking to have healthy limbs amputated and surgeons just say "no". There was even a court case about it. RLE allows the surgeons to be more certain that they are making someone's life better. So both trans and cis people need to convince surgeons that they are doing the right thing otherwise we might not have surgeons to operate at all.

Informed Consent is alright if the person is able to make an informed choice, but I have met people at support groups who say they want surgery but are barely able to decide whether to drink tea or coffee. There was even somebody on here who could not convince the NHS to do GRS so she went to Thailand and has since blogged about her medical disaster.

If Informed Consent = "I want to buy that diagnosis, no questions asked" then it is as flawed as the method that requires RLE for everything. The extremes are no use, the answer lies somewhere in the middle.

Quote from: ♡ Emily ♡ on August 04, 2015, 09:08:12 AM
Having to obtain quite significant amount of money (if paying out of Your pocket) seems to be significant deterrent time-wise which will slow You down anyway - like You wont be able to decide that "hell, yeah, I wanna have that surgery and let's do it tomorrow!".

It would slow many people down, but I think there's quite a few people here who could easily pay for it. That "decent jobs" thread was petty interesting. Its probably more older people who have that kind of money at hand, and I'd hope they (we) have learned some common sense over the years.

One thing that Im finding interesting in this conversation is we don't seem to be able to propose a 'better' model. Reflecting on that, many of the leaders of WPATH and the group who are responsible for the SOC are themselves trans*, having met a number of them they are only interested in providing the best care and guidelines they can under the constraints of legal issues, and to an extent the USA insurance companies.

I do get a very strong feeling the the health care providers want the best outcomes, are not interested in gate keeping but need to comply with the legal systems they work under. In saying that, I am obviously aware that not all medical providers are in WPATh etc and may not share those principles.

Quote from: vcjhyt on August 04, 2015, 09:25:34 AM
One thing that the discussion here has not focused on is the responsibility of surgeons. Doctors and other medical staff have a philosophy of "do not harm" and they need to be convinced that they are doing no harm.

I have seen stories about cis people asking to have healthy limbs amputated and surgeons just say "no". There was even a court case about it. RLE allows the surgeons to be more certain that they are making someone's life better. So both trans and cis people need to convince surgeons that they are doing the right thing otherwise we might not have surgeons to operate at all.

I don't think there's much to be said about the surgeons responsibility. A surgeon is not trained to evaluate someone to know if this is the right thing to do, so they just have to follow the guidance of someone who is. To that extent its their responsibility, but if you have that letter they are going to do their job. I doubt they much care about 1 year RLE, and why should they be expected to know if its a good idea, or if someone has even done it. In contrast they don't ask for a diagnosis for any cosmetic surgery. I think the difference is that if you want SRS you're crazy until proven otherwise, and maybe even then, but everyone can understand the advantages of bigger breasts.

I also don't believe this "do no harm" idea. The entire USA medical system seems to be predicated on extracting the maximum amount of money from people and harming them as necessary to do exactly that. I'm feeling quite cynical.

Quote from: vcjhyt on August 04, 2015, 09:25:34 AM
Informed Consent is alright if the person is able to make an informed choice, but I have met people at support groups who say they want surgery but are barely able to decide whether to drink tea or coffee. There was even somebody on here who could not convince the NHS to do GRS so she went to Thailand and has since blogged about her medical disaster.

If Informed Consent = "I want to buy that diagnosis, no questions asked" then it is as flawed as the method that requires RLE for everything. The extremes are no use, the answer lies somewhere in the middle.

I agree with you, and those examples are not informed consent as I understand it, or as Wikipedia defines it

"An informed consent can be said to have been given based upon a clear appreciation and understanding of the facts, implications, and consequences of an action. To give informed consent, the individual concerned must have adequate reasoning faculties and be in possession of all relevant facts. Impairments to reasoning and judgment that may prevent informed consent include basic intellectual or emotional immaturity, high levels of stress such as PTSD or a severe intellectual disability, severe mental illness, intoxication, severe sleep deprivation, Alzheimer's disease, or being in a coma."
https://en.wikipedia.org/wiki/Informed_consent

Quote from: Cindy on August 04, 2015, 09:45:23 AM
I do get a very strong feeling the the health care providers want the best outcomes, are not interested in gate keeping but need to comply with the legal systems they work under. In saying that, I am obviously aware that not all medical providers are in WPATh etc and may not share those principles.

What legal systems do they need to comply with? I wasn't aware there were any, though I suppose malpractice must be based on something.

Thailand has some laws, but for foreigners that's basically to get a letter from a foreign psych, the details of which don't seem to be terribly important.