Real life experience (transgender)

Standards of Care

The sixth version of the World Professional Association for Transgender Health's (WPATH) Standards of Care (SOC), published in 2001, lists the parameters of the RLE as follows:

1. To maintain full or part-time employment;
2. To function as a student;
3. To function in community-based volunteer activity;
4. To undertake some combination of items 1-3;
5. To acquire a (legal) gender-identity-appropriate first name;
6. To provide documentation that persons other than the therapist know that the patient functions in the desired gender role.

The seventh version of the SOC – which was published in 2011 and is the most recent edition of the standards – is more ambiguous, and does not list any specific parameters for the RLE. Instead, they merely state that the individual should be living full-time in their preferred gender role continuously for the duration of the RLE. They also state that documentation of a name and/or gender marker change can be presented as a way of providing proof that the RLE has been completed, but do not state that a name and/or gender marker change is a necessary requirement for completion of the RLE. Taken together, these changes may be signs of WPATH moving away from gatekeeping, which the SOC have been criticized for.

Necessity

The SOC are followed by most medical professionals who specialize in the care of transgender individuals, and are the most widely followed clinical guidelines for the treatment of transgender persons in use. Hence, the SOC criteria for HRT and GRS, including completion of an RLE when applicable, must usually be met for one who seeks such treatments to receive them.

As of the seventh version of the SOC, a three-month minimum requirement of RLE is no longer part of WPATH's recommended criteria for HRT. A referral letter alone from a qualified mental health professional now suffices. The SOC state:

Although professionals may recommend living in the desired gender, the decision as to when and how to begin the real-life experience remains the person's responsibility.

With respect to mastectomy/chest reconstruction and breast augmentation, the seventh version of the SOC do not require an RLE for these procedures; nor is an RLE required for hysterectomy, salpingo-oophorectomy, or orchiectomy, or for other procedures such as facial feminization surgery and voice feminization surgery. However, for GRS, including metoidioplasty, phalloplasty, and vaginoplasty, one year of continuous RLE is a listed requirement.

Previous versions of the SOC stated that an RLE for GRS was an absolute requirement that could not be skipped or ignored. However, the seventh version of the SOC appears to be less stringent, and does not contain any such statements. In addition, WPATH emphasizes that the SOC are merely clinical guidelines, and are intended to be both flexible and modifiable to meet the circumstances of the patient and the preferences and judgement of the clinician. Hence, the latest version of the SOC appear to allow for, in certain circumstances, the RLE to be skipped.

Clinical practice in many places may be more or less stringent. In the United Kingdom, most National Health Service trusts will require two years of RLE before surgery, whereas in countries such as Thailand and Mexico, some surgeons may not require the completion of any RLE at all.

Proof of completion

The seventh version of the SOC state that medical professionals should clearly document a patient's RLE in their medical chart, including the start date of living full-time for those preparing for GRS. Sometimes surgeons may require proof that the RLE has been completed. The SOC state that, if applicable, proof may be provided in the form of communication with individuals who have related to the patient in a gender identity-congruent role (such as, presumably, the patient's physician, therapist, boss, or a teacher), or as documentation of a legal name and/or gender marker change.

Criticism

Though the SOC's one-year RLE requirement prior to GRS is almost universally followed by surgeons, it has not gone without criticism. Like the previous three-month RLE requirement for HRT, some transgender people have expressed unhappiness with it, declaring that it is unnecessary. Supporting such claims, physician and sexologist Anne Lawrence, in a paper presented at the XVII Harry Benjamin International Symposium on Gender Dysphoria, stated that there is little scientific evidence that a one-year RLE is necessary or sufficient for favorable outcomes following GRS. In addition, she presented the results of a study she conducted on a group of trans women in which she showed that GRS without a prior one-year RLE could be undergone without the subsequent expression of regret. She concluded that her results did not support the SOC requirement of a one-year RLE as an absolute requirement for GRS.

Further in support of the idea that a one-year RLE requirement prior to GRS is unnecessary is the fact that regrets, as well as suicide, are very rare in post-operative transgender people in general. In another study conducted by Lawrence, she showed that in a group of 232 post-operative trans women, none expressed outright regret, and only a few expressed even occasional regret. In addition, a 2002 review of the literature reported that there is less than a 1% rate of regrets, and a little more than a 1% rate of suicide, among post-operative transgender people; for comparison, the rate of suicide in the general population is only about 1%, while the suicide attempt rate of the transgender population as a whole is about 41%.