The Real Life Experience (RLE), sometimes known as the Real Life Test, is the first significant hurdle that most transsexuals face in order to gain access to treatment, such as hormone therapy and gender reassignment surgery. The RLE is a process where transsexual individuals live full-time in their preferred gender role for a specified period of time and historically was an important prerequisite to receive medical care.

The History of the RLE

The RLE has been part of the Standards of Care developed by the Harry Benjamin International Gender Dysphoria Association. Controversially, no research preceded the recommendation for a RLE, which became a central component of the treatment process from 1979.

Following several revisions of the Standards of Care, a minimum requirement of RLE is no longer part of Harry Benjamin's recommendations before hormone treatment. Either three months of RLE or a specified time in psychological therapy is now needed. Before surgery is permitted, there is a requirement of at least one year lived in the new gender role, along with the support of two psychiatric opinions.

The RLE and Clinical Practice

The Standards of Care are open to interpretation, to a certain degree. It states "although professionals may recommend living in the desired gender, the decision as to when and how to begin the RLE remains the person's responsibility".

Clinical practice varies from country to country, but specialist services tend to follow a more cautious, slower-paced approach. In the UK, most National Health Service trusts and specialist gender services require a minimum of two years. Similar views are held by health services in the USA and across European countries. However some countries, such as Thailand, view the Standards of Care as guidelines and not requirements and for some services there, the RLE may not be required at all.

Starting the RLE

The RLE is generally accepted as starting after transitioning full-time. The individual will change their name legally at the start of the period and is expected to work or continue education and function socially as the transitioned gender. They will also have to provide evidence for this. Clearly, particularly at the early stages, this can be a very stressful time so careful planning is needed with the opportunity to access as much support as possible during this time. For some, starting the RLE needs to be more gradual. Some opt for a partial RLE, such as living full-time with the exception of attending work transitioned. There is the expectation that this is only temporary, and for some services, does not count towards the time required for the RLE.

Aims of the RLE

The aim of the RLE is to allow a longer period of decision-making in order to try to reduce the number of people with post-operative regret. Transitioning is a huge task and provides an important insight into how successful treatment may be, the consequences of these decisions and the affects on gender feelings.

It allows a longer period of adjustment in terms of functioning at work, education and in social situations. Also, during this time, there are opportunities to formally change documents, such as legally changing name and birth certificate. The expectation is for the individual to remain in contact with the specialist services throughout the RLE process, with regular reviews. Ongoing monitoring and support are key to its success.

Evidence for the RLE

It is surprising that there is very little research evidence supporting the use of the RLE, and there is very little information to back-up the time-frames specified, yet it remains an important component of treatment. Clinicians argue that it makes sense to allow the time to try to ensure that correct decisions are made but the RLE has attracted criticism from some of the transgender community.

More recent research by Lawrence (2001) studied a small number of post-operative transsexuals who underwent less that 12 months of RLE before surgery and found no evidence of regret.

"There is surprisingly little empirical evidence that a one year RLE, or indeed any RLE, is either necessary or a sufficient condition for achieving favourable outcome after sex reassignment surgery." (Anne Lawrence).

A review of the literature by Rachlin (2002) found that the incidence of post-operative regret is generally very small, perhaps only 1%, with no relation to the length of RLE prior to transition. Negative prognostic factors tend to be associated with psychological readiness and stability, poor emotional support and social isolation rather than to the RLE itself. However the specialist services argue that, without the RLE, many of these factors associated with poor outcome can remain hidden until too late and feel that the RLE is a central requirement to protect transsexuals in their decision-making.

It is clear that larger scale research is needed before the next draft of the Standards of Care is released. Don't forget to tell us your views in the Blog .