Where did the real-life test originate?
The origin of the real-life test is shrouded
in mystery. According to one researcher, Aaron Devor Ph.D., the real-life test
may be traced to a 1974 pamphlet entitled "Guidelines for Transsexuals." The
pamphlet was originally written, published, and distributed by the Erickson
Educational Foundation, an organization founded by Reed Erickson, a wealthy
female-to-male transsexual, to facilitate research into transsexuality. The
EEF sponsored annual international gender dysphoria conferences, a series that
grew into the HBIGDA Symposia, and financed the work of many pioneers in
transgender research: Erickson himself wrote the foreword of the path breaking
Transsexualism and Sex Reassignment, published in 1969. It is Devor's position
that Erickson's personal doctor, James Lorio, was behind many of the
recommendations and much of the medical information disseminated through the
EEF, and that the real-life test, then suggested as a six month to two year
period "trial period," was recommended by Dr. Lorio who independently
developed the idea.
The brochure indicates that gender clinics would likely hold their patients to
a trial period of up to two years before administering hormones or performing
SRS, and provides two cautionary tales of would-be transsexuals who, after
taking on a real-life test, discovered that living full-time as women was not
for them: one was a married heterosexual transvestite, while the other was
dismayed at the second-class social status afforded women and ultimately
accepted himself as a homosexual man.
That gender clinics used a real-life test can also attributed to the work of
the EEF, the principal organization through which doctors working in gender
clinics exchanged new ideas and research during the early years. However,
earlier references to a trial period exist in the literature, with the
earliest appearing to be Harry Benjamin in 1966. Richard Green identifies the
necessity of a trial period in Transsexualism and Sex Reassignment and
attributes the recommendation to Benjamin. Green also notes the difficulty in
passing without electrolysis and hormones, and noting that estrogen's effects
cease with the end of hormone therapy, has no misgivings in referring his
patients for endocrinological care during the trial period.
The reasons given for the real-life test by the Guidelines are "to allow you
to overcome awkwardness, establish new behavior patterns, and approach
unfamiliar situations with an unforced inner confidence." Rather than fixing
the time period of the trial, it says, "[w]hen you have achieved this, the
moment will have arrived for surgery to confirm the changes which you have so
well prepared."
Green's explanation of the trial period closely mirrors that of the brochure.
His practice of referring patients for hormone therapy at the induction of
their trial period is in accordance with the Guidelines, which state "it is
advisable to postpone your testing of the new identity until the hormones
administered by your physician produce adequate physical changes." In the
Guidelines, the real-life test is practically defined as a period of six
months leading up to sex reassignment surgery.
These early positions on providing sufficient medical intervention to allow a
transsexual patient to pass during the real-life test are in opposition to the
HBIGDA Standards of Care. The Standards of Care, in their first release in
1979, were far more conservative than many of the well-known doctors working
in the field at the time. For instance, patients had to undergo a six-month
real-life test in order to gain access to plastic surgery on any part of the
body other than the genitals and breasts (such as for rhinoplasty or to have
the Adam's apple "shaved"). This requirement was dropped in 1981.
It's commonly believed by both transsexual people and their care providers
that a real-life test of any duration is required before beginning hormonal
therapy. This requirement was dropped from the 1981 version of the HBIGDA SoC,
although the requirement that a clinician make the formal recommendation for
hormones remains. By 1988 the real-life test had made its way back into the
SoC, although as part of an either/or proposition: patients are now required
to perform either a three-month RLT or undergo a period of psychotherapy, with
three months being a recommended period of therapy. It is in this form that
the real-life test exists in the current version of the HBIGDA SoC, although
with a caveat for harm reduction: if the patient is taking black market
hormones, monitored hormone therapy is recommended as an alternative, even if
the patient has not undergone a real-life test or psychotherapy of sufficient
duration.
Despite Green's early claims that hormones do not have serious long-term
effects, the HBIGDA Standards of Care have always included strong language to
the opposite viewpoint: they maintain that hormone therapy is potentially
dangerous and its effects possibly irreversible. In both cases, these views
seem primarily directed at males taking estrogen and antiandrogens, the
effects of which are largely reversible; the effects of testosterone on voice
and body hair, although not in the short-term for fertility, are irreversible.
At the same time, the SoC maintain a curious position that the only way to
know whether living as a woman (or as a man) is to try it (i.e. the real-life
test), and beyond initial diagnosis and therapy, the only way to know whether
hormones are indicated is to administer them: if the patient comfortably
adapts to living in the gender of his or her choice, and if he or she is
pleased with the effects of hormones, then they have been correctly
prescribed.
Does the real-life test work?
Leah Schaefer Ed.D, a charter member of HBIGDA, two-time past president of
HBIGDA and one of the authors of the most recent version of the Standards of
Care says "I have never believed in that [the real-life test]. How can you
make those changes... what if you decide you don't want to [transition] now or
ever?" Instead of a real-life test, Dr. Shaefer requires patients to attend
fifteen educational sessions, with two to three weeks between sessions to
allow patients to digest the information provided, before referring patients
for hormones. No research has backed up the assumption that a real-life test
of any set duration is most beneficial to transsexual patients seeking hormone
therapy and surgery, and until recently, no research refuted it, either. Anne
Lawrence writes:
The importance of the Real-Life Experience is probably the closest thing to a
"sacred cow" that exists in the world of transsexual care. But there is
surprisingly little empirical evidence that a one year real-life experience--
or indeed that any real-life experience-- is either a necessary or a
sufficient condition for achieving favorable outcomes after SRS.
In Lawrence's research in a small sample of post-op transsexuals who underwent
less than a full year of the real-life test before surgery, she has found no
instances of regret. Among the reasons given by the subjects for taking
shorter RLEs were financial stability in the former gender role, and
discomfort in living as or fear of discovery as a pre-operative transsexual
woman.
Katherine Rachlin's review of the literature on post-operative regret suggests
that incidence of postoperative regret is generally extremely low, at around
1-1.5% of post-operative transsexuals. Of the contraindications for SRS found
in the research, none are absolute contraindications, and length of real-life
experience prior to transition is not one of them. Rachlin writes: "Negative
prognostic factors tend to lie in the area of psychological dysfunction,
family background, sexual orientation, disrupted social contacts, insufficient
professional support during the 'real life test', and complications in
surgery."
Rachlin brings up further issue with the either/or requirement of a real-life
test or psychotherapy provided by the HBIGDA Standards of Care. If, as
Lawrence discovered, there are valid reasons for avoiding the RLE before SRS
that do not negatively affect post-operative regret, this leaves therapy as
the requirement. However, Rachlin points out many difficulties in complying
with the therapy requirement: in addition to the difficulty in finding a
qualified therapist with experience in gender dysphoria issues, there is the
ethical issue of a professional being both therapist and gatekeeper, a dual
role that does not inspire trust from the patient. Further, patients seeking a
therapist only to fulfill the HBIGDA requirement tended not to get much
personal growth from their therapy experiences.
Conclusions
Because HBIGDA's Standards of Care require either a real-life test or a
required period of therapy, there is a necessity to research whether either of
these significantly benefit clients seeking cross-gender hormones and SRS.
Benefit being a subjective term, this research should be performed by
interviewing post-operative patients as Lawrence has done, but on a larger
scale, to determine their satisfaction and level of regret with their decision
to transition. If further research reveals that the real-life test or a period
of fixed length in therapy has no value in increasing satisfaction or reducing
regret, HBIGDA should be bound to consider this when drafting the next version
of the Standards of Care for Gender Identity Disorders.
Sources
Devor A. Reed Erickson and the Erickson
Educational Foundation. Available online at http://web.uvic.ca/~erick123/.
Guidelines for Transsexuals. (1974). Erickson Educational Foundation.
Available online at http://www.genderweb.org/general/ts-inf.phtml.
Harry Benjamin International Gender Dysphoria Association. (March 1981).
Standards of care for the hormonal and surgical sex reassignment of gender
dysphoric persons.
Lawrence A. (4 November 2001). SRS without a one year RLE: still no regrets.
Paper presented at the XVII Harry Benjamin International Symposium on Gender
Dysphoria, Galveston, TX.
Levine et al. (15 June 1998). Harry Benjamin International Gender Dysphoria
Association's Standards of care for gender identity disorders (fifth version).
Meyer W et al. (February 2001) The standards of care for gender identity
disorders - Sixth Version. IJT 5,1, http://www.symposion.com/ijt/soc_2001/index.htm.
Rachlin K (2002) Transgender Individuals' Experiences of Psychotherapy. IJT
6,1, http://www.symposion.com/ijt/ijtvo06no01_03.htm.
Transsexualism and sex reassignment. (1969). Green R & Money J Eds. Baltimore:
The Johns Hopkins Press.
