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Are the Criteria for the ‘Real-Life Experience’ (RLE)Stage of Assessment for GID Useful to Patients andClinicians?Helen Barker a & Kevan Wylie aa The University of Sheffield & Porterbrook Clinic in Sheffield , United KingdomPublished online: 12 Dec 2008.

To cite this article: Helen Barker & Kevan Wylie (2008) Are the Criteria for the ‘Real-Life Experience’ (RLE) Stage ofAssessment for GID Useful to Patients and Clinicians?, International Journal of Transgenderism, 10:3-4, 121-131, DOI:10.1080/15532730802297314

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Are the Criteria for the ‘Real-Life Experience’ (RLE) Stageof Assessment for GID Useful to Patients and Clinicians?

Helen BarkerKevan Wylie

ABSTRACT. A clinician’s recommendation for progression to gender reassignment surgery is usuallysupported by a successful RLE. However, the gate-keeping role of clinicians can put them at odds withthe supportive position most caring professionals adopt. The RLE criteria used in a regional clinic werereviewed with a cohort of patients undergoing gender role transition.

All nineteen patients were male to female trans women, with eighteen living in role all of the timeand fourteen being fully aware of the RLE criteria. Eighteen found it useful to live in role full-time, withthirteen finding clinicians’ knowledge of their RLE very useful. Five patients experienced problemswith living in role, while the majority (n = 14) reported no/not many problems. Despite this, seventeensaid they would live in role all of the time, even if their behaviour was not being assessed for progressionto surgery. One hundred percent of responders thought that living in role was an important part of theassessment process for gender dysphoria.

Although patients found living in role valuable and important, a number of suggestions were madefor improvements to the RLE criteria used by the regional clinic. These included the ability to commencehormone therapy as soon as the RLE begins, and incorporating time spent living in role whilst on thewaiting list with documented real life experience.

KEYWORDS. Real-life experience (RLE), living-in-role, HBIGDA standards of care, genderdysphoria, gender role transition

INTRODUCTION

Regional clinics use standards of carewhen designing their assessment and treatmentservices. Diagnostic assessment (using the diag-nostic criteria outlined in the DSM-IV-TR), ther-apy sessions, the prescription and monitoring ofhormones, supporting the real life experience(RLE) of cross-gender living, and referral forsex reassignment surgery (SRS) are core servicesand adhere to the Harry Benjamin InternationalGender Dysphoria Association (HBIGDA) (nowrenamed World Professional Association forTransgender Health—WPATH) Standards of

Helen Barker is a student doctor and Kevan Wylie, MD, DSM, FRCP, FRCPsych, is Consultant in SexualMedicine at The University of Sheffield & Porterbrook Clinic in Sheffield, United Kingdom.

Address correspondence to Dr. Kevan Wylie, Sexual Medicine, 75 Osborne Road, Nether Edge, SheffieldS11 9BF, UK (E-mail: kevan.wylie@sth.nhs.uk).

Care. The investigators examined the criteriafor the RLE stage of the assessment in a re-gional clinic and set out to explore the ad-vantages and disadvantages of this stage ofassessment.

BACKGROUND AND JUSTIFICATION

When searching the current literatureavailable on this topic, it becomes clear that in-formation and data specific to this topic is nonex-istent. Searching Medline and PsychINFO withthe terms ‘living in role,’ ‘real life experience,’

International Journal of Transgenderism, Vol. 10(3–4) 2008C© 2008 by The Haworth Press. All rights reserved.

doi: 10.1080/15532730802297314 121

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and ‘real life test’ as keywords, published after1998, identified no published papers.

However, the RLE is usually mentioned inoutcome research of SRS, for example in,Sex Reassignment. Thirty Years of InternationalFollow-Up Studies after SRS: A ComprehensiveReview, 1961–1991 by Pflaffin and Junge (1998).It is mentioned in follow-up studies concern-ing treatment effectiveness factors by Blanchard,Clemmensen, and Steiner (1983), Blanchard,Steiner, and Clemmensen (1985), Fahrner et al.(1987), and Kuiper and Cohen-Kettenis (1988),finding that psychological benefits were demon-strated during the entire process of gender re-orientation, not just following hormones andsurgery, but also following the appearance andestablishment of oneself in the new gender role,i.e., during the RLE. These findings were con-firmed by Kuiper and Cohen-Kettenis (1988),who found that whether surgical treatment hadbegun or not was less important to subjectivewell-being than just being connected to a treat-ment facility and having started the RLE andstarted hormones, as opposed to being com-pletely untreated. Fahrner et al. (1987) found thatstatistically significant positive changes in well-being already manifest during the time of RLEin comparison to beforehand. However, thesepapers are all discussing benefits of embarkingon an RLE as part of the ‘treatment’ in compar-ison to beforehand, and not looking at benefitsand limitations of an RLE as part of a prerequi-site assessment for surgery. It is also mentionedmore recently in the work of Carroll (1999),Lawrence (2001), Mate-Kole (1990), and Rach-lin (2002), whose findings are discussed in thediscussion section.

Of the five elements of the transition process(diagnostic assessment, psychotherapy, RLE,hormonal therapy, and surgical therapy), the firstthree require the mental health professional’s as-sessment, and, only when the patient has beendeemed eligible, do the last two come into play.This is generally based on the success of theRLE, and, therefore, much emphasis is based onthis assessment.

According to the Standards of Care, the RLEis defined as the act of fully adopting a new orevolving gender role or gender presentation in

everyday life, and, when assessing this stage,the following abilities should be reviewed.

1. To maintain full- or part-time employment.2. To function as a student.3. To function in a community-based volun-

teer activity.4. To undertake some combination of 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 per-son functions in the desired gender role.

The HBIGDA guidelines state that “sincechanging one’s gender presentation has immedi-ate profound personal and social consequences,the decision to do so should be preceded byan awareness of what the familial, vocational,interpersonal, educational, economic, and legalconsequences are likely to be, and professionalshave a responsibility to discuss these as changeof gender role and presentation can be an im-portant factor in employment discrimination, di-vorce, marital problems, and the restriction orloss of visitation rights with children” (Meyeret al., 2001, p. 17).

The Standards of Care continue to be eval-uated and updated as information in the fieldexpands, and they are not legally binding butmerely an ethical guideline for the care of peo-ple with gender dysphoria. As Meyer et al. state:“The Standards of Care are intended to provideflexible directions for the treatment of personswith gender identity disorders. . . . Individualprofessionals and organized programs can mod-ify them” (2001, p. 1).

These criteria are to ensure that those peoplewho fulfill the criteria (and are therefore mostlikely to have the diagnosis of GD) are eligiblefor hormonal or surgical treatment and “thosewho do not are ‘protected’ from treatment to en-sure any emotional, mental, or comorbid mentalhealth problems are resolved,” and to prevent anyfeelings of regret following sex reassignmentsurgery due to “other psychological difficul-ties, previous traumas, mental illnesses, orunresolved sexual identity disturbances” beingconfused with a gender identity disorder. (IstarLev, , pp. 45 and 48). Another primary reason

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for the SOC’s existence is to defend people’sright to treatment. By creating criteria, wecreate the expectation that people who followthe criteria are entitled to treatment (and thatdoctors have a right to deliver that treatment).It is used by lawyers to support civil rightsfor trans people, access to health care, and forhumane treatment of transgender prisoners incorrectional facilities.

Unfortunately, this places the mental healthprofessional into the “gatekeeper” role, which,although protecting the patient with gender dys-phoria and the surgeon from litigation, places theclinician in a complex role of trying to create anopen, honest, and trusting therapeutic environ-ment while also deciding whether the case is le-gitimate according to the criteria outlined. It maybe quite difficult to create an authentic relation-ship while the patient is aware that the diagnos-tic evaluation puts the clinician in the positionof controlling the access to medical treatment.

Individuals may be desperate to pass throughthe gateway and may feel that being honestwould hinder this pathway and therefore be un-truthful with the clinician. In a study of 52postoperative male-to-female transsexuals, Wal-worth outlined several areas where clients hadlied to therapists in order to meet what theythought the guidelines for transitioning were(1997, using old SOC). Clients may also tryto “fit” the diagnostic criteria as approval fortreatment rests on the clients’ conformity to theoutlined treatment. According to research doneby Denny and Roberts (1997) on 339 patients,nearly 80% were familiar with (previous ver-sions of) the clinical standards of care. Individ-uals who do not fit the diagnostic criteria butidentify as transgendered or transsexual are in adifficult position, as they risk being rejected fortreatment by the clinician if they tell the truth,but equally so should they lie about their expe-riences to try and gain treatment.

A question that could be asked at this stageis what training do the clinicians makingthese decisions have? The HBIGDA guidelinesindicate a master’s degree or higher in a clinicalbehavioral science field, specialized training andcompetence in assessing DSM-IV and ICD-10Sexual Disorders, and supervised training andcompetence in psychotherapy. However, it

statesno specific training in gender identitydisorders is needed before commencing workin this field except “continuing education in thetreatment of gender identity disorders, whichmay include attendance at professional meet-ings, workshops, or seminars, or participatingin research relating to gender identity issues”(Meyer et al., 2001, p. 7), which is essentiallygained in experience while working in the field.This is typical of specialist clinical services,which often have no specific training programsor degree courses.

In practice, within regional clinics, the re-quirement for cross-gender living prior to hor-mone treatment differs: Coetten-Kittinis (1999)states: “Treatment centers vary in their policyon eligibility for hormone treatment. Some re-quire a period of successful cross-gender liv-ing without hormone treatment in addition toa diagnosis of transsexualism, whereas, in oth-ers, hormones are prescribed as soon as cross-gender living has started” (p. 324, again usingold SOC).On this matter, Raj (2002) states “[TheRLE] as a rigid prerequisite for those desiringsex hormone treatment (a partially reversible in-tervention); open dialog between provider andconsumer is encouraged, recommending negoti-ation and flexibility wherever possible. Clinicaldiscretion to waive this requirement ultimatelydepends upon the specific situational realities ofthe individual, such as, for example, a potentialrisk to the safety of those who might be vulner-able to ‘trans-bashing’ because their biologicalsex status would be detected without the benefitof opposite-sex hormones” (p. 12).

RLE Is Not an Absolute Requirementfor Hormones

The Standards of Care state three eligibil-ity criteria for starting hormone therapy: “age18 years, demonstrable knowledge of what hor-mones medically can and cannot do and theirsocial benefits and risks; either a documentedreal life experience of at least three months priorto the administration of hormones, or a periodof psychotherapy of a duration specified by themental health professional after the initial eval-uation (usually a minimum of three months)”(Meyer et al., 2001, p. 13).

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“In selected circumstances, it can be accept-able to provide hormones to patients who havenot fulfilled criterion 3—for example, to facil-itate the provision of monitored therapy usinghormones of known quality as an alternativeto black market or unsupervised hormone use”(Meyer et al., 2001, p. 13). Therefore, it is notspecifically necessary according to the Standardsto Care to commence the RLE before the com-mencement of hormones, and the criteria for thisvary between regional clinics.

It is, however, necessary to have completedassessment via the RLE before progression tosurgery.

The specific RLE criteria developed by theregional clinic attended by the patients takingpart in this study are as follows:

� Attended supervised gender clinic for 18months.

� Attended speech therapy as considerednecessary.

� Attended peer group support as recom-mended.

� Change to appropriate new name andchange by statutory declaration.

� Alteration of identification documents(bank a/c, driver’s license, credit card).

� Full-time (1 year) or part-time (2 years)work or as a student with proof from em-ployer or college (letter, pay slip). If retired,proof of regular social interaction (bingo,church).

� Involvement in social interactions in cross-gender role for 2 years.

� Dressing in appropriate gender role duringhormone therapy.

� No recent significant mental health prob-lems/distress.

� Over 21 years of age (for surgery).� No medical contraindications evident for

surgery.� Second opinion obtained from gender

clinic.� Surgical opinion obtained.

Some transgender activists (and many profes-sionals who work with transgender individuals)have started to question both the ethics of thegatekeeping process, and that the outlined cri-teria in the ICD and DSM-IV-TR do not ac-

curately describe the full spectrum of gendervariance. Denny (1996) asks, “Should medicaltechnologies continue to be available only to anarrowly defined class of persons called trans-sexuals, with mental health professionals hav-ing the responsibility and privilege of decidingwho does and does not qualify to receive it?”(p. 44). Does this unrest with the diagnostic cri-teria extend into the criteria for real life experi-ence? In his review of the outcomes of treatmentfor gender dysphoria, Carroll (1999) identifiesseveral groups whose needs may not be beingmet, as they rarely present to professionals fortreatment; these include gynephilic (attracted towomen); transvestic-transexual males who haveurges to become female but are happy to liveprimarily in a male role while cross dressing,etc.; gynephilic females who take on masculinequalities and sometimes a male role while neverseeking treatment; and androphilic males whotake on female roles, often to attract men. Thus,he proposes that only a small proportion of thebroad population of transgendered individualsactually present for treatment. Do the criteriareinforce outdated stereotypes and ignore thewide range of patients with wide-ranging gen-der expression that still define as transgender,suffer from gender dysphoria, and would likeaccess to treatment? Should the criteria be thesame for male-to-female (MTF) and female-to-male (FTM) transgender people, even thoughtheir transition pathways may be different, andthere is little research in this FTM area? Are thecriteria too restricting for patients with genderdysphoria who cannot adequately complete thereal life experience due to fear, ignorance, oreconomy? And, furthermore, do they hinder thedevelopment of an open and trusting relation-ship essential to assessing and treating genderdysphoria? Or, is the RLE, with its criteria,merely an essential part of ensuring that the pa-tient is aware, prepared, and ready for livingin the cross-gender role full-time after surgery,and to ensure gender dysphoria is the correctdiagnosis?

METHODS

Using the population of patients attendinga regional gender dysphoria clinic in 2005,

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questions were asked of 19 individuals attend-ing a regional gender clinic for a routine ap-pointment. The interviews were carried out be-fore or after the patient’s appointment, with thepatient’s informed consent. Confidentiality wasmaintained at all times, and 19 of the 20 patientswho were asked to partake agreed. All the partic-ipants were undergoing a change in gender frommale to female. All participants were asked allquestions (see Box 1), but not all participantsresponded to every question.

Box 1.

1. What stage of assessment/treatment forgender dysphoria are you at?

2. Do you live in role all the time?3. Are you aware of the criteria for living in

role?4. Are you aware of the necessity of living in

role for progression with hormones andsurgery?

5. Do you find it useful to yourself to live inrole?

6. Do you think it is useful to clinical stafffor you to be living in role?

7. Do you find it easy to live in role?8. Have you experienced any problems due

to living in role?9. Would you live in the same way if your

behavior was not being assessed forprogression with treatment for genderdysphoria?

10. Do you think that living in role should bean important part of the assessment forgender dysphoria?

11. How could the assessment for living inrole be done differently?

12. What different support could the clinicgive you to help with the assessment forliving in role?

RESULTS

The results shown in Table 1 are for the ques-tions numbered 1–10. In response to question11, several common suggestions for how theassessment of the RLE could be done differentlywere discussed. The common suggestions are

listed in Box 2, along with the numbers ofpatients who suggested them. The suggestionsgiven in question 12, of further support thatcould be offered by regional clinics, are listed inBox 3, along with the number of patients whosuggested them.

Box 2. Patients Suggestions of How the RLEAssessment Could be Done Differently

• The criteria in the Standards of Care aretoo rigid and need modification (9).

• Individual cases need to be consideredwith more flexibility regarding thecriteria in the Standards of Care andthose used at regional gender clinics (7).

◦ The criteria regarding work/voluntary/work/studying isimpossible to fulfill for somepatients, e.g., those with adisability (3).

◦ requirement to live in the newgender role full-time to fulfill thecriteria is sometimes difficult, e.g.,in a family situation if familymembers are not accepting (2).

• The length of the RLE assessment couldbe shortened to 12 months (5).

• The length of the RLE should be flexibledependent on the individuals needs andas soon as the criteria are fulfilledshould be regarded as complete (5).

• The length of time spent on the waitinglist (often >2 years) could be used asthe real life experience, if living in roleduring this time and documentationcould be shown to prove this, so afurther period would not need to bespent once attending the clinic (4).

• Hormones should be started as soon asthe RLE is started, as it is unreasonableto expect patients to live in a new genderrole without the assistance of the newgender hormones (3).

• The clinicians should have morerealistic expectations of how genderroles may be presented, e.g., not allfemales wear skirts and make up (1).

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Box 3. Patients’ Suggestions of FurtherSupport that the Clinic Could Give to PatientsUndergoing Their RLE

• Practical tips sessions should be available,e.g., where to find wigs and shoes and howto do make up (6).

• Electrolysis should be funded, as facial hairis one of the main factors in “passing” asmale or female and therefore a successfulRLE (3).

• More regular peer group sessions should beavailable (2).

• A buddy system between pre- and postoptranssexuals should be available (1).

SUMMARY OF RESULTS

The results show concordance on all of theanswers to the first 10 questions and some com-mon themes highlighted in response to the last

two questions. Amongst a sample of this size(25% of the current clinic patients), this is un-likely to be down to coincidence. They show:

� The majority of patients are aware of thecriteria for the RLE set out by the clinicsand in the Standards of Care (this wasnot objectively tested and relied on thepatient’s own subjective interpretation oftheir level of awareness of both the clinicsand the Standards of Care criteria), and allare aware of the necessity of undertakingan RLE for progression with hormones andsurgery.

� The RLE is a very important part of the as-sessment process for patients. The reasonsgiven for this are to learn how to functionin the new gender role before embarkingon physical changes, to ensure awarenessand preparation for any problems follow-ing surgery, and to confirm gender dyspho-ria as the correct diagnosis.

TABLE 1. Patients’ perceptions of the RLE

1. Stage Preop and hormones Preop on hormones Postop2 13 4

2. In role Never <half the time half the time >half the time All the time0 0 0 1 18

3. Criteria Unaware A bit aware Quite aware Totally aware1 2 2 14

4. Necessity Unaware A bit aware Quite aware Totally aware0 0 0 19

5. Useful to patient Not useful A bit useful Quite useful Useful Very useful0 0 1 0 18

6. Useful to clinician Not useful A bit useful Quite useful Useful Very useful0 0 0 5 13

7. Ease Very difficult Difficult Variable Easy Very easy0 0 1 8 10

8. Problems None Not many Some Many6 8 3 2

9. In role if not assessed Never <half the time half the time >half the time All the time0 0 1 1 17

10. Importance Not important A bit important Quite important Important Very important0 0 0 0 18

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� Patients find the RLE useful, if not anecessity or already an established wayof life. They also think it is useful forclinicians to see them undertaking theRLE.

� Patients generally find it easy to undertaketheir RLE, although some patients can ex-perience problems. These depend on thesituation and are wide ranging, althoughthe main areas identified are family, work,neighbors, and the general public, espe-cially teenagers.

� The majority of patients would live in roleeven if they were not being assessed by aclinic for progression with hormones andsurgery.

� Patients have many suggestions of how theRLE assessment could be changed. Themain issues identified are the length of theRLE, the rigidity of the RLE Criteria inthe Standards of Care and the clinics inter-pretation and application of them, and theeligibility for hormones at the commence-ment of the RLE.

� Patients also have many suggestions ofhow the clinic could further support themwith their RLE. The main ways identifiedinvolve practical assistance and electroly-sis facial hair removal.

The Patient Clinician Relationship

As the majority of patients stated they wouldbe living in exactly the same way even if theywere not attending the clinic, and most describefeeling a necessity to live in the new gender role,along with those for whom it is an establishedway of life, there was no suggestion that thepatients found it difficult to build an open andhonest relationship with the clinician regardingthe RLE from these results. So it seems theproblems raised by some transgender activistsregarding the “paternalistic tone of protection[being] ultimately a control tactic dictating whohas access to the tools of the medical establish-ment” may not be a rejection of the RLE specif-ically, but a rejection of the entire process oftransitioning through a gender clinic due to afundamental disagreement with having to jus-tify their way of life according to criteria, as

they argue that “anyone can have a nose jobor other cosmetic surgeries . . . without a notefrom their doctor,” and many transgender ac-tivists feel that hormones and surgery should beavailable on demand” (Bornstein, 1994, quotedin Istar Lev, 2004, pp. 49–50). This, however,did not seem to be echoed by the patients inter-viewed here, as they found the RLE to be use-ful and saw it as being useful to clinicians, too.There was, however, still some dissatisfactionwith the RLE, as there were many suggestionsof improvements. These seemed to do with dif-ferences in perceptions of important issues, i.e.,to the patients—practicalities of undertaking anRLE, and to the clinicians—ensuring the crite-ria are fulfilled, and the differences in agendasbetween patients and clinicians with regards totimeframe.

Rigidity of RLE Criteria

Many patients stated that the currently usedcriteria in the HBIGDA Standards of Care weretoo rigid and that they need modification (al-though, even though many patients claimed toknow the Standards of Care criteria, it is diffi-cult to tell whether these patients were actuallydistinguishing between them and the regionalclinics’ criteria interpretation of them). Oth-ers merely suggested that more flexibility wasneeded in applying them to individuals, specif-ically regarding work and hormones. This wasechoed in the report of the needs of transgen-der people in Brighton and Hove (West, 2004).The Royal College of Psychiatrists (RCPsych)is currently consulting to produce good practiceguidelines for the assessment and treatment ofpeople with gender dysphoria. Differences in theRLE from the HBIGDA Standards of Care theypresently suggest include:

� The quality of RLE is assessed via dis-cussion; there is not necessarily a need fordocumentation in all cases, although it maybe needed in some situations.

� There is no specific necessity for employ-ment, just a stable and domestic lifestyle inthe new gender role.

� The time on the waiting list for attendingthe gender clinic may be used as part of

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the overall RLE, if documentation can beprovided.

� A second opinion for surgery should besought early in the RLE so that undue de-lay following a successful RLE will not beexperienced while waiting for the opinion.

� The progression for hormones requireswritten opinion from a psychiatrist or char-tered psychologist and needs discussionwithin a team or network, but there is nomention of a period of RLE prior to com-mencement (Wylie et al., 2006, p. 20).

The suggestions made by patients regardingthe criteria inflexibility, specifically regardingwork and hormones, seem to have been, to someextent, catered for in these guidelines. However,one of the criteria that was mentioned by sev-eral patients as needing modification was thelength of RLE, which in the guidelines is statedas “a minimum of 12 months but usually 12–24 months, which may need extending in somecases” (Wylie et al., 2006, p. 20).

Length of RLE

The patients interviewed came up with a fewsuggestions of how the length of RLE could bechanged. The most popular suggestion was thatit should be reduced to 12 months, this being dueto the dissatisfaction with this particular clinic’scriteria of a 24-month RLE, as the Standards ofCare cite only a minimum 12-month RLE as aprerequisite for surgery. Other suggestions werethat it should be more flexible and consideredcomplete as soon as the criteria are fulfilled, orthat waiting list time be used as the RLE if ap-propriate. The only case control trial cited inthe “Evidence-Based Commissioning Collabo-ration Report of evidence associated with keypoints on the treatment pathways for gender dys-phoria,” produced by SCHARR(Sutcliffe andDixon, 2006) and considered relevant to lengthof RLE, was conducted by Mate-Kole (1990).This was astudy of psychological and socialchange after surgical gender reassignment in agroup of 40 male-to-female transsexual people.The group was randomly divided into two furthergroups with similar family and psychiatric his-tories, both of which were eligible for surgery

according to the HBIGDA Standards of Care(1985). These involved psychiatric assessmentfor six months, a persistent wish for two yearsto change gender, and one year of living in thecross-gender role. One group was then immedi-ately given surgery and the other given surgeryin due course, consistent with the usual wait-ing list. They were followed up two years later,when the second group had still not receivedsurgery. The results of the study showed: “Al-though the groups were similar initially, signif-icant differences emerged at follow-up in termsof neuroticism and social and sexual activity,with benefits being enjoyed by the operatedgroup”(Mate-Kole, 1990). This seems to sug-gest, as our patients did, that the RLE could besafely shortened to 12 months in many cases,which would be a change to the clinic’s criteriain line with the Standards of Care. Evidence foran even shorter RLE comes from Lawrence’sunpublished research with a group of postoptranssexuals who underwent surgery before thefull year of RLE and still experienced no re-grets. Lawrence states: “There is surprisinglylittle empirical evidence that a one-year reallife experience—or indeed that any real lifeexperience—is either a necessary or a sufficientcondition for achieving favorable outcomes af-ter SRS” (2001, p. 1). Indeed, Rachlin (2002)agreed in her research on individual experienceof psychotherapy and states that, in the liter-ature she reviewed, incidence of postoperativeregret following SRS is low, at around 1–1.5%.Of the contraindications for SRS found in theresearch, none are absolute contraindications,and length of real life experience prior to tran-sition is not one of them. “Negative prognosticfactors include psychological dysfunction, fam-ily background, sexual orientation, disrupted so-cial contacts, insufficient professional supportduring the ‘real life test,’ and complications insurgery” (Rachlin, 2002, p. 3). Many patientsstated their reasons for suggesting shortening theRLE or using waiting list time as an RLE hadto do with feeling that they had already waitedlong enough to reach the point of actually at-tending the gender clinic. However, in Carroll’sreview of outcomes of treatment for gender dys-phoria, he cites a large unpublished review byBotzer and Vehrs on factors contributing to a

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favorable outcome of SRS, which found: “Pa-tients reported more satisfaction when they hadspent at least one year living in the desired gen-der role, and that the longer the period, the betterthe outcome” (Carroll, 1999, p. 7).

Patient-Led Pathways

If a patient were to be unhappy with an as-pect of their assessment or treatment for genderdysphoria, for instance, the RLE, under the newNHS initiatives regarding giving patients morechoice about when, how, and where they receivetreatments, they should be able to change theirpathway. The NHS aims to develop new ser-vice models, build on current experience andideas to become truly patient led, and, wher-ever possible, give patients more choice andcontrol(Department of Health, 2005). This iscurrently a contentious issue in all NHS ser-vices as to which services this applies to andhow to practically go about it, but it seemsthat, at the moment, this does not apply to gen-der services. If, following an appropriate periodof assessment, gender reassignment surgery isrecommended, it is usually via a consultant-to-consultant referral, which is outside the scope ofthe requirement to offer a choice of provider.

Supportive Clinics: Image vs. Therapy

Within the suggestions of further support thatthe clinic could offer, the issue that came up mostwas one of image, whether it is practical adviceon where to find hair pieces, shoes, etc., or thecontentious issue of funding for electrolysis andother forms of hair removal. The ParliamentaryForum on Transsexualism (2005) has produced afirst edition of Guidelines for Health AuthoritiesCommissioning Treatment Services for ThoseExperiencing Transsexualism and Gender Dys-phoria to try and help these commissioners makeclinically appropriate decisions regarding fund-ing all aspects of treatment. These guidelinessuggest: “Hair removal treatment of male pat-tern facial hair is likely to form an early partof treatment. For most, this treatment shouldbe regarded as an essential ingredient and notmerely cosmetic” (p. 14). This seems to sug-gest that funding of electrolysis could form partof a patient’s funded treatment, but, at present,

this doesn’t happen in the gender clinics, eventhough many patients see it as a vital and impor-tant part of passing and a large personal financialexpenditure.

Limitations

There are some limitations to this research.There are around 80 patients currently attendingthe regional gender clinic where the researchtook place, and therefore, ideally, a larger num-ber would have been interviewed. In addition, thepatients interviewed were all attending the sameregional gender clinic and are therefore likely tohave had a similar experience of the RLE, ac-cording to the specific criteria of that clinic. Fi-nally, the patients interviewed were all undergo-ing transition from male to female, and, althoughmales present more commonly for treatment atgender clinics (Bornstein, 1994), this obviouslydoes not represent all patients with gender dys-phoria, as the regional clinics do assess and treatseveral patients undergoing transition from fe-male to male. We did not formally identify if therespondents ever read the SOC or saw writtencriteria for the RLE.

Further Work

This research has identified several issueswith, and suggestions of, change to assessmentof the RLE. A larger study with participants indifferent regional gender clinics would be veryuseful to see if the themes highlighted in thiswork can be generalized, and this should also in-clude patients transitioning from female to malewho may highlight a different perspective onissues with the RLE. A study could also be con-ducted on clinicians’ views on the RLE and itscriteria. There is a lack of evidence to supporta rigid position on length of time for RLE, al-though there are many suggestions that the cur-rently specified period could be shortened to 12months. The extent to which changes to guide-lines may meet the demands of a generationof transgender patients with wide-ranging gen-der expression who would like access to treat-ment, and the extent to which the criteria of theRLE, both in the Standards of Care and thoseused at regional clinics, will hopefully accom-modate issues outlined here. Another area that

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130 INTERNATIONAL JOURNAL OF TRANSGENDERISM

clearly requires more work is concerning howtrans healthcare can be made more patient cen-tered in line with the current government policyinitiatives, regardless of any change to classi-fication as a mental health problem or not. Inaccordance with making treatment more patientcentered, the issue over funding and how thiscould be flexibly adjusted according to patients’individual needs clearly needs further investiga-tion, although the Parliamentary Forum Guide-lines on Commissioning, if they become widelyimplemented, may go some way to addressingthese issues.

CONCLUSIONS

In conclusion, this research has found that pa-tients in this clinic find the RLE to be a usefuland important part of the assessment process forgender dysphoria. Aside from the assessmentprocess, patients with gender dysphoria enjoythe experience of living in the new gender role.Those who have been living in the new genderrole previously find it a continuation of an al-ready established lifestyle, which is just part ofbeing themselves. For those whom it is a newerexperience, they are enthusiastic about livinghow they perceive their true self. However, itseems that unrest within the trans communityregarding the gatekeeping process and access totreatment may to some extent influence patientsviews on the RLE criteria. Although the major-ity of patients support the present approach, asizeable minority of patients do find the crite-ria somewhat restricting and inflexible. This isprimarily with regard to length of time, whichis an area where evidence-based controlled tri-als would be helpful so as to support a minimalduration. Some of the clinicians who are work-ing with patients with gender dysphoria also feelrestricted by these criteria. Anecdotally, a clin-ician may feel their hands are tied while tryingto progress a patient for hormones or surgery ifthat patient has a disability that does not allowthem to fulfill the RLE criteria for work. This hasbrought about change in delivery of care withinthe service described. However, as clinicianviews were not sought within the scope of thissurvey there is no evidence here to support this.

Until there is further research in this and widerareas of the assessment and treatment of patientswith gender dysphoria, or the RCPsych guide-lines are finalized, the current HBIGDA Stan-dards of Care will continue to set the guidelinesfor the care of patients with gender dysphoriaand, therefore, the guidelines for the RLE crite-ria. Although, even then, it is likely they will re-main important and influential until these guide-lines are updated by HBIGDA (now WPATH).However, it seems there is a need to use theguidelines flexibly. The advice of “flexible di-rections” should be considered, and each casetreated in its entirety, specifically with regardsthe RLE individually.

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