Origins of the Real-Life Test

The real-life test is the first significant hurdle most transsexuals face in gaining access to hormone therapy and gender-confirming surgery. The real-life test has been part of the Standards of Care developed by the Harry Benjamin International Gender Dysphoria Association since their inception in 1979. It may come as a surprise to learn that no research preceded the recommendation for a real-life test, and that no research was published on the efficacy of the real-life test in determining success in the new gender role or in minimizing regret after physical transition to the other sex until nearly twenty years after the HBIGDA Standards of Care were developed.

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 “[i]t 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. (3 Jan 2003). Personal interview.

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.

Rachlin K (2002) Transgender Individuals’ Experiences of Psychotherapy. IJT 6,1, http://www.symposion.com/ijt/ijtvo06no01_03.htm.

Shaefer L. (3 Jan 2003). Personal interview.

Transsexualism and sex reassignment. (1969). Green R & Money J Eds. Baltimore: The Johns Hopkins Press.