BlogShare: “RLE – Really!?” by Darlene Tando, LCSW

When I first began the “Conversations with a Gender Therapist” blog in June 2013 (now I was given the advice to scout out my “competition.” Since the goal of my blog isn’t to make money or for me to be seen as the best gender therapist in the world, I didn’t feel the need to approach it’s creation in such a manner.

However, I did spend a lot of time on the internet trying to discover other gender therapists out there who care as much about the work they do as I did. That’s when I came across Darlene Tando.

Darlene is a Licensed Clinical Social Worker with a private practice in San Diego. She has been working with transgender clients since 2006, and a large part of her practice is dedicated to working with gender nonconforming/transgender youth and adults. Darlene believes the individual is the “expert” on one’s own gender identity.

She has been keeping a blog since 2011 in which she discusses her work in the gender field. Besides my blog, hers is the only other one in the world I have been able to find that is written by a gender therapist (please correct me if I am wrong, readers!). I’ve been turning to her blog frequently for insight and advice, especially when it comes to working with transgender youth, and will be turning to her as a mentor in the days to come.

I wanted to take this opportunity to introduce you Darlene and her blog. And what better way to do so than to share with you one of her most recent posts!

This one is from August 2013 and is entitled RLE – Really!? In it she discusses the controversial issue of the “Real Life Experience” that some health care professionals are still (mistakenly) using as a requirement for transgender patients before they will provide them with medical assistance with transitioning. Her perspective provides a much-needed explanation to those who do not understand just how unfair, illogical, and even dangerous it is to expect someone who is transgender to endure the RLE.

RLE – Really!? – by Darlene Tando, LCSW

Recently in my quest for a doctor to provide hormones for a teenager outside of San Diego, the issue of “Real Life Experience” came up. The doctor made reference to the fact that this teen had “less than a year of Real Life Experience”. I wanted to respond, “Really!? This teen, who has minimal family support or advocacy, has socially transitioned and has tried to present as male for almost a year, with no medical assistance??” I think that’s amazing. Another doctor told a (then future) client of mine he would need at least 3 months of RLE before getting any type of medical assistance with transitioning. This is an overwhelming concept for most, and I’m glad my client pursued a session with me even after that! I think asking someone to have “real life experience” as the gender with which they identify in order to receive hormones is like asking someone to earn a prosthetic leg by running a marathon!

For those of you who don’t know, “Real Life Experience” used to be a REQUIREMENT for those seeking gender transition. It is, thankfully, becoming an antiquated concept. In the Standards of Care Version 6 (2001), the Real Life Experience is defined this way: 

“The act of fully adopting a new or evolving gender role or gender presentation in everyday life is known as the real-life experience. The real-life experience is essential to the transition to the gender role that is congruent with the patient’s gender identity. Since changing one’s gender presentation has immediate profound personal and social consequences, the decision to do so should be preceded by an awareness of what the familial, vocational, interpersonal, educational, economic, and legal consequences are likely to be. Professionals have a responsibility to discuss these predictable consequences with their patients. Change of gender role and presentation can be an important factor in employment discrimination, divorce, marital problems, and the restriction or loss of visitation rights with children. These represent external reality issues that must be confronted for success in the new gender presentation. These consequences may be quite different from what the patient imagined prior to undertaking the real-life experiences. However, not all changes are negative.”

Yes, there may be negative outcomes to transitioning. Transitioning can be one of the most (if not the most) stressful undertakings an individual ever experiences in his or her lifetime. However, these negative outcomes are not a reason not to do it, they are side effects of someone living true to one’s self.  Asking someone to transition without any assistance medically is quite simply a set-up for more discrimination, and decreases the chance of a positive outcome. The ability to present more as the gender with which someone identifies while transitioning increases the chance of being accepted and acknowledged as one’s asserted gender. This individual described it beautifully:

“Whilst individuals vary greatly, some people have considerably more difficulty being read as their gender prior to HRT [Hormone Replacement Therapy], and AMAB (Assigned Male at Birth) people are more likely to receive certain forms of harassment if people read them incorrectly. Forcing people into public facing roles to get the treatment they need puts them at direct risk of violence, harassment and discrimination.  What ‘real life’ is being experienced? From my own and others’ experience, I know that living full time as a woman pre HRT is vastly different to being full-time after a year on HRT. The near daily abuse and marginalization, with incumbent stress, is not the real life I’m experiencing now, but was a feature of living as a woman who was visibly trans*. The RLE required is entirely unrepresentative.”

In my opinion, the Real Life Experience requirement was a very tricky, if not dangerous, requirement for kids or adults to do before receiving hormone treatment. Being teased, rejected, and bullied can be more of a risk when one is trying to present as the “opposite” gender and not being able to pass due the presence of natal sex markers and the absence of traits of one’s asserted gender. I understand it feels riskier to prescribe quickly with a youth, but the decision-making should be based more on how consistent and persistent his male gender identity has been, his distress at being read as female, etc. Doctors seem to be just as resistant to prescribing hormones right away for adults who have decided to transition. So many people are worried about making certain the individual is “sure.” I can understand this, however- how many people do you think are going to decide to transition when they are unsure about their gender identity, really? The most common source of indecision is the choice about if/when to transition, not one’s gender identity. About that most people are sure, especially when they make the big decision to undergo gender transition.  Attempting to transition while struggling to “pass” may make someone more unsure about their decision to transition, but doesn’t change their gender identity.

I recently watched “TRANS”, a documentary feature film.  When speaking about Christine McGinn, a successful and eloquent doctor, they tell about the steps of her transition like this: “First, live life as a woman.” Really?! That’s FIRST?? With no medical assistance of hormones to soften male facial structure, redistribute body fat, etc.? Just simply, “live life as a woman”? This seems completely backwards. It simply makes more sense to create physical changes first to assist in passing as one’s asserted gender (the gender identity in line with their brain).  Allowing a transgender individual to medically transition IS the way to allow them to get on with life- their real life. Making medical transition harder and less accessible is a sure way to increase stress, depression, and the risk of suicide in a population that already struggles with these issues far more than the general population.

Wondering what the current version (Version 7, 2011) of the Standards of Care says about “Real Life Experience”? Absolutely nothing.  From a weblog written by Dr. Kelley Winters:

“The tone and language of the SOC7 are more positive than in previous versions, with more emphasis on care and less emphasis on barriers to care. Some highlights include […] removal of the three month requirement for either “real life experience” (living in a congruent gender role) or psychotherapy before access to hormonal care.”

Here’s to you, and living YOUR real life, whatever that may be.

Homework Assignment

If you are a reader who is trying to understand better some of the challenges that come with being transgender, what sort of understanding did you gain from what Darlene had to say in this blog post? For those of you who are transgender, leave a comment below the post and let us know your thoughts!

Be sure to visit Darlene’s blog to learn more about her work in the gender field at

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  • zoebrain

    October 5, 2013 at 8:33 AM Reply

    The RLE has little to do with the patient: it has everything to do with the social millieu.

    The idea is that there’s no point providing hormones and surgery if the culture is so transphobic the patient won’t survive. Whereas if treatment is denied, yes, they’ll still die (from suicide rather than murder or starvation) but limited resources won’t have been expended. “Primum non nocere” – First, do no harm. Denying treatment – a negative act – is seen as more ethical than providing treatment that will just get the patient killed, or leave them in a worse situation than before – not through gender issues, but hostility and prejudice.

    That has always been the justification for the RLE.

    However… to insist on this without the changes HRT brings seems to be taking caution rather too far. I’d even call it inhuman cruelty, a relic of the days when patients were deemed “mentally ill” and incompetent to give informed consent. It was feared that prescribing hormones under those circumstances to a “poor deluded maniac” could lead to malpractice lawsuits in case of patient regret – the probability of which was unknown and unmeasured at the time.

    We know a bit more now.

    In my own situation, although I knew an RLE wasn’t necessary, I was happier having one than not. I was in uncharted territory, and here was a system, however hidebound, obsolescent and wasteful, that had a good track record. It wasn’t forced on me, if I’d insisted, the medical team would have gone along with my wishes – but they felt “warm fuzzies” too at my decision. My transition was already very non-standard, first change to gender role (I no longer passed as male), then HRT (necessary to calm the natural hormonal chaos anyway), then months later the first opportunity to see a psych who actually knew what she was doing.

    I did rather surprise her, I was nothing like what she expected, or the case notes would have suggested. Let’s see… middle aged 46 yr old 46,XY karyotype, first presentation to a GP 5 months ago, on minimal HRT for 10 weeks…no history of cross-dressing.. anomalous hormone levels…what would you have expected?

    And in walks a rather frumpy though cheerful middle-aged woman, as if she’d been on HRT for years. 3 months later, retroactive authorisation for feminising as well as stabilising HRT (I still was ramping up), and authorisation for surgery too. I delayed that 9 months due to work commitments (and the 12 month RLE). On the other hand… I’d already paid a deposit on the surgery and booked a date before getting the letters.

    The joys of Intersex.

    • Dara Hoffman-Fox

      October 5, 2013 at 9:59 AM Reply

      Thank you for sharing your experience with this Zoe. Fascinating indeed, and gives us all the reminder of what a “new” science this is in so many ways. We can only continue to “do no harm” as best as we feel we are doing at that moment, even if that changes later the more we learn. Your openness and patience with the process is notable as well. 🙂

  • Megan Wesley

    November 9, 2013 at 7:17 PM Reply

    I’ve been on HRT for nearly 8 months, still no RLE. My life is medically complicated, however, so just getting healthy enough to move forward has been trying. I plan to be starting RLE next month. I still need a lot of electrolysis and laser, but at this point moving forward is my goal.

    RLE without HRT seems like setting us all up for failure. My therapist asked me if I would consider doing it… and I said no, I wouldn’t feel safe living and working in rural South Carolina as a woman without proper hormones. She agreed that it would be foolish, though, and said her asking was curiosity of my reaction to it than actually wanting me to.

    I find the concept of RLE without hormones to be more than a little disrespectful. I do believe in caution, but that’s what therapy itself is for: caution, and the safety and mental well being of someone going through rough patches in their life. What could be worse than going to someone for help and being told you have to go through months or years of hell, between gender lines – obviously so, and tormented by people around you that you’re forced to put up with – BEFORE you will help them? Oh and if you don’t so everything just right to a niggling infinitesimal degree, that help goes away too.

    Thank goodness times have changed.

    • Dara Hoffman-Fox

      November 22, 2013 at 11:12 PM Reply

      Here here. 🙂 Thank you for sharing your thoughts with us Megan!

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