AEGIS Position Statements: Mandatory RLT Before Hormonal Therapy (1992, 1998)

A number of gender clinics, including the Clarke Institute of Psychiatry in Toronto, Canada and the Rosenberg Clinic in Galveston, Texas have as a blanket criterion for the initiation of hormonal therapy the requirement that clients with gender dysphoria be living full-time in the gender of choice. The individual must make the necessary arrangements to change gender roles and in some cases cross-live for an extended period of time before hormonal therapy is initiated.

This far exceeds the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, Inc.

The reasons for the prior cross-living requirement have been given variously as clinical judgement and concern about the irreversibility of some of the effects of hormones and the medical risks involved in their administration in persons. Clinicians have been unwilling to prescribe hormones to persons who have not experienced life fully in the new gender. However, in some cases (not necessarily at the facilities we have mentioned), this criterion seems to have been set up as a roadblock, with the idea that those who want sex reassignment badly enough will persevere, no matter what the obstacle.

We are unaware of any empirical evidence showing an advantage to requiring a period of real-life test before initiation of hormonal therapy. ^1,2,3 Our experience, in fact, suggests the obverse—that those who go totally into the new role without prior physical preparation are more likely to suffer harassment, have employment and interpersonal difficulties, and focus on genital surgery as a “fix” for their problems.

Advisory

 It is our position that the psychological and social effects which occur as a result of preparing for and beginning a period of full-time cross-living are in most cases potentially far more disruptive and dangerous to the individual than the physical dangers of hormones or any permanent body changes they cause. We believe that requiring a period of real-life test before initiation of hormonal therapy can be and often is very harmful, and should not be a universal requirement or even the usual rule. We urge practitioners and clinics who adhere to this practice to change it.

Hormones are not without hazard, and some of their effects, like breast development in the genetic male and hirsutism and voice-deepening in the genetic female are indeed irreversible. Hormones should not be administered except in accordance with the Standards of Care of the Harry Benjamin International Gender Dysphoria Association; that is, the individual should be in therapy and have been given a diagnosis of gender dysphoria by a clinical behavioral scientist. Before hormonal therapy is initiated, care should be taken to rule out other conditions which can masquerade as transsexualism, and the individual should have some experience with public crossdressing.

Discussion

Real-life test does not occur in a vacuum. Friends and family must be informed, marriages must be dissolved, and accommodations must be made at work—if the individual is fortunate enough to be able to keep his or her position. Not only the primary client, but others are effected as well: parents, children, husbands and wives, neighbors, employers, co-workers.

The result of failed hormonal therapy is at worst some physical characteristics which run counter to type and which may be difficult for the individual to explain. The result of a failed real-life test is a life in shambles. Family, friends, and employers cannot be un-told about transsexualism, marriages and family life are unlikely to be resumed, and lost employment is unlikely to be regained. A non-passable appearance, which is likely if the individual has not been on hormones for a significant period, can be highly stigmatizing, and can place the individual in physical danger in this era of hate crimes. Furthermore, a failed real-life test can result in a high potential for self-destructive behavior, including suicide.

A stigmatizing appearance is not necessarily a counterindication for sex reassignment, but it is certainly a disadvantage, and one which can be lessened by the availability of hormonal therapy and other feminizing or masculinizing medical treatments prior to actually changing gender role. The individual who has had such treatment is more likely to be viable—and therefore successful—when the role of choice is assumed.

Globally denying needed medical treatment, including hormonal therapy, in persons diagnosed as transsexual, or making it contingent on the individual following the instructions of the health professional or clinic is in our opinion needlessly obstructionistic, a holdover from the days of less sophisticated treatment.

We believe that although conservativism is usually given as a reason for requiring cross-living before initiation of hormonal therapy, it is not a conservative approach, except from the purely medical standpoint of the effect hormones have on the body—a narrow viewpoint, in light of the profound and largely irreversible social changes that real-life test requires.

1. there is some evidence for the converse. administration of small doses of estrogens has proved to be a useful diagnostic tool in differential diagnosis. some male transvestic fetishists on a minimally feminizing regimen of estrogens abandon their desire for sex reassignment and re-embrace their identities as men.
2. procedures such as orchidectomy, hysterectomy, and sex reassignment surgery, which are absolutely irreversible, should not be performed before the individual has been living successfully in the new gender. this is in accordance with the HBIGDA Standards of Care. we support the standards of care.
3. it is certainly a good idea for the individual to have considerable experience dressing and interacting with others in the new gender, but this can be accomplished in any number of ways short of total role change. we do not object to mandating this type of experience, and in fact advocate doing so. it is the unnecessary requirement that a life be dismantled before the individual is physically prepared to take on a new life that we find objectionable.

1998 Position Statement

Mandatory Real-Life Test Before Hormonal Therapy: Unethical

Since 1992, we have advised against clinicians requiring transsexual clients to cross-live 24 hours a day as a prerequisite for initiation of hormonal therapy. We consider this practice ill-advised and not in the best interest of the clients. Our reasons for believing so are described in the advisory which accompanies this statement. It differs in only minor ways from the 1992 advisory.

To the credit of the North American therapeutic community, this once common practice is now rare. Still, a few therapists and at least one North American gender program continue to impose this requirement on all their transsexual clients. They do so without empirical evidence to support their position and in opposition to the majority opinion of the treatment community, which considers this practice needlessly intrusive and based on outdated assumptions (Denny, 1997; Devor, 1997; Kirk, 1997).

After consultation with our advisory board, we are now prepared to state that we consider it not only poor practice but in all but the rarest cases unethical to require a transgendered or transsexual client to enter a period of 24-hour real-life test in order to receive hormones. We believe that such a requirement places a tremendous burden on the client, causing grave risk for unemployment; loss of habitat; public harassment or physical attack; estrangement from family, friends, and church; and hostile treatment from public service agencies, government officials, and strangers. Many of these risks are minimized if the client enters real-life test after a period of masculinization or feminization caused by hormones. Needlessly placing a client at risk by requiring a change in public identity is antithetical to human dignity and good clinical practice and is an abuse of the clinical/client relationship.

References

Denny, D. (1997). Endocrine issues: Consumer-driven perspective. Paper presented at the XV Harry Benjamin International Gender Dysphoria Association Symposium: The State of Our Art and the State of Our Science, Vancouver, BC, Canada, 10-13 September, 1997.

Devor, H. (1997). A social context for gender dysphoria. Paper presented at the XV Harry Benjamin International Gender Dysphoria Association Symposium: The State of Our Art and the State of Our Science. Vancouver, BC, Canada, 10-13 September, 1997.

Kirk, S. (1997). Endocrine issues: Medical perspective. Paper presented at the XV Harry Benjamin International Gender Dysphoria Association Symposium: The State of Our Art and the State of Our Science. Vancouver, BC, Canada, 10-13 September, 1997.

This position statement was prepared after consultation with the AEGIS Interdisciplinary Advisory Board, which is comprised of 30+men and women who serve without compensation. Advisory Board members represent various professions, including psychiatry, psychology, sexology, endocrinology, plastic and reconstructive surgery, and electrology. Individuals with gender identity issues are well-represented on the board.