SRS Without a One Year RLE: Still No Regrets

By Anne A. Lawrence, M.D., Ph.D.

Paper presented at the XVII Harry Benjamin International Symposium on Gender Dysphoria, Galveston, TX, November 4, 2001


The Real-Life Experience (RLE) is considered to be among the most important diagnostic and therapeutic requirements for persons seeking sex reassignment surgery. It has been an article of faith among professionals for at least a quarter century that if persons seeking SRS are able to live successfully in their desired gender role for at least one year, then they are probably reasonable candidates for sex reassignment surgery. Conversely, it has also been widely accepted that persons who are not willing, or not able, to live full-time in cross-gender role for at least one year should not be offered sex reassignment surgery, because they would be at high risk for regret.

Indeed, Laub and Fisk's formulation of the concept of Gender Dysphoria Syndrome in 1974 was based on the premise that a precise diagnosis was less important than a demonstrated ability to live in role. The authors wrote:

"The diagnostic category is of much less importance than the patient's preoperative performance in a one-to-three-year trial of living in the gender of his choice."
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.

A real-life experience of one year or longer certainly is not a guarantee against regret. For example, in Kuiper and Cohen-Kettenis' 1998 study of 10 regretful postoperative patients, 9 of whom were male-to-female, the duration of preoperative real-life experience ranged from 1 to 5 years, and averaged 1.6 years.

Nor is there much evidence that a short or non-existent real-life experience is associated with regret. It is true that there were a handful of cases in the early literature in which patients underwent genital surgery without any real-life experience at all, and later regretted their decision. Pfäfflin and Junge, in their comprehensive 1992 review, reported 4 such cases. All were from the period 1968 to 1974, and one case involved a patient who was floridly psychotic.

There is also the much-quoted 1995 study by my colleagues Marsha Botzer and Bryant Vehrs. They reported that in a large sample of male-to-female patients of Dr. Stanley Biber, duration of real-life experience was significantly associated with self-rated satisfaction and self-rated success of surgery.

My office is right next door to that of Ms. Botzer and Mr. Vehrs. I've asked on more than one occasion to see the statistical data supporting their conclusions, especially the strength of the associations they claim to have found. I have yet to see any such data. It has been 6 years since the Botzer and Vehrs study was presented at the Biennial Symposium in Germany. If we are going to base our belief in the importance of the real-life experience on this one study, it is important that the data be published in a refereed journal for everyone to examine. Until that happens, I hope my colleagues will forgive me if I express some reservations concerning their conclusions.

What would happen if we allowed persons to undergo male-to-female sex reassignment surgery after a much briefer real-life experience -- or with no real-life experience at all? There are at least two ways to try to answer that question. One is to study outcomes of SRS in a cohort of patients, and if any of them managed to undergo surgery without completing a one year real-life experience, to compare their outcomes with the outcomes of patients who did live for one year or longer in role

If any of you saw my poster Thursday night, you saw the results of such a study. Among 232 of Dr. Toby Meltzer's recent male-to-female patients, 36 patients -- 16% -- reported that they underwent surgery after less than 12 months of real-life experience. Their outcomes were no different statistically than in those who had lived full time in role for an entire year or longer.

Another approach is to attempt to locate persons who had surgery without a one-year RLE, and ask them about feelings and outcomes. This was the method I used in my 1997 report at the Vancouver Symposium, and it was the method I used to collect the data I'm reporting today. In both cases, I used a solicitation on my Internet web site, Transsexual Women's Resources, to locate participants.

In 1997, I reported results in 18 male-to-female patients who had undergone SRS without a one-year real-life experience. Their mean duration of RLE was 6 months, with a range of 0 to 9 months. None of these individuals regretted undergoing SRS, and none wished their real-life experience had been longer.

Today I'm reporting on 13 additional persons, all of whom lived full-time in role for less than 10 months before undergoing SRS. The mean duration of their full-time real-life experience was 5 months. On average they were surveyed about 19 months after surgery. Typically they were in their 30s or 40s, were highly educated, and were employed in scientific or technical fields.

None of these individuals regretted having undergone SRS, and only one wished her pre-surgical real-life experience had been longer. Her reasons were purely technical, and we'll consider them in a moment.

My respondents reported several benefits from undergoing SRS without first living full-time in role for an entire year. These included: sustaining needed employment; reducing fear of physical harm; pursuing significant relationships; and perhaps most important of all, achieving personal comfort.

One reported benefit of a short real-life experience involved sustaining needed employment prior to SRS. Here are some representative comments:

"I kept my job long enough to get the money for SRS. Had I begun RLT any earlier, I would not have been able to save the money for several years, if ever."

"[Living in role] would have been difficult financially; my...employment would have been challenged."

"Financial difficulties would have put me in Thailand for SRS. Or it may not have happened at all."

Another benefit was reduced fear of being harmed if discovered to be preoperative. Here are some representative comments:
"I was...in fear of being somehow discovered as a "chick with a dick" and possibly being harmed because of it."

"I live in the centre of London, and did not wish, if attacked, to be found out -- rather a rape than a beating for being male."

A third reported benefit was the ability to engage in significant relationships earlier. Here are some representative comments:
"I was able to engage in a romantic relationship that I would not have felt comfortable doing before SRS."

"My current relationship may not have happened since men don't seem to want a preop very often."

Perhaps the most important benefit was increased personal comfort. Here are some representative comments:
"I was able to feel more comfortable with my body sooner."

"I couldn't resolve the existence of a penis on my body. It had caused me tremendous anxiety over the years and I felt it would have worsened in the female role."

"The benefit was almost immediate relief from the conflict with which I lived for so many years."

These self-reports are consistent with the findings of the 1990 study by Mate-Kole, Freschi, and Robin, which demonstrated that persons who were able to have SRS earlier were more active socially, and displayed fewer neurotic symptoms than those in whom SRS was delayed.

I asked the respondents in the current study whether they experienced any disadvantages from a short or non-existent real-life experience. 10 of the 13 reported no disadvantages at all. The other three answered as follows:

"I was forced by court order to revert to 'presenting as a male' up until 2-1/2 months prior to SRS. [This] forced me into an obsessive thought pattern which persisted several months after SRS."
This was the only person who wished her real-life experience had been longer. Other replies were:
"Lots of surgery and electrolysis in a short period of time."

"Having to wear double-breasted suits to hide my breasts."

I also asked respondents about opportunities they felt they might have missed by having SRS after an abbreviated real-life experience. 12 of 13 replied that there were no opportunities they felt they had missed. The thirteenth said:

"I could have pondered the options a while longer. But after a certain point it's pretty silly."
Indeed it is.

These results suggest that some individuals can successfully undergo SRS without a one year full time real-life experience. The results call into question the value of the one year real-life experience as an absolute eligibility requirement for SRS.

For some gender dysphoric persons, the desire for surgery may center on the sexed body, and may have little to do with the desire to enact a specific gender role. Recall that in DSM-IV, gender identity disorder can involve either:

"Persistent discomfort with his or her sex, or a sense of inappropriateness in the gender role of that sex."
Either somatic discomfort or gender role discomfort qualifies one for the diagnosis. And for persons whose dysphoria is primarily somatic, the real-life experience may be little more than an irrelevant barrier to care. Here is what one of my respondents wrote:
"My incongruity was with my anatomy exclusively, so...RLT...did nothing to alleviate my anxiety. I know it is popular to say it is the role that is important, and SRS is [just] 'the icing on the cake,' but for me that [was] simply not true. SRS was the whole enchilada."
The comments of this patient are consistent with Jay Prosser's analysis in his book, Second Skins: Body Narratives of Transsexuality. Prosser's study of over 50 transsexual autobiographies led him to conclude that the essence of transsexuality was a profound sense of "wrong embodiment," which went beyond concerns about enacting a particular gender role. It may be that in the case of transsexuals, we have paid too much attention to gender role, and too little attention to the dysphoria associated with the sexed body.

It is important to note that even though the individuals in the present study did not live in role for an entire year, nearly all of them followed the Standards of Care in one respect: In all but two cases, they received approval letters for surgery from the mental health professionals involved in their care.

This suggests a qualification of the present results: a short real-life experience was not associated with regret, provided that the patient's therapists agreed that she was a good candidate for SRS. Thus, the present results do not imply that the Standards of Care are unimportant. They simply call into question the value of the real-life experience as a minimum eligibility requirement for persons who would in other respects receive their therapists' recommendations.

What are the implications of the present study, and of the related studies I have reviewed today?

First and most obviously, these results should lead us as clinicians to ask whether a real-life experience of a specific duration has any genuine value as an eligibility requirement for SRS, at least for male-to-female persons. If we are to practice evidence-based patient care, perhaps we should discard this requirement until there is persuasive evidence that it is important. A required one year real-life experience is not harmless. It can delay treatment; it can cause financial losses; it can subject persons to the risk of physical harm; and it can prolong suffering. In some cases, it may prevent persons from ever being allowed to find peace in their own bodies.

Second, while these issues are being debated, the present study suggests that mental health professionals can trust their own judgment rather than relying on slavish adherence to minimal requirements. Almost all the patients in the present study received their therapist's approval despite not fulfilling minimal requirements, and none of them regretted undergoing SRS.

Finally, the present study is just one more reason why our Association should consider uncoupling the decision to change the sexed body from the decision to live in a particular gender role. It is possible to undergo SRS without regret after living in role for only six months. Perhaps for some persons it is possible to undergo SRS without regret without having lived in cross-gender role at all.

Perhaps it is time to find out.

If we are serious about reducing the suffering of persons who experience body dysphoria, but who are unwilling or unable to live full-time in cross-gender role, then it is important that such a discussion begin.

In summary, I have presented evidence that some male-to-female transsexuals can undergo therapist-supported SRS without a one year real-life experience, without expressing regret. These results do not support the Standard of Care requirement of a one year real-life experience as an absolute eligibility requirement for SRS.

References:

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: Author.

Botzer, M., & Vehrs, B. (1995, October). Psychosocial and treatment factors contributing to favorable outcomes of gender reassignment. Paper presented at the XIV International Symposium on Gender Dysphoria, Kloster Irsee, Germany.

Laub, D. R., & Fisk, N. M. (1974). A rehabilitation program for gender dysphoria syndrome by surgical sex change. Plastic and Reconstructive Surgery, 53, 388-403.

Kuiper, A. J., & Cohen-Kettenis, P. T. (1998). Gender role reversal among postoperative transsexuals. International Journal of Transgenderism, 2(3).

Mate-Kole, C., Freschi, M., & Robin, A. (1990). A controlled study of psychological and social change after surgical gender reassignment in selected male transsexuals. British Journal of Psychiatry, 157, 261-264.

Lawrence, A. A. (1997, September). SRS after less than a one-year real-life test: Absence of regrets. Poster presented at the XV HBIGDA Symposium, Vancouver, BC, Canada.

Lawrence, A. A. (2001, November). Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Poster presented at the XVII Harry Benjamin International Symposium on Gender Dysphoria, Galveston, TX, USA.

Pfäfflin, F., & Junge, A. (1998). Sex reassignment. Thirty years of international follow-up studies after sex reassignment surgery: A comprehensive review, 1961-1991 (R. B. Jacobson & A. B. Meier, Transl.). (Original work published 1992).

Prosser, J. (1998). Second skins: The body narratives of transsexuality. New York: Columbia University Press.


© 2001 by Anne A. Lawrence, M.D., Ph.D. All rights reserved.