The real-life experience (RLE), sometimes called the real-life test (RLT), is a period of time or process in which transgender individuals live full-time in their identified gender role in order to be eligible to receive gender-affirming treatment. The purpose of the RLE has been to confirm that a given transgender person could function successfully as a member of said gender in society, as well as to confirm that they are sure they want to live as said gender for the rest of their life. A documented RLE was previously a requirement of many physicians before prescribing gender-affirming hormone therapy, and a requirement of most surgeons before performing gender-affirming surgery.
In September 2022, the World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transgender and Gender Diverse People (SOC) Version 8 were released and removed the requirement of RLE for all gender-affirming treatments, including gender-affirming surgery. Previous versions of the WPATH SOC had required completion of RLE for initiation of gender-affirming hormone therapy (3 months) and gender-affirming surgery (12 months).
Criteria
Standards of Care
Version 6
The sixth version of the World Professional Association for Transgender Health's (WPATH) Standards of Care (SOC), published in 2001, listed the parameters of the RLE as follows:
Version 7
The seventh version of the SOC, which was published in 2011, was more ambiguous, and did not list any specific parameters for the RLE. Instead, they merely stated that the individual should be living full-time in their preferred gender role continuously for the duration of the RLE. They also stated that documentation of a name and/or gender marker change can be presented as a way of providing proof that the RLE has been completed, but did not state that a name and/or gender marker change was a requirement for completion of the RLE. These changes may have been signs of WPATH moving away from gatekeeping, which the SOC had been criticized for.
The seventh version of the SOC state that medical professionals should clearly document a patient's RLE in their medical chart, including the start date of living full-time for those preparing for GRS. Sometimes surgeons may require proof that the RLE has been completed. The SOC state that, if applicable, proof may be provided in the form of communication with individuals who have related to the patient in a gender identity-congruent role (such as, presumably, the patient's physician, therapist, boss, or a teacher), or as documentation of a legal name and/or gender marker change.
Version 8
The eighth version of the SOC, published in 2022, removed all requirement of RLE for gender-affirming treatments, including gender-affirming surgery.
Necessity
The SOC are followed by most medical professionals who specialize in the care of transgender individuals, and are the most widely followed clinical guidelines for the treatment of transgender persons in use. Hence, the SOC criteria for HRT and GRS, including completion of an RLE when applicable, must usually be met for one who seeks such treatments to receive them.
As of the seventh version of the SOC, a three-month minimum requirement of RLE is no longer part of WPATH's recommended criteria for HRT. A referral letter alone from a qualified mental health professional now suffices. The SOC state:
With respect to mastectomy/chest reconstruction and breast augmentation, the seventh version of the SOC do not require an RLE for these procedures; nor is an RLE required for hysterectomy, salpingo-oophorectomy, or orchiectomy, or for other procedures such as facial feminization surgery and voice feminization surgery. However, for GRS, including metoidioplasty, phalloplasty, and vaginoplasty, one year of continuous RLE is a listed requirement.
Previous versions of the SOC stated that an RLE for GRS was an absolute requirement that could not be skipped or ignored. However, the seventh version of the SOC appears to be less stringent, and does not contain any such statements. In addition, WPATH emphasizes that the SOC are merely clinical guidelines, and are intended to be both flexible and modifiable to meet the circumstances of the patient and the preferences and judgement of the clinician. Hence, the latest version of the SOC appear to allow for, in certain circumstances, the RLE to be skipped.
Clinical practice in many places may be more or less stringent. In the United Kingdom, most National Health Service trusts will require two years of RLE before surgery, whereas in countries such as Thailand and Mexico, some surgeons may not require the completion of any RLE at all.