Requirements
The requirements for hormone replacement therapy vary greatly; often, at least a certain period of psychological counseling is required, as is a period of living in the desired gender role, if possible, to ensure that they can psychologically function in that life-role.
Generally speaking, physicians who perform sex-reassignment surgery require the patient to live as the members of their target gender in all possible ways for at least a year ("cross-live"), prior to the start of surgery, in order to assure that they can psychologically function in that life-role. This period is sometimes called the Real Life Test (RLT); it is part of a battery of requirements. Other frequent requirements are regular psychological counseling and letters of recommendation for this surgery.
Most US professionals who provide services to transsexual women and men follow the controversial Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People put forth by the World Professional Association for Transgender Health. Outside the USA, many other SOCs, protocols, and guidelines exist, although the Harry Benjamin SOCs are certainly the best known. A significant and growing political movement exists, pushing to redefine the SOC, asserting that they do not acknowledge the rights of self-determination and control over one's body, and that they expect (and even in many ways require) a monolithic transsexual experience. In opposition to this movement is a group of transsexual persons and caregivers who assert that the SOC are in place to protect others from "making a mistake" and causing irreversible changes to their bodies that will later be regretted – though few post-operative transsexuals believe that sexual reassignment surgery was a mistake for them.
The requirements for hormone replacement therapy vary greatly. Often, a minimum time period of psychological counseling, or a time period spent living in the desired gender role is required. This time period of "cross-living" is usually known as the Real-Life-Test (RLT) or Real-Life-Experience (RLE). This is not always possible; transsexual men frequently cannot "pass" this period without hormones. Transsexual women may also require hormones to pass as women in society. Most trans women also require facial hair removal, voice training or voice surgery, and sometimes, facial feminization surgery, to be passable as females; these treatments are usually provided upon request with no requirements for psychotherapy or "cross-living". The most recent revision of the HBIGDA Standards of Care recognizes this limitation for some transgender people. Therefore, the SOC state that patients may be approved for hormone treatment after either a period of successful cross-living or a period of diagnostic psychotherapy – generally at least three months. Some doctors are willing to prescribe hormones to any patient who requests them; however, most physicians are reluctant to do so, especially for trans men. In trans men, some hormonally-induced changes may become virtually irreversible within weeks, whereas trans women usually have to take hormones for many months before any irreversible changes will result. Some transsexual men and women are able to avoid the medical community's requirements for hormone therapy altogether by either obtaining hormones from black market sources, such as internet pharmacies which ship from overseas, or more rarely, by synthesizing hormones themselves.
Some surgeons who perform sex reassignment surgeries may require their patients to live as members of their target gender in as many ways as possible for a specified period of time, prior to any surgery. However, some surgeons recognize that this so-called real-life test for trans men, without breast removal and/or chest reconstruction, may be difficult. Therefore, many surgeons are willing to perform some or all elements of sex reassignment surgery without a real-life test. This is especially common amongst surgeons who practice in Asia. However, almost all surgeons practicing in North America and Europe who perform genital reassignment surgery require letters of approval from two psychotherapists; most Standards of Care recommend, and most therapists require, a one-year real-life test prior to genital reassignment surgery, though some therapists are willing to waive this requirement for certain patients. A recent study done on trans women has shown that a real-life test of less than one year, or no real-life test at all, does not increase the likelihood that a patient will regret genital reassignment surgery. Many transsexual people opt for a real-life experience longer than is officially required, to remove any doubts they may have of whether they should undergo surgery or for financial reasons.
The requirements for chest reconstruction surgery are different for transmen and transwomen. The Standards of Care require trans men to undergo either 3 months of Real-life-test or psychological evaluation before surgery whereas transwomen are required to undergo 18 months of hormone therapy. The requirement for trans men is due to the difficulty in presenting as male with female breasts, especially those of a C cup or larger. For very large breasts it can be impossible for the trans man to present as male before surgery. For trans women, the extra time is required to allow for complete breast development from hormone therapy. Having breast augmentation before that point can result in uneven breasts due to hormonal development, or removal of the implant if hormonal breast development is significant and results in larger breasts than desired.
Read more about this topic: Sex Reassignment Therapy