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Culturally Informed Practice – Transgender Healthcare

Webinar Series February Topic: Culturally Informed Practice – Transgender Healthcare

On February 27, Joanne Wiedman, LCSW, adolescent social worker, hosted a webinar on transgender healthcare—”Culturally Informed Practice with the Transgender and Gender Nonconforming Patients”—in support of LGBT month.

This post provides a breakdown of the information discussed during the webinar and is intended for mental health professionals. Through this information, we seek to promote awareness, understanding, and informed practice for all transgender and nonconforming patients. Skip down to read that information. We are also sharing the video and audio recordings that you may watch/download if interested.

Culturally Informed Practice with the Transgender & Gender Non-conforming Patients from BizBudding Inc. on Vimeo.

Culturally Informed Practice with the Transgender and Gender Nonconforming Patients

Learning Objectives: General

In this post, we’ll cover the following general and clinical learning objectives:

  • Review culturally informed terms for members of the LGBT community
  • Identify myths and facts about the trans/GNC population
  • Examine the development and diagnostic criteria of Gender Dysphoria
  • Understand the systematic and interpersonal oppression of transfolk

Learning Objectives: Clinical

  • Identify evidence-based best practices for the Trans/GNC population
  • Review legal and ethical issues related to the population in treatment
  • Discuss clinical recommendations

Natal Sex vs Gender

Natal Sex

  • Sex assigned at birth based on genitalia
  • Male vs. Female
  • Intersex
    • 1 in 1,500 to 2,000 births

Gender

  • Socially accepted norms or behavior and presentation
  • Socially defined roles and expectations of what makes a person a man or a woman
    • Masculine
    • Feminine

Gender as a Lived Experience

  • Gender Identity
    • The internal sense of being male, female, or somewhere on the spectrum of male to female
  • Gender Expression
    • How a person outwardly demonstrates their gender through clothing, makeup, hair, behavior

Sexual Orientation

  • Physical, emotional, and/or romantic attraction to others
  • The orientation is defined by how the other defines their sex
    • Straight -→ attraction to other sex
    • Gay/Lesbian → attraction to the same sex
    • Bisexual → both sexes
    • Pansexual → regardless of gender identity
    • Demisexual → need emotional connection prior to physical attraction
    • Asexual → little to no physical attraction to others

Important Terms

  • Cisgender/Cis: someone who identifies their gender identity with their natal sex
  • Transgender: someone who identifies their gender identity with the other sex than their natal sex
  • Gender Fluid: someone sees their gender as changeable
  • Gender non-binary: someone who sees their gender as not conforming to that of a male or female or do not identify with the binary of male/female
  • Genderqueer/queer: same as non-binary. More abstract term
  • Gender Non-conforming: gender expression is different from social expectations
  • Bigendered: identify that their gender encompasses both male and female in differing strengths
  • Two-Spirit: Native American term for trans folk, now used as an alternative to LGBT in First Nations communities as part of reclaiming culture

Other Terms

  • Transvestite: Derogatory and not to be used because it is pejorative and diagnostic in nature
    • Transvestic Disorder
    • → Crossdresser- enjoy wearing clothes of the other gender but do not want to be the other gender
      • Drag Queen: male dressing as female
      • Drag King: female dressing as a male

Trans-Inclusive Language

  • Transman/Transmale: someone who is trans and identifies as male
    • Female to Male (FTM)
    • Female to male transgender
  • Transwoman/transfemale: someone is trans and identifies as female
    • Male to female (MTF)
    • Male to female transgender

Language

  • The use of language to describe the trans population is a key part of affirming practice
  • Transgender is an adjective
    • Yes: Trans, Transgender, Transgender person
    • NO: transgendered, transgenders
    • Example: The mens in the group were angry at the nurse.
  • Derogatory terms
    • Shemale
    • It
    • Tranny

What’s in a Name?

  • Birth name: many trans folk are not able to change their birth name legally because of the cost
  • Birth names are often identified as dead names or legal names.
    • Legal names are used on documentation such as paper charts
  • Use the preferred/affirming name and pronouns in practice and documentation

Pronouns

  • Ask someone what pronouns they use AND use them
  • Male: he/him/his
  • Female: she/her/hers
  • Gender neutral: they/them/theirs
  • NEVER use: it

Continuing to use a young person’s birth-assigned name and associated pronouns when they have requested the use of their ‘new’ name and pronouns is disrespectful and both denies and invalidates that individual’s identity. It communicates that you do not see them for who they are. When someone continues to use male pronouns for a trans woman, it communicates an underlying message that they do not believe she is ‘really’ a woman. It sends a message that in their eyes she is, and always will be, a man.

-Eliha C. Nealy (2017) from Transgender Children and Youth

Coming Out

  • Process of disclosing one’s gender identity and/or sexual orientation
  • Constant process as opposed to an individual event
  • Possibility of high stress and potential for violence
  • Potential for losing relationships and employment
  • NEVER out another person
    • For the purpose of patient care it should be treated as medically necessary information

Common Myths and Questions

  • Choice to be trans
  • Why be a transmale if you want to date men
  • Aren’t you just bi/gay
  • Phase

Statistics

  • Estimated 1 million adults identify as transgender
    • Precision is difficult because of census gathering
  • Double the national unemployment rate
  • 26% report losing a job due to gender identity (2003)
  • 1 in 5 trans people are homeless
    • Most shelters are single-sex
    • Shelters that are not LGBT specific can be more dangerous than the streets

Violence

  • 27 Trans folk murdered in 2016
  • 27 Trans folk were murdered in 2017
  • 24 murders in 2018
  • Most are transwomen of color

Physical Health

  • “From 2009 to 2014, 2,351 transgender people were diagnosed with HIV in the United States. Eighty-four percent (1,974) were transgender women, 15% (361) were transgender men, and less than 1% (16) had another gender identity.” (CDC)
  • In 2013 the rate of trans people being diagnosed with HIV was 3 times the national average
  • 30-40% do not use medical care due to turned away by providers, lack of health insurance, etc. (2003)

Transition

  • Social Transition: the process of changing one’s gender presentation and expression to match gender identity
    • Growing/shaving hair
    • Packing, tucking, binding
    • Gendered clothing
  • Medical transition
    • Hormones (HRT)
    • Surgery
    • SRS and Gender Confirming Surgery

Legal Transition Process in NJ

  • Name Change
    • Court order
    • Publishing the name change in the newspaper
  • ID change
    • Court order and signed paperwork by a mental health professional confirming gender ID
  • Birth Certificate change
    • Documentation has undergone SRS
    • Healthcare provider letter

Medical Transition Process

  • Hormones
    • Informed consent documented by a mental health professional
    • May or may not be covered by insurance plan
  • Top Surgery
    • Requires 1 to 2 mental health professional signatures of informed consent and medically necessary
    • Documented gender dysphoria
  • Bottom Surgery
    • 2 signatures of MH providers

Transfolk and Healthcare

  • Historical and current denial or treatment due to ID
    • 2010 survey 27% or trans respondents reported being denied treatment due to Gender ID
  • Many transfolk are reluctant to seek care due to negative experiences

Gender Dysphoria

  • Marked incongruence between one’s experienced/expressed gender of at least 6 months’ duration manifested by at least 6 of the following:
  • Strong desire to be the other gender
  • Strong preference for cross-dressing and aversion to clothing of assigned gender
  • Strong association with cross-gender roles in make believe
  • Strong preference for toys stereotypically used by other gender
  • Rejection or masculine/feminine toys/activities
  • Strong dislike of one’s sexual anatomy
  • Strong desire for secondary sex characteristics of the other gender
  • Clinically significant distress or impairment in functioning in everyday life

Mental Health and the LGBT Population

LGBTQ people must confront stigma and prejudice based on their sexual orientation or gender identity while also dealing with the societal bias against mental health conditions. Some people report having to hide their sexual orientation from those in the mental health system for fear of being ridiculed or rejected. Some hide their mental health conditions from their LGBTQ friends.

As a community, LGBTQ individuals do not often talk about mental health and may lack awareness about mental health conditions. This sometimes prevents people from seeking the treatment and support that they need to get better.

-NAMI, 2017

Historical Considerations

  • SRS first performed in 1910s in Soviet Russia and Germany
  • 1960s and 1970s- John Hopkins Gender Identity Clinic was closed citing a lack of change in mental health of those who had SRS
  • 1970s- psychiatry focused on transgender identity as pathology
  • Until 1972 homosexuality was classified as a mental disorder

Mental Health Statistics and LGBT Folk

  • 3X more likely to have MDD or GAD
  • 50% MTF folk survey reported MDD Vs 19.6% general population
  • Under 35 suicide and murder are the leading causes of death
  • Youth are 4x more likely to have SI, suicide attempts, and self-harm
  • 38-65% experience SI
    • Family rejection is the key factor in suicide prevention
    • If the family is supportive LGBT folk are 8x less likely to attempt suicide
  • 2015 National Transgender Discrimination Survey:
    • 41% of respondents attempted suicide compared to 1.6% of the population
    • Suicide rate is 9X that of the general population

Substance Abuse and LGBT Folk

  • 20-30% abuse substances vs 9% straight population
  • 25% abuse alcohol vs 5-10% straight population
  • 2012 study reported a correlation between experience transphobic events and substance abuse

Stressors

  • Minority stress
  • Stigma, discrimination
  • Hate crimes
  • Family rejection
  • Participation in the street economy
  • Gender dysphoria
  • Internalized and lived experiences of transphobia
  • Unemployment/financial hardship

Gatekeeping and the Role of Providers

  • Medical transition process requires mental health treatment
  • Many will not disclose their true mental health issues in treatment for fear it will inhibit their gender transition
  • Providers are often seen as in a position of determining who is “trans enough” Power imbalance is exacerbated

What About NJ?

  • 2015 National Transgender Survey  550 NJ residents
  • 13% unemployed
  • 20% living in poverty
  • 79% reported bullying/harassment in K-12 due to gender identity
  • 31% who saw a health provider in last year reported mistreatment due to gender identity: refused treatment, harassment, assault, culturally incompetent provider
  • 41% reported severe psychological distress in the month prior to the survey Vs 39% for national response

Cultural Competence

  • Know your own perspectives and biases
  • The transition process or identity of a patient is not about you
  • Highest indicator of a positive outcome is unconditional acceptance and empathy on the part of the provider
  • From the Transgender transition
  • Focus on those health issues for which the transgender individual seeks treatment
  • Avoid intrusive behavior
  • Consider transgender people as individuals
  • Treat individuals according to their preferred gender

DON’T

  • Assume some one’s gender identity or pronouns
  • Ask about genitalia and top/bottom surgery
  • Ask about sex practices
  • Question why someone is trans/GNC
  • Out someone to others to whom it is not relevant
  • Assume being trans/GNC is a stressor and someone is not supported

DO

  • Ask how a patient identifies their gender identity
  • Ask what name/pronouns a person wants to use
  • Use the affirming name/pronouns
  • Apologize when mistakes are made
  • Review policies with patients
  • Review that binders, hormones, etc can be used on the unit
  • Ask if there is anything staff can do to help pt feel safe and affirmed

Resources: Organizations

Healthcare Organizations

Trainings and Conferences

Reading

References

  • American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author
  • Brill, S. & Kenney, L. (2016). The Transgender Teen. Jersey City: Cleis Press.
  • Brill, S. & Pepper, R. (2008). The Transgender Child. Jersey City: Cleis Press.
  • Centers for Disease Control and Prevention. (2017). HIV Among Transgender People. Retrieved from: htttp://www.cdc.gov
  • Erickson-Schroth, Elizabeth (Ed). (2014). Trans Bodies, Trans Selves: A Resource for the Transgender Community. Oxford: Oxford University Press.
  • GLAAD. (2012). Violence Against Transgender People and People of Color is Disproportionately High, LGBTQH Murder Rate Peaks. Retrieved from: htttp://www.glaad.org.
  • Henig, Robin Marantz. (2017, January). Rethinking Gender.” National Geographic, 48- 72.
  • Human Rights Campaign. (2017). Healthcare Equality Index 2017. Retrieved from: http://www.hrc.org
  • Hunt, Jerome. (2012). Why the Gay and Transgender Population Experience More Substance Abuse. Retrieved from: htttp://www.Americanprogress.org
  • Intersex Society of North America. (2008). How Common is Intersex? Retrieved from: http://www. isna.org
  • Krieger, Irwin. (2017). Counseling Transgender and Non-Binary Youth: The Essential Guide. Philadelphia: Jessica Kingsley Publishers.
  • Lambda Legal, and Human Rights Campaign. (2016). Creating Equal Access to Quality Health Care for Transgender Patients. New York City, Author.
  • Mallon, G. P. (ed.). (2008). Social Work Practice with Lesbian, Gay, Bisexual, and Transgender People (2nd ed.). New Routledge.
  • Morrow, D.F. & Messinger, L. (eds.). (2006). Sexual Orientation and Social Work Practice. New York: Columbia University Press.
  • National Alliance on Mental Illness. (2017). LGBTQ. Retrieved from: http://www.nami.org National Center for Transgender Equality. (2015). 2015 U.S. Transgender Survey. Retrieved from:
    http://www.ustranssurvery.org
  • Nealy, Elijah C. (2017). Transgender Children and Youth. New York: W.W. Norton and Company.
  • NetCE. (2015). Clinical Care of the Transgender Patient. Retrieved from: www.netce.com
  • Steinmetz, Katy. (2017, March 27). Infinite Identities. Time, 48- 56.
  • Stryker, S. & Aizura, A.Z. (Eds). (2013). The Transgender Studies Reader (2nd ed.) New York: Taylor and Francis.
  • Wolf, Sherry. (2009). Sexuality and Socialism. Chicago: Haymarket Books.
  • World Professional Association of Transgender Health. (2017). Standards of Care. Retrieved from: htttp://www.wpath.org