Goal: • To leave participants better aware of how to be trans inclusive by increasing participants’ understanding of terms, definitions, and issues impacting the transgendered/transsexual community.Objectives: • To learn new language inclusive of trans clients. • To understand the social determinants of health for trans clients. • To explore ways of supporting choices amongst trans clients that minimize risks and reduce transmission of HIV . • To develop strategies for reducing barriers for trans clients who wish to access services.
Introductions Definitions Game Issues affecting Trans Folks HIV and Trans Folks Social Determinants of Health The Process of Transitioning Q & A
Name Agency Have you ever had a trans training before? What are you hoping to get out of today?
Purpose: To build a safe, respectful, and supportive learning environment for the workshop. Some of you have chosen to be here, while some of you have been mandated to be here by your work. We value diversity and learn from comparing and contrasting experiences. Some participants may have a personal connection to the issues we will be discussing and we should acknowledge this. Everyone participates in their own way. Risk taking and self-disclosure is encouraged and supported. Everyone has the right to pass. All voices are heard. Use “I” statements. Everyone uses their own strengths and resources. One person speaks at a time. Confidentiality is maintained but not guaranteed. (context of coworkers and people you know outside of work) Learning is a process. Open yourself to the possibilities. Step Up, Step Back
Divide into teams Remember that identities are personal
Realizing you are trans Sudden vs Process Fluidity of Gender Question gender the same you might question sexuality For some gender can change over time, same as sexuality Gender Binary System Some are for it, some are against it Some transition along gender binary, some like to complicate Don’t assume sexuality of a trans person
Pronouns ◦ Female to Male (FTM)/ Trans Man Male to Female (MTF)/ Trans Woman ◦ Gender Neutral They Ze, Hir ◦ Ask what pronoun to use if you’re not sure Respectful ways and not so respectful ways ◦ Changing pronouns can be challenging ◦ Dangers of using the wrong pronoun or name Passing ◦ The importance of passing ◦ Choose when to “crossdress” (“real life test”)
As a medical practitioner be mindful of the language you use to talk about people’s “bits and pieces” Some folks may be uncomfortable with descriptors like “vagina” or “penis” Ask what language they would like to use or use gender neutral language like “genitals”
Bathrooms/Change Rooms ◦ Most bathrooms are gendered for men and women ◦ Trans and genderqueer folks may not feel safe using a restroom, a basic human right ◦ Importance of unisex restrooms ◦ No need to gender single stall bathrooms ◦ Ontario Human Rights Code states that we should have access to washrooms and change rooms in our lived gender Quick Tip: assume the person in the bathroom knows which bathroom they feel the safest in
Outting ◦ Don’t out people as trans LGB + T organizations and groups ◦ It’s more than just an acronym
Institutional ◦ LGB + T ◦ Gender Identity Disorder (some for being in the DSM, some against) Now categorized as Gender Dissassociative Disorder in latest DSM Interpersonal ◦ Blatant “it” ◦ Subtle “real man” or “real woman”
What questions do you think are inappropriate to ask? Why do we want to know?
Can help in understanding the degree of HIV transmission risk with certain behaviours: High Risk: Unprotected vaginal or anal intercourse; Sharing injection Low Risk: equipment Intercourse with a condom; Oral sex without a condom; Negligible Risk: SharingNo Risk: Oral sex with a snorting/Kissing; condom smokingmasturbation equipment 28
Our understanding of what makes and keeps people healthy continues to evolve and be further refined. A population health approach reflects the evidence that factors outside the health care system or sector significantly affect health. It considers the entire range of individual and collective factors and conditions - and their interactions - that have been shown to be correlated with health status. These are complex and inter-related. Commonly referred to as the “Determinants of Health”, these factors currently include… 29
Income and Social Status Social Support Networks Education Employment/Working Conditions Social Environments Physical Environments Personal Health Practices and Coping Skills Healthy Child Development Biology and Genetic Endowment Health Services Gender Culture 30
Influences affecting self worth/esteem: Grief Loss Risk Behaviours: Bereavement • Alcohol/Drug Depression Use Social Exclusion Acquisition Stigma • Unprotected Sex or Discrimination • Presence of STI Transmission Homophobia • Multiple and of HIV or STI Transphobia Anonymous Racism Partnering Loss of Hope 31
Trans folks face social exclusion and marginalization due to society’s hostility towards people who don’t conform to the gender binary categorizations Trans folks choose medical and non-medical ways to change their bodies or physical appearance to make them fit more closely with their gender identity Trans folks identify with a range of sexual orientations and engage in an array of sexual behaviours with people of varying genders
Individual Factors: ◦ Mental health issues and impact of psycho-social stresses including suicidal thoughts and anxiety and depression ◦ Misperceptions or a low perceived risk of HIV ◦ Low self-esteem, internalized stigma and shame ◦ Fear of rejection by prospective sexual partners and perceived shortage of sexual partners ◦ Seeking self-affirmation and validation of gender identity through sex with desired partners ◦ Experience of “gender dysphoria” and lack of language around personal body parts ◦ Physiological and/or sex-drive changes associated with hormone use and surgeries
Interpersonal factors: ◦ Physical and sexual abuse and violence at home ◦ Complicated gender and power dynamics in relationships ◦ Difficulties associated with disclosure of trans identity to, and discussing their bodies and sex with, prospective sexual partners, including the lack of language to communicate these issues There can be a real lack of language to describe body parts as well: “Jokingly I say ‘glory hole’ and ‘bonus round’; but when actually talking about my body seriously…frankly, I don’t have any words at all. It’s just a big void in my vocabulary.” ◦ Partner’s resistance to condom use
Structural/Societal Factors: ◦ Narrowly constructed gender norms and societal oppression of gender non-conformity ◦ Barriers to employment, social services, housing, legal assistance and health and mental health care Health care administrative procedures often do not promote opportunities for trans people to share pertinent information about their identities or needs; can sometimes be hostile or phobic ◦ Barriers to changing any legal documents to reflect current lived gender identity ◦ Barriers to access to SRS, hormones, etc.
Some trans people report having unprotected penetrative and oral sex Some trans people report having sex while under the influence Some trans people report engaging in sex work Some trans people report having sex with populations with a high rate of HIV infection (MSM)
Over 25% of trans people use substances and may be sharing equipment or making sexual decisions while under the influence Trans people need access to new needles for hormone or silicone injection
Of transmen who have sex with other transmen only 33.3% reported using a condom while having “front hole” sex Of transmen who have sex with other transmen only 17.7% reported using a condom for anal sex There may be a role for agencies to provide education on proper use of sex toys
“One of the first guys I pick up [online]- we met. And I’d been very explicit in my ad, but, I still wasn’t sure, but he said ‘let’s meet’..I think I was kind of confronting or coming face-to-face with my internalized transphobia. ‘How can you be so excited so soon?’ So, we’re at the bar having one drink and he’s like ‘let’s go back to your place’ and I’m like ‘okay.’ Even though I might have naturally known it was coming, I still couldn’t believe it…” * excerpt from Getting Primed: Informing HIV Prevention with GBQ Trans Men in Ontario
“So then we go and we’re lying in bed and I was kind of like, ‘do you know what a trans guy is?’ He’s like “oh yeah, oh yeah. I know what it is. I’ve been with them before.’ And I was scared at that point...I was really kind of freaked out. We were fooling around and it comes to fucking – no condom. We fucked twice. He came in me both times – no condom. “ * excerpt from Getting Primed: Informing HIV Prevention with GBQ Trans Men in Ontario
“And, the sex was alright..it was...I felt terrible because of all the internal stuff...I was like with all my knowledge...I have a bucket of condoms here...all this shit..which was a great lesson to me that you can have all the knowledge in the world, but there are so many other things that can go there with it. “ * excerpt from Getting Primed: Informing HIV Prevention with GBQ Trans Men in Ontario
“But, I really think in hindsight that I had so much stuff going on that it was as if I was so grateful that this guy would sleep with me, that he could just do what he wanted. I was very upset afterwards and it was quite a shock to me. Fortunately, I have...since then all the ‘fucking’ sex has been with condoms.” * excerpt from Getting Primed: Informing HIV Prevention with GBQ Trans Men in Ontario
Policy work around trans inclusion (ie women’s only, men’s only shelters) Prepwork ◦ Training, education, and advocacy ◦ Stating inclusion of trans folks with ALL service users (avoids outting certain people) Paperwork ◦ Names ◦ Separate envelope for checks and contracts ◦ M/F on forms Be Flexible See Handouts
Housing is harm reduction – what are your local shelters’/housing organizations’ policies around trans clients Need to be able to discuss risk reduction in with all sexual risk taking behaviours Support trans clients with getting access to proper and adequate health care for hormones and surgeries Make sure local harm reduction resources have equipment for intramuscular injections
Ask politely which pronouns to use, if you aren’t sure Use the pronoun you’ve been asked to use Correct others if they use the wrong pronoun Don’t ask about surgeries or hormones unless they’ve given you permission to Don’t call someone by their old name, use their current chosen name Don’t out others as trans Don’t use just male/female on forms Advocate for unisex restrooms or be a “bathroom guard” for someone using a gendered washroom Be honest about what you do and don’t know
I don’t bite, feel free to ask questions I may not know the answer to all questions but I am willing to look it up
Rainbow Health Ontario ◦ http://www.rainbowhealthontario.ca Trans Health ◦ http://www.trans-health.com Trans Pulse Project ◦ http://transpulseproject.ca/
Plan A: Try using only single stall restrooms for a day Plan B: At least notice how many times you come across an all gender washroom/change room