Michigan School of Professional Psychology Presentation 3.6.08


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Providing Culturally Competant Care to Transgender Individuals

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Michigan School of Professional Psychology Presentation 3.6.08

  1. 1. Providing Culturally Competent Care to Transgender Individuals Rachel Crandall LMSW Knoll Larkin MPH
  2. 2. Icebreakers <ul><li>Name </li></ul><ul><li>Location </li></ul><ul><li>Experience working with the Transgender Community? </li></ul><ul><li>What information you would like to leave with today? </li></ul>
  3. 3. Seminar Overview <ul><li>Terms and Definitions </li></ul><ul><li>Gender Diversity Activity </li></ul><ul><li>Myths and Facts </li></ul><ul><li>Identity, Culture, and Life Cycle Issues </li></ul><ul><li>Rachel’s Story </li></ul><ul><li>The Trans Experience and Mental Health </li></ul><ul><li>Knoll’s Story </li></ul><ul><li>Barriers to Care </li></ul><ul><li>Standards of Care and Best Practices </li></ul><ul><li>Community Resources </li></ul><ul><li>Making your Practice T Friendly </li></ul><ul><li>Contracting for Change! </li></ul>
  4. 4. Terms and Definitions
  5. 5. LGBT 101 <ul><li>Lesbian : Term used to describe women who experience sexual, emotional, and spiritual connections to other women. </li></ul><ul><li>Gay : Men who experience sexual, emotional, and spiritual connections to other men. </li></ul><ul><li>Bisexual/Bi-Attractional : People who experience sexual, emotional, and spiritual connections to people of many genders. </li></ul><ul><li>Sexual Orientation : An identity which describes one’s emotional, romantic, sexual, affectionate and relational attraction to another person. </li></ul>
  6. 6. LGBT 101 Cont. <ul><li>Same Gender Loving: Language commonly use din communities of color to describe same gender attraction. </li></ul><ul><li>Queer: Inclusive language used to describe people who’s experience may not necessarily be defined by LGB. </li></ul><ul><li>Ally: Some who commits to personally and publicly advocate for social and political equality for LGBT people. </li></ul>
  7. 7. LGBT 101 Cont. <ul><li>Identity vs. Behavior </li></ul><ul><ul><li>Identity- the “label” one applies to oneself and one’s community of affiliation </li></ul></ul><ul><ul><li>Behavior -the specific activities the person engages in </li></ul></ul>
  8. 8. Gender Explorations <ul><li>Volunteer  </li></ul><ul><li>What pronouns would you use to describe this person? </li></ul><ul><li>What physical cues told you about this person’s gender? </li></ul><ul><li>What non verbal cues told you about this person’s gender? </li></ul><ul><li>What verbal cues told you about this person’s gender </li></ul><ul><li>What would it take to see this person as another gender? </li></ul>
  9. 9. Gender Terms and Definitions <ul><li>Sex: Male, female, or Intersex, depending on one’s primary sex characteristics. </li></ul><ul><li>Intersex: People born with an anatomy that someone else decided is not standard for male or female. </li></ul><ul><li>Gender: Socially and culturally constructed roles ascribed to males and females. These roles, which are learned, changed over time and vary widely within and between cultures as well as from individual to individual. </li></ul><ul><li>Gender Identity: One's sense of belonging to a particular gender. </li></ul><ul><li>Gender Expression: the way in which someone conveys gender attributes. </li></ul>
  10. 10. Gender Terms and Definitions <ul><li>Drag: Gender performance, often for entertainment purposes. </li></ul><ul><li>GenderQueer: An individual whose gender identity lies outside the gender binary system of male and female. This individual may be fluid with their gender expression. </li></ul><ul><li>Gender Neutral Pronouns: and may use gender neutral pronouns (such as *sie, hir, hirs, hirself* or *zie, zir, zirs, zirself*) or choose to use the pronoun closest to the end of the masculine or feminine spectrum they are presenting. </li></ul>
  11. 11. Transgender <ul><li>Transgender (TG): individuals who do not conform to gender stereotypes, roles, and expectations. This is referred to as the &quot;umbrella definition” as it covers everyone. </li></ul><ul><li>Transsexual: A person who identifies as the sex opposite to the one assigned at birth. Folks who identify this way may alter their physical appearance to match their gender identity. </li></ul><ul><li>Female-to-Male: A person whose sex was assigned as female at birth, but who now identifies as a man. Also known as FTM, F2M or F>M for short. </li></ul><ul><li>Male-to-Female: A person whose sex was assigned as male at birth, but who now identifies as a woman. Also known as MTF, M2F, or M>F for short. </li></ul>
  12. 12. Common language: Summary (cont.) <ul><li>Preferred vs. Other Terms </li></ul><ul><ul><ul><li>Lesbian, Gay, Bisexual Homosexual </li></ul></ul></ul><ul><ul><ul><li>Partner Lover/Roommate </li></ul></ul></ul><ul><ul><ul><li>Sexual orientation Sexual preference </li></ul></ul></ul><ul><ul><ul><li>Crossdresser Transvestite </li></ul></ul></ul><ul><ul><ul><li>Transgender Transsexual </li></ul></ul></ul><ul><ul><ul><li>Intersex Hermaphrodite </li></ul></ul></ul><ul><li>WHEN IN DOUBT… ASK! </li></ul><ul><li>Words/Phrases Often Used “Within” the Community </li></ul><ul><li>Dyke, Queer, Family, In the Life, Tranny </li></ul>T4:8
  13. 13. Using Language: Summary <ul><li>One way to demonstrate inclusiveness in a healthcare setting is through use of language. </li></ul><ul><li>Use terms preferred by your patients. These may be different for each person, regionally or generationally based. </li></ul>T4:7
  14. 14. Appropriate Ways to Ask About Gender Identity (created by Affirmations Trans Youth Group-Jan 2007) <ul><li>Ask on a need-to-know basis </li></ul><ul><li>If feasible, only ask about pronouns </li></ul><ul><li>Ask the person-not those around you </li></ul><ul><li>Until you find an appropriate time and place to ask someone about pronoun preference, try to use gender neutral pronouns, or no pronouns at all. </li></ul><ul><li>*Sample Inquiry* Do you have a pronoun preference </li></ul>
  15. 15. Inappropriate Ways to Ask About Gender Identity <ul><li>Are you a boy or a girl? </li></ul><ul><li>Do you pee standing up </li></ul><ul><li>Don’t ask questions about genitalia </li></ul><ul><li>Don’t label someone who hasn’t first labeled themselves </li></ul><ul><li>Don’t ask someone if they were “born as a boy or a girl” </li></ul><ul><li>No asking someone what their “birth name” is </li></ul><ul><li>Don’t be nosey </li></ul>
  16. 16. Myths and Facts
  17. 17. Myths/Facts About Transgender Identity <ul><li>MYTH: All transgender individuals want or have had sex reassignment surgery. </li></ul><ul><li>FACT: Actual or desired surgical status is separate from one’s gender identity. Some transgender individuals feel “complete” once they have had surgery, while others opt to not have surgery because of limited funds and/or lack of medical insurance coverage, medical complications, or because they are dissatisfied with current technological limitations. </li></ul>
  18. 18. Myths/Facts About Transgender Identity <ul><li>MYTH: Transgender individuals go from either male-to-female or from female-to-male. </li></ul><ul><li>FACT: “Transgender” is an umbrella term, which includes people who do not conform to gender stereotypes, roles, and expectations. Some transgender individuals appreciate an androgynous or gender queer identity. Many drag monarchs (kings and queens), cross-dressers, butch women and feminine men also consider the transgender community home. </li></ul>
  19. 19. Myths/Facts about Transgender Identity <ul><li>MYTH: Being transgender is a birth defect that can be corrected through hormones and surgery. </li></ul><ul><li>FACT: While some transgender individuals believe this, some believe that their transgender identity is a gift or a blessing. Some transgender individuals also feel that there isn’t anything defective about their transgender identities. </li></ul>
  20. 20. Myths/facts About Transgender Identity <ul><li>MYTH: Transgender people are trying to become a particular gender. </li></ul><ul><li>FACT: Transgender people are coming out as the people they feel themselves to be. </li></ul>
  21. 21. Trans Culture and Lifecycle Issues
  22. 22. Life Cycle Issues For Trans Individuals <ul><li>Trans youth face additional stressors </li></ul><ul><li>(conformity, and coming out) </li></ul><ul><li>Transgender young adults (social life revolving around bars and substance use settings) </li></ul><ul><li>Coupling </li></ul><ul><li>Parenting </li></ul><ul><li>Aging </li></ul><ul><li>Treatment Providers need to consider a T client’s partner, children, family of origin and family of choice when providing care! </li></ul>
  23. 23. Transition <ul><li>Medical Transition </li></ul><ul><ul><li>Hormones </li></ul></ul><ul><ul><li>Surgery </li></ul></ul><ul><ul><li>Other (electrolysis, etc.) </li></ul></ul><ul><li>Social Transition </li></ul><ul><ul><li>Appearance </li></ul></ul><ul><ul><li>Gender markers (Id, birth certificate, etc) </li></ul></ul><ul><ul><li>Name change </li></ul></ul><ul><ul><li>Coming out </li></ul></ul>
  24. 24. Transgender Clients May Be Coping With: <ul><li>Coming out </li></ul><ul><li>Accessing physical and mental health services including transition related services </li></ul><ul><li>HIV/AIDS </li></ul><ul><li>Discrimination and violence </li></ul><ul><li>Transphobic family members, employers, and work colleagues </li></ul>
  25. 25. Coming Out: <ul><li>Refers to the experiences of some, but not all, LGBT people as they work through and accept a stigmatized identity. </li></ul><ul><li>Transforming a negative self identity into a positive one </li></ul><ul><li>Often described as a process of self-actualization. Transgender youth may face far more barriers (legal & medical). </li></ul>
  26. 26. Coming Out (cont) <ul><li>There is no correct way to come out </li></ul><ul><li>Some people may decide they do not want to take on a LGBT identity and may choose not to disclose their feelings and experiences to anyone. </li></ul>
  27. 27. What is Non-Transgender Privilege? <ul><li>Non transgender privilege means living without ever having to face, confront, engage in, cope with, most things on the list. </li></ul><ul><ul><li>Not questioning your normalcy with regard to your gender or your body. </li></ul></ul><ul><ul><ul><li>Never questioning the assumed connection between your genitals and your gender </li></ul></ul></ul><ul><ul><ul><li>Experiencing childhood or adolescence while being treated as your gender. </li></ul></ul></ul><ul><ul><ul><li>Keeping your name, pronouns, and voice the same throughout your life. </li></ul></ul></ul>
  28. 28. Non Trans Privilege <ul><li>Validation from the culture in which you live including family, friends, and partners </li></ul><ul><ul><li>Assuming that people will be able to interpret your gender correctly from my appearance, and not worrying about what might happen if they can’t. </li></ul></ul><ul><ul><li>Having a valid accepted gender without evaluation by a medical professional, surgery, or a “judgment” of your appearance and ability to pass. </li></ul></ul>
  29. 29. Non Trans Privilege <ul><li>Institutional Acceptance </li></ul><ul><ul><li>Using bathrooms, showers, or locker rooms without fear. </li></ul></ul><ul><ul><li>Marking one of the two sex options on most forms without question. </li></ul></ul><ul><ul><li>Adopting children, fostering children. </li></ul></ul><ul><ul><li>Making choices about your body by yourself without having to be declared mentally ill. </li></ul></ul>
  30. 30. Rachel’s Story The Trans Experience and Mental Health
  31. 31. Knoll’s Story
  32. 32. Barriers to Care
  33. 33. Barriers to receiving care/services: <ul><li>Marginalization and labeling of gender identity as deviant or pathological in medical or psychiatric communities. </li></ul><ul><li>Anticipated, perceived, or actual discrimination </li></ul><ul><li>Fear of mistreatment </li></ul><ul><li>Lack of research about Trans community </li></ul><ul><li>Provider lack of information </li></ul><ul><li>Fear of being outed will result in loss of job, custody, housing, or social supports. </li></ul><ul><li>Exclusion of partner and family of choice from health care settings </li></ul><ul><li>Lack of insurance coverage for basic health and transition needs </li></ul><ul><li>Internalized Transphobia </li></ul>
  34. 34. Barriers to Care and Treatment Cont. <ul><li>Providers lack basic knowledge and have discomfort </li></ul><ul><li>Lack of research and information </li></ul><ul><li>Extensive negative experiences with healthcare. </li></ul><ul><li>Medicalization and pathologization of experiences </li></ul><ul><li>Intake forms, office environment, alienating process </li></ul><ul><li>Documentation(sex marker on state ID and birth certificates, SSN, etc) </li></ul>
  35. 35. Health Issues Affecting Trans Youth <ul><li>Access to healthcare </li></ul><ul><ul><li>Insurance </li></ul></ul><ul><ul><li>Treatment by providers </li></ul></ul><ul><li>Risk Behaviors </li></ul><ul><ul><li>Street hormones </li></ul></ul><ul><ul><li>Self surgery </li></ul></ul><ul><ul><li>Pumping parties </li></ul></ul><ul><ul><li>Survival sex work </li></ul></ul><ul><ul><li>Poverty/Violence </li></ul></ul>
  36. 36. Sex Segregated Areas <ul><li>Bathrooms </li></ul><ul><li>Locker rooms </li></ul><ul><li>Residential facilities </li></ul><ul><li>Homeless shelters </li></ul><ul><li>Jails/prison </li></ul><ul><li>Rehab/mental health </li></ul>
  37. 37. Robert Eads <ul><li>Eads, a transgender man diagnosed with ovarian cancer, was turned down for treatment by two dozen doctors out of fear that treating such a patient would hurt their reputation. By the time Eads received treatment, the cancer was too advanced to save his life. </li></ul>
  38. 38. Standards of Care and Best Practices
  39. 39. Best Practices <ul><li>“People of diverse gender expression should be afforded the same respect and rights as those whose gender identity and expression conform to societal expectations” </li></ul><ul><ul><li>American Psychological Association </li></ul></ul>
  40. 40. Gender Identity Disorder and the DSM <ul><li>The core symptom of gender identity disorders is gender dysphoria, literally being uncomfortable with one's assigned gender. </li></ul><ul><li>This feeling is usually reported as &quot;having always been there&quot; since childhood, although in some cases, it appears in adolescence or adulthood, and has been reported by some as intensifying over time. </li></ul><ul><li>Since many cultures strongly disapprove of cross-gender behavior, it often results in significant problems for affected persons and those in close relationships with them. In many cases, discomfort is also reported as stemming from the feeling that one's body is &quot;wrong&quot; or meant to be different. </li></ul>
  41. 41. Gender Identity Disorder <ul><li>The current edition of the Diagnostic and Statistical Manual of Mental Disorders has five criteria that must be met before a diagnosis of gender identity disorder (302.85) can be given: </li></ul><ul><ul><li>There must be evidence of a strong and persistent cross-gender identification. </li></ul></ul><ul><ul><li>This cross-gender identification must not merely be a desire for any perceived cultural advantages of being the other sex. </li></ul></ul><ul><ul><li>There must also be evidence of persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender role of that sex. </li></ul></ul><ul><ul><li>The individual must not have a concurrent physical intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia ). </li></ul></ul><ul><ul><li>There must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning. </li></ul></ul>
  42. 42. Controversy <ul><li>Many transgender people do not regard their cross-gender feelings and behaviors as a disorder. </li></ul><ul><li>Some trans people object on the grounds that there may be a physical cause, as suggested by recent studies about the brains of transsexual people. Many of them also point out that the treatment for this disorder consists primarily of physical modifications to bring the body into harmony with one's perception of mental (psychological, emotional) gender identity, rather than vice versa </li></ul><ul><li>In order to access “treatment”—meaning hormones and, perhaps, surgery—you first have to be diagnosed. But calling trans people sick creates the same stigma gay/lesbian/bisexual people faced for decades. </li></ul>
  43. 43. WPATH Standards of Care <ul><li>The World Professional Association for Transgender Health (WPATH, formerly HBIGDA) Standards of Care (Version 6 from 2001) are considered by some as definitive treatment guidelines for providers. </li></ul>
  44. 44. Health Law Standard <ul><li>Developed in the early 1990s, the Health Law Standard (HLS) takes an entirely different approach from the medical-model paradigm of the original SOC. </li></ul><ul><li>Informed consent approach, and is written in the form of a contract between client, doctor, and legal spouse. Clients sign the HLS, indicating they understand and take full responsibility for all risks inherent in the transition process. </li></ul><ul><li>Once they have signed the HLS, they may access hormones and any surgical procedures related to transition, bypassing the therapeutic process altogether if they so choose. </li></ul>
  45. 45. Others <ul><li>guidelines outlined in Gianna Israel and Donald Tarver's classic 1997 book &quot;Transgender Care&quot;. </li></ul><ul><li>Several LGBT health clinics in the United States (e.g. Tom Waddell in San Francisco, Callen Lorde in New York City, Mazzoni in Philadelphia) have developed “protocols” for transgender hormone therapy following a “harm reduction” model which is coming to be embraced by increasing numbers of providers. </li></ul><ul><li>In their 2005 book Medical Therapy and Hormone Maintenance for Transgender Men , Dr. Nick Gorton et al suggest a flexible approach based in harm reduction, “Willingness to provide hormonal therapy based on assessment of individual patients needs, history and situation with an overriding goal of achieving the best outcome for patients rather than rigidly adhering to arbitrary rules has been successful.” </li></ul>
  46. 46. Making Your Practice T Friendly
  47. 47. Solutions: <ul><li>Before the patient/client encounter </li></ul><ul><ul><li>Marketing materials, brochures, ways services are introduced. Are they representative of the diversity of the populations within the service area? Will trans people feel like the advertised facility is a comfortable place for them? How is this communicated? What is the current reputation in Trans community? Is there a need to address past negative experiences? </li></ul></ul>
  48. 48. Creating an Affirming Environment: <ul><li>Display health info, magazines, posters, and other decorations that reflect the faces and interests of clients served. Staff should also be representative of clients served. Consider posting a written non-discrimination policy that gender identity and gender expression. </li></ul>
  49. 49. Inclusive Paperwork <ul><li>Goes beyond “Male” or “Female” </li></ul><ul><li>Offers a place for clients to include preferred name not just legal name. </li></ul><ul><li>Takes into account discrepancies in legal documentation </li></ul><ul><ul><li>driver’s license (name and gender marker) </li></ul></ul><ul><ul><li>Birth Certificate & Social Security Card </li></ul></ul><ul><ul><li>Insurance Card </li></ul></ul>
  50. 50. Culturally Competent Approach: <ul><li>Is client centered </li></ul><ul><li>Uses client’s own language </li></ul><ul><li>Non-judgmental </li></ul><ul><li>No assumptions </li></ul><ul><li>Open ended questions </li></ul><ul><li>Begins with less threatening questions </li></ul><ul><li>It’s okay to not know! </li></ul>
  51. 51. If a Trans person comes out to you, DO: <ul><li>Remember that gender identity or gender expression is just one dimension of your client. </li></ul><ul><li>Be yourself. </li></ul><ul><li>Recognize your limitations. </li></ul><ul><li>Remember that the person may be nervous or afraid. </li></ul><ul><li>Use the vocabulary they use. </li></ul>
  52. 52. <ul><li>Do your homework: find out more about gender identity & local resources. </li></ul><ul><li>Remember that it doesn’t take a transgender therapist to help a transgender client. </li></ul><ul><li>If the client seems nervous, you can assure him or her that the information is confidential. </li></ul><ul><li>Remember that you have an obligation to respect the person’s right to privacy and confidentiality. </li></ul>If A Trans Person Comes Out to You (CONT)
  53. 53. Contracting for Change <ul><li>Identify two or more changes you are willing to make in how you provide services? </li></ul><ul><ul><li>What personal obstacles do you face? </li></ul></ul><ul><ul><li>What professional obstacles do you face? </li></ul></ul><ul><ul><li>How might these obstacles be overcome? </li></ul></ul>
  54. 54. Community Resources
  55. 55. Contact Us <ul><li>Knoll Larkin MPH </li></ul><ul><ul><li>[email_address] </li></ul></ul><ul><li>Rachel Crandall, LMSW </li></ul><ul><ul><li>[email_address] </li></ul></ul><ul><li>248-398-7105 ( www.goaffirmations.org ) </li></ul><ul><li>517-420-1544 ( www.TransGendermichigan.org ) </li></ul>