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Working with the Transgender Population: what you need to know
 

Working with the Transgender Population: what you need to know

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Doctoral Seminar presentation to MiSPP 2.20.2011

Doctoral Seminar presentation to MiSPP 2.20.2011

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  • Transgender: There are many kinds of people who fit this term and the rest of the terms describe some of them. Intersex: It is now considered offensive to use the term hermaphrodite, so it is more appropriate to call people intersex. Some intersex people identify as transgender while others do not. Some intersex conditions are know at the time of birth while others are not discovered until later in life, if at all. Some intersex conditions are anatomical while others are chromosomal. Crossdressers: They may do so because they find it fulfilling in emotional or sexual ways. Crossdressing is more than sexuality-it is a way a person expresses all of who they are, both masculine and feminine. The word transvestite is outdated and offensive to some people. The currently used term is crossdresser.
  • FTM/MTF: You’ll often hear transgender people referring to ourselves as MTF or FTM, so if you know these terms, you’ll sound much more knowledgeable about our issues. Remember, the first letter is the gender assigned to someone at birth, the T stands for to, and the last letter is how the person identifies now. Gender: Different societies have different ideas about what it means to be feminine or masculine and how people are expected to act.
  • Sex: This is the scientific term for what makes males and females different; remember though that not everyone fits into these 2 categories. There are a number of different factors that determine sex, not just chromosomes. Drag queen: in the African American community some people use the word queen to refer to gay men—these men may or may not crossdress. Transsexuals are the people who generally life full time as a different gender than the one they were assigned at birth.
  • Everyone has a sexual orientation, gender identity and gender expression. Transgender people can be straight, gay ,lesbian, or bisexual—gender identity is separate from your sexual orientation.
  • While these words have been reclaimed and used by some members of the LGBT communities, they should never be used by people who don’t identify as LGBT themselves.
  • Conway looked at the number of transition related medical procedures in the United States and calculated prevalence numbers that way. The 1% is only for people who can be counted by professionals and other researchers. Folks that do not medical transition are harder to count, for example, others falling under the broader transgender umbrella The majority of these people do not come to the attention of professionals who would record these statistics, and, therefore, their numbers are very difficult to estimate.
  • When you look across cultures you will find that people have a wide range of beliefs about gender. Some culures look at people and see six genders whole other see two. Different cultures also vary in their definitions of masculine or feminine. Whether we view someone as transgender depends on the cultural lenses we are looking through as well as how people identify themselves. Biologists tell us that sex is a complicated matter, much more complex than what we may have been taught in school. A person has XX chromosomes is generally considered female, while a person with XY chromosomes is generally considered male. However, there are also people who have XXY, XYY, and other variations of chromosomes; these genetic differences may or may not be visibly apparent or known to the person. A variation in gender may just be part of the natural order and there are more varieties than we generally realize. People with biological differences in gender may be considered intersex; they may or may not identify as transgender. There are medical theories about why people are transgender. Some speculate that fluctuations or imbalances in hormones or the use of certain medications during pregnancy may cause intersex or transgender conditions. Other research indicates that there are links between transgender identity and brain structure. Some people believe that psychological factors are the reason for the existence of transgender people. There are theories about early childhood influences and other factors; however, it is clear that there are people who are aware that they are transgender from their earliest memories. Many trans people feel that their gender identity is an innate part of them, an integral part of who they were born to be. Then there are people who feel that everyone has a right to choose whatever gender presentation feels best to that individual. People should have the freedom to express themselves in whatever way is right for them.
  • For some people, this leads to emotional distress. This pain often can be relieved by freely expressing our genders, wearing clothing we are comfortable in, and, for some, making a physical transition from one gender to another. For people who identify as transsexual, counseling alone, without medical treatment, is often not effective. Until 1973, homosexuality was considered a mental illness; mental health professionals now know that it is part of the normal range of human sexuality. In the same way, we believe that in the future people will recognize that gender differences are also part of the spectrum of human expression. Our society is, however, very harsh on gender-variant people. Some transgender people have lost their families, their jobs, their homes and their support. Transgender children may be subject to abuse at home, at school or in their communities. A lifetime of this can be very challenging and can sometimes cause anxiety disorders, depression and other psychological illnesses. These are not the root of their transgender identity; rather, they are the side effects of society’s intolerance of transgender people.
  • Not all transsexual people follow these steps nor does the community agree about their importance. The Standards of Care not legally mandated. We believe that people should make their own decisions about their health care, in consultation with medical or mental health professionals as appropriate to their individual situation. I’ll briefly touch on a few other models in a moment.
  • These surgeries are often referred to as Sexual Reassignment Surgeries or SRS. I’ve also heard some transgender people refer to them as GCS or Gender Confirming Surgeries.
  • Dr. Nick Gorton describes the guidelines as a “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.”
  • Transsexual people may undergo hormone therapy. Transwomen may take estrogen and related female hormones; transmen may take testosterone. It is important that people obtain hormones from a licensed medical professional if at all possible to be sure that the medications are safe and effective. Doctors should monitor the effects on the body, including checking for negative side effects. Some of the effects of hormone treatment are reversible when a person stops receiving hormone therapy; other effects are not. Hormones can have an impact on some people’s emotional states. Many people report feeling more at peace after they begin hormone treatments, but hormones may also cause other fluctuations in mood. For many transgender people, there is no discernable difference in moods after beginning hormone treatments. Some people and their doctors decide to pursue a full dose of hormones while others choose to go on a lower dose regimen or not take hormones at all for personal or medical reasons. Hormone therapy is covered by some medical insurance.
  • There are a variety of surgeries that people can have, including: Genital reconstructive surgery, to create a penis and testes or clitoris, labia and vagina Facial reconstruction surgery, to create a more masculine or feminine appearance Breast removal or augmentation For FTMs, surgery to remove the ovaries and uterus For MTFs, surgery to reduce the Adam’s apple or change the thorax.
  • Different states have different procedures for changing driver’s license and state IDs. In Michigan you need a letter from a medical provider stating the you had irreversible gender reassignment surgery.
  • People decide to transition from one gender to another because they are seeking a sense of well-being and wholeness in their lives. They feel that they will have a better quality of life as a result of this change. For some people, gender transition is the only effective therapeutic treatment for real, disabling distress.
  • Some people feel that their lives would not be improved by transitioning and so decide not to. Others are unwilling to risk losing their family, job or other things that are also very important to them that would be threatened by a decision to transition. Because little is known about the long term effects of hormone therapy, some transsexuals feel that the medical risks are too high. Others have medical conditions that make it dangerous for them to take hormones or have surgery. Finally, because insurance rarely covers these treatments and so many transgender people do not have insurance or even jobs, many people are simply unable to afford the medical treatment that they need and desire. There are a variety of reasons people don’t have surgery—because they don’t want to, because they can’t afford it, because it is not medically possible for that person, because it is not therapeutically necessary, etc.—and therefore it is not helpful to draw distinctions between “pre-op,” “post-op” and “non-op.” Not everyone will have surgery and we support the rights of individuals to determine their own path. Civil rights—such as employment non-discrimination, the ability to have accurate identity documents, etc.—should not be based on this distinction either. Remember, too, that not all transgender people are transsexual, and therefore do not want to access medical treatment to change their sex.
  • Some transgender people are able to keep their jobs, stay with their families and maintain their support networks—while enjoying their life much more fully because they have transitioned.
  • LGBT individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights. Experiences of violence and victimization are frequent for LGBT individuals, and have long-lasting effects on the individual and the community. 1. McLaughlin KA, Hatzenbuehler ML, Keyes KM. Responses to discrimination and psychiatric disorders among black, Hispanic, female, and lesbian, gay, and bisexual individuals. Am J Public Health. 2010;100(8):1477-84. 2. Ibanez GE, Purcell DW, Stall R, et al. Sexual risk, substance use, and psychological distress in HIV-positive gay and bisexual men who also inject drugs. AIDS. 2005;19(suppl 1):49-55. 3. Herek GM, Garnets LD. Sexual orientation and mental health. Annu Rev Clin Psychol. 2007;3:353-75. 4. Remafedi G, French S, Story M, et al. The relationship between suicide risk and sexual orientation: Results of a population-based study. Am J Public Health. 1998;88(1):57-60. 5. Roberts AL, Austin SB, Corliss HL, et al. Pervasive trauma exposure among US sexual orientation minority adults and risk of posttraumatic stress disorder. Am J Public Health. 2010 Apr 15. 6. US Department of Health and Human Services. Healthy People 2010. [Internet]. Available from: http://www.hhs.gov

Working with the Transgender Population: what you need to know Working with the Transgender Population: what you need to know Presentation Transcript

  • Working With the Transgender Population: what you need to know Knoll Larkin MPH
  • Learning Objectives
    • Understand basics of transgender identity, culture, coming out process and transition experiences.
    • Understand various models of transgender physical and mental health standards of care and best practices (Harry Benjamin/WPATH, informed consent models, etc.)
    • Increase awareness of common mental health concerns facing transgender individuals.
    • Understand life cycle issues for transgender populations (gender variant youth, parenting issues, aging, etc.)
  • Terminology
    • Transgender: Is an umbrella term that refers to people who live differently than the gender presentation and roles expected of them by society.
    • Intersex: People with physical characteristics that do not match the typical understandings of male and female; previously called hermaphrodites.
    • Crossdresser: Refers to people who choose to wear the clothing generally associated with the opposite gender.
  • Terminology
    • FTM and MTF : are abbreviations used by many female-to-male transgender persons (also known as transmen) and male-to-female transgender persons (also known as transwomen).
    • Gender: refers to the societally-determined characteristics of a particular sex; these characteristics are commonly referred to as masculine or feminine.
  • Terminology
    • Sex : Refers to the designation of the biological differences between females and males.
    • Drag Queen : Is a term historically used by gay men who dress in the clothing usually associated with women for the purposes of entertainment or personal fulfillment. There are also drag kings who are biologically female and dress as men.
    • Transsexual : People who seek to live in a gender different from the one assigned at birth and who may seek or want medical intervention for them to live comfortably in that gender.
  • Terminology
    • Sexual Orientation: Describes who people fall in love with and/or are sexually attracted to.
    • Gender Identity: Describes how people perceive their own internal sense of maleness or femaleness. Overall, one’s sense of belonging to a particular gender.
    • Gender Expression: the way in which someone conveys gender attributes.
  • Terms to Avoid
    • “ He-she”
    • “ She-male”
    • Tranny—should only be used by transgender people; non transgender people should avoid this word.
    • Fag, faggot, dyke, queer—sometimes words used against LGB people are also used against transgender people.
  • *Appropriate Ways to Ask About Gender Identity
    • Ask on a need-to-know basis
    • If feasible, only ask about pronouns
    • Ask the person-not those around you
    • 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.
    • Sample Inquiry: Do you have a pronoun preference
    • *Created by Affirmations Trans Youth Group 2008
  • Inappropriate Ways to Ask About Gender Identity
    • Are you a boy or a girl?
    • Do you pee standing up?
    • Don’t ask questions about genitalia
    • Don’t label someone who hasn’t first labeled themselves
    • Don’t ask someone if they were “born as a boy or a girl”
    • No asking someone what their “birth name” is
    • Don’t be nosey
  • Myths/Facts About Transgender Identity
    • MYTH: You can tell someone is transgender by looking at them.
    • FACT: There’s no one way Transgender people look. Transgender people represent a cross-section of the general population. Some transgender people pass, some don’t, and others don’t want to. Further, there is a difference between identity and expression/behavior.
  • Myths/Facts About Transgender Identity
    • MYTH: All transgender individuals want or have had sex reassignment surgery.
    • 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.
  • Myths/Facts About Transgender Identity
    • MYTH: Transgender individuals go from either male-to-female or from female-to-male.
    • 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.
  • Myths/Facts about Transgender Identity
    • MYTH: Being transgender is a birth defect that can be corrected through hormones and surgery.
    • 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.
  • How Many Transgender People are there?
    • APA estimates between .25% and 1% of the population is transsexual.
    • Others (Conway et. al) estimate 1/500 people
    • % much lower than the reality
      • Isn’t anyone collecting this data
      • Transgender people aren’t always open about identities
      • There is no mechanism in place to “count” people who do not transition.
  • Why Are People Transgender?
    • Culture
    • Biology
    • Medical theories
    • Psychological factors
    • Choice
    • No one reason?!
      • Sex and gender are complex issues. A variety of factors are at work in making people the individuals that they are. Transgender people are part of the variety that makes up the human community.
  • Is Being Transgender a Mental Illness?
    • No, but this remains a stereotype about transgender people. However, Gender Identity Disorder is listed in the Diagnostic and Statistical Manual-4th Edition (DSM-IV), a guide used by mental health professionals to diagnose psychological conditions.
    • Transgender identity is not a mental illness that can be cured with treatment. Rather, transgender people experience a persistent and authentic difference between our assigned sex and our understanding of our own gender.
  • Controversy
    • Many transgender people do not regard their cross-gender feelings and behaviors as a disorder.
    • 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
    • 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.
  • How do Transsexual People Change Genders?
    • There are a variety of paths that people follow
      • Many use World Professional Health Association for Transgender Care (WPATH) Standards of Care (SOC)
      • Health Law Standard
      • Harm Reduction
      • Informed Consent
  • WPATH Standards of Care
    • A series of steps that people may take:
      • Counseling with mental health professional
      • A “real life” experience where the person lives as the “target gender” for a trial period
      • Learning about options and effects of medical interventions
      • Communication between therapist and physician indicating readiness to begin medical treatment. (Letter)
      • Undergoing hormone therapy
      • Having various surgeries to alter the face, chest, and genitals to be more congruent with the individuals sense of self.
  • Health Law Standard
    • Developed in the early 1990s, the Health Law Standard (HLS) takes an entirely different approach from the medical-model paradigm of the original SOC.
    • 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.
    • 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.
  • Others
    • Guidelines outlined in Gianna Israel and Donald Tarver's classic 1997 book "Transgender Care".
    • 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. These are also called informed consent models.
    • 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
  • Medical Transition
    • Hormones
      • Estrogen for MTFs
        • Softening the skin
        • Redistributing body fat for feminine appearance
        • Reducing some body hair
        • Altering moods
      • Testosterone for FTMs
        • Lowering voice
        • Growth of body/facial hair
        • Redistributing body fat for masculine appearance
        • Ending menstrual cycle
  • Medical Transition
    • Surgery
      • No single “sex change” surgery
      • Surgery almost always excluded from health plans
      • Not every transgender person wants, or has surgery.
      • Whether or not someone has surgery should not make a difference in how they are treated.
  • Social Transition
    • Appearance
    • Name change (legal or not)
    • Pronoun change
    • Legal change of gender markers
      • Driver’s license
      • Social Security Account
      • Passport
      • Birth Certificates
  • Why Do People Decide to Transition?
    • Seeking a sense of well-being
    • Wholeness
    • Quality of life
    • Therapeutic treatment for distress
  • Why Would Someone Decide Not To Transition?
    • Feel their lives would not be improved by transitioning
    • Unwilling to risk loss of family, job, etc.
    • Feel medical risks are too high, or have medical conditions that prevent them from taking hormones or having surgeries.
    • Expensive (no insurance coverage)
  • Costs of Not Transitioning
    • While there are many costs associated with transitioning, there is also a cost when people who desire it do not do so . They may live a lifetime in which they never feel congruence between their body and their sense of self. They may be depressed and unhappy, or even suicidal, because they are not able to dress, live or work as they are comfortable. They may not have the opportunity to fulfill their dreams or live as they wish to live.
  • Life Cycle Issues For Trans Individuals
    • Trans youth face additional stressors
    • (conformity, and coming out)
    • Transgender young adults (social life revolving around bars and substance use settings)
    • Coupling
    • Parenting
    • Aging
    • Treatment Providers need to consider a T client’s partner, children, family of origin and family of choice when providing care!
  • Stigma, Violence, and Mental Health
    • Discrimination against LGBT persons has been associated with:
      • high rates of psychiatric disorders 1
      • substance abuse 2, 3
      • Suicide 4
    • Personal, family, and social acceptance of sexual orientation and gender identity affects the mental health and personal safety of LGBT individuals 5
    1. McLaughlin KA, Hatzenbuehler ML, Keyes KM. Responses to discrimination and psychiatric disorders among black, Hispanic, female, and lesbian, gay, and bisexual individuals. Am J Public Health. 2010;100(8):1477-84. 2. Ibanez GE, Purcell DW, Stall R, et al. Sexual risk, substance use, and psychological distress in HIV-positive gay and bisexual men who also inject drugs. AIDS. 2005;19(suppl 1):49-55. 3. Herek GM, Garnets LD. Sexual orientation and mental health. Annu Rev Clin Psychol. 2007;3:353-75. 4. Remafedi G, French S, Story M, et al. The relationship between suicide risk and sexual orientation: Results of a population-based study. Am J Public Health. 1998;88(1):57-60. 5. US Department of Health and Human Services. Healthy People 2010. [Internet]. Available from: http://www.hhs.gov
  • Transgender Clients May Be Coping With:
    • Coming out
    • Accessing physical and mental health services including transition related services
    • HIV/AIDS
    • Discrimination and violence
    • Transphobic family members, employers, and work colleagues
  • Coming Out:
    • Refers to the experiences of some, but not all, LGBT people as they work through and accept a stigmatized identity.
    • Transforming a negative self identity into a positive one
    • Often described as a process of self-actualization. Transgender youth may face far more barriers (legal & medical).
  • Coming Out (cont)
    • There is no correct way to come out
    • 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.
  • Knoll’s Story
  • Barriers to receiving care/services:
    • Marginalization and labeling of gender identity as deviant or pathological in medical or psychiatric communities.
    • Anticipated, perceived, or actual discrimination
    • Fear of mistreatment
    • Lack of research about Trans community
    • Provider lack of information
    • Fear of being outed will result in loss of job, custody, housing, or social supports.
    • Exclusion of partner and family of choice from health care settings
    • Lack of insurance coverage for basic health and transition needs
    • Internalized Transphobia
  • Barriers to Care and Treatment Cont.
    • Providers lack basic knowledge and have discomfort
    • Lack of research and information
    • Extensive negative experiences with healthcare.
    • Medicalization and pathologization of experiences
    • Intake forms, office environment, alienating process
    • Documentation(sex marker on state ID and birth certificates, SSN, etc)
  • Health Issues Affecting Trans Youth
    • Access to healthcare
      • Insurance
      • Treatment by providers
    • Risk Behaviors
      • Street hormones
      • Self surgery
      • Pumping parties
      • Survival sex work
      • Poverty/Violence
  • Sex Segregated Areas
    • Bathrooms
    • Locker rooms
    • Residential facilities
    • Homeless shelters
    • Jails/prison
    • Rehab/mental health
  • Best Practices
    • “ People of diverse gender expression should be afforded the same respect and rights as those whose gender identity and expression conform to societal expectations”
      • American Psychological Association
  • Making Your Practice Transgender Friendly
    • Before the patient/client encounter
      • 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?
  • Creating an Affirming Environment:
    • 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.
  • Inclusive Paperwork
    • Goes beyond “Male” or “Female”
    • Offers a place for clients to include preferred name not just legal name.
    • Takes into account discrepancies in legal documentation
      • driver’s license (name and gender marker)
      • Birth Certificate & Social Security Card
      • Insurance Card
  • Culturally Competent Approach:
    • Is client centered
    • Uses client’s own language
    • Non-judgmental
    • No assumptions
    • Open ended questions
    • Begins with less threatening questions
    • It’s okay to not know!
  • If a Trans person comes out to you, DO:
    • Remember that gender identity or gender expression is just one dimension of your client.
    • Be yourself.
    • Recognize your limitations.
    • Remember that the person may be nervous or afraid.
    • Use the vocabulary they use.
    • Do your homework: find out more about gender identity & local resources.
    • Remember that it doesn’t take a transgender therapist to help a transgender client.
    • If the client seems nervous, you can assure him or her that the information is confidential.
    • Remember that you have an obligation to respect the person’s right to privacy and confidentiality.
    If a Trans person comes out to you:
  • Contracting for Change
    • Identify two or more changes you are willing to make in how you provide services?
      • What personal obstacles do you face?
      • What professional obstacles do you face?
      • How might these obstacles be overcome?
  • Contact Me
    • Knoll Larkin, MPH
    • Research Associate
    • Center for Bioethics and Social Sciences in Medicine www.cbssm.org
    • [email_address]