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, MPHResearch AssociateCenter for Bioethics and Social Sciences in Medicine www.cbssm.org LKLarkin@med.umich.edu