4 Steps to Providing Care to Transgendered Patients

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4 Steps to Providing Care to Transgendered
Patients

• Pacific AIDS Education and Training Center
• Training for Trainers
• March, 2003
• Curriculum developed by Samuel Lurie
• www.tgtrain.org

Welcome!
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Training Goal

• To examine specific health care and HIV
  prevention and treatment needs of transgendered
  people and to build skills for clinical providers
  to work more effectively with Transgendered
  people.

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Learning Objectives

• At the end of the presentation, providers in
  attendance will
• 1) Understand basic definitions and range of
  transgender expressions, including differences in
  desire for and access to surgical or hormonal
  intervention.
• 2) Distinguish between biological sex, gender
  identity and sexual orientation and ways in which
  care for transgendered populations specifically
  differs from care for Gay, Lesbian and Bisexual
  communities.
• 3) Become familiar with protocols for care for
  Transgendered people and examine methods for
  collaboration and referral with other providers
  with expertise in working with transgendered
  people.
• 4) Identify 2-3 barriers within their agencies or
  practice and solutions to those barriers,
  including using principles of cultural competence
  to provide access to care for transgendered
  patients.

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Training Study Findings

• 2001-2002 Needs Assessment of Health Care
  Providers showedFace-to-face key informant
  interviews with providers around New England,
  funded with support of New England AIDS Education
  and Training Center
• Experience with a range of transgendered
  expressions but lack of information on
  populations, terminology, differences
• Desire to treat TG patients respectfully but
  admitted discomfort and lack of tools for
  specific interviewing/assessments.
• Concern and frustration with lack of information,
  studies and research
• Concern and frustration with lack of treatment
  guidelines, referral contacts and ways to
  advocate for transgender clients.
• Time constraints create an overarching barrier in
  building trusting relationships with clients, and
  trusting relationships are integral to quality
  care

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Four Steps to Providing Care

• Understand range of gender expressions and
  differences in desire for and access to surgical
  or hormonal interventions.
• Recognize distinctions between gender identity
  and sexual orientation and understand differences
  (and similarities) in health care delivery needs.
• Become familiar with local expertise, protocols,
  and access to collaboration and referral.
• Establish policies to make agencies more
  trans-friendly

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Step 1 Recognize Range of Expressions and
Desires

• Many words to identify gender-variance,
  including
• MTF, FTM, transman, transwoman, bi-gendered,
  gender-blender, phallic woman, passing man,
  she-male, femme queen, non-op, boi, two-spirit,
  new man, new woman, etc.
• Identities can and do change, based on context,
  culture, geography, and individuals place on
  their life journey
• Hormones and surgical interventions may be
  desired in an order or degree other than what
  protocols dictate.
• Watch for pathologizing/medicalizing situation
  (even words like pre-op and post-op assume
  op as final outcome. Also, emphasis is on
  genitals, not person.)

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Step 2- Gender identity and sexual orientation
are different things

• Every individual has a biological sex, a gender
  identity and a sexual orientation.
• All can be considered fluid.
• Homophobia is different than Transphobia
• Being transgendered does not mean youre gay and
  being gay does not mean youre transgendered.
• There is overlap, in part because gender variance
  is often seen in gay context.
• Masculine females and feminine males are
  assumedto be gay
• anti-gay discrimination and violence often
  targets gender expression, not sexuality
• Anatomy does not determine sexual orientation

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Step 2, Distinctions continued

• Coming out as gay is different than coming out as
  trans
• Trans people are often outcast in G/L context.
• How do we apply cultural competency lessons that
  apply around heterosexism to gender variance?
• CDC categorizes MTFs and partners as MSM neither
  partner self-identifies as MSM
• Power relationship between provider and client is
  intensified provider as gate-keeper who must
  give ongoing approval
• TG people have particular relationship to medical
  technology, and need to access services through
  trans-identity

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Step 3 Finding protocols and expertise

• Not enough providers doing this work.
• Long waiting lists, inundated when known
• Benjamin Standards of Care
• Tom Waddell Clinic Protocols for Care
• Real-world issues
• Insurance and money
• Informed Consent
• Harm Reduction, or low-threshold services
• Lack of long-term studies
• Need for research, Trans issue is hot, how to
  do research while respecting choices

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HIV Prevalence and Risks

• Not many studies, but all show painfully high
  rates of HIV infection.
• 35 in SF MTFs 63 African-American MTFs
  (Clements-Nolle, Am. Journal of Public Health,
  June 2001)
• 68 of MTF sex workers in Atlanta(Elifson et al,
  Am. Journal of Public Health, 1993)
• Often people dont know they are infected, or
  have no access to care.
• In SF study, 50 of those who knew status, not
  receiving care.
• CDC places TG people in MSM category for funding
  and prevention programs

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Medical-Related Trans Losses
Billy Tipton Did not seek care for bleeding ulcer
for fear of trans status being revealed. Outed
in mass media upon his death.

• Tyra
• Hunter
• Died after paramedics withdrew treatment at scene
  of car accident.

Robert Eads Died of ovarian cancer refused
treatment by a number of GYNs difficult for FTMs
to seek/receive GYN care.
Alexander John Goodrum Trans activist and writer,
died in a psychiatric facility.
Photo by Mariette Pathy Allen
Photos from Remembering Our Dead,
www.gender.org/remember And Transsexual,
Transgender and Intersexed History,
www.transhistory.org
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Step 4- Agency-related issues to provide services

• Dont just add T without doing work to
  understand what it means
• Train all staff--receptionists, security guards,
  director
• Make in-take forms trans friendly, i.e. include
  chosen name not just legal name include more
  than M/F
• Dont make assumptions about sexuality or
  transition goals
• Respect confidentiality, choices and fluidity
• Honor presenting gender
• Acknowledge limitations
• Challenge transphobiain staff and community
• Have consequences for repeated anti-trans
  behavior
• Have Unisex bathrooms!

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Closing thought
Working with someone going through a gender
transition is a joyous part of medicine. Its
very similar to feelings obstetricians have
about facilitating birth. -Edward Cheslow, MD
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Resources

• Protocols for Hormonal Reassignment of Gender
  from the Tom Waddell Health Center,
  2001,www.dph.sf.ca.us/chn/HlthCtrs/HlthCtrDocs/Tra
  nsGendprotocols.pdf
• Harry Benjamin International Gender Dysphoria
  Association (February 20, 2001). Standards of
  Care for Gender Identity Disorders, Sixth
  Version. www.hbigda.org/socv6.html
• Oriel, K. A. (2000). Medical care of transsexual
  patients. Journal of the Gay and Lesbian Medical
  Association 4(4) 185-193
• AIDS Education and Training Centers National
  Resource Center www.aidsetc.org, includes slides
  sets, links and other resources
• Post, P, (2002), Crossing to Safety Transgender
  Health and Homelessness, Healing Hands A
  publication of the Health Care for the Homeless
  Clinicians Network, 6 (4), June 2002.
  www.nhchc.org/Network/HealingHands/2002/June2002He
  alingHands.pdf
• Bockting, W and Kirk S, editors, Transgender and
  HIV Risks, prevention and care. Bringhamton, NY
  The Haworth Press (2001) Originally published as
  a special issue of International Journal of
  Trangenderism 3.12. Available online at
  http//www.symposion/ijt

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Resources continued

• Clements-Nolle, K., Marx, R., Guzman, R., Katz,
  M. (2001, June). HIV prevalence, risk behaviors,
  health care use, and mental health status of
  transgender persons implications for public
  health intervention. American Journal of Public
  Health, 91(6), 915-921.
• Keatley, J and Clements-Nolle, K. Factsheet What
  are the Prevention Needs of Male-to-Female
  Transgender Persons? University of California,
  San Francisco, Center for AIDS Prevention
  Studies, (2001) (English and Spanish versions)
  www.caps.ucsf.edu
• Gender Identity 101 A Transgender Primerby
  Alexander John Goodrum, a publication of TGNet
  Arizona, www.tgnetarizona.org
• Intersex Society of North America www.isna.org
  The organiation founded and led by intersex
  people, committed to ending isolation among those
  born with intersex conditions and eliminating
  shame, secrecy and unwanted genital surgeries for
  people born with intersex conditions.
• For a copy of the Needs Assessment Identifying
  Training Needs of Health Care Providers Related
  to Treatment and Care of Transgendered PatientsA
  Qualitative Needs Assessment contact the author,
  Samuel Lurie, at slurie_at_gmavt.net