2. Improving the Wellness of Transgender, Gender Non- Conforming, and Intersex Individuals SAMHSA’s Wellness Initiative Wednesday, August 27, 2014 22

3. Disclaimer The views expressed in this training do not necessarily represent the views, policies, and positions of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), the U.S. Food and Drug Administration (FDA), or the U.S. Department of Health and Human Services (HHS). 3

4. SAMHSA’s Wellness Initiative Goals – Raise awareness of early mortality rates; – Promote ways to improve health behaviors; – Incorporate the Eight Dimensions of Wellness into recovery; and – Enhance quality of life and increase longevity through wellness. 4

5. The Eight Dimensions of Wellness (Adapted from Swarbrick, 2006.) 5

6. National Wellness Week 2014 Celebrating wellness since 2011: – 300+ organizations; – 700+ wellness events and activities; and – 46 States, Puerto Rico, and Guam. 6

7. Get on the Map! Send the following information about your 2014 events to wellness@samhsa.hhs.gov and we’ll feature it on the new map: wellness@samhsa.hhs.gov – Organization/host; – Event location: building/landmark name, street address, city, State, and ZIP code; – Event name and description; – Event date and time; and – Event contact information (name, phone, email address, Web site, etc.). 7

8. Iden Campbell McCollum The Campbell Center Washington, DC 8

9. Earline Budd HIPS Washington, DC 9

10. Language Transgender – An umbrella term for individuals whose gender identity and/or gender differs from their assigned sex at birth. Gender Non-Conforming – An umbrella term that includes all individuals whose gender varies from the traditional norm. This also includes individuals who are born anatomically female or male but feel that their identity is neither female nor male. Intersex – An individual born with male and female anatomy, unclear genitalia, and/or varying chromosomes. 10 (Adapted from Fenway Health, 2010.)

11. Language *Always ask what language an individual prefers before using pronouns and other terms to identify that person. Transition – The process individuals go through as they change their gender expression and/or physical appearance. This may, but does not always, include physically altering the body through hormones and/or surgery. FtM – Female to Male. Sometimes called trans man or transsexual. MtF – Male to Female. Sometimes called trans woman or transsexual. GNC – Gender non-conforming. 11 (Adapted from Fenway Health, 2010.)

12. Gender Gender is: – A socially constructed classification system that ascribes qualities of masculinity and femininity to individuals. – An individual’s sense of self as masculine or feminine regardless of external genitalia. Words and phrases that refer to gender include man, woman, transgender, masculine, feminine, gender non- conforming, gender variant, and genderqueer. Gender characteristics can change over time and differ between cultures. Gender 12

13. Invisible Minority An invisible minority is a group whose minority status is not always immediately visible, such as individuals with disabilities or transgender, GNC, and intersex individuals. This lack of visibility may make organizing for rights difficult. We need to create safe spaces for individuals to “come out” if they wish. 13

14. Harry Benjamin, M.D. Harry Benjamin, M.D., (1885‒1986) was: – An endocrinologist by trade; and – Well known for his work with the transgender (then known as transvestism) community. In 1979, the Harry Benjamin International Gender Dysphoria Association was formed. It is now called the World Professional Association for Transgender Health (WPATH). 14

15. Harry Benjamin’s Standards of Care The Standards of Care: – Allow professionals to understand how they may offer assistance to those in the community; – Are flexible and allow for individualized treatment; and – Discuss the role of the provider, the patient, diagnostic assessment, psychotherapy, hormonal therapy, and surgical therapy. 15

16. Traumatic Events Traumatic events involve: – Experiencing, witnessing, or confronting event(s) that include actual or threatened death or serious injury or a threat to the physical integrity of self or others; and – Responding with intense fear, helplessness, or horror. Examples of traumatic events in our community: – Being “outed” or fear of being “outed”; – Internalizing expectations; – Being unable to access appropriate health care; and – Having a repeated and constant awareness of negative incidents. (Adapted from American Psychiatric Association, 2000.) 16

17. The Effect of Trauma Trauma may lead to negative mental health and substance use challenges, including suicidal ideation and attempts and alcohol and drug use. 17

18. National Transgender Discrimination Survey Report on Health and Health Care Transgender and GNC individuals across the country reported regularly facing discrimination in the form of denial of health care. Medical providers’ awareness of the individual’s transgender status increased the likelihood of the individual experiencing discrimination. (Grant, Mottet, & Tanis, 2010.) 18

19. Key Findings: Medical and Mental Health Statistics High levels of postponing medical care when sick or injured due to: – Discrimination (28 percent); or – Inability to afford it (48 percent). Significant hurdles to accessing health care, including: – Refusal of care (19 percent, and higher among individuals of color); – Harassment (28 percent) or violence (2 percent) in medical settings; and – Lack of provider knowledge (50 percent). 19

20. Seeking Health Care Visual conformers and those whose identity documents matched their presentation had the highest rates of using doctors’ offices for their care. 20

21. Key Findings Epidemic levels of HIV infection, including: – Overall (2.64 percent, compared to 0.6 percent of the general population); – Among transgender women (3.76 percent); – Among the unemployed (4.67 percent); and – Among those who have engaged in sex work (15.32 percent). Current or past use of drugs or alcohol to cope with discrimination related to being transgender or GNC (26 percent). Extreme levels of suicide attempts (41 percent, compared to 1.6 percent of the general population). Unemployment, low income, and sexual and physical assault significantly increased this risk. 21

22. Delay in Seeking Health Care Many individuals delay seeking health care due to fear of, or previous experiences with, discrimination from providers. – Many (48 percent) delay seeking necessary health care, and 50 percent delay seeking preventive care. 22

23. Culturally Attuned, Competent Care Providers: – Learn about transgender, GNC, and intersex individuals and their treatment options. – Become familiar with current standards of care and how they affect transgender, GNC, and intersex individuals’ health and well-being. – Understand the common traumatic events that transgender, GNC, and intersex individuals may face. 23

24. Discrimination by Medical Providers Denial of health care occurs in multiple places, including: – In doctors’ offices and hospitals (24 percent); – In emergency rooms (13 percent); – In mental health clinics (11 percent); – By emergency medical technicians (EMTs) (5 percent); and – In drug treatment programs (3 percent). Denial of health care also differs among respondents’ ethnic groups. 24

25. Health Insurance Uninsurance rates among FtM (19 percent) and MtF (20 percent) respondents were higher than GNC respondents (17 percent). Health insurance also differs among respondents’ ethnic groups. 25

26. Mental Health Care Rates of those who have received transition-related counseling: – Seventy-five percent of respondents report having received counseling related to gender identity. – Transgender respondents were more likely than GNC respondents to have received counseling (80 percent compared to 48 percent). – Eighty-nine percent of those who medically transitioned and 91 percent of those who had some type of surgery received transition-related counseling. 26

27. Suicide Attempts 27

28. Suicide Attempts 28

29. Substance Use Drug and Alcohol Use – Eight percent currently use alcohol or drugs specifically to cope with mistreatment, and 18 percent have done so in the past. – Nineteen percent of those involved in sex work, drug sales, and other underground economies for income currently use alcohol and/or drugs; 36 percent have done so in the past. – Twelve percent of those who have lost a job due to discrimination currently use drugs and alcohol; 28 percent have done so in the past. Smoking – Thirty percent reported smoking daily or occasionally. – Seventy percent of smokers selected “yes” when asked whether they would like to quit. 29

30. Substance Use Strategies exist to prevent and treat substance use in our community, both at the individual and community levels, but gaps in knowledge, resources, and policies exist. 30

31. Substance Use and Incarceration These gaps may lead to incarceration and recidivism, especially when many individuals in the criminal justice system would benefit and do not receive mental health and substance use treatment. 31

32. Substance Use and Incarceration, cont. Individual and community barriers Exacerbation of our community’s substance use challenges. (Adapted from Community Advancement Network.) 32

33. Unique Barriers to Wellness Concerns about public restrooms include safety and inclusivity. Some ways to support the transgender, GNC, and intersex community’s access to public restrooms: – Create all-gender restrooms; and – Do not label single-stall restrooms with genders. 33

34. #safebathroomsDC 34

35. Unique Barriers to Wellness, cont. Concerns about proper documentation include obtaining identification (ID) documents that match one’s identified name and gender. Some ways to support the transgender, GNC, and intersex community in obtaining proper ID (e.g., in Washington, DC): – Help them obtain the proper medical form that allows them to change their ID to their identified gender; – Connect them with assistance for changing their birth certificate (even if they have not surgically transitioned); and – Inform them that the Social Security Administration allows the transgender, GNC, and intersex community to change their gender in the agency’s database. 35

36. Unique Barriers to Wellness, cont. Concerns about flying include packing, body scans, and proper ID. Some ways to support transgender, GNC, and intersex individuals when they fly: – Remind them to carry proper ID if they have not been able to have ID changed to the gender with which they identify; – Use the name on their ID; – Remind them that they can request a private search if body scans make them uncomfortable; and – Listen to their concerns. 36

37. Federal Policies Allies should note that some Federal policies allow for discrimination when it comes to health care for the transgender, GNC, and intersex community, including: – The Agency for Healthcare Research and Quality does not include information about the LGBT community when researching health care quality, cost, or outcomes. – The National Institutes of Health do not fund research on transition-related treatments, such as hormone therapy. – The U.S. Food and Drug Administration bans transgender individuals from donating blood, regardless of their sexual orientation or gender. 37

38. Our Community 38

39. Our Community 37

40. Transgender and Gender Identity Respect Campaign Washington, DC’s Office of Human Rights Campaign: – Occurred during the fall and winter of 2012; – Appeared on more than 200 bus shelters across the city; and – Was the first of its kind in the US and the first government- funded antidiscrimination campaign focusing exclusively on transgender and GNC individuals. 40

41. Ashley 41

42. Kisha 42

43. Consuella 43

44. Wesley 44

45. Iden 45

46. Resources National Center for Transgender Equality – http://transequality.org http://transequality.org Trans Advocacy Network – http://transadvocacynetwork.org http://transadvocacynetwork.org Gender.Org – http://www.gender.org http://www.gender.org Black Trans Men – http://blacktransmen.org http://blacktransmen.org 46

47. Resources, cont. Black Trans Women – http://blacktranswomen.org http://blacktranswomen.org Casa Ruby – http://www.casaruby.org http://www.casaruby.org DC Trans Coalition – http://www.dctranscoalition.org http://www.dctranscoalition.org Hearts and Ears – http://www.heartsandears.org http://www.heartsandears.org 47

48. 48 References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Arlington, VA. Fenway Health. (2010). Glossary of gender and transgender terms. Boston, MA. Retrieved from http://www.fenwayhealth.org/site/DocServer/Handout_7- C_Glossary_of_Gender_and_Transgender_Terms__fi.pdf http://www.fenwayhealth.org/site/DocServer/Handout_7- C_Glossary_of_Gender_and_Transgender_Terms__fi.pdf Grant, J. M., Mottet, L. A., & Tanis, J. (with Herman, J. L., Harrison, J., & Keisling, M.). (2010). National transgender discrimination survey report on health and health care. Washington, DC: National Center for Transgender Equality. Retrieved from http://transequality.org/PDFs/NTDSReportonHealth_final.pdf http://transequality.org/PDFs/NTDSReportonHealth_final.pdf

49. 49 References, cont. Prescription for Wellness. (n.d.). CAN - Home | CAN | Community Advancement Network. Retrieved August 27, 2014, from http://canatx.org/health/PrescriptionForWellness/SubstanceAbuse/B arriers.htm http://canatx.org/health/PrescriptionForWellness/SubstanceAbuse/B arriers.htm Swarbrick, M. (2006). A wellness approach. Psychiatric Rehabilitation Journal, 29(4), 311–314.

50. Iden Campbell McCollum―Contact Iden Campbell McCollum The Campbell Center http://www.thecampbellcenter.org https://www.facebook.com/TheCampbellCenter https://www.youtube.com/user/IdaMaeTV idenmccollum@gmail.com 50

51. Earline Budd―Contact Earline Budd earline_budd@yahoo.com 51

52. Iden Cambell McCollum―Biography Iden Campbell McCollum, CPRP, CPS, is the founder and executive director of The Campbell Center, a peer-run resource center for individuals living with mental health and substance use challenges in Washington, DC. He has chaired the DC Protection and Advocacy for Individuals with Mental Illness (PAIMI) Advisory Council and the DC State Vocational Rehabilitation Commission, and is a board member of the DC State Independent Living Council, University Legal Services, and Cornerstone Investments. Iden was awarded the 2013 National LGBT Leadership Award at the Alternatives Conference, the 1999 Direct Care Professional of the Year by Arc of Maryland, and 1999 Direct Care Professional of the Year by the Maryland Association of Community Services. Iden has also served in an advisory capacity to SAMHSA. 52

53. Earline Budd―Biography Earline Budd is one of the founders and former executive director of Transgender Health Empowerment, Inc., and has more than 20 years of expertise working with cultural competency issues, HIV/AIDS, and special populations. Currently, Earline serves transgender or gay/bisexual male clients as a treatment adherence specialist at HIPS in Washington, DC. Earline is also starting a new nonprofit organization, Empowering Transgender Coalition (ETC). Earline is one of the first transgender women to serve on the DC Commission on Human Rights. She also serves on the DC Mayor’s Commission on HIV/AIDS and the Ryan White Planning Council. The National Institute of Corrections recently selected Earline to help develop a national white paper about policies for working with LBGT, HIV-positive inmates. 53

54. Questions and Answers To submit your question: – Press *1 on your telephone keypad. – You will enter a queue and will be able to ask your question in the order in which it is received. – When you hear the conference operator, announce your first name. – You may then proceed with your question. 54

55. The ADS Center SAMHSA’s ADS Center enhances acceptance and social inclusion by ensuring that people with mental health problems can live full, productive lives within communities without fear of prejudice and discrimination. We provide information and assistance to develop successful efforts to counteract prejudice and discrimination and promote social inclusion. We encourage you to join the ADS Center listserv at http://promoteacceptance.samhsa.gov/main/listserve.aspx to receive further information on recovery and social inclusion activities, including information about future teleconferences. http://promoteacceptance.samhsa.gov/main/listserve.aspx 55

56. Archive This training teleconference is being recorded. In a few months, the following information will be available for download at http://www.promoteacceptance.samhsa.gov/10by1 0/training.aspx: http://www.promoteacceptance.samhsa.gov/10by1 0/training.aspx – PowerPoint presentation; – PDF version of the PowerPoint; – Audio recording; and – Written transcript. 56

57. Survey We value your suggestions. Within 24 hours of this teleconference, you will receive an email request to participate in a short, anonymous online survey about today’s training. Survey results will help determine what resources and topic areas need to be addressed at future training events. The survey will take approximately 5 minutes to complete. Survey participation requests will be sent to all registered event participants who provided email addresses at the time of their registration. Each request message will contain a Web link to our survey tool. Thank you for your feedback and cooperation. Written comments may be sent to the Substance Abuse and Mental Health Services Administration’s Wellness Initiative at wellness@samhsa.hhs.gov. wellness@samhsa.hhs.gov 57