1. Access to Care for Transgendered Patients Pacific AIDS Education and Training Center Training for Trainers March, 2003 Welcome! Curriculum developed by Samuel Lurie, www.tgtrain.org

2. 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.

3. Learning Objectives  Provide overview of terms and concepts to understand transgendered people’s lives and experiences.  Identify distinctions between gender identity and sexual orientation and importance of these differences in serving transgendered patients.  Examine HIV prevalence, and issues of HIV risks, risk reduction and treatment for transgendered clients and patients.  Examine barriers in health care delivery systems for transgendered patients, identifying at least three specific barriers to HIV treatment and primary care.  Understand and assess solutions to providing services and care in participants’ agencies or work, identifying at least three specific strategies for improvement.

4. Overview  Welcome and setting tone for the training  Language and Concepts  Gender Identity vs. Sexual Orientation: What’s the difference and why does it matter?  Distinctions from G/L/B work  HIV Prevalence and Risks for TG People  Barriers and Solutions to Care  Bringing trans awareness into our work beyond this training

5. Compassion as an Important Tool “Let me say, at the risk of seeming ridiculous, that a true revolutionary is guided by great feelings of love.” -Che Guevara

6. Training Study Findings 2001-2002 Needs Assessment of Health Care Providers showed: Face-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

7. Language and Concepts  Transgender vs. Transexual  Intersexual, Intersexed  FTM, Female-to-Male (Transman)  MTF, Male-to-Female (Transwoman)  SRS, GRS. Pre-op, post-op, non-op (Benjamin Standards of Care)  no-ho, low-ho  SOFFA, transition  Read, clock, pass  LGBTST, hir, zie, s/he

8. Gender Identity and Sexual Orientation are Different Things  Every individual has a biological sex, a gender identity and a sexual orientation.  Being transgendered does not mean you’re gay and being gay does not mean you’re transgendered.  Gender is about who we believe ourselves to be; sexual orientation is about who we are attracted to.

9. Traditional Binary Gender Model  Biological Sex:MaleFemale Hormones, genitalia secondary sex characteristics  Gender Expression MasculineFeminine Dress, posture, roles, identity  Sexual Orientation Attracted Attracted to Women to Men

10. Revolutionary Gender Model  Biological Sex: MaleIntersexualFemale Hormones, genitalia secondary sex characteristics  Gender Expression Masculine Androgynous Feminine Dress, posture, roles, behavior  Note: Expression and Identity are different i.e. Identity=I am a man/woman/etc. Expression=masculine, feminine, etc.  Sexual Orientation Attracted to: women men both neither other

11. Revolutionary Gender Model Many configurations are possible  Biological Sex: MaleIntersexualFemale Hormones, genitalia secondary sex characteristics  Gender Expression Masculine Androgynous Feminine Dress, posture, role, behavior  Note: Expression and Identity are different i.e. Identity=I am a man/woman/etc. Expression=masculine, feminine, etc. Sexual Orientation Attracted to: women men both neither other

12. Distinctions from Gay and Lesbian Issues  Homophobia is different than Transphobia  Anatomy does not determine sexual orientation  Gender variance is often only seen in gay context Masculine females and feminine males are assumed to be gay; “anti-gay” discrimination and violence often targets gender expression, not sexuality)  Trans people are often outcast in G/L context  Transgendered people must be able to access services through their trans identities, not through gay/lesbian identities.

13. 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 don’t 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

14. Transgendered People and Risks for HIV:  Isolation and shame  Quest to be desired and loved  Discomfort with and disassociation from own bodies  Myths and lack of information  Social marginalization, fringe existence, survival sex  Lack of access to existing programs and services  Lack of targeted services  Unknowledgeable and even hostile providers  Insensitive, incongruent outreach and programs  Sex role stereotypes  Black market hormones, tucking  Drug and alcohol use.  Cost of surgery/need for $$$

15. Barriers to Care  Providers lack basic knowledge  In-take forms, office environment, alienating process  Long waiting lists and insurance issues  Medicalization and Pathologizing of Experience- judgmental and patronizing treatment  Topic still derided by professionals  Not enough people doing the work  Workers and agencies come from a deficit perspective

16. Medical-Related Trans Losses Tyra Hunter Died after paramedics withdrew treatment at scene of car accident. Photo by Mariette Pathy Allen Robert Eads Died of ovarian cancer; refused treatment by a number of GYNs; difficult for FTMs to seek/receive GYN care. Billy Tipton Did not seek care for bleeding ulcer for fear of trans status being revealed. “Outed” in mass media upon his death. Photos from Remembering Our Dead, www.gender.org/rememberwww.gender.org/remember And Transsexual, Transgender and Intersexed History, www.transhistory.org Alexander John Goodrum Trans activist and writer, died in a psychiatric facility.

17. Barriers and Solutions Small Group Brainstorm Exercise  Barriers to Health Care for TG People  Challenges for Providers in Offering Care  Agency and Institutional Barriers  Challenges in creating effective programs  Solutions for Providing Health Care  Ways to Overcome Provider’s challenges  Ways to Overcome Agency and Institutional Barriers  Necessities for Creating Effective Programs

18. Harm Reduction/ Client-centered Model  Client sets goals and outcomes  Non-judgmental, respectful  Culturally relevant  Incorporates Stages of Change  Allows for slow, incremental change  Holistic  Solution-focused  Acknowledges continuum of possibilities  Strength-based

19. Agency and Policy Issues  Don’t 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  Don’t make assumptions about sexuality or transition goals.  Respect confidentiality, choices and fluidity  Honor presenting gender  Acknowledge limitations  Challenge transphobia—in staff and community  Have consequences for repeated anti-trans behavior  Have Unisex bathrooms!

20. “Working with someone going through a gender transition is a joyous part of medicine. It’s very similar to feelings obstetricians have about facilitating birth.” -Edward Cheslow, MD Closing thought…