GENDERED INEQUALITY: DECONSTRUCTING BARRIERS TO ENABLE SENSITIVE SYSTEMIC PRACTICE WITH DIVERSE PEOPLE AND RELATIONSHIPS

ANNE PROUTY OCTOBER 2017 AUSTRALIAN ASSOCIATION FOR FAMILY THERAPY ANNUAL CONFERENCE ADELAIDE, AUSTRALIA “IF WE COULD CHANGE OURSELVES, THE TENDENCIES IN THE WORLD WOULD ALSO CHANGE.”

- MAHATMA GANDHI Global Gender Inequities are

DEADLY MISERABLE REAL “GENDER”

CUTTING EDGE * TO PROMOTE SOCIAL JUSTICE * ADVOCATE FOR CLIENTS SEX AND GENDER THE WORLD HEALTH ORGANISATION HAS RECOGNISED SEX AND GENDER GLOBALLY AS CORE SOCIAL DETERMINANTS OF PHYSICAL AND MENTAL HEALTH AND WELL-BEING 44 • LGBTI are 11% of Australians as of 20146 • 1.7% of Australians are estimated to be Intersex (Australian Human Rights Commission) • 2% of people globally estimated to be non-binary gender • 34% of LGBTI Australians hide their identity when accessing services 2007 “Yogyakarta Principles”: 28 Principles of the Application of International Human Rights Law in Relation to Sexual Orientation and Gender Identity 64

• www.Yogyakartaprinciples.org • GENDER Keynote/Yogyakarta principles_en.pdf Approaches to Social Justice

Multiple Cultural Communities Human Diversity within Communities/Contexts Human Diversity Across Lifespans

INTERSECTIONALITY INTERSECTIONALITY AND PERSONAL IDENTITY

• WHO DEFINES WHOM? • EACH PERSON’S EXPERIENCE? • BY INTERACTING WITH EACH OTHER? • INTERACTING BY PROXY AND VIA COMMUNITIES? INTERSECTIONALITY – IDENTITIES

PLACE TIME

SEX &/OR GENDER ID ETHNIC ID

SEXUAL ORIENTATION SPIRITUAL ID

RELATIONAL ORIENT CITIZEN ID

RELATIONAL ROLES PHYSICAL ABILITY

AGE “Just as the constant increase of entropy is the basic law of the universe, so it is the basic law of life to struggle against entropy.

- Vaclav Havel SEX or GENDER? Non-Binary Sex Survey of Medical Literature by Blackless and Colleagues (2000) Estimated as high as: 2 % of live births 7 SEX

Historically Relied on Phenotype – Physical Appearance

Physical Body Parts – outside and inside – many different reasons

Hormones & Hormone Receptors (can be from chromosomal condition) Example: Androgen Insensitivity Syndrome: Complete or Incomplete https://medlineplus.gov/ency/article/001180.htm http://emedicine.medscape.com/article/924996-overview

Hormones in-utero exposure and brains – studies with small samples of people who donate brains to science, researchers are showing that cismale and transmale stain alike, cisfemale and transfemale stain alike 35 Medicalized Narrative of Binary Sex

Babies • Used a small caliper to measure penis / clitoris – where is urethra? • https://en.wikipedia.org/wiki/Phall-O-Meter

• Orchidometer (testes)

• Differentiation of Testes / Labia • Vaginal Foramen Present? SEX and CHROMOSOMES

Male, Female, and Intersex

Mosaic / Chimaera – some cells XX, others XY

Examples of Sex Chromosome Variants – some cause infertility X0 “Turners” XXX+ ”Triple X” XXY “Kleinfelters” XYY “Jacobs” Medicine and Binary Bodies

• Babies • Interdisciplinary Team Articles Arising • https://oii.org.au/category/media/videos/ (video hyperlink to Bonnie Hart, author of “Orchids, My Intersex Adventure” – ex. of Androgen Insensitivity Syndrome in a family – 4 minutes) • Preteens and Teens • Hormone blockers to pause puberty • Hormones to move puberty toward sexual body development • Adults • Endocrine System Hormones, Bones, Epiglottis, Vocal Cords, Gonads, Secondary Sex Characteristics; Cultural gendered social, vocal, & movement • https://oii.org.au/category/comment/personal-stories/ • Not necessarily a LINEAR or binary gender (medical) journey Humans’ Sexes are Complex, Diverse, Unique WHAT IS GENDER????

GENETICS

BODY MY IDENTITY

CULTURAL Child Development & Gender50

• Gender Identity or Awareness – by age 3 • Idea of Gender Stability – if taught – by 5 • Idea of Gender Consistency by 7 • CONTEXT! •Familial and Community Reinforcement •Peers - Options for Trying-on Identities as well as Bullying •Internet Community Options and Bullying Myth of Binary Gender

Male Androgenous Female Intergender Cisgender Privilege 29 • Sex assigned at birth is linked to your experience of gender • Your gender identity is not pathologized and dx not required for medical support • Your identity documents have your preferred gender and you do not need to share personal or medical information to get them changed • People use your preferred pronouns (infrequent misgendering) • People and identity documents use your preferred name • Cosmetic surgery probably wasn’t performed on you without your consent just so others would feel more comfortable • No one asks you about your genitals, or whether you will take hormones or get surgeries • You may be able to marry and stay married– in some countries • Safety – based on gender anyway (intersectionality plays-out here too) • Gender option available on most paperwork and forms • Community, Money & Medical, ….. Cisgender Assumptions

• Not everyone who’s gender does not match their assigned sex (whether it’s binary or not) wishes to become either male or female 45 • Of those who wish medical corrective interventions not everyone wishes to do them in the order often directed by medical institutions (hormones then surgery or all surgery options or stereotyped outcomes) 45 Common Examples of Microaggressions Including Those Used by Partners (see IPV section) • Personal questions, including “why?” • “real” man/woman does x,y,z • “Biological man/woman” instead of using person’s preferred gender term • Misgendering or misnaming • “You’re not doing it [gender] right” • Pathologizing thoughts, feelings, etc. – in order to obtain access/resource • MORE?? Long History of Gender as Non-Binary Identities

National Geographic 2017: http://www.nationalgeogr aphic.com/magazine/2017/ 01/how-science-helps-us- understand-gender- identity/ http://www.nationalgeogr aphic.com/magazine/2017/ 01/gender-issue-reader- comments-faq/#/gender- revolution-ngm- covers.png Gender Singular Pronouns in English

HE SHE ONE ZE THEY HIM HER ONE ZIR THEM HIS HERS ONE’S ZIR THEIR HIS HERS ONE’S ZIRS THEIR’S HIMSELF HERSELF ONESELF ZIRSELF THEMSELF Multiculturalism Applied to Gender

• Cultures of gender, gender identity, gender journey • Influences on my beliefs • Influence my attitudes about people and their needs • Influence definition of helpful, support, resilience • Experience with gendered communities and diversity of people • Experience with Advocacy (practical and legal rights) Gender Diversity within Gender Variant Communities and Transgender Communities

• Gender Fluid - Dynamic, Moving Among , Simultaneously More than One

• Some non-binary people identify as Transgender or Gender Variant (TGV), while others do not Relational Intersections

•Sexual Orientation

•Relational Orientation Models of Sexual Orientation • Many models are based on whether the desired person is similar or different from one’s own gender identity (that’s not helpful) • Static? Dynamic? • Influenced by social context’s options? • Should include asexual • Often helps if includes an intersection with sex drive, with a definition that can vary over time/situations • Note: I am talking about human adult-adult & consensual only Sexual Orientation

http://www.soc.ucsb.edu/sexinfo/article/overview-sexual-orientations

RELATIONAL ORIENTATION59 Relational Orientation

An enduring pattern of romantic or sexual attraction (or a combination of these two) to monogamy, nonmonogamy, or to a degree of both 9,18 Types of Amorous Relationships • Sexual Freedom/ No Commitment • Friends with Benefits • Monogamy • Serial Monogamy • Partnerships - Committed – Legally Recognized • Non-monogamous (Consensual & Nonconsensual) • Open, Swinging, Geographical • Plural Commitments & Marriages • Polygamy (polygyny, polyandry) • Poly-Network

Global Prevalence of Plural Families • More than 850 societies within Africa, Asia, Oceania, Middle East, and Americas • North America: Several Indigenous Nations practiced polygamy prior to European invasion (KOSTER 2012). • Tibet - polyandry – until China invaded in 1950 – kept brother-husbands’ family land in their family • Now two religious groups are responsible for most of growth in the U.S. (100,000 + plural families estimated) Context Challenges & Resiliency Strategies

• Legal – Trusts, Wills, Financial Accounts, Adoption, Custody Papers, Divorce/Dissolutions, Official Papers & Gender Identity • Immigration – Who is acknowledged as whom • Spousal Evidentiary • Visibility/ Invisibility Management – Adults and Children (parents) • Medical & Mental Health Access – gender affirmative care • Police Protection & Respect • Illegality can make vulnerable to cults & other closed systems – these are the dynamics that lead to serious vulnerability and harm Violence Violence: Hate Crimes

• U.S. National Coalition of Anti-Violence Programs reported that Transgender Women experience 72% of anti-LGBT homicide victims, and 89% of these are people of color 1 • 20% of hate crimes in U.S. are against people who identified as LGBTQ with highest rates among transgender people, and transgender women in particular 23 • Australian Human Rights Commission 2014: 47% of Trans-Men and 37% of Trans-Women report experiencing verbal abuse • Transgender Men and Women experience high rates physical abuse Family Violence: Interpersonal Violence PARTNER(S) AND FAMILY VIOLENCE30

• More than half (>60%) of transgender people have been victim of violence • Cisgender and Not-cisgender sample (not just T) of teens in a study of peer violence and bullying and substance use, a history of bullying during recent year fully mediated relationship between gender identity and use of substances, i.e. substance use associated with peer violence, like bullying 44 • Researchers found that transgender people were significantly more likely to report being victims of IPV than were cisgender people in a sample who identified as LGBTQ. No difference in reporting to police. 30 Gender and IPV

• Researchers have found that a majority of people who are seriously injured/killed by IPV are women 4 and women are twice as likely to report being fearful of bodily injury or death than are men5 • Gay and lesbian couples under-report violence – heterosexist context – but researchers estimate gay and lesbian couples similar prevalence to heterosexual couples 5 • Lesbian couples’ violence might be [erroneously] dismissed by therapists as mutually combative and unimportant, and heterosexist physical appearance evaluation was subconsciously involved in evaluation of threat (study of therapists) 33 Johnson’s 4 Types of Violent Couples 27, 28 Based on Heterosexual, Cisgender, Dyads (1) Situational Violence • Can be mutually violent but neither are controlling • Conflict over particular issue(s) – often conceptualized as communication deficit • Hypothesized to be the most prevalent type (2) Intimate Terrorist • Unilaterally Violent with High Level of Coercive Control (Violence may be past) (3) Violent Resistance • Violent & Controlling with Partner has (short-lived) violent resistance/self-defense (4) Mutual Violent Controlling • Two controlling partners engaged in struggle for power/control POWER & CONTROL WHEEL2, 11, 47 LARGER CULTURES/SYSTEMS OWN CULTURE/S HISTORY OF ABUSE/NEGLECT/HATE CRIMES SEXUAL ABUSE COUPLE/FAMILY PHYSICAL ABUSE/NEGLECT PEOPLE & PETS PHYSICAL VIOLENCE WITH/TO THINGS USING CHILDREN OR PETS EMOTIONAL ABUSE SPIRITUAL ABUSE INTIMIDATION THREATS INTERNALIZED COERCION ISOLATION CONTROL OF SEXUAL/REPRODUCTIVE HEALTH ECONOMIC ABUSE IMMIGRATION THREATS PASSING, DENYING, MINIMIZING, BLAMING HATE CRIMES GENDERISMS & OTHER LIMITING OR OPPRESIVE STORIES ABOUT IDENTITIES IPV & Context Questions • Couple’s Community – Is the couple in an open or closed system? Is the community a minority? (fear of harming the community by being open about violence?)

• Does the Community have resources for People? Resources for Same-Sex and non-binary gender people welcomed?

• What about Violence in Plural Families – Community responsive, visibility management risks? RESILIENCE WHEEL OWN CULTURE/S COUPLE/FAMILY ACCESS TO SAFE ENVIRONMENT CULTURE ACCESS TO MEDICAL CARE OF CHOICE HISTORY OF SUCCESSES SENSE OF COMPLEX IDENTITY/IES IDENTITY AS A JOURNEY PRIDE IN IDENTITIES INTERNALIZED PHYSICAL & EMOTIONAL HEALTH COUPLE/FAMILY – VISIBILITY AGREEMENT AND COOPERATION RICH NETWORK OF FAMILY & FRIENDS SAFETY PLANS FOR MULTIPLE SITUATIONS FINANCIAL/ECONOMIC RESOURCES – OVERTLY DISTRIBUTED CONCRETE LEGAL PROTECTIONS – POWERS OF ATTORNEY; WILLS; TRUSTS LARGER CULTURES/SYSTEMS “SAFE” Assessed and Strengths-based, Solution- focused, Couples Therapy when Situational IPV Exists 32, 48, 54, 55, 56

• SAFE (Smith et al.) Assessment: Each Adult Reviews own involvement, emotional path, and responsibility • If thought to be safe, couple reviews, identifies triggers and warning signs • Negotiated Time-Out training, practice • Miracle Question to Identify Solution-focused, Steps toward Small Goals • Communication and Disagreement Training • Couple Therapy GENDER AFFIRMATIVE THERAPY

SEX &/OR GENDER ID ETHNIC ID

SEXUAL ORIENTATION SPIRITUAL ID

RELATIONAL ORIENT CITIZEN ID

RELATIONAL ROLES PHYSICAL ABILITY Pulling Intersections Together and Remembering that Peoples’ Identities Across Systems May Vary

• Sexes • Genders • Sexual Orientations • Relational Orientation and Varied Family Structures/Boundaries • Physical, Emotional, & Economic Safety – Visibility Management • Contexts – situational and along developmental life cycle • Intersections with other Identities and Group Memberships – Ethnicity, SES, Nationality/Geography, Ableness, Military/not, Religion, Career, etc… World Professional Association for Transgender Health (WPATH)

• Standards of Care • http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1347&pk_a ssociation_webpage=4233 Gender Identity Affirmative Therapy Practice • Knowledge of what World Health Organisation calls the Three Traumas: intrapersonal (self), interpersonal, and collective (policy/laws) traumas • Knowledge about Community and On-line Social Support Networks • In addition to evolving our ideas, assessments, intake and consent paperwork, our language, models of change to be more inclusive of gender identity and intersections with other identities…. • Make sure our electronic health records allow for non-binary identities • Make sure our waiting rooms and professional spaces are safe, welcoming, and reflect lots of diverse people • We can use Strengths-Based Assessments • Connor & Davidson’ 17 25-item Resilience Scale Gender Affirmative Therapy continued

• Safe place to be authentic and work on life and relationships AND • Place to prepare when making changes (ex: relocation, travel, jobs) • Informed Consent & Advocacy Expectations – clarity • “Safe passage letters” of support/explanation on professional letterhead - In case need such letters for airlines, international border crossing, arrest 52 • Community Advocate and Educator to promote safe community spaces, interactions, spaces (schools to police forces) • Community Activism to expand Identity Documents & Human Rights Policies Resilience • Strengths-based approaches • Competencies – Against both Macro and Microaggressions • Stress is cumulative and so are Resilience Skills • Assess All Clients for PTSD • Compensation 45 • Coping Resources • Struggling Well 61 • Explore/Develop Gender identity pride and connections • Develop All Identities Pride – Connect with multiple communities • Connect to Religious and Spiritual Resilience 51, 53 Resiliency as a Relational Process

• Relationships buffer and distribute stress • Struggles are seen as part of journey – the “we” humanizes • People and couples/families gain new skills and resources along the journey • Identify symptoms and support people when physical and mental health symptoms arise • Finding and being a part of larger human communities of strength and pride - at individual, couple, family levels • Useful in dealing with situational and developmental stressors Across Many Human Identities Sex/Gender/Sexual Orientation/Relational Orientation14, 62

Visibility & Equity Across multiple Adaptation Legal Recognition of identities - the capacity to Identities, respond to Relationships, and Vibrant and changing social Families Multiple environments Communities across life cycle Security & Respect – Laws and Public Strong Families Innovation Policies Intimate - the capacity to inspire and drive Access to Relationships and Knowledgeable Care Friendships change – socially and in concrete Professionals IN FAMILY THERAPY Health Promoting environments Communities Role of Family Therapy

• Discuss fluidity of gender rather than binary version • Gender Journey • Some people’s journey includes transition to another – with or without hormones and/or surgery(ies) 31, 40 • Screen ALL clients for PTSD and trauma 52 • Family Emergence – non-linear stages of adjustment • Shock, betrayal, grief, confusion (sex, gender, sexual orientation, identities – indiv & family) • May be chaotic – move toward flexible, trials for success • Pace of change(s) • Gender-queering the whole family in context, in culture(s) – previously invisible privledge now noticed Parental Support 46

• https://www.hrw.org/topic/lgbt-rights (6 min video of Parents’ story) • Acknowledge grief, flooding, guilt, whatever people are feeling • Acknowledgement of pressure parent(s) are feeling to make decisions now • Acknowledge okay to not agree – process – until agree on initial journey map • Acknowledge lots of people have strong opinions – including medical • Help parents develop skills, resources, community of support 12 • Affirmative approaches 26,35,37,46 Affirmative Approach with Parents 26,34,35,37,46

• Work with parents to support child’s gender journey and self-identified gender • Help parents to advocate for their child(ren) • Sex not binary and Gender not binary • Saeger’s 4 stages: • Discovery, Turmoil, Decision-making, Finding Balance • “Balance” – Changes with child’s/teen’s development • Extended Family & Community(ies) Couples 34

• Couple Therapy with Transgender People and Their Partners • New relationship for both/all partners • New relationships with all family members • How people find out, length of secret, involvement in decisions about pace of changes 31 • Important of connections, relationships, good emotional boundaries • Bisexuality correlated with staying together as a couple 34 • Sexual Identities of both partners – is there a wording change/or not or does it feel that way? – does their community, culture, religion embrace and support them? (any issues of external labels and internal identities?) Couples Therapy continued

• Writing own, new story(ies) and relationships • Importance of connection and supports • Importance of grief (everyone’s) throughout journey 34 • Ambiguous losses 13 • Constructive instead of destructive separation/divorce 34 • Family Motto of “there are always lots of changes and we always figure them out” correlated with better outcomes “HOPE is a thing with feathers That perches in the soul And sings a tune without words, And never stops at all…”

- Emily Dickinson