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Improving Care for Transgender and Gender-Nonconforming Patients

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Improving Care for Transgender and Gender-Nonconforming Patients Getting to Better - Improving Care for Transgender and Gender-Nonconforming Patients britt walsh, LICSW, CPH Director of Gender Affirming Services at Whitman-Walker Health Pronouns: they/them/britt Objectives • Update some vocabulary • Understand challenges faced by transgender communities • Gain tools to be better advocates and allies • Hear what worked well for some (consider what works well for you) • Connect with others; share resources! Goal: Cultural Humility • Lifelong learning and critical self‐reflection • Recognize and challenge power imbalances for respectful partnerships • Institutional accountability versus Cultural Competency implies it can be “achieved” Vocabulary 101 Birth Sex Gender Identity Gender Expression Sexual Orientation Non-Binary, Gender Fluid, Gender Expansive, Gender Non- Conforming Cisgender Gender Affirmation Medical Transition Legal Transition Social Transition Vocabulary Transgenders, transgendered, a transgender, the trans Transgenderism Sex change Pre/post operative Biological/genetic/born a man/born a woman “Real” name/gender “Preferred” Pronouns How do I know what language to use? You can Ask!! ALWAYS refer to the person by their chosen name and pronouns. BE RESPECTFUL ‐ Use Transpositive, Affirming Language. Ask open‐ended questions. Allow each individual the chance to tell their story. Before asking ‐ Think: DO I NEED TO KNOW?? It’s ok to admit you don’t know everything (you don’t). DC’s Trans Needs Assessment: • The nation’s largest, city‐based, trans‐specific community‐produced trans needs assessment project • Began in early 2010 • Upon closing in May 2013, 624 surveys completed with a total of 521 surveys qualifying for inclusion in the data • Data published in 2015 Access Denied – key findings • Nearly half of all trans persons living in DC earn below $10,000 a year • Over 46% compared to only 11% of DC residents • Roughly half who report being unemployed earn income through grey or underground economy work • 20% of respondents currently facing homelessness • 50% of all of those who reported interacting with an LGBTQ specific organization report having had a negative experience. • 35.7% report having engaged in sex work, or the exchange of sexual acts for money, housing and/or drugs • 21% of all respondents reported living with HIV • Among those who knew themselves to be HIV positive, 45% of the uninsured were not taking HIV medication, compared to 11% of those with insurance. Whitman‐Walker Health in DC • Primary care, ID medicine, and Dental • Informed Consent for Hormones • Behavioral Health support for surgical assessment • Psychiatry, Individual therapy, Peer Support • Specialty Pharmacy • Insurance Navigation • Legal Services – appeals and documents • Youth Services – as young as 13yo for medical care • HIV Care Management • Trans Care Navigation • PrEP Navigation • STI testing, including HIV risk reduction counseling What is gender affirming Primary Care? • No set pathway • Psychological assessment hormone therapy genital surgery • Current standard is to allow each person to seek only those interventions which they desire to affirm their gender identity. 1 • WPATH Medically Necessary Procedures 2 • Hormone therapy • Surgery • Counseling or psychotherapy • Facial hair removal • Speech modification • Genital tucking, packing, or chest binding • Legal name and gender change • Trauma Informed Approach Coleman E et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgenderism. 2012;13(4):165-232. 2 WPATH. 2016. Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A.. [ONLINE] Available at: http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1352&pk_association_webpage=3947. [Accessed 26 November 2017]. Collaborative Decision Making • Listen to your patient and make decisions together • Understand their treatment goals • Physical changes they desire • Timeline • Balance safety goals • Patient • Provider • Informed consent model • Consider starting hormones as soon as possible while working with the patient on managing co‐morbid conditions • Harm reduction model Inside Whitman‐Walker Health • Ongoing learning! • Trans 101 and 202 trainings, required for all staff • Medical providers receive trans‐specific medical coaching before beginning direct patient care • Remedial courses available or 1:1 • Feedback loops – real time, responsive, inform our practices • High # of feedback from our trans patients • Board‐issued memo • Multidisciplinary case consults • Regular “trans‐specific” content at medical provider and behavioral health team meetings • Leveraging our Medical/Legal partnership • Inclusive work environment • Hiring practices • Transition at work • Misgendering or deadnaming fol‐up • Insurance coverage for gender affirming care • Pronoun stickers and badges It takes each one of us • Solicit feedback from community; involve key stakeholders • Investigate workplace policies and areas for improvement • Notice processes , images, documents etc that use outdated language, make assumptions, or lack inclusion • Pronoun pins, and more? • Allow people to identify themselves; use open-ended questions to solicit necessary information for screening • Say Thank You (not I’m sorry) when someone corrects you about their name or pronoun. Keep Going! Reach out: [email protected] National Center for Trans Equality UCSF Transgender Care National LGBT Health Education Center at Fenway GLSEN Gender Spectrum Philadelphia Trans Wellness Conference World Professional Association of Transgender Health Trans Law DC.
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