BEYOND RAINBOWS: Affirming Mental Health Care with and Sexuality Diverse Clients

Santa Clara County Behavioral Health Friday, October 23, 2018

1 PART 2: AND GENDER NONCONFORMING (TGNC) CLIENTS

2 THE TIPPING POINT

“the moment of critical mass, the threshold, the boiling point” “that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire” -Malcolm Gladwell

3 4 5 REALITY: STATE OF EMERGENCY 23 transgender women murdered in U.S. in 2015 83% increase from 12 homicides in 2014 80% were women of color (Black/Latina) 41% transgender people have attempted suicide 4x HIV infection rate of general population 90% report employment 4x as likely to live in extreme poverty 41% don’t have ID reflecting correct gender

6 SAFE AND ACCESSIBLE RESTROOMS

7 Awareness Basics Compassionate Care 8 AWARENESS • Know thyself • Social position • Values • Beliefs • Biases • Cultural humility 9 EXERCISE Gender Training

10 11 TERMS For here and now

12 ■ : sexual and/or emotional attraction to another person

■ : Internal sense of being a man, woman, or another gender

13 Sex Assigned At Birth based on appearance of external genitalia.

14 ■A person who identifies with sex assigned at birth. ■Cisgender privilege: benefits that result from alignment of gender identity and perceived gender

15 Transgender (adj.) ■ Also trans or gender nonconforming (GNC) ■ Describes the full range of people whose gender identity and/or do not fully align with sex assigned at birth. 16 THE The classification of gender into two dichotomous, fixed categories

17 “Is It A Boy Or A Girl?”

Maybe Maybe. not.

18 Nonbinary gender identities: just a few examples

• Genderqueer • • Ladyboi • Nonbinary • Androgyne • • Gender neutral • Multigender • • Neutrois • Polygender • Demiboy • Agender • Bigender • Demigirl • Genderless • Gender fluid • Intergender • Neutrois • Demi gender • Gender variant • Null-gender • Pangender • Masculine of center • Nongendered • Two-spirit • Epicene • Gender nonconforming • • Polygender And the list goes on… Tip: You don’t have to understand the intricacies of every identity. Just be respectful of client self-designation. 19 Traditional Gender Model adapted from Samuel Lurie

(ASSIGNED) SEX male Organic markers: hormones, genitalia, secondary sex characteristics, genes…

GENDER ROLES masculine feminine Social expression: Dress, posture, actions…

GENDER IDENTITY man woman Self conception: “I am…”

SEXUAL ORIENTATION women men Attracted to…

20 Alternative/Authentic Gender Model adapted from Samuel Lurie

Male () Female (ASSIGNED) SEX Organic markers: hormones, genitalia, secondary sex characteristics, genes…

Masculine (Androgynous) Feminine GENDER ROLES Social expression: Dress, posture, actions…

Unique GENDER IDENTITY Self conception: “I am…”

Women-Both-Neither-Trans-All-Other-Men SEXUAL ORIENTATION Attracted to…

21 “GENDER IS A UNIVERSE, AND WE ARE ALL STARS.”

22 Speaking about transgender people ■ Incorrect: – “That person is a male transgender.” – “I have known many .” – “She is transgendered.” – “The patient will trans from female to male.” ■ Correct usage: – “Transgender people…” – “I have a client who is transgender.”

– “I have a client who is a transgender woman.” 23 Self-Identification

There are many different ways to describe gender identity. When in doubt, ASK and always respect self-identification. “How do you identify in terms of gender?” “What are your pronouns?”

Always use the name and the pronoun that someone chooses or prefers, regardless of: – What they look like to you (how you perceive them) – Sex assigned at birth – Legal name or gender marker – What their genitals are – Whether they have had surgery or hormone therapy

24 FUN WITH PRONOUNS!

A pocket-size card created by the L.G.B.T. Resource Center at the University of Wisconsin, Milwaukee

Tip: Always use correct (self-designated) pronouns. This is not a

preference! 25 INTERSECTIONAL IDENTITIES

26 Religion Race/Ethnicity

Queer

Trans Ability Migration Status

Geographic Location

Lesbian Family Structure

Social Class Questioning

27 28 29 COMPASSIONATE CARE

30 GENDER-AFFIRMING MEDICAL CARE

31 Simply none of your business.

32 TRANSITION? One size does not fit all. ■ Length, scope, and process are unique – Medical (e.g., hormones, surgery) – Social (e.g., changes in gender expression, name, pronoun) – Legal (e.g., changing ID documents) ■ Not every trans person desires medical transition. ■ Some nonbinary people medically transition. ■ There is no “complete” transition.

33 BARRIERS TO HEALTH CARE

■ 1 out of 3 transgender people have had gender- related negative experiences when seeking health care in the past year ■ 1 out of 4 transgender people avoid going to the doctor out of fear of discrimination ■ 50% report having to teach their medical providers about transgender care

34 Gender-Affirming Medical Procedures ■ Hormone therapy ■ Facial feminization ■ Top surgeries – Brow reduction – Breast augmentation – Facial implants – Chest reconstruction – Face lifts ■ Lower surgeries – Jaw reduction – Hysterectomy – Tracheal shave – Oophorectomy – Rhinoplasty – Metoidioplasty ■ Laser hair removal – ■ Hair transplants – ■ Scalp advancement – Orchiectomy ■ Silicone injections – Vaginoplasty ■ Voice surgery – Labiaplasty

35 Hormone Therapy (aka HRT) ■ Hormonal transition can mimic puberty ■ Development of secondary sex characteristics: – Body hair – Fat redistribution – Muscle growth – Breast development ■ Timeline and results vary depending on the individual and factors such as physical condition, age, and genetics. ■ Considerations of bone health

36 DIAGNOSING DIFFERENCE Film by Annalise Ophelian, 2009

37 Film Discussion 1. What are some reactions you have to the individuals in the film? 2. What surprised you about the characters or people in the film? What surprised you about your reactions? 3. Were there parts of the film that made you feel uncomfortable? 4. What questions would you like to ask the people depicted in the film? 5. What voices or perspectives were missing from the film?

38 COMPASSIONATE AND AFFIRMING TRANS HEALTH CARE ■ Listen ■ Use name and pronoun designated by patient ■ Accessible environments (restrooms, forms, signs) ■ Understand there is no one-size-fits- all identity or approach ■ Interdisciplinary ■ Informed consent

39 NOT-SO-COMPASSIONATE TRANS HEALTH CARE ■ Views patients as incapable of making decisions for themselves ■ Excessive requirements (past and present)

40 MENTAL HEALTH Assessment and Treatment

41 WPATH Standards Of Care (SOC) (formerly Harry Benjamin SOC)

First published 1979; V1-4: “Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons

V5-6: “Standards of Care for Gender Identity Disorders”

V7 (2011): “Standards of Care for the Health of , Transgender, and Gender Nonconforming People” Flexible clinical guidelines Gender nonconformity ≠ Reviews treatment options for gender dysphoria Reviews tasks of provider (assessment vs. psychotherapy)

42 WPATH SOC7: Highlighted Updates

PRIOR VERSIONS OF SOC STANDARDS OF CARE V7 Focus on trans people’s Focus on providers’ behavior (cultural behavior; emphasize barriers competency); emphasize access Psychotherapy required for eligibility Psychotherapy highly recommended (V5)

Traditional medical narrative More flexible; non-binary gender ID Gender nonconformity as pathological; Gender nonconformity as human diversity; GID focus on gender dysphoria Unclear on public coverage, Txs trying Acknowledges public coverage. Txs trying to to change GI to conform to assigned change GI to conform to assigned sex are sex unethical “Family intolerance”, “inter-personal Removal of these barriers issues”, pre-existing conditions = barriers to care

43 Some Common Presenting Concerns

■ Anxiety concerns ■ Depression ■ Self-harm ■ Lack of family support ■ Suicidality ■ ■ Isolation ■ Navigating institutional ■ Eating disorders oppression ■ Addictions or compulsive ■ Relationship issues behaviors ■ Workplace concerns ■ Trauma or abuse ■ Body image and eating ■ To get a “letter”

44 A Question Of Ethics “Treatment aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with sex assigned at birth has been attempted in the past (Gelder & Marks, 1969; Greenson, 1964), yet without success, particularly in the long term” (Cohen-Kettenis & Kuiper, 1984; Pauly, 1965).

“Such treatment is no longer considered ethical.” (SOC V7, p. 32)

45 Limitations and Considerations

■ Many doctors do not use current version ■ Inconsistency among doctors, insurance, SOC ■ Less stringent “real life experience”, but still 12 months living “congruent with gender ID” ■ Costs and financial access ■ Assumption of gender dysphoria ■ Hormone therapy prerequisite to “bottom” surgery ■ Gatekeeper model is still in place; mental health not required for other medically necessary surgeries

46 Gatekeeping History

■ University gender clinics ■ Community organizing and medicalized narrative ■ Relationship requirements ■ Race-based stereotypes and discrimination ■ Behavior modification (forced feminization or forced masculinization) ■ “Passing” or being “successful” ■ Affirmative models of care ■ World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) 7

47 Gender Dysphoria Diagnosis ■ Gender Dysphoria (DSM-5) replaced diagnosis of Gender Identity Disorder (GID). ■ “Marked incongruence between” a person’s gender assigned at birth and gender identity. ■ Discomfort or distress related to incongruence between a person’s gender identity, sex assigned at birth, gender role, and/or primary and secondary sex characteristics. ■ Not all TGNC people have Gender Dysphoria. This is acknowledged by WPATH, yet Gender Dysphoria is still needed to access gender-affirming medical care.

48 To Diagnose or Not Diagnose? ■ Gender Dysphoria is extremely controversial ■ Meant to be less pathologizing than GID, but does not allow for healthy, disorder-free transgender experience ■ Only diagnose if all of the following are true: – A gender-related diagnosis is an absolute necessity for accessing gender-related procedures (e.g., surgery) – The client is requesting a diagnosis for this purpose – You have informed the client that you are using this diagnosis – The client is fully aware of how having the diagnosis on record may impact them

49 Distress / Symptoms ■ People often assume that this distress is caused by being TGNC. ■ It is more accurate to say that transgender people suffer from society’s reactions. ■ Treatment for Gender Dysphoria (or , or cisgenderism) also needs to be targeted toward society rather than blamed on the individual. ■ For people who do experience distress, however, gender-affirming medical procedures can alleviate or reduce it.

50 “Gender” Assessment aka Letter-Writing

■ Provider must have basic knowledge of procedures, risks and benefits, recovery times, etc. – Without this you cannot assess informed consent! ■ Rely on self-identification; in this way we are not assessing gender ■ More accurate to say we are assessing gender-related concerns or desires ■ Evaluate decision-making capacity ■ Informed consent model – Capacity to give consent – Able to identify risks and benefits – Mental health symptoms are reasonably stable (though medical intervention is shown to increase emotional stability and decrease mental health symptoms).

51 Interdisciplinary Approach ■ Interdisciplinary approach to care is essential

■ Build relationships with other professionals – Medical doctors (surgeons, endocrinologists) – Mental health providers – Speech therapists – Dieticians/Nutritionists – Clergy members – Attorneys – Community organizers, activists – Educators – Policy makers

■ Importance of TGNC involvement and leadership

52 APA* Practice Guidelines (2015) *American Psychological Association ■ 52% of psychologists and graduate students reported learning about transgender issues in school. Only 27% “feel sufficiently familiar with transgender issues” (N = 294; APA, 2009x). ■ APA Task Force on Gender Identity and (2005-2008) called for practice guidelines. Task Force of 10 psychologists appointed in 2011-2012. ■ Guidelines approved August 2015 and will be published December 2015. ■ Fundamental information for trans-affirmative practice (not treatment) ■ Defines application of practice across: – Foundational Knowledge – Healthcare – Research and Education – Lifespan Development, Aging, Youth – Relationships and Sexuality – Advocacy 53 ACA Competencies For Counseling With Transgender Clients (2010) ■ Wellness, resilience, and strengths-based ■ Social justice and advocacy (e.g. privilege) ■ Organized into 8 domains ■ Client-centered language, e.g. preferred pronouns, including gender-neutral pronouns (e.g. zie/hir, they/them). ■ Not all trans people identify with concept of “transition” or with gender binary (M or F)

54 Examples of ACA Competencies ■ B1: “appropriate language…respect client’s declared vocabulary” ■ B5: “intersecting identities of transgender people” ■ C2: “counselors’ gender identity” ■ C7: “acknowledge that…helping professions have compounded discrimination” ■ C9: “welcoming, affirming environment” ■ F10: “consultation and education on gender identity to facilitate workplace changes”

55 ASSESSMENT AND REFERRAL ■ Reasons for seeking treatment at this time: – Exploring gender identity/expression – Facilitation of coming out as variable process – Assessment/referral for medical interventions (including letters) – Support for family/loved ones – Concerns unrelated to gender ■ If applicable, assess gender-related concerns and provide options for treatment ■ Assess and treat co-existing mental health concerns

56 TASKS OF PSYCHOTHERAPY ■ Psychotherapy is not an absolute requirement for attaining surgery or hormones. There is no minimum number of sessions recommended. ■ Provide support for shifting gender identity/role. ■ Provide follow-up care for later life stages. ■ Provide therapy and referrals for family. ■ Educate and advocate within the community (schools, workplaces, other organizations). ■ Assist clients with making changes in identity documents.

57 The First Session: What to Keep In Mind ■ Wide variation of gender identities ■ Be aware of your own gendered experience and assumptions about TGNC people ■ Curiosity is not clinical rationale ■ Gender identity may or may not be related to presenting concern ■ The mental health field’s history of harm and abuse, reasonable defensiveness or guardedness ■ Follow the client’s lead regarding language (pronouns, ways to describe gender) ■ Provider’s responsibility to educate oneself about gender and to practice cultural humility in a rapidly changing field

58 Holding Complexity ■ Maintain awareness of all cultural identities, including age, disability, immigration status, national origin, race/ethnicity, relational status, religion, sexual orientation, and socioeconomic status, amongst others. ■ In what ways does the client hold power in society? How might this impact or be impacted by shifts in gender? ■ Maintain awareness that stressors and resilience may be additive across cultural identities. ■ Explore and highlight areas of skills and resilience trans people have developed in the process of navigating intersecting identities – Religious and spiritual beliefs may be a strong component of trans people of color’s resilience (Dowshen et al., 2011; Singh, 2012).

59 Example: Challenging Binary Perceptions

Provider: “He comes in saying he’s a woman, asking me to refer to him as “she” and “her”…but he just doesn’t look feminine to me.” ■ Respect and use patient’s self-designated name, gender identity, and pronoun. ■ Expand notions of of gender: masculine women, feminine men, trans women who identify as butch, etc. ■ Recognize that gender identity is different from gender role/expression. We can’t see gender identity. ■ Recognize that gender socialization is learned and reinforced over a lifetime.

60 A Word About Youth ■ Great controversy in the field about treatment ■ Work closely with parents/family if possible ■ Puberty suppression can buy time ■ Be transparent about treatment approach so they can decide if it fits for their child/family ■ Unethical (and ineffective) to try to change child’s gender expression (WPATH SOC7, recent Obama Administration statements re: , CA SB1172). ■ Most agree to let child have freedom to explore ■ Some kids will grow up to be TGNC, some may end up being cisgender/gay

61 Family, Relationships, Community ■ If possible, invite but do not require family participation. ■ Family acceptance acts as protective factor. This includes chosen family. ■ Provide resources for family members and partners. They are going through their own transition. ■ Explore parenting and fertility concerns.

62 Romantic and/or Sexual Relationships

■ Relationships may be both similar to and different from relationships that do not involve trans people (successful, challenging, healthy, unhealthy) ■ History/impact of inaccurate assumptions about trans people’s sexuality and relationships (e.g., dissolution of marriage as prerequisite for accessing transition care) ■ Stability and fluidity ■ Endocrine changes may affect sex drive and attraction ■ Exploration is common and healthy ■ Partners may experience shifts in their own identities (e.g., attraction, perceived sexual orientation) ■ Partners may feel compelled to express their gender in ways that affirm their trans partners’ gender identities

63 Common Reactions From Health Providers

■ Fear ■ Betrayal of one’s perceptions ■ Pathologizing ■ Betrayal (feminism/) ■ Difficulty tolerating ambiguity ■ Wanting to determine an individual’s “real” gender ■ Labeling as pathological or perverted ■ Trying to force gender binaries ■ Feeling threatened / threat to one’s own sense of gender ■ Morbid curiosity ■ Overt transphobia / Violence ■ Revulsion ■ “Acceptable” discrimination ■ Fascination / Fetishism ■ Grief (especially friends and family) ■ Tokenism ■ Wanting to know the person’s “real” name/gender ■ Confusion ■ Refusal to respect pronouns and chosen ■ Shock / Disbelief name unless the person “passes” ■ Anger ■ Trying to determine causality / “what went wrong” / assuming sexual trauma or ■ Denial abuse ■ Premature acceptance ■ Diagnosing the person as narcissistic, histrionic, borderline ■ Assumptions about an individual’s sexual ■ Labeling partners as sick/disturbed for orientation/attractions choosing a TGNC person 64 Key References American Psychological Association. (2015). Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. Retrieved from http://www.apa.org/practice/guidelines/transgender.pdf American Counseling Association (2010). Competencies for Counseling with Transgender Clients. Journal of LGBT Issues in Counseling, 4(3), 135-159. American Psychological Association, Task Force on Gender Identity and Gender Variance (2009). Report of the Task Force on Gender Identity and Gender Variance. Washington, DC: Author. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … Zucker, K. (2011). Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th version. International Journal of Transgenderism, 13(4), 165-232. Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Kiesling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. Washington, DC: National Center for Transgender Equality and National Gay and Task Force. Lev, A.I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. New York, NY: Clinical Practice.

65 Additional Reading

Bornstein, Kate (1995). Gender Outlaw: On Men, Women, and the Rest Of Us. New York: Routledge. Boylan, Jennifer (2003). She’s Not There: A Life In Two . New York: Broadway Books. Brill, Stephanie A. & Pepper, Rachel (2008). The Transgender Child: A Handbook For Families and Professionals. : Cleis Press. Ehrensaft, Diane. (2011). Gender Born, Gender Made. New York: The Experiment. Feinberg, Leslie (1997). Transgender Warriors: Making history from Joan of Arc to Dennis Rodman. Beacon Press. Kuklin, Susan (2014). Beyond Magenta: Transgender Teens Speak Out. Somerville: Candlewick Press. Lev, Arlene Istar (2004). Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and their Families. New York: Haworth Press. Nestle, Joan, Wilchins, Riki, & Howell, Clare, Eds. (2002). Genderqueer: Voices from Beyond the Sexual Binary. Los Angeles: Alyson Books. Pepper, Rachel, Ed. (2012). Transitions Of the Heart: Stories of Love, Struggle, and Acceptance by Mothers of Transgender and Gender Variant Children. Berkeley: Cleis Press. Reiff Hill, Mel & Mays, Jay (2013). The Gender Book. Houston: Marshall House Press. Serano, Julia (2007). Whipping Girl: A Transsexual Woman on Sexism and The Scapegoating of Femininity. Emeryville, CA: Seal Press. Spade, Dean (2010). Normal Life: Administrative Violence, Critical Trans Politics and the Limits of Law. Cambridge: South End Press.

66 Once a young woman asked me, How Does It "How does it feel to be a man?" Feel to Be a And I replied, Heart? "My dear, I am not so sure." by Hafiz Then she said, "Well, aren’t you a man?" And this time I replied, "I view gender As a beautiful animal That people often take for a walk on a leash And might try to enter in some odd contest To try to win prizes. "My dear, A better question for Hafiz Would have been, "How does it feel to be a heart?” 67 QUESTIONS?

68 CONTACT

Sand Chang, Ph.D. 510-545-2321 [email protected]

69