Affirmative Care for Transgender and Gender Non-Conforming People: Best Practices for Front-line Health Care Staff Updated Fall 2016 NATIONAL LGBT HEALTH EDUCATION CENTER A PROGRAM OF THE FENWAY INSTITUTE INTRODUCTION Front-line staff play a key role in creating a health care environment that responds to the needs of trans- gender and gender non-conforming (TGNC) people. Everyone, no matter their gender identity or expres- sion, appreciates friendly and courteous service. In addition, TGNC people have unique needs when in- teracting with the health care system. First and fore- most, many TGNC people experience stigma and dis- crimination in their daily lives, including when seeking health care. In light of past adverse experiences in health care settings, many fear being treated disre- spectfully by health care staff, which can lead them to delay necessary health care services. Additionally, the names that TGNC people use may not match those listed on their health insurance or medical records. Mistakes can easily be made when talking with pa- tients as well as when coding and billing for insurance. Issues and concerns from TGNC patients often arise at the front desk and in waiting areas because those are the first points of contact for most patients. These issues, however, are almost always unintentional and can be prevented by training all staff in some basic principles and strategies. This document was devel- oped as a starting point to help train front-line health care employees to provide affirming services to TGNC patients (and all patients) at their organization. What’s Inside Part 1 Provides background information on TGNC people and their health needs. Part 2 Provides tips and strategies to improve communication and create a more affirming environment. Suggested Methods for Using this Document • Include this document in orientation packets for new hires. Provide a brief verbal introduction to the document and why it is included. • Host a mandatory training on TGNC identities and health at your or- ganization, or require staff to watch the webinar “Meeting the Health Care Needs of Transgender People,” which describes the information in this document (http:/www.lgbthealtheducation.org/lgbt-education/we- binars/). • Hold a discussion afterwards around how to improve the environment of your organization. Distribute this document, and discuss how you will implement the best practices. • Encourage staff to post the Best Practices Sheet (included on the last page of this document) near their work station. Part 1: Gaining a Better Understanding of TGNC People WHAT DO WE MEAN BY TGNC? TGNC stands for transgender and gender pect of them based on their sex assigned at birth. non-conforming people. Transgender people have Nevertheless, knowledge of both sex assigned at a gender identity that does not align with the sex birth and gender identity are essential elements of they were assigned at birth. When they are born, providing affirming, quality health care. babies are assigned a sex by a doctor, typically The transgender “umbrella” includes people who based on their external genitalia. Sex could also be were assigned female sex at birth who now iden- defined by chromosomes, internal anatomy, and tify as men (transgender men or trans men) and even neurobiology in the brain, although these people who were assigned male sex at birth who factors are not typically taken into account when now identify as women (transgender women or a sex is assigned. Each person also has an inter- trans women). It also includes people who iden- nal sense of self, known as gender identity, which tify as both a man and a woman, as neither, or as develops over the course of a person’s life and a gender somewhere in between these two points which may change over time. For centuries, the on the gender spectrum. These gender identities, idea that there are only two genders, which match which are outside of the binary identities of “man” two distinct physical sexes (masculine men/males and “woman,” are known as non-binary gender and feminine women/females), has been assumed identities. A list of related terms (for example, by most, but not all people in our society. As non-binary and genderqueer) are included in our a child grows up, it is usually assumed that their glossary. A person’s gender identity develops and gender identity and expression will correspond changes over the course of their life. to the sex they were assigned at birth, and fit into this binary understanding of gender. Transgender The ways in which a person presents their inter- people have an internal sense of their gender iden- nal gender identity may be through their gender tity that does not match the one society may ex- expression, which can include clothing, hair style, 1 | or mannerisms, among other characteristics. Often, TGNC people change their name or pro- However, gender expression does not necessar- nouns to align more closely with their gender ily correspond to either assigned sex at birth or identity. Some TGNC people take steps toward gender identity, so we can never assume a per- a gender transition. This can begin with a social son’s gender identity based on their appearance transition (such as asking friends and family to use or mannerisms. A gender non-conforming per- a different name and/or pronoun) and sometimes son is anyone who has a gender expression that continues to include a medical transition (such as does not conventionally align with the person’s gender-affirming hormone therapy or surgery). assigned sex at birth. For example, someone who The goal of any transition is to align outward pre- was assigned female sex at birth may adopt a con- sentation with internal gender identity, as incon- ventionally masculine gender expression. Many sistency between the two can cause significant gender non-conforming people are not transgen- emotional distress. As a matter of their health and der. For example, a person who is assigned female well-being, it is important for TGNC people to be at birth may identify as a woman, and may also respected and affirmed for who they are. wear more traditionally masculine clothing and hair styles. However, even gender non-conform- ing people who are not transgender can face ha- rassment or physical violence. Both transgender and non-transgender people may conform to their community’s expectations around gender expres- sion for a number of reasons, whether due to hab- it, convenience, or as a matter of safety. | 2 Glossary There are many different identities that fall under the TGNC umbrella, and many terms used by TGNC people to describe themselves and their communities. Many TGNC people consider their gender identity to be fluid, and may change the way they identify over time. In addition, terminolo- gy itself changes over time. Keep in mind that definitions can vary greatly across communities and individuals, and that it is best to give all patients an opportunity to provide information on how they identify when seeking care. Here are some terms related to the experience of those who are TGNC; some are names of gender identities, while others describe elements of gender. Agender (adj.) Describes a person who identifies as having no gender. Bigender (adj.) Describes a person whose gender identity is a combination of two genders. Cisgender (adj.) A person whose gender identity and assigned sex at birth match (i.e., a person who is not transgender). Gender affirming surgery (GAS) (noun) Surgeries used to modify one’s body to conform more with one’s gender identity. Gender binary (noun) The idea that there are only two genders, male and female, and that a person must strictly fit into one category or the other. Gender dysphoria (noun) Distress experienced by some individuals whose gender identity does not correspond with their assigned sex at birth. Manifests itself as clinically significant distress or impairment in social, occupational, or other important ar- eas of functioning. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes gender dysphoria as a diagnosis. Gender expression (noun) The way a person acts, dresses, speaks, and behaves. This can be feminine, masculine, a combination of the two, or neither. Gender expression does not have to match assigned sex at birth or gender identity. Gender fluid (adj.) Describes a person whose gender identity is not fixed. A person who is gender fluid may always feel like a mix of the two traditional genders, but may feel more one gender at some times, and another gender at other times. Gender identity (noun) A person’s internal sense of being a man/male, woman/female, both, neither, or another gender. Gender non-conforming (adj.) Describes a gender expression that differs from a given society’s norms for males and females. Gender role (noun) A set of societal norms dictating what types of behaviors are generally considered acceptable, appropriate, or de- sirable for a person based on their actual or perceived sex. Genderqueer (adj.) Describes a person whose gender identity falls outside the traditional gender binary. Other terms for people whose gender identity falls outside the traditional gender binary include gender variant, gender expansive, etc. Some- times written as gender queer. Non-binary (adj.) Describes a person whose gender identity falls outside the traditional gender binary. Sometimes abbreviated to NB or “enby.” Some people identify as “non-binary,” while others identify with another non-binary gender identity, such as genderqueer, gender fluid, or agender. 3 | Pangender (adj.) Describes a person whose gender identity is comprised of many genders. Questioning (adj.) Describes an individual who is unsure about or is exploring their own sexual orientation and/or gender identity. Sex assigned at birth (noun) The sex (male or female) given to a child at birth.