Culturally Competent Medical Care of Transgender Patients Gal Mayer, MD January 31, 2013 Introduction Presenter Information Gal Mayer, MD (former) Medical Director Callen-Lorde Community Health Center Primary care Cross-Gender Hormone care HIV care Oral health care Gynecology/Women’s health Mental health/social services 356 West 18th Street Sexual health clinic New York, NY 10011 Adolescent health 212-271-7200 Mobile health www.callen-lorde.org Introduction Course Objectives 1. Describe the modifiable barriers to accessing healthcare for transgender people and how to create a welcoming, inclusive environment. 2. Provide cross-gender hormone therapy to transgender patients by understanding their effects, benefits, risks, and administration. 3. Provide HIV and primary care to transgender patients by understanding the ways in which their clinical needs may differ from non-transgender patients. Introduction CME Disclosures Virtually all mentioned uses of the hormonal medications contained in this presentation are not FDA-approved and considered off-label. The presenter has the following disclosures: Gilead Sciences – speaker bureau What does transgender mean? Exploring meanings What does transgender mean? Exploring meanings What does gender mean? Questions to ponder What is gender? How do we know a person’s gender is? How many genders are there? What does gender mean? Gender vs. sex Traditional . Gender is binary (M/F) . Synonymous with sex (chromosomes, genitalia) New . Gender is a spectrum . Defined by several criteria . Separate from sex What does gender mean? Components of Gender Identity - The psychological awareness or sense of where one fits in on the man-woman spectrum Role – That part of behavior that is influenced by society’s expectation of what is gender- appropriate Expression – The way in which one communicates his or her identity through appearance and behavior (mannerisms, dress, speech, etc.) What does gender mean? A Combination of Traits Sex Genetic XY XXY (Klinefelter), XYY, XO (Turner) XX Anatomic Male CAH, Androgen Insensitivity Female Gender Identity Man Transgender, Genderqueer Woman Role Masculine Neutral Feminine Expression Masculine Androgynous Feminine Sexuality Attraction Homosexual Bisexual Heterosexual Label Gay, Lesbian, Straight, Queer, Butch, Fag, Bi, Femme, Dyke Behavior Same Sex Both Other Sex What does gender mean? Gender in a Population What does transgender mean? Exploring meanings What does transgender mean? Transgender Terminology Definitions vary across cultures and communities and are only offered here for the sake of consistency. Transgender, Gender Variant, Gender Non-Conforming, Gender Different . Umbrella terms used to group the many gender different communities . People who transcend typical gender paradigms . (Non-transgender people are sometimes called cisgender) What does transgender mean? Transgender Terminology Transgender, Transsexual . Biological men and women whose gender identity most closely matches the other gender Genderqueer . Used to describe people whose gender identity does not fit neatly into either male or female categories Transsexual . Sometimes used to specifically describe persons who have undergone genital surgery What does transgender mean? Transgender Terminology Crossdresser . Individuals with a desire to wear the clothing of the other sex but not to change their gender; many are heterosexual men who crossdress for erotic arousal; previously called transvestite Drag Queen/King . Individuals, usually in the gay/lesbian community, who crossdress for entertainment purposes and/or to challenge social stereotypes What does transgender mean? Sexual Orientation . Sexual orientation not the same as gender identity . Transgender people can be of any sexual orientation . Trans-women attracted to men and trans-men attracted to women may identify as heterosexual . Trans-women attracted to women may identify as lesbian . Trans-men attracted to men may identify as gay . Trans-people may also identify as straight, homosexual, bisexual, pansexual, omnisexual, asexual, queer, celibate, etc. Source: Grant et al. (2011). Injustice at Every Turn: http://www.thetaskforce.org/downloads/reports/reports/ntds_full.pdf What does transgender mean? Diverse Communities … androgyne, bi-gendered, butch queen, CD, crossdresser, drag king, drag queen, female-to-male, femme queen, FTM, gender bender, gender blender, gender challenged, gender fucked, gender gifted, gender-queer, male-to- female, MTF, new man, woman, non-op, non-operative transexual, passing man, passing woman, phallic woman, post-op, post- butch, TG, third sex, trannie/tranny, trannie-fag, trans, trans-butch, transexual/transsexual, transgender, transgenderist, transie, trans-man, trans- person, transexed, transexed-man, transexed-woman, transexual, transexual-man, transexual-woman, transvestic-fetishist, transvestite, trans-woman, tryke, TS, two-spirit… What does transgender mean? Transgender Prevalence No reliable data: Surveys suggest that at least 0.3% of the US population is transgender 0.2% 1:500-2,000 TG identity1 1:2,000 TG hormones (Belgium) 1:2,900 MtF surgery/hormones (Singapore)2 1:11,900 MtF surgery (Netherlands)3 0.003% 1:30,000 MtF surgery (USA) What does transgender mean? Transgender Terminology Transition . The process from living and being perceived as the gender assigned at birth according to the anatomical sex (M or F) to living and being perceived as the individual sees and understands themselves . Does not necessarily include surgery or hormones . Transgender identity transition can be similar to the LGB “coming out” process What does transgender mean? Transgender Terminology Transition (continued) . Some transitions have milestones (living part- time, living full-time, etc.) and an endpoint, while others are continual processes . Transitions happen on many levels: hormonal, linguistic, psychological, intellectual, spiritual, surgical, social, emotional, legal, etc. Common terms to describe transition: . MTF – male-to-female (transgender women) . FTM – female-to-male (transgender men) . Genderqueer What does transgender mean? Medical Diagnostic Terms Psychiatric Diagnoses . DSM IV – Gender Identity Disorder (302.85) . Often perceived as pathologizing . DSM V – Gender Dysphoria . Revised definition intended to depathologize will be released in 2013 Medical Diagnoses NB: Many clinicians avoid . Transsexualism these diagnostic codes and use more neutral . ICD-9: 302.5x ones (i.e. Unspecified . ICD-10: F64.0 Endocrine Disorder 259.9) What does transgender mean? Medical Terminology Cross-Gender Hormone Therapy . Not universally desired nor necessary (No-Ho) Sex Reassignment Surgery (SRS) or Gender Confirming Surgery (GCS) . Not universally desired (Pre-op, Non-op, Post-op) . Not easily obtainable: . Cost/insurance coverage . Need to meet criteria What does transgender mean? Diverse Utilization of Surgery Feminizing Procedures Source: Grant et al., 2010: http://transequality.org/PDFs/NTDSReportonHealth_final.pdf What does transgender mean? Diverse Utilization of Surgery Masculinizing Procedures Source: Grant et al., 2010: http://transequality.org/PDFs/NTDSReportonHealth_final.pdf What does transgender mean? Prejudice kills Transphobia . An irrational fear of gender-different people leading to systematic discrimination and violence Tyra Hunter (1970-1995) Robert Eads (1945-1999) Brandon Teena (1972-1993) Died in Washington DC Care for ovarian cancer Raped and murdered by after paramedics withdrew delayed for one year John Lotter and Marvin treatment at scene of car because more than two Nissen after they discovered accident. dozen doctors refused to he was anatomically female. treat him. What does transgender mean? Health Disparities HIV Lifetime Suicide Attempt Risk Mental health 41.0% Suicidality and self-harm Substance use and abuse Tobacco use 2.5% Lack of culturally- 1.6% competent care Transgender General U.S. U.S. Military Population What does transgender mean? Stressful Psychosocial Realities 4x more likely19% to uninsured live on <$10,000 annuallyLack of Sexual 12% report Assault sexualHate violence compared to averageHealth Crimes 19%American refused care dueInsurance in school to transgender or 2x the rate of unemploymentWrongful gender non-Poverty conforming status 28compared% postponed to U.S. necessary rateIncarceration medical care when sick or 53% verbally 57% rejected injured due to harassedDiscrimination or Homelessness by family discrimination by health disrespected in publiccare providers accommodation 33% delayedFamily or did not Police (e.g.,Rejection hotel, Brutality try restaurantto get preventive, bus, etc.) healthcare due to discriminationHarassment by health Domestic care providers Violence What does transgender mean? Barriers to Healthcare Real and perceived hostility in Negative prior experience healthcare settings Real and perceived ID/Identity Lack of insurance/lack of lack of provider mismatch hormone coverage knowledge Immigration Hours of Disproportionately affected by issues clinics psychosocial stressors Institutional settings-lack of Culture of self-sufficiency transgender appropriate housing Creating a welcoming environment What can we do? Creating a welcoming environment It’s not just a clinical issue Cultural competency and sensitivity training for ALL staff Transgender-sensitive and inclusive education brochures, prevention information available Become familiar with local support resources . Especially for assisting with name/gender designation