Sara Wiener, LMSW December 16, 2016 Working Effectively with Transgender Patients: Language, Best Practices, Referrals Sara Wiener, LMSW December 16, 2016

Disclosures I have no financial disclosures

Overview and Goals Learn basic concepts and terminology Learn ways to speak to patients about gender and assess needs, including interpersonal best practices when examining trans patients Learn about health disparities and lived experiences of transgender people

Terminology Biologic sex – the genetic, anatomic, and hormonal determinants that define male and female Gender identity – a person’s own classification of self as male or female Gender expression – how you demonstrate your gender through the way you dress, act, behave and interact Sexual orientation – the sex of the persons that one finds sexually desirable

Gender Dysphoria in Adolescents and Adults (DSM 5) A. Marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifest by at least two of the following Marked incongruence between expressed gender and primary/secondary sex characteristics Strong desire to be rid of primary/secondary sex characteristics or desire to prevent development of anticipated secondary characteristics Strong desire for the primary/secondary sex characteristics of the other gender Strong desire to be the other gender (or some alternative gender) Strong desire to be treated as the other gender (or alternative gender) Conviction that one has typical feelings of the other gender B. Clinically significant distress or impairment in social, occupational, or other areas of functioning

Using Language Yes: Laura is a transgender woman. No: Laura is a transgender. Yes: Marcus is transgender. No: Marcus is transgendered. Always refer to a person using their preferred name and pronouns, both verbally and in documentation.

Using Language Physical exams: Many transgender patients do not use the language you may use for their body parts. ASK “Before we get started today, I want to make sure I am using the words for your body parts that make you feel most comfortable. What do you call what you have up here? [Gesture] What do you call what you have here? Thanks! I’m going to try to use those words.”

Interpersonal Best Practices with Trans Patients Video clips from Mount Sinai

Speaking to Patients about Gender Proactive versus reactive approach Learning a pt’s gender from information on screening form Learning a pt’s gender from verbal, face-to-face disclosure The first thing to say: Thank you Assessing what your patient needs and wants

To Whom Do I Send My Patient Now? Referrals No referrals may be necessary! Assess what the patient is seeking Psychotherapy? Hormones or surgery? Patient will need 1 or 2 letters from a mental health clinician Referring to trans competent mental health clinicians Process after letters of support for gender affirming medical treatment are obtained

Comprehensive Gender Services at UMHS No need for physician referral. Patient contacts office directly: genderservices@med.umich.edu or 734-998-2150 Patient fills out service inquiry form Patient receives referrals to resources they are seeking Comprehensive Gender Services receives letters of support written by mental health clinicians for hormones and surgery Comprehensive Gender Services reviews letters, ensures pt meets WPATH Standards of Care criteria for medical intervention, schedules patient with hormone provider or surgeon for consultation Very limited to generally no availability for psychotherapy at UMHS

National Transgender Discrimination Survey (2011) 6,450 people, all 50 states Diverse sample in terms of race, ethnicity, age, SES, employment status, educational attainment, disability, citizenship, transition status 63% of participants experienced a serious act of discrimination Anti transgender bias plus persistent, structural racism is devastating Hundreds of dramatic findings on the impact of anti-transgender bias are presented in this report. In many cases, a series of bias-related events lead to insurmountable challenges and devastating outcomes for study participants. Several meta-findings are worth noting from the outset: Discrimination was pervasive throughout the entire sample, yet the combination of anti transgender bias and persistent, structural racism was especially devastating. Respondents lived in extreme poverty. The sample was nearly 4 times more likely to have a household income of less than $10,000/yr compared to the general population 41% of the respondents reported attempting suicide compared to 1.6% of the general population, with rates rising for those who lost a job due to bias (55%), were harassed/bullied in school (51%), had low household income, or were the victim of physical assault (61%) or sexual assault (64%). What is a SERIOUS ACT OF DISCRIMINATION? Events that would have a major impact on a person’s quality of life and ability to sustain themselves financially or emotionally. These events include the following: lost job due to bias, eviction due to bias, school bullying so severe the respondent had to drop out, teacher bullying, physical assault due to bias, sexual assault due to bias, homelessness due to gender identity, lost relationship with partner or children due to gender identity or expression, denial of medical service due to bias, incarceration due to gender identity/expression. Almost a quarter, 23% of the respondents, experienced a catastrophic level of discrimination—having been impacted by at least three of the above major life disrupting events due to bias. These compounding acts of discrimination—exponentially increase the difficulty of bouncing back and establishing a stable economic and home life. These are the real life experiences of trans and GNC people. Imagine the impact of these experiences on a person’s psychological well-being

Findings Employment Discrimination & Economic Insecurity Housing Discrimination and Homelessness Double the rate of unemployment (POC 4x the nat’l unemployment rate) 90% experienced harassment, mistreatment, or discrimination on the job 26% lost a job due to being trans or GNC 19% reported having been refused a home or apartment b/c of gender ID 19% experienced homelessness at some point in their lives b/c of gender ID 55% of respondents who accessed a shelter were harassed by staff or residents 2% of respondents were homeless, which is double the rate of the general population 47% experienced an adverse job outcome such as being fired, not hired, or denied a promotion because of being transgender or GNC

Findings Discrimination in Health Care and Poor Health Outcomes Family Acceptance Higher rates of HIV infection, smoking, drug and alcohol use, and suicide attempts than general population 19% of respondents were denied care due to gender identity 50% had to teach their medical provider about transgender care When sick, 28% postponed medical care due to discrimination 43% maintained most of their family bonds, while 57% experienced significant family rejection Family acceptance has a protective effect against many threats to well-being like HIV infection and suicide

Sara Wiener, LMSW sarawie@med.umich.edu 734-998-2049