WSU Pharm 2008 Presentation

Welcome Providing Culturally Competent Care to Lesbian, Gay, Bisexual, and Transgender Individuals Knoll Larkin MPH Mautner Project-”Removing the Barriers” Funded by the Centers for Disease Control and Prevention Affirmations—”The Community Center for Lesbian, Gay, Bisexual, Transgender People and their Allies” T0

Sexual Orientations Lesbian: A women who is emotionally, romantically, spiritually attracted to women. Gay: A man who is emotionally, romantically, and spiritually attracted to men. Bisexual/bi-attractional: Attraction to members of either sex T4:1

Sexual Orientations Same Gender Loving: A term used in communities of color to describe women who partner with women or men who partner with men. Queer: a more inclusive term used to describe folks who don’t fit “neatly” into the LGB categories.

Identity vs. Behavior Who we say and feel ourselves to be might be different than what we actually do. Identity- the “label” one applies to oneself and one’s community of affiliation Behavior- the specific activities a person engages in. T 4:3

Levels of Identity Involved in gay, lesbian, bisexual politics or culture “ Closeted and isolated from valuable support resources” Sexual orientation may be only a minor part of personal identity T4:4

Negative effects of heterosexism Self-blame for the victimization one has suffered Negative self concept Anger directed inward resulting in destructive patterns A victim mentality or feelings of hopelessness or despair, interfering with leading a fulfilling life NOT A RESULT OF ONES SEXUALITY!

Life Cycle Issues For LGB Individuals LGB youth face additional stressors (conformity, and coming out) LGB young adults (social life revolving around bars and substance use settings) Coupling Parenting Treatment Providers need to consider an LGB client’s partner, children, family of origin and family of choice when providing care!

LGB Clients May Be Coping With: Coming out Societal stigmas HIV/AIDS Discrimination Homophobic family members, employers, and work colleagues

Coming Out: Refers to the experiences of some, but not all, LGB people as they work through and accept a stigmatized identity. Transforming a negative self identity into a positive one Important for those trying to recover: Feeling positive and hopeful about themselves is at the heart of recovering from addition

What the coming out process means? Because many programs and counseling approaches value authenticity, discussing the process of coming out is crucial. Counselors who accept and validate client’s feelings, attractions, experiences, and identities can play an important role in success.

Coming Out (cont) There is no correct way to come out Some people may decide they do not want to take on a LGB identity and may choose not to disclose their feelings and experiences to anyone.

Cass Model of Identity Development Stage 1: Identity Confusion Stage 2: Identity Comparison Stage 3: Identity Tolerance Stage 4: Identity Acceptance Stage 5: Identity Pride Stage 6: Identity Synthesis

Gender Terms and Definitions Sex: Male, female, or Intersex, depending on one’s primary sex characteristics. Intersex: People born with an anatomy that someone else decided is not standard for male or female. Gender: Socially and culturally constructed roles ascribed to males and females. These roles, which are learned, changed over time and vary widely within and between cultures as well as from individual to individual. Gender Identity: One's sense of belonging to a particular gender. Gender Expression: the way in which someone conveys gender attributes.

Gender Terms and Definitions Drag: Gender performance, often for entertainment purposes. GenderQueer: An individual whose gender identity lies outside the gender binary system of male and female. This individual may be fluid with their gender expression. Gender Neutral Pronouns: and may use gender neutral pronouns (such as *sie, hir, hirs, hirself* or *zie, zir, zirs, zirself*) or choose to use the pronoun closest to the end of the masculine or feminine spectrum they are presenting.

Transgender Transgender (TG): individuals who do not conform to gender stereotypes, roles, and expectations. This is referred to as the "umbrella definition” as it covers everyone. Transsexual: A person who identifies as the sex opposite to the one assigned at birth. Folks who identify this way may alter their physical appearance to match their gender identity. Female-to-Male: A person whose sex was assigned as female at birth, but who now identifies as a man. Also known as FTM, F2M or F>M for short. Male-to-Female: A person whose sex was assigned as male at birth, but who now identifies as a woman. Also known as MTF, M2F, or M>F for short.

Using Language: Summary One way to demonstrate inclusiveness in a healthcare setting is through use of language. Use terms preferred by your clients. These may be different for each person, regionally or generationally based. T4:7

Common language: Summary (cont.) Preferred vs. Other Terms Lesbian, Gay, Bisexual Homosexual Partner Lover/Roommate Sexual orientation Sexual preference Crossdresser Transvestite Transgender Transsexual Intersex Hermaphrodite WHEN IN DOUBT… ASK! Words/Phrases Often Used “Within” the Community Dyke, Queer, Family, In the Life T4:8

Appropriate Ways to Ask About Gender Identity (created by Affirmations Trans Youth Group-Jan 2007) Ask on a need-to-know basis If feasible, only ask about pronouns Ask the person-not those around you Until you find an appropriate time and place to ask someone about pronoun preference, try to use gender neutral pronouns, or no pronouns at all. *Sample Inquiry* Do you have a pronoun preference

Inappropriate Ways to Ask About Gender Identity Are you a boy or a girl? Do you pee standing up Don’t ask questions about genitalia Don’t label someone who hasn’t first labeled themselves Don’t ask someone if they were “born as a boy or a girl” No asking someone what their “birth name” is Don’t be nosey

Myths/Facts About Transgender Identity MYTH: All transgender individuals want or have had sex reassignment surgery. FACT: Actual or desired surgical status is separate from one’s gender identity. Some transgender individuals feel “complete” once they have had surgery, while others opt to not have surgery because of limited funds and/or lack of medical insurance coverage, medical complications, or because they are dissatisfied with current technological limitations.

Myths/Facts About Transgender Identity MYTH: Transgender individuals go from either male-to-female or from female-to-male. FACT: “Transgender” is an umbrella term, which includes people who do not conform to gender stereotypes, roles, and expectations. Some transgender individuals appreciate an androgynous or gender queer identity. Many drag monarchs (kings and queens), cross-dressers, butch women and feminine men also consider the transgender community home.

Myths/Facts about Transgender Identity MYTH: Being transgender is a birth defect that can be corrected through hormones and surgery. FACT: While some transgender individuals believe this, some believe that their transgender identity is a gift or a blessing. Some transgender individuals also feel that there isn’t anything defective about their transgender identities.

Myths/facts About Transgender Identity MYTH: Transgender people are trying to become a particular gender. FACT: Transgender people are coming out as the people they feel themselves to be.

Transition Medical Transition Hormones Surgery Other (electrolysis, etc.) Social Transition Appearance Gender markers (Id, birth certificate, etc) Name change Coming out

What is Non-Transgender Privilege? Non transgender privilege means living without ever having to face, confront, engage in, cope with, most things on the list. Not questioning your normalcy with regard to your gender or your body. Never questioning the assumed connection between your genitals and your gender Experiencing childhood or adolescence while being treated as your gender. Keeping your name, pronouns, and voice the same throughout your life.

Non Trans Privilege Validation from the culture in which you live including family, friends, and partners Assuming that people will be able to interpret your gender correctly from my appearance, and not worrying about what might happen if they can’t. Having a valid accepted gender without evaluation by a medical professional, surgery, or a “judgment” of your appearance and ability to pass.

Non Trans Privilege Institutional Acceptance Using bathrooms, showers, or locker rooms without fear. Marking one of the two sex options on most forms without question. Adopting children, fostering children. Making choices about your body by yourself without having to be declared mentally ill.

Negative effects of heterosexism and Transphobia Self-blame for the victimization one has suffered Negative self concept Anger directed inward resulting in destructive patterns A victim mentality or feelings of hopelessness or despair, interfering with leading a fulfilling life NOT A RESULT OF ONES SEXUALITY!

Rachel’s Story The Trans Experience and Mental Health

Barriers to Care and Treatment Cont. Providers lack basic knowledge and have discomfort Lack of research and information Extensive negative experiences with healthcare. Medicalization and pathologization of experiences Intake forms, office environment, alienating process Documentation(sex marker on state ID and birth certificates, SSN, etc)

Health Issues Affecting Trans Youth Access to healthcare Insurance Treatment by providers Risk Behaviors Street hormones Self surgery Pumping parties Survival sex work Poverty/Violence

Sex Segregated Areas Bathrooms Locker rooms Residential facilities Homeless shelters Jails/prison Rehab/mental health

Robert Eads Eads, a transgender man diagnosed with ovarian cancer, was turned down for treatment by two dozen doctors out of fear that treating such a patient would hurt their reputation. By the time Eads received treatment, the cancer was too advanced to save his life.

Best Practices “People of diverse gender expression should be afforded the same respect and rights as those whose gender identity and expression conform to societal expectations” American Psychological Association

Gender Identity Disorder and the DSM The core symptom of gender identity disorders is gender dysphoria, literally being uncomfortable with one's assigned gender. This feeling is usually reported as "having always been there" since childhood, although in some cases, it appears in adolescence or adulthood, and has been reported by some as intensifying over time. Since many cultures strongly disapprove of cross-gender behavior, it often results in significant problems for affected persons and those in close relationships with them. In many cases, discomfort is also reported as stemming from the feeling that one's body is "wrong" or meant to be different.

Gender Identity Disorder The current edition of the Diagnostic and Statistical Manual of Mental Disorders has five criteria that must be met before a diagnosis of gender identity disorder (302.85) can be given: There must be evidence of a strong and persistent cross-gender identification. This cross-gender identification must not merely be a desire for any perceived cultural advantages of being the other sex. There must also be evidence of persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender role of that sex. The individual must not have a concurrent physical intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia ). There must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Controversy Many transgender people do not regard their cross-gender feelings and behaviors as a disorder. Some trans people object on the grounds that there may be a physical cause, as suggested by recent studies about the brains of transsexual people. Many of them also point out that the treatment for this disorder consists primarily of physical modifications to bring the body into harmony with one's perception of mental (psychological, emotional) gender identity, rather than vice versa In order to access “treatment”—meaning hormones and, perhaps, surgery—you first have to be diagnosed. But calling trans people sick creates the same stigma gay/lesbian/bisexual people faced for decades.

WPATH Standards of Care The World Professional Association for Transgender Health (WPATH, formerly HBIGDA) Standards of Care (Version 6 from 2001) are considered by some as definitive treatment guidelines for providers.

Health Law Standard Developed in the early 1990s, the Health Law Standard (HLS) takes an entirely different approach from the medical-model paradigm of the original SOC. Informed consent approach, and is written in the form of a contract between client, doctor, and legal spouse. Clients sign the HLS, indicating they understand and take full responsibility for all risks inherent in the transition process. Once they have signed the HLS, they may access hormones and any surgical procedures related to transition, bypassing the therapeutic process altogether if they so choose.

Others guidelines outlined in Gianna Israel and Donald Tarver's classic 1997 book "Transgender Care". Several LGBT health clinics in the United States (e.g. Tom Waddell in San Francisco, Callen Lorde in New York City, Mazzoni in Philadelphia) have developed “protocols” for transgender hormone therapy following a “harm reduction” model which is coming to be embraced by increasing numbers of providers. In their 2005 book Medical Therapy and Hormone Maintenance for Transgender Men , Dr. Nick Gorton et al suggest a flexible approach based in harm reduction, “Willingness to provide hormonal therapy based on assessment of individual patients needs, history and situation with an overriding goal of achieving the best outcome for patients rather than rigidly adhering to arbitrary rules has been successful.”

LGBT Health Disparities At the most fundamental level, their general health issues are similar to those of all people. In terms of physiology and pharmacology, there is no evidence to date that suggests that biology differs by sexual orientation. There is evidence to suggest that there are certain health behaviors and health conditions that may be more prevalent among LGBT which the pharmacist may be more likely to encounter in this population

LGBT Health Disparities Cont. Alcohol Tobacco Mental Health

Trans Health Disparities Gynecological/Urological care Female-to-male transgender persons may retain female body parts and continue to produce female sex hormones which may interfere with exogenous testosterone or other medications. Male-to-female persons who have had sex confirmation surgery will still retain the prostate gland, and this may be overlooked during physical exams. Female-bodied FTMs often resist gynecological care because of body dysphoria and the discomfort of being male and entering a space dedicated to female care. Both FTMs and MTFs may have difficulty finding health care providers who are knowledgeable and sensitive to their unique issues and bodies, thus transgender people may be more likely to have undiagnosed conditions, or chronic conditions that are not fully treated.

Trans Health Disparities Continued HIV/AIDS HIV infection reported in MTF’s and men who have sex with men (MSM), though most government reporting agencies have not distinguished between the two populations. Recent systematic review of the literature found 29 studies with HIV+ rates ranging from zero to 68%, and reported that the rate of new infections was higher for MTFs than other groups. Rates of HIV infection among FTMs were reported as much lower (0% to 3%), but these figures represented only five studies. Other studies have reported that the rate of risky sexual behaviors by FTMs may be as high or higher than those of MTFs and that FTMs are less likely to get tested for the virus.

Role of Pharmacists when working with LGBT Clients The American College of Clinical Pharmacy, the American Pharmacists Association and the American Association of Colleges of Pharmacy have all recognized the importance of cultural competence. Cultural competency as it pertains to lesbian, bisexual or transgender populations requires awareness of population-specific issues and concerns, corresponding sensitivity to these issues and ultimately, the provision of services that evince such awareness and sensitivity. Awareness might mean remaining cognizant that not all people are heterosexual and that some women identify as lesbian or bisexual or transgender, regardless of appearance, age, race or geographic location. For instance, while large cities may have highly visible lesbian and gay communities, in reality, sexual minority women and transgender persons reside in large and small, urban and rural communities all over the United States. Data from the 2000 census showed that there are same-sex couples living in 99% of counties in the United States.

Pharmacists Role Cont. Sensitivity to language Transgender persons often struggle with others accepting their self-identified gender as legitimate—a struggle that pervades both personal and professional interactions. Pronoun usage, preferred name usage. Confidentiality must be strictly adhered to, as not all lesbian, gay bisexual, or transgender clients are open about their identities, and carelessness could bring about harm. Keep records secure from those who do not need personal information, and respect the needs of clients for privacy and confidentiality. Do not assume someone is heterosexual or assume someone is LGBT based on stereotypes. Become familiar with population-specific resources. Advocate for inclusive policies, work to change policies and procedures that are discriminatory, or create guidelines for the provision of culturally competent care, and/or educating staff and coworkers.

Solutions: Before the patient/client encounter Marketing materials, brochures, ways services are introduced. Are they representative of the diversity of the populations within the service area? Will trans people feel like the advertised facility is a comfortable place for them? How is this communicated? What is the current reputation in Trans community? Is there a need to address past negative experiences?

Creating an Affirming Environment: Display health info, magazines, posters, and other decorations that reflect the faces and interests of clients served. Staff should also be representative of clients served. Consider posting a written non-discrimination policy that gender identity and gender expression.

Inclusive Paperwork Goes beyond “Male” or “Female” Offers a place for clients to include preferred name not just legal name. Takes into account discrepancies in legal documentation driver’s license (name and gender marker) Birth Certificate & Social Security Card Insurance Card

Culturally Competent Approach: Is client centered Uses client’s own language Non-judgmental No assumptions Open ended questions Begins with less threatening questions It’s okay to not know!

If a Trans person comes out to you, DO: Remember that gender identity or gender expression is just one dimension of your client. Be yourself. Recognize your limitations. Remember that the person may be nervous or afraid. Use the vocabulary they use.

Do your homework: find out more about gender identity & local resources. Remember that it doesn’t take a transgender therapist to help a transgender client. If the client seems nervous, you can assure him or her that the information is confidential. Remember that you have an obligation to respect the person’s right to privacy and confidentiality. If A Trans Person Comes Out to You (CONT)

Contracting for Change Identify two or more changes you are willing to make in how you provide services? What personal obstacles do you face? What professional obstacles do you face? How might these obstacles be overcome?

Affirmations LGBT Community Center Presentation Slides can be found at: www.slideshare.net/klarkin Knoll Larkin [email_address] 248-398-7105 (Main Line) 800-398-GAYS (Crisis Line) www.goaffirmations.org

WSU Pharm 2008 Presentation

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WSU Pharm 2008 Presentation