Transcript Slides C2 - Collaborative Family Healthcare Association

Session # C2
Addressing the Needs of Transgender &
Gender Non-Binary People in Primary Care
Julie M. Austen, PhD
Behavioral Health Provider
Piedmont Health Services
Carrboro, NC
Jessica Rubio, FNP
Piedmont Health Services
Carrboro, NC
CFHA 18th Annual Conference
October 13-15, 2016 ∙ Charlotte, NC U.S.A.
Faculty Disclosure
The presenters of this session currently do not have any
following relevant financial relationships (in any amount)
during the past 12 months.
Learning Assessment
A learning assessment is required for CE credit.
A question and answer period will be conducted
at the end of this presentation.
Learning Objectives
At the conclusion of this session, the participant will
be able to:
• Define terminology related to gender diverse people.
• Identify the physical and mental health care needs of gender diverse
patients Identify.
• Discuss opportunities and challenges for creating an inclusive
environment for transgender and gender non-binary people.
• Identify resources for best practices in gender diverse healthcare.
References
1. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., ... &
Monstrey, S. (2012). Standards of care for the health of transsexual, transgender, and gendernonconforming people, version 7.International Journal of Transgenderism, 13(4), 165-232.
2. Deutsch M. Guidelines For The Primary And Gender-Affirming Care Of Transgender And Gender
Nonbinary People. 2nd ed. University of California, San Francisco: The Center of Excellence for
Transgender Health (CoE) at the University of California – San Francisco; 2016.
3. Erickson-Schroth, L. (Ed.). (2014). Trans bodies, trans selves: A resource for the transgender
community. Oxford University Press.
4. Grant, J. M., Mottet, L., Tanis, J. E., Harrison, J., Herman, J., & Keisling, M. (2011). Injustice at every
turn: A report of the national transgender discrimination survey. National Center for Transgender
Equality Reference
5. ACLU Taskforce: A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., ... & Kocet, M. (2013).
Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling Competencies for
counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals: Approved
by the ALGBTIC board on June 22, 2012. Journal of LGBT Issues in Counseling, 7(1), 2-43.
Jumping In: Terminology
Who are transgender & gender non-binary people?
General Terminology
Natal sex + gender are congruent = cisgender
Natal sex + gender are incongruent = transgender, gender non-binary,
gender creative, gender diverse



There is no one narrative
Gender can be fluid
Gender identity and gender
expression do not need to be
congruent, ever.
Time, 2016
Mythbusting 101:
Providing culturally sensitive care is hard!
“So are you a man or a woman?”
“You mean you’re a transgender woman?”
“But have you had the surgery?”
“Pronouns don’t really matter”
“They/them is clunky/hard/weird”
“What if I mess it up?”
Social Concerns Related to Gender Identity
Results from National Transgender Discrimination Survey (2011):
57% family rejection
53% verbally harassed or disrespected in a place of public accommodation
(e.g., hotel, restaurant, bus, etc)
40% harassed when presenting ID
 26% lost a job
19% refused a home or apartment
 4x more likely to live on < $10,000 annually compared to average American
 2x the rate of unemployment compared to U.S. rate; higher for Transwomen
 Murder is second leading cause of death, surpassed only by suicide
Healthcare Accessibility and Discrimination
Transgender patients are more likely to postpone primary or emergency medical care due to
fear of discrimination (28% reported) and inability to afford (48% reported).




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Report being refused care: 19%
Report harassment and violence in medical settings: 28%
Report lack of provider knowledge: 50%
Reported being refused care altogether: 19%
Likelihood of discrimination increased when medical
providers were aware of TGGNB status
What do people need?
Medical Risk and Needs
Behavioral Health Risks and Needs
Opportunities for integrated approaches
Physical Health
Risks
Transwomen

56.3% of African-American male-to-female transgender people in the U.S. are HIV+

Transwomen may be at increased risk for osteoporosis, myocardial infarction, stroke (Radix & Deutch, 2015)

Increased risks and complications from testicular “tucking” and street use of silicone

Increase in prostate cancer particularly for transwomen who started Estrogen after age 50
Transmen

Similar rate of breast cancer as natal/non-transgender women with decreased risk for those who have
undergone bilateral mastectomies, similar rates of cervical cancer.

Theoretical risk of endometrial hyperplasia or cancer
Mental Health
Risks
25% of participants report misuse of drugs and/or alcohol specifically to cope with discrimination related to
their gender identity or expression
Experience depression, PTSD, anxiety at higher rates than general population; also experience secondary
adjustment issues if/when transitioning
Complex interpersonal, social, and medical trauma with polytraumitization being characteristic
41% of transgender and gender-nonbinary people reported attempting suicide (1.6% in gen. population)
(dickey, 2015)
An example of the need for integrated care
56.3% of African-American transgender women in the U.S. are HIV+
Psychological
• Increase in risky sexual
behaviors (e.g. sex work,
limited condom/lube use)
• Increase in risky needle
use (substances,
hormones, and silicone)
• Increased use of
substances overall
Social
• Job discrimination
• Housing discrimination
• Limited family/social
support
• Medical discrimination
• Limited affordability of
medications
Opportunities for Affirming
Integrated Primary Care
Organizational
Culture
Change
Systems,
Logistics &
Flow
Direct Patient
Care
Patient SelfAdvocacy
Organizational and Culture Change
•Administrative Champions
•Training at EVERY level
•Transgender fluency
•Trauma-informed care
•Sensitivity and culture
•Creating an inclusive physical and cultural environment
•Approving dedicated paid time to work on these changes for providers and other leaders
•Have information and handouts available for patients, providers
•Secure collaborations with other clinics and
community resources.
•Organize community outreach
Systems, Logistics, & Flow
Change to EMR
-SOGI Data collection
-Change to patient information banner
Change to patient registration
-Currently piloting wipe off boards at registration
-Still working through challenges about patient disclosure to
medical providers when not provided at registration
Team-Based Direct Patient Care
.
• Chart review
• Notes about patient’s
desire for genderaffirming primary care
• Screening and testing
• Reminders to all staff
Previsit
Planning
Physical Health
Needs
• CDSS based on body
parts and behavior
• Typical Health Care
• Gender Care Needs?
• Universal Screening
• PCBH
• Gender Care Needs?
• Trauma informed care
• Assessing readiness
and obtaining informed
consent
Behavioral
Health Needs
Family and
System Needs
• Children/Adolescents
• Family planning
• Referral to surgery or
endocrine or other
• Specialty Mental Health
• Community Resources
Opportunities for Impact in Primary Care:
Preventive Medicine
Medical
General Rule: If you have it, check it
 Remember to order routine cancer screening according to
existing anatomy, not gender identity:
Breast tissue, ovaries, uterus and cervix for affirmed men
 AND diagnostic testing if symptomatic for Prostate issues in
transgender women: help people remember that they have one
 All of this starts with a good sexual history
Behavioral health screening/assessments
 General behavioral health: depression, anxiety,
trauma, and issues perhaps not related to gender.
PTSD,
Opportunities
for Impact in
Primary Care:
Gender
Affirming Care
Medical
Behavioral
• Hormone
therapy/puberty
blocking
• Exploration of
gender identity
What is gender affirming care?
• Possible postoperative issues
“ Care provided with the intent to
respect gender as identified by
the patient, no matter how fluid
or static, provided without
judgement and with cultural
sensitivity and competence”
• Patient advocacy
for any concerns
• Coming out and
social transition
• Assessing
readiness for
treatment obtaining
informed consent
Opportunities for Impact in Primary Care:
Family Planning
Transgender and gender non-binary people have the same breadth of desires
for family planning as anyone else
Conversation both as part of informed consent for medical affirmation treatment
and as part of regular medical care
• Banking sperm/eggs
• Discussing unknown effects on future fertility of hormone use in your
informed consent process
• Discussing other ways to build a family, e.g., adoption
Special Populations
Youth
•
•
•
•
•
Require a special sensitivity to developmental stages
May require “Rainbow Charts” or special privacies
Required more counseling on social transition and consent
May be more fluid
Vocabulary is MUCH more dynamic
SAGE/Transgender and Gender Non-binary Elders
• Often re-closeted as they enter nursing facilities
• More isolation from their families
• Endure the most medical discrimination, age wise
Homeless, imprisoned, or other severely marginalized people
• More likely to be turned away from shelters
• More likely to be sexually assaulted
• Less likely to have medical needs addressed even when they don’t pertain to gender identity
Hey! I’ve got a problem!
Lets put our heads together to resolve common issues that
transgender people face.
Form groups with your peers of like-colored cards.
Take 10 minutes to explore options for solutions from multiple
perspectives.
Designate reporters to share three potential solutions with
everyone
Clinical Pearls
Gender, gender care, and affirming services are non-linear processes.
Be humble! Learn from mistakes and move on (at every level)!
Be upfront with patients about where your organization is at in the process of
becoming affirming and inclusive.
Diagnoses and Medicaid rules are changing.
You are not alone and you don’t have to reinvent the wheel!
-Start from where you are and reach out to the vast network of supporter.
Questions?
Feel free to contact us with follow up questions!
Julie Austen
[email protected]
Jessica Rubio
[email protected]
Session Evaluation
Please complete and return the evaluation form
before leaving this session.
Thank you!