clinical issues in transgender populations

Addressing Clinical Issues inAddressing Clinical Issues in Transgender Populations: : F t t C id

JoAnne Keatley, Director

Factors to Consider JoAnne Keatley, Director

CoE for Transgender Health

Copyright 2012. Center of Excellence for Transgender Health. All Rights Reserved.

1. Understand terms and concepts regarding transgender people’s lives and experiences.

2. Identify distinctions between gender identity and sexual orientation and importance ofand sexual orientation and importance of these differences in providing care for transgender patients.transgender patients.

3. Increase participant understanding of issues relative to the provision of quality healthcare services for transgender people.

Copyright 2012. Center of Excellence for Transgender

Health. All Rights Reserved.

Our mission is to increase access to comprehensive, effective, and affirming healthcare services for trans and gender varianthealthcare services for trans and gender-variant communities.


We include community perspectives by actively engaging a national advisory body (NAB) of 12 transgender identified leaders from throughout the countrythe country.


A working definition of A working definition of ggTransgender:Transgender:

“Trans” can be shorthand for “Trans” can be shorthand for transgender and transsexualtransgender and transsexualtransgender and transsexual.transgender and transsexual.


Inaccurate national estimates due to poor data collection methods

Regional studies have relied almost exclusively on convenience samples (i.e. participants recruited convenience samples (i.e. participants recruited from medical and social service agencies, bars, and streets)

Studies have focused primarily on trans women; very little information is available on trans men very little information is available on trans men but we have not seen high incidence in public health settings


The average prevalence for 1 i 4transwomen is 28%

◦ (lab-confirmed) 12% (self report)

1 in 4

12% (self report)

African American transwomen have the highest prevalence (56%), compared to other racial/ethnic gro psgroups.


(Herbst, et.al, 2008; Nemoto, Operario, Keatley, et.al,2004)

Highest newly identified confirmed HIV positivity f d t d i was found among transgender persons in

2008 and 2009 (2.4% and 2.6%, respectively) p y)

Black/African Americans (4.5% and 4.4%, ti l )respectively)

Hispanics (2.7% and 2.5%, respectively)Hispanics (2.7% and 2.5%, respectively)

(Centers for Disease Control and Prevention, 2011)


Highest newly Identified confirmed HIV positivity Highest newly Identified

confirmed HIV

2008 2009 2008 2009 2008 2009 2008 2009

Male TransgenderFemale

confirmed HIV positivity by race

2008 2009 2008 2009 2008 2009 2008 2009Black/African Americans 0.9% 0.8% 1.2% 1.1% 0.5% 0.5% 4.5% 4.4%Hispanics 0.7% 0.6% 1.1% 1.0% 0.2% 0.2% 2.7% 2.5%White 0.5% 0.5% 0.8% 0.7% 0.2% 0.2% 0.6% 0.7%American Indian or Alaska Native 0.4% 0.4% 0.6% 0.7% 0.2% 0.1% 2.4% 0.0%

(Centers for Disease Control and Prevention, 2011)


The Center of Excellence for Transgender gHealth (www.transhealth.ucsf.edu) makes the following recommendation for trans-inclusive d ll idata collection:

◦ What is your current gender identity?◦ What is your current gender identity?

◦ What was your assigned sex at birth?


Assigned Sex N % Two-Step Model N %Assigned Sex N %

Male 151,654 53.48

Female 131 855 46 49

Two Step Model N %Male Male 150,268 52.99Male Female 415 0.15

lFemale 131,855 46.49

Decline 88 0.03

Total 283,597 100.00

Male MTF 931 0.33Male Declined 15 0.01Male Other 6 0.00,Female Female 131,229 46.27Female Male 387 0.14Female FTM 184 0 06

Current Gender N %l Female FTM 184 0.06

Female Declined 17 0.01Female Other 3 0.00D li d M l 1 0 01

Male 150,672 53.13Female 131,670 46.43Trans - MTF 967 0.34

Declined Male 17 0.01Declined Female 26 0.01Declined MTF 1 0.00

Trans – FTM 203 0.07Decline 76 0.03Other 9 0 00

Other 98 0.03Total 283,597 100.0

0

Other 9 0.00

Total 283,597 100.00

Substance use among Substance use among transgender peopletransgender peopleIDU has been reported in a number of studies ranging from 2-40%, p g g ,among them:

•Chicago, Kenagy & Bostwick, 200512%

•Atlanta, Boles & Elifson, 199413%

•Philadelphia, Kenagy, 200215%

•Boston, CCA, 200620%

S F i N l 200623% •San Francisco, Nemoto et al, 200623% •MTFs, 18% in FTMs, San Francisco, Clements

(SFDPH report)34 %


•Houston, Risser et al, 200540%

Methamphetamine lifetime use Methamphetamine lifetime use • Philadelphia, Carson, 20092 %• NYC Murrill et al (House/Ball Study Report) 20034 % • NYC, Murrill et al., (House/Ball Study Report), 20034 %• Chicago, Garofalo (MTF youth), 20064 %• Los Angeles, Reback & Lombardi, 19995 %• San Diego, Zians, 20065 %• (14% in MTFs, 20% in FTMs) Virginia, Xavier et al, 200716 %• Houston Risser et al 200528 % • Houston, Risser et al, 200528 %• by injection, 30% by non-injection San Francisco, Rose et al, 200125 %


• ever used, 28% in past 6 months, Los Angeles, Reback et al, 200146 %

(Clements-Nolle et. al, 2006; Garofalo et. al, 2006; Nemoto et. al, 2006)


Incarceration rates among trans women: 37 to 65%In an LA study, 15% reported unprotected sex y, p pduring incarceration.


• Coping• Mental Health

d

• Housing & Job DiscriminationI t li d • Unprotected Sex

• 1, 3, 4, 6• Internalized• Self Esteem

T DTrans-phobia

Drug Use

PrisonS Prison & Jail37- 65%

Sex Work

• Sex-segregated facilities

• Unprotected Sex1 2 7 8

• Gender Affirmation

• Unprotected Sex4 5 6 • 1, 2, 7, 8• 4, 5, 6


A study of four US cities found that transgender women living with HIV were less likely to women living with HIV were less likely to receive highly active antiretroviral therapy (HAART) than a non-transgender control group (59% 82% < 001)(59% vs. 82%, p < .001).

(Melendez et al, 2005)


Consistently between 2004-08, transgender people represented at least 2% of the newly diagnosed AIDS cases (SFDPH 2008)diagnosed AIDS cases (SFDPH, 2008)


Survival curves for persons diagnosed persons diagnosed with AIDS between 1996-2008 show extreme drop off for Transgender people (SFDPH, people (SFDPH, 2008).


Although between 2004-08, transgender people represented 2% of the newly diagnosed AIDS cases in 2008 they represented 7% of the total cases, in 2008 they represented 7% of the total deaths (SFDPH, 2008).


Adequate fundingCommunity involvement in programHire trans staff at all levelsAssurance of privacy


Transience of clientsVaried needs of a diverse communityAvoidance of services due to past experiences of stigma and discriminationHormone use is not optional


First ask yourself…Is my question necessary k for am I just asking it for my own curiosity

and thus not appropriate?Example: Are you going to have surgery?

Some important guidelines to keep in mind so that you ask questions that areso that you ask questions that are appropriate to your work:

1) What do I know?2) What do I need to know?2) What do I need to know?3) How do I ask in a sensitive way?


Don’t sweat it. Politely ask!

Remember individual trans people:◦ May have a preference of he or she

M h f d i ’ k h h◦ May not have a preference and it’s okay to use he or she◦ May prefer you use a gender neutral pronoun such as “ze”◦ May prefer you not use any pronoun at ally p y y p


DO’SDO’S

• Use proper pronouns

Get clinical supervision if you have issues or• Get clinical supervision if you have issues or feelings about working with trans individuals.

• Allow trans clients to continue the use of hormones**** Facilitate trans clients using “street” hormones to obtain competent medical carehormones to obtain competent medical care

• Take required training on trans issues. Copyright 2012. Center of Excellence for Transgender Health. All Rights Reserved.


DO’SDO’S

• Able to use bathrooms and showers based on gender self-identities and gender roles.

• Create and maintain a safe environment for all trans clients.

• Post a nondiscrimination policy that explicitly includes sexual orientation and p ygender identity.

(A Provider’s Introduction to Substance Abuse for LGBT Individuals Module 5 -12 Clinician’s Guide)


TREATMENTTREATMENT DO'SDO'S ANDAND DON'TSDON'TSDON’TSDON’TS

• Project transphobia onto the trans clientj p

• Make the trans client choose between hormones or treatment and recovery.

• Make the trans client educate staff.

A t• Assume trans women or men are gay.

• Make trans individuals live in inappropriate gender segregated facilitiesgender segregated facilities.

• Allow staff members or clients to make transphobic comments.transphobic comments.

(A Provider’s Introduction to Substance Abuse for LGBT Individuals Module 5 -12 Clinician’s Guide)


Family acceptanceSocial supportHealthy self esteemHealthy self-esteemAccess to competent health careAccess to gender confirming hormone therapy Access to gender confirming hormone therapy and other gender-related careCommunity engagement


Race & Ethnicity:Race & Ethnicity:One Size Does Not Fit All

Advocate for Structural & Systemic Changes

Use Multidisciplinary ApproachesGround Your

W k i th Ground Your W k i th

Developing and

Work in the CommunityWork in the Community

Developing and Supporting Staff

Increase Access

Get the Facts: Assess, Evaluate & Enhance

CommunityCommunity

Access to Health Care

Looking in All the Right Places: Recruitment and Retention

34Copyright 2012. Center of Excellence for Transgender


JoAnne G Keatley, MSWJ y,Email: [email protected]

415-597-4960

www.transhealth.ucsf.eduwww.transhealth.ucsf.edu“Like" us on Facebook!

www facebook com/transhealthwww.facebook.com/transhealthCopyright 2012. Center of Excellence for Transgender


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