Providing safe, affirming and evidence based care for transgender persons: The basics

Providing Safe, Affirming
and Evidence-Based Care
for Transgender Persons:
The Basics
AUGUST 5, 2016

Today’s Objectives
As a result of participating in today’s presentation, you
will be able to:
§ Recall terms and definitions relevant to transgender
lives and culture;
§ List health disparities experienced by transgender
persons;
§ Identify best practices for providing clinical services to
transgender persons.
2
8/5/2016Infectious Disease Prevention and Health Services Bureau & Johns Hopkins Bloomberg School of Public Health

Today’s Agenda
 Words, Definitions, Language Usage
 Transgender Health Disparities
 Health Policy & Research Update
 Best Practice Tips
 Open Q & A
3

Words, Definitions, Language Use
Talking Trans
4

Sex, Gender, Sexual Orientation 5
SEX
(biological)
• CHROMOSOMES
• GENITALIA
• REPRODUCTIVE ORGANS
• SECONDARY SEX CHARACTERISTICS
GENDER
(psychosocial)
• IDENTITY: SELF-CONCEPT AS MALE /
FEMALE / OTHER
• EXPRESSION: COMMUNICATING YOUR
GENDER TO OTHERS
• ATTRIBUTION: WHAT OTHERS PERCEIVE
AND RESPOND TO
SEXUAL ORIENTATION
(biological &
psychosocial)
• EROTIC & EMOTIONAL ATTRACTION TO
OTHERS

Gender Words
 Transgender
 Describes a person whose gender identity and assigned sex at
birth do not correspond. Also used as an umbrella term to
include gender identities outside of male and female. Sometimes
abbreviated as trans.
 Gender non-conforming
 Describes a gender expression that differs from a given society’s
norms for males and females.
 Cisgender
 A person whose gender identity and assigned sex at birth
correspond (i.e., a person who is not transgender).
6

Binary Gender Model
5
Biological Sex: hormones,
genitalia, reproductive
organs, secondary sex
characteristics
Gender Identity:
“I am…”
Sexual Orientation:
erotic, emotional attraction
to others
MaleMale FemaleFemale
MasculineMasculine FeminineFeminine
WomenWomen MenMen
Gender Expression:
mannerisms, role, social
context
ManMan WomanWoman
*GENDERLINE*DONOTCROSS!

Impact of Gender Binary View
 Assumes, reinforces, and privileges
 Cisgender identity
 Heterosexual “norm”
 Assigns and distributes gender-exclusive roles,
mannerisms, clothing, relationships, and other social
capital
 Invalidates
 Identities and expressions that do not conform to societal
sex/gender expectations
 Equality of transgender individuals
6

Gender Continuum Model
7
Biological Sex: hormones,
genitalia, secondary sex
characteristics
Gender Identity: “I am …”
Sexual Orientation:
erotic, emotional
attraction to others
male female intersex
man bigender nongender
women men both neither other
Gender Expression:
mannerisms, role,
social context
masculine feminine androgynous neutral
woman
asexual

Gender Grammar
10
PROBLEM CORRECTION REASON
“transgendered”
(adjective)
transgender
Only adjectives that are derived from nouns
and/or verbs (unlike transgender) end in “ed”.
“transgendered”
(verb)
transition
Only verbs can have “ed” added onto the end of
the word to become a participle. Transgender is
an adjective, not a verb. One does not
transgender, they transition.
“a transgender”,
“transgenders”
a transgender
person,
transgender people
Transgender is not a noun. “Jake is a
transgender” is not only grammatically
incorrect, it can also be offensive.
“sex change”,
“sex reassignment
surgery”, “gender
reassignment
surgery”
gender affirming
surgery, genital
reconstruction
surgery, genital
reassignment
surgery
Surgery does not change one’s sex or gender,
only one’s genitalia.

Let’s Talk About Pronouns!
 Binary pronouns
 She, her, hers and he, him, his
 (Xena ate her food because she was hungry.)
 Common gender-neutral pronouns :
 They, them, theirs
 (Xena ate their food because they were hungry.)
 Ze, hir
 (Xena ate hir food because ze was hungry.)
 Just use my name!
 (Xena ate Xena's food because Xena was hungry)
11

Intentions vs. Impact 12

Misgendering
 Feels humiliating and disrespectful
 Damages your rapport
 Makes the person wonder if you are cruel or clueless
 Can “out” someone and make them emotionally or
physically unsafe
 Can contribute to someone being so uncomfortable they
do not get the care they need
13
Pronouns are aPronouns are a
Really BIG DEALReally BIG DEAL

HIV Disparities in
Transgender Populations
14

How many trans people are there?
Worldwide estimates
 25 millions people1
 Estimates range 0.1% - 3%
United States estimates
 1.4 million people
 0.6% of the population
Baltimore estimates
 1,250 people (Wisdom of the Crowd)
 912 (Service Multiplier Method)
1. Winter et al. The Lancet 2016;
2. Williams Institute 2016
15

Gender Affirmation
http://www.thelancet.com/series/transgender-health
16

Ascertaining Transgender Status
1. What is your current gender identity? (Check
and/or circle ALL that apply)
☐ Male
☐ Female
☐ Transgender Male/Trans man/FTM
☐ Transgender Female/Trans woman/MTF
☐ Genderqueer
☐ Additional category (please specify):
________________________________
☐ Decline to answer
2. What sex were you assigned at birth? (Check one)
☐ Male
☐ Female
• Not all under the “transgender umbrella” self-identify as
transgender
̶ Anatomy, sexual practices, and sexual identities ≠ gender identity
• Current best practice: ascertain identity via the 2-step method1
1. UCSF Center of Excellence for Transgender Health. 2016. Available at http://www.transhealth.ucsf.edu/trans?page=lib-data-collection.
2. Mulatu M, et al. 2015 NHPC, Atlanta GA, December 6-9, 2015. Abstract 1559.
17

New HIV Positive Tests among
Trans People, 2009-2011
18
 New HIV+ test results highest in
trans people
 2.4% among trans people
 0.9% cis males & 0.2% cis females
 Gender trajectory matters
 2.7% trans feminine
 0.5% trans masculine
 New HIV+ highest in trans women
of color
 54% African American
 30% Hispanic/Latina
 3-fold increase in new HIV+ tests
in trans women at 20 years
Habarta N, Wang G, Mulatu MS, et al. HIV testing by transgender status at centers for disease control and prevention-funded sites in
the United States, Puerto Rico, and us Virgin Islands, 2009–2011. Am J Public Health. 2015;105:1917–1925.

HIV Prevalence: Trans Masculine
 Systematic review (2012-2015)
 6 U.S. prevalence studies
 0.4% - 4.3% (n=1)
Poteat et al. JAIDS 2016
Transgender MSM risk from cisgender
male partners
“I took a certain
pleasure in
informing the
gender clinic that
even though their
program told me
that I could not
live like a gay
man, it looks like
I’m going to die
like one.”
— Lou Sullivan, gay
trans activist, 1951-
1991
19

 Global meta-analysis of laboratory-confirmed HIV
(2000-11)
 United States: 22% prevalence
 34-fold greater than the general population
 Systematic review and data synthesis (2012-2015)
 Highest: 40% among trans women of color
 Lowest: 4.5% in youth (16-24 years old)
 Incidence estimate: 2.9 per 100 person-
years
Baral et al. TLID 2013, Poteat et al. JAIDS 2016
Alexis Rivera, transgender activist
Died from HIV at age 34 (2012)
Trans women who have sex with men have the
highest HIV burden of any key population
HIV Prevalence: Trans Feminine
20

HIV Care and Viral Suppression 21
HRSA RSR data 2014

Baltimore Data: Trans Women
 Baltimore BESURE data (49 trans women)
 Cross-sectional anonymous behavioral surveillance survey
 Data collection: June 2004 – April 2005
 Designed as MSM study, wanted to be inclusive of trans
 Transgender women participated, questions not ideal
 Led to development of transgender supplement
 Baltimore Transgender Supplement (40 trans women)
 Data collected 2004-2005
 Locally sponsored supplement
 Included only transgender women
22

Baltimore Data: Trans Women
 HIV Prevalence
 Transwomen in NHBS (n=40): 42.5%
 Transwomen in supplement (n=21): 33.3%
 Unrecognized HIV infections
 Transwomen in NHBS (n=17): 64.7%
 Contextual Risks (Supplement)
 45% got hormones from a non-medical source
 45% self-injected hormones
NHBS 2004-2005, Baltimore EMA
23

Context Matters
Why such high HIV prevalence
among trans women? 24

Stigma and Discrimination
 US National Trans Discrimination Survey1
 63% of trans people surveyed experienced an
act of discrimination, including
 Lost job or eviction
 School bullying/harassment
 Physical or sexual assault
 Homelessness
 Lost relationship with partner or children
 Denial of medical service
 Incarceration
 23% experienced a catastrophic level of
discrimination, ie, were impacted by
 3 such events
1. Grant JM, et al. 2011. National Center for Transgender Equality and National Gay and Lesbian Task Force. Available at
http://www.thetaskforce.org/static_html/downloads/reports/reports/ntds_full.pdf.
2. Kellaway M, Brydum S. Advocate. Updated January 12, 2016. Available at http://www.Advocate.Com/transgender/2015/07/27/these-are-
trans-women-killed-so-far-us-2015.
21 documented trans
women were murdered
in the US in 20152
Image source: Advocate
25

Pervasive Violence
26

Trans Discrimination in Maryland
(n=132)
 Workplace Discrimination
 71% harassed on the job
 42% fired, not hired, or denied a promotion
 Discrimination at school
 81% harassed, 38% assaulted, 16% sexual violence
 Mistreatment in public spaces
 54% were verbally harassed or disrespected in a place
of public accommodation or service, including hotels,
restaurants, buses, airports and government
agencies.
 Hopelessness
 43% reported attempting suicide at some point in
their life -- More than 26 times the rate of the
general population of 1.6%
27
National Transgender Discrimination Survey, 2009

Trans Discrimination in Baltimore
(n=47), 2011
Problems getting a job 51%
Lost a job 40%
Denied or kicked out of housing 17%
Problems getting HIV prevention services 0%
Problems getting drug treatment services 2%
Problems getting health or medical services 23%
Every physically abused or beaten 26%
Ever verbally abused or harassed 77%
Ever sexually assaulted 27%
Ever arrested 17%
28

Stigma is a Barrier to Care-Seeking
 Delay getting health care due to
experiences of discrimination
 28% delayed care when ill or injured
 33% delayed or did not try to get preventive
care
 Anticipate discrimination in health care
 52% fear they will be refused care
 73% worry they will be treated differently
 89% feel that too few health care professionals
are adequately trained to provide appropriate
care for them
29
. Grant 2011, Lambda Legal 2010

Stigma is a Barrier to Care Provision
 Denial of medical care
 19% in a US survey of 6450
 27% in a US survey of 617
 Uninformed providers
 50% had to teach their medical provider
about transgender care
 Discrimination from a provider
 70% experienced some kind of
mistreatment, eg. providers
 Refused to touch them/excessive precautions
(15%)
 Blamed them for health status (20%)
 Used harsh/abusive language (21%)
 Were physically rough (8%)
30
Grant 2011, Lambda Legal 2010

Health Policy & Research Update
31

Changing Gender/Sex on Identity
Documents
32
Document Government
Level
Criteria
Birth certificate State Sworn statement from a healthcare practitioner stating you
have received treatment appropriate to change sex or have
been diagnosed with an intersex condition.
Driver’s License/ID
Card
State 3 letters: self, treating physician, treating psychotherapist
stating intention to undergo gender transition.
US Passport Federal A physician statement that validates that you have either
completed or are in process of treatment for gender
transition.
Social Security
Record
Federal • Full-validity, 10-year U.S. passport showing the new
gender;
• State-issued amended birth certificate showing the new
gender;
• Court order directing legal recognition of change of
gender; or
• Medical certification of appropriate clinical treatment for
gender transition in the form of an original letter from a
licensed physician.

LGBTQ Civil Rights - Maryland
 Maryland state law prohibits discrimination in employment,
housing, credit and lending, and public accommodations based
on sexual orientation or gender identity or expression.
 Anti-Discrimination Act of 2001 (Sexual Orientation)
 Fairness for All Marylanders Act, 2013 (Gender Identity and
Expression)
 Maryland public schools are prohibited from discriminating
against students based on sexual orientation or gender
identity/expression.
 They must also adhere to a statewide bullying and harassment
prevention policy that is inclusive of bias based on real or perceived
sexual orientation or gender identity/expression.
33

Reversing Decades of Health
Care Discrimination
From Maryland Insurance Administration, Bulletin 15-33, December 10, 2015
34
The formerly permissible exclusion which reads
“treatment leading to or in connection with
transsexualism, or sex changes or modifications,
including, but not limited to surgery,” which is
found on pages B49 and B50 of the 2017 benchmark
plan and originally permitted by COMAR
31.11.06.06B(32), is required to be deleted as
federal guidance has determined that this type of
exclusion is a discriminatory benefit design
prohibited by 45 CFR § 156.200(e).
Small Employer Essential Health Benefits, item 12, page 6.

HHS Final Rule on Sec. 1557
 Issued May 13, 2016 : Effective July 18, 2016
 Provides protections based on race, color, national origin, sex,
age, and disability. Protections for LGBT people come under
the category of sex discrimination, which includes gender
identity and sex stereotyping.
 Applies to all federally-supported health programs and most
health insurance and coverage, including Medicaid, Medicare,
AIDS Drug Assistance Programs (ADAP), and individual
insurance plans purchased through a state or federal health
exchange.
 Beneficiaries cannot “be excluded for participation in, be
denied the benefits of, or otherwise be subjected to
discrimination under any health program or activity to which
[the rule] applies.”
35
Affordable Care Act Fact Sheet: What the Section 1557 regulations banning
discrimination based on gender identity mean for you. Transgender Law Center, 2016

New Rules: Collection of SOGI
Data
 ACA contains language supporting the collection of
sexual orientation and gender identity data, to further
research to end health disparities (Sec. 4302).
 HHS issued new rules on Oct. 6, 2015 that require
collection of SOGI data in clinical settings in EHRs
(effective 2018).
 CMS and ONC-IT requires EHRs to allow users to record,
change, and access structured data on sexual
orientation and gender identity.
36
to a job near you…

Research Updates
37

8/5/2016Infectious Disease Prevention and Health Services Bureau & Johns Hopkins Bloomberg School of Public Health 38

STROBE Study: Supporting Transgender
Research and Opportunity in the
Baltimore Environment
Funded by the Johns Hopkins Center for AIDS Research
http://www.strobebaltimore.com
39

Baltimore Trans Community
Needs Assessment
40
www.baltimore
btcstudy.com
Funded by the
Johns Hopkins
Urban Health
Institute

Count Me In, Maryland!
41
Opened Sept. 2015
109 Responses with Data

Transgender-Inclusive HIV
Surveillance
 Voluntary “Change Your Record”
 Secured online site
 Form allows changes to multiple data variables
 Separate collection of Sex at Birth and Current Gender
 Paper version will also be available
 Local health departments
 HIV Clinics
 Targeted Health Provider Re-Report
 Request update of Sex at Birth and Current Gender for HIV caseload
 Educational component over summer (videos, webinars)
 Community
 Health providers
 Implementation
 Pilot late 2016
 Statewide roll-out early spring 2017
42

Best Practice Tips
For serving lgbtq clients
43

Ally Skills
 Deep listening
 Embracing being “wrong”
 Removing barriers
 Educating other cisgender people
 Interrupting homophobia/transphobia
 Patient advocacy
 Getting out of the way
44

Trans-Affirming Clinic
Environments
 Avoid Ma’am, Sir, Mr/Mrs/Ms
 Use gender neutral forms of address
 Use 2-step process to determine gender identity at
intake
45
SHOW EXAMPLESHOW EXAMPLE

Example: Two-Step Gender
Question
46
1. What is your current gender identity? (Check and/or circle ALL that apply)
☐ Male
☐ Female
☐ Transgender Male/Transman/FTM
☐ Transgender Female/Transwoman/MTF
☐ Genderqueer
☐ Additional category (please specify): ________________________________
2. What sex were you assigned at birth? (Check one)
☐ Male
☐ Female
UCSF Center of Excellence for Transgender Health. 2016. Available at
http://www.transhealth.ucsf.edu/trans?page=lib-data-collection.

Environments
 Do not assume gender identity or sexual orientation
 How do I know which pronoun to use
(eg, he, she, they)?
 Ask politely
 What is the presenting gender?
 Echo the language you hear
 Make an effort to use the correct pronoun consistently
 Anatomical terms – what words to use
47

Environments
 Use preferred pronouns and name
 Ask for patient preference, in private, if unsure
 Include preferred name on chart and train staff
 Defer unnecessary questions and exams
 Build rapport before performing genital exams
 Avoid satisfying your curiosity
 Conduct sensitive genital exams only when
necessary
 Always explain the purpose of the exam
 Use gender neutral terms
 Ask patients what words they prefer
 Acknowledge barriers and offer solutions
 Stress of stigma and discrimination
 Limitations of medical knowledge
 Offer to find out and get back to patient
48

Improving the HIV Continuum for Trans
Women
 Barriers to Engagement & Retention in HIV Care
 Avoidance due to stigma and past negative experiences
 Prioritization of hormone therapy
 Concerns about interactions between HIV meds and hormones
 Facilitators of Engagement & Retention in Care
 Providers knowledgeable about trans-related medical issues
 Able to provide and integrate hormone therapy and HIV care
 All staff respectful and sensitive to trans issues (eg. IDs)
 Correlates of Adherence and Viral Load
 Less stress due to trans discrimination (adherence and VL)
 Adherence to hormone therapy (adherence)
Sevelius, Ann Behv Med, 2014; Sevelius, AIDS Care, 2014
49

Gender Affirmation and HIV
Care
Top 5 Health Concerns of HIV+ trans people,
in order
1. Gender-affirming and non-discriminatory care
2. Hormone therapy and side effects
3. Mental health care, including trauma
4. Personal care, eg. nutrition
5. Antiretroviral therapy and side effects
50
Deutsch 2015 (preliminary
self-report data presented
at NHPC); Positively Trans
Survey, n = 157
TW whose HIV primary care provider is also their hormone prescriber,
more likely to:
 Have an undetectable viral
 Have an HIV primary care visit in the previous 6 months

Transgender Response Team
If you share our vision of a Maryland where new HIV
infections are rare, and where transgender and
gender nonconforming children, adolescents, adults,
and their families, participate fully as equal citizens
in safe, supportive communities where culturally and
linguistically responsive services and supports are
available, accessible, and appropriate, then join us!

To find out how, contact:
Jean-Michel Brevelle
Sexual Minorities Program Manager
Prevention and Health Promotion Administration
Maryland Department of Health and Mental Hygiene
500 North Calvert Street, 5th Floor
Baltimore, Maryland 21202
(410) 767.5016 Office
jean-michel.brevelle@maryland.gov Email
51
https://sites.google.com/site/trtnetwork/

Transgender Action Group
52
 Coalition of transpeople, service
providers, non-profits, and
volunteers organized in Fall 2012,
meetings 2nd Thurs @ noon
 Outreach to trans sex workers
every 2nd and 4th Fridays, 12-4AM
 Provides
 Legal services
 Housing and employment counseling
 Safer sex materials and information
 Referrals for HIV testing and other
services
http://www.tagoutreach.net

8/5/2016Infectious Disease Prevention and Health Services Bureau & Johns Hopkins Bloomberg School of Public Health 53
Questions?What else did youWhat else did you
want to learn about?want to learn about?

Please fill
out and
turn in your
evaluations
Don’t
hesitate to
contact us
if you have
questions.
54
Tonia Poteat, PhD, PA-C, MPH
Assistant Professor
Department of Epidemiology
Johns Hopkins Bloomberg School of Public Health
tpoteat@jhu.edu
Jean-Michel Brevelle
Sexual Minorities Program Manager
Center for HIV/STI Integration & Capacity
Maryland Department of Health and Mental Hygiene
jean-michel.brevelle@maryland.gov

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