Many thanks to local expert, Dr. Arunima Kohli, for her excellent Grand Rounds this week on Gender Affirming Care: Beyond Pronouns and Hormones.
A recording of her presentation can be found HERE.
My notes:
Transgender Awareness Week, observed November 13th to November 19th, is a one-week celebration leading up to the Transgender Day of Remembrance (TDoR), which memorializes victims of transphobic violence. In Santa Rosa, TDoR will be honored during an event at Brew Coffee House Saturday 11/20/21 5pm. More information click HERE. All are welcome.
Of note, in talking about gender affirming care it is important to acknowledge who we are and what our biases are.
No lecture on gender affirming care is complete without going over terminology and definitely not a presentation without the Gender Unicorn. Take a look at the unicorn and try to identify where you would place yourself.
- gender is a construct AND a spectrum
- gender identity is different than gender expression, physical and emotional attraction are also separate (sexual orientation)
In addition to the gender unicorn, Dr. Kohli likes to think of gender as a multi-dimensional ball-- everybody is kind of fluid-- we are all constantly figuring out our identity, especially when we are younger. This is not isolated to people who identify as trans.
Language keeps evolving in this field. Very quickly.
- gender diversity and gender expansiveness: umbrella terms that capture the full spectrum (including gender binary people)
- transgender: person whose gender does not correspond to sex assigned at birth based on traditional expectations
- cisgender: person whose gender does correspond to sex assigned at birth
- non-binary (enby): person whose gender does not fit into typical binary norms, based on traditional expectations
- intersex: people with unique variations in reproductive/sexual anatomy, may or may not need to talk about hormones, pronouns, etc
Terms to avoid: transgendered, transgenderism, trans-sexual, biologically/genetically/born as, gender reconstruction surgery. Instead use assignation, designation, and socialization.
What is gender affirming care? "Health care that holistically attends to transgenders people physical, mental and social needs and well being while respectfully affirming their gender identity."
- social: pronouns, clothing, gender expression, community support
- legal: name change, sex designation, gender marker or legal documents
- medical: gender affirming HRT, surgery, laser tx, voice therapy, pelvic floor therapy
- mental: medication management, mental health service
Professional Guidelines for gender affirming care
- World Professional Association Transgender Healthcare Standards of Care (v7, 2013, v8 may be coming soon)
- UCSF Guidelines for Primary and Gender Affirming Care of Transgender and Gender non-binary People (good for hormone doses, lab monitoring, etc)
- Endocrine Society: Endocrine Treatment of Gender Dysphoric/Gender Incongruent People: Clinical Practice Guidelines (2017)
Health disparities in the gender expansive population are marked
- 1/2 of trans people had to teach their healthcare provider about trans care
- 20% of people don't access health care for fear of mistreatment
- 62% (or more) of gender expansive people suffer depression
- High rates smoking and alcohol
- Higher rates of HIV infection, particularly in black trans women population
Data specific to teens (CDC data)
- Nearly 2% of high schoolers identify as transgender (number increasing)
- 27% of trans-identified high schoolers feel unsafe at school
- 35% of trans-identified high schoolers report being bullied at school
- 35% of trans teenagers attempt suicide
- Higher rates of early sex, multiple partners, having sex without contraception or STD prevention
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| cdc mmwr 2017 |
It is INCREDIBLY effective to have supportive parents for trans kids. Check out this graphic to understand why! Markedly improved rates of depression, suicide attempts. . .
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| https://transstudent.org/graphics/youthsupport/ |
Gender affirming care is life saving care
- Well documented improved mental health in adults and children with gender affirming care (including psychotherapy, gender affirming surgery, hormones, even proper use of pronouns)
- decreased depression, anxiety, SI
- Decreased rates of suicide attempts by 40% if there is ANY gender affirming person in a trans person's life
- increased engagement with health care system
- improved school performance, improved social skills
. . .But affirmation isn't everything.
Discrimination
- 65% of trans-people experience discrimination (DMV, nursing homes, gym/health club)
- 59% of trans people avoid using public restroom because of fear of discrimination, 1/3 limit food and drink so they can avoid bathrooms
- 3x higher unemployment rate, worse in BIPOC
- 2/3 of states coverage cover gender affirming hormone therapy
- Few states have Medicaid protections for transgender people
- Being undocumented is additional risk factor; high rates of anti-trans violence in Latin America, have
- Higher rates of incarceration, higher rates of assaults in prisons, many denied medically necessary gender affirming healthcare while incarcerated
Safety is a real issue
- Sexual assault, sexual violence
- 2021
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| https://transrespect.org/en/tmm-update-tdor-2021/ |
- Advocate for change in health systems
- EMR
- Ask EVERY one who comes into your system SOGI (sexual orientation, gender identity), not just those who you assume are different
- organ inventories (so you don't assume gender tells you screening needs)
- formulary
- education and trainings for staff
- hiring people who are transgender
- Do the work before you signal you are safe!
- Learn the language and vocabulary
- Learn insurance rules: sometimes insurance will initially decline but they are not allowed
- Think beyond your own panel
- specialists, other providers--> improve access
- In CA, all medically necessary care MUST be covered for transition (this includes everything in WPATH of what is medical necessity and what procedures, e.g. laser, body contouring)
- Know your State and National Laws, Legal rights about restroom, Sports participation, etc
- Know local referral providers (e.g. surgeons for gender affirming surgeries)
- Advocacy with schools and workplaces
Additional resources
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