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Working with Transgender & Gender Diverse Individuals and Communities in Field Education

1/20/2023

Dana M. Prince (she/her/hers), Ph.D., M.P.H., Associate Professor

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Land Acknowledgement

I acknowledge that Cuyahoga County is located on the ancestral, traditional, and contemporary lands of the Lenape (Delaware), Shawnee, Wyandot Miami, Ottawa, Potawatomi, and other Great Lakes tribes (Chippewa, Kickapoo, Wea, Pinkashaw, and Kaskaskia).

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I acknowledge the thousands of Native Americans who now call Northeast Ohio home.

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Case Western Reserve University and the greater Cleveland area occupy land taken from 1100 chiefs and warriors who were coerced into signing the Treaty of Greenville in 1795. Incredible violence was enacted on tribes during this time, with over 100 villages burned and destroyed.

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Who Am I?

• PhD from University of Washington, focus on marginalized youth development, substance abuse, and future orientation
• Postdoctoral Fellow Yale School of Medicine, focus on foster care, kinship and transition-age youth wellbeing and mental health
• Associate Professor at Case, Mandel School, community-engaged research on LGBTQ+ youth involved in foster care, juvenile court, suicide prevention
• Decades as educator, working in middle school, high school, and university focused on empowerment and social justice
• White, cisgender woman, middle class, English speaking, Jewish, neurodivergent, chronically ill (COVID-19 long hauler), queer, fat, femme with U.S. citizenship privilege
• Social Justice and Youth Advocate
• Bridge Builder
• Institutional Boundary Pusher
• Mama, partner, cross-stitcher, gardener, animal lover

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Guidelines

• Why are we here?
• Everyone here wants the best care for their clients
• Assume best intent

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• Questions are welcome and encouraged
• Chat box, raise hand, send to me later

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• Open and honest communication
• It is ok not to know!

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• Different backgrounds 🡪 Different reactions

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• Self Care and disability welcoming space

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• There are LGBTQIA2S+ people here right now, working in your agencies, and among the clients you serve – questions to learn are welcome, judgement of this population is not

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Breakout Group Activity

• Sets of 2-3
• Think of the last person you share a meal with/went on a date with/hung out with
• Tell your group about this experience…WITHOUT any gendered language
• This means no boy/girl/man/woman, no he/she, not pretty/handsome, no feminine/masculine, etc.
• Come back to the main room!

Debrief

• How was that experience for you?
• What was challenging? What was easy?
• Why do you think we started here?

Alphabet Soup: �GLBT, LGBTQ, LGBTQIA2S+, LGBTIQQAA,

• We are actually talking about several things
• Sex
• Gender identity
• Gender expression
• Sexual orientation
• (romantic orientation)

Sex

• This is what is assigned at birth (i.e. sex assigned at birth)
• Male (AMAB)
• Female (AFAB)
• Intersex (can be assigned at birth or later in life)

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• Four things we use to determine sex in society
• Chromosomes
• Secondary sex characteristics (distribution of body fat, height, chest/breasts, menses, body hair distribution, voice, etc.)
• Gonads (testes/ovaries)
• External genitals

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Reflection: Where are some places in your life that you are required to enter/name your sex?

Gender +

• Transgender (trans)
• Sex assigned at birth ≠ social expectations of the gender we connect with that sex
• Cisgender (cis)
• Sex assigned at birth = social expectations of the gender we connect with that sex
• Cisgender was coined by Julia Serano in 2006
• Based in science; trans means to go opposite directions, cis means to go the same direction

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Gender is a social construct, based on socialization, cultural, familial, and broader society expectations of what being a ‘man’ or a ‘woman’ means, including roles, behaviors, interests, and appearances.

Gender Identity

• This is your internal sense of who you know yourself to be as a gendered person; relates to a core identity
• Cis woman/Trans woman/transfeminine
• Cis man/Trans man/transmasculine
• Nonbinary/Enby
• Genderqueer
• Two spirit
• Agender
• Genderfluid
• …

Gender Expression

• How one presents themselves to the world
• Can include things like hair styles, clothing, jewelry, make up, facial hair, gait, posture, voice infections, and more.
• Important: gender identity ≠ gender expression in all case
• You can have a very feminine presenting nonbinary person or a masculine presenting woman, for example.

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Sexual Orientation

Sexual Attraction/Sexual Orientation

Some examples of labels include:

• Lesbian
• Straight/heterosexual
• Gay
• Bisexual
• Pansexual
• Queer
• Omnisexual
• Two spirit
• Asexual…

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Romantic orientation: romantic/emotional attraction

• These can overlap (someone who is gay and homoromantic) or not (someone who is asexual and heteromantic, or someone who is a lesbian and panromantic)
• People can be aromantic

Language Notes

• Mirror what your clients use
• Example 1: Some language is seen as outdated by the community, and if you use homosexual or transsexual in a general space, many people will likely be offended. However, if an individual says “I am a homosexual woman” or ”I am a transsexual man,” then definitely use that language, when referring to that individual.
• Some language is regional, cultural, or age specific
• Just ask them their identities (and then mirror their language!)

Pronouns�

www.colorsplus.org

Be aware of the expectations you project onto others based on their gender, and strive to support others and validate their experiences.

Believe others. You do not need to understand it to respect it. Respect is trusting someone when they tell you who they are.

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1 in 4 LGBTQ youth use pronouns or pronoun combinations that fall outside of the binary construction of gender.

Pronouns…A Few Ways To Ask

www.colorsplus.org

• Offer your name and pronouns, which indirectly asks the person you speaking to share their name and pronouns.
• Explain why you are asking (e.g., “I want to introduce you to my friend, and make sure I get your pronouns right. What are they?”).
• Just ask! “What are your pronouns?” (And be ready to explain why you’re asking, or for the person to be confused and need a little coaching)
• ALL PRONOUNS ARE VALID

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Biggest Language Note

• USE PEOPLE’S CORRECT PRONOUNS
• Seriously, if you take nothing else from this, use people’s correct names and pronouns
• Misgendering people is violence…
• But luckily…Using correct names and pronouns literally saves lives!

Renley, B. M., Burson, E., Simon, K. A., Caba, A. E., & Watson, R. J. (2022). Youth-specific sexual and gender minority state-level policies: implications for pronoun, name, and bathroom/locker room use among gender minority youth. Journal of Youth and Adolescence, 51(4), 780-791.

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Take a Second to Try This Yourself

Fluidity of Identity Across the Life course

Sexuality and gender identity/expression self-awareness are fluid and continuous processes, especially in adolescence.

• This means changing terms, identities, and affiliations are common, normal, health, and expected!
• Individuals may ‘come out’ later in life.
• Generational differences in norms/attitudes about LGBTQ+ people
• Religious background
• Later life self discovery

Other Language/Identity Questions?

Why does all this matter?

• LGBTQIA2S+ individuals face alarming rates of discrimination, refusal of care, other barriers

These result in incredibly horrifying rates of health and mental health concerns

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• Ohio does not have a statewide law that protects LGBTQ people from discrimination. This means many LGBTQ Ohioans can be fired from their job, denied housing, asked to leave a public facility, or denied access to the appropriate restroom based on gender identity, expression and/or sexual orientation. [Note: 34 cities/counties have passed local ordinances including Cuyahoga County, however, only 22 of these include protections based on gender identity/expression]

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• LGBTQIA2S+ individuals have less access to services/resources and face greater obstacles navigating systems, e.g. healthcare, mental health, addiction and recovery services, homelessness services
• Increased for Black, Indigenous and other LGBTQIA2S+ people of color
• Also for disabled, older, younger, low income, and immigrant LGBTQIA2S+ people

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• This increases the likeliness that LGBTQIA2S+ individuals
• Will avoid the health care systems altogether
• Will avoid or relay preventative care/screenings (e.g. Paps, mammograms, prostate, dental visits, cholesterol screenings, eye exams, etc.)
• Will avoid, delay, or terminate early mental health services –or, receive harmful, deadly mental health treatments based on conversion therapy ideologies.
• Will face additional violence when seeking transitional or emergency shelter
• Will not receive appropriate resources and support when experiencing intimate partner violence
• Are at risk for unique health, mental health, and other concerns that go unaddressed

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LGBTQ+ Trauma-Informed Care

www.colorsplus.org

What is SGM Affirming Mental Health Care?

SGM-affirming care validates a wide range of SGM identities as normal and healthy, addresses the impact of societal SGM-based discrimination and stigma and improves outcomes.

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• Help clients understand how stigma impacts stress burden and mental health
• Address internalized queer/trans-phobia (guilt/shame/disgust)
• Builds pride, connection to the LGBTQ+ community
• Builds agency and self/other advocacy plus resilience/resistance�

Gender Affirming Care Saves Lives

• Gender Congruence
• Physical body aligning with internal sense of self
• Early medical intervention for adolescents may include puberty blockers; puberty blockers + gender affirming hormones; or blockers + hormones + affirming surgery/ies.

• Gender Euphoria and Gender Joy
• Pleasure
• Joy
• Love

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Joy

Ava, a 30-year-old Black trans woman, delighted in how she appreciated her appearance:

Being pretty. I know [Laughs] it’s bad. But when I look at my picture, I get happy. I remember being that little boy who always wanted to look like this. Sometimes I look at my pictures and am like “Oh, my god, you look so pretty.” And that makes me happy... . It just makes me feel really proud I became that girl that I always thought of in my head.

Schuster, 2022, pg. 11

Intersectionality Approach with SGM Populations

• SGM-based stigma, discrimination and violence is not a single source of oppression impacting SGM peoples.

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• Intersection of race, gender, sexual orientation, socioeconomic class, and other social/cultural group memberships operate synergistically.

• Must look at/attend to MULTIPLE forms of dominance/oppression; attend to micro and macro levels of power/oppression; work at multiple layers of social work (micro-mezzo-macro)

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Think about your org…

• What are some things that you are doing well to support LGBTQIA2S+ clients?
• What are some things that you are doing well to support LGBTQIA2S+ co-workers?
• What are some areas of growth to better support LGBTQIA2S+ clients?
• What are some areas of growth to better LGBTQIA2S+ co-workers?
• How about intersectionality? What are some areas of strength and growth in supporting/addressing the needs of ‘multiply marginalized’ clients?

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Covid-19 Impacts on Sexual and Gender Minorities

• 13.5% of LGBT respondents lived in a household that experienced food insecurity compared to 7.4% of non-LGBT respondents.

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• Nearly a quarter (21.6%) of LGBT respondents reported the loss of employment income in their household compared to 16% of non-LGBT respondents.

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• Nearly half (47.9%) of LGBT respondents reported experiencing anxiety for more than half of the days in a week compared to 23.5% of non-LGBT respondents.

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• A larger share (38.2%) of LGBT respondents than non-LGBT respondents (16.1%) experienced depression for more than half of the days in a week.

Other Pandemic Impacts

• Having to go “back into the closet”
• Misgendering and abuse from family
• Misgendering in virtual spaces
• Loneliness
• Lack of access to supportive spaces/shared community

What can YOU do?

• Establish non-discrimination policies in your workplace that explicitly include gender identity/expression and sexual orientation
• Develop strategies to maintain diverse and culturally responsive providers and staff
• Offer treatment based on actual needs and behaviors, not labels and assumptions
• Not every gay man is at risk for HIV
• Sexually active lesbian/bi/queer women should have access to STI tests
• Not every trans person wants a medical transition/not every nonbinary person doesn’t want a medical transition
• EVERYONE should be screened for IPV/safety at home
• Faith based practices/spaces are not safe for everyone

What can YOU do?

• Report unfriendly and discriminatory practices and share referrals to friendly/aware/knowledgeable providers and institutions.
• Continue educating yourself and encourage others to learn about LGBTQIA2S+ communities and populations
• Language shifts over time, new info comes out. A two hour workshop once is not good for the next ten years
• Train office staff around language use, best practices, gender presentation diversity, etc. (not just providers should be inclusive)
• Check your referrals to make sure THEY are LGBTQIA2S+ inclusive (especially when referring to faith based organizations)

Overall Environment

• Gender inclusive bathrooms (and signs to them)
• Posted non-discrimination policies
• Inclusive names/signs
• Example: not “women’s clinic”
• Collateral that is inclusive
• Don’t just have heterosexual couples on their brochures/handouts
• Referral lists of LGBTQIA2S+ inclusive providers
• Both in and outside your org
• Inclusive intake forms
• Advertising in community spaces
• Pronouns on name tags/badges
• Rainbow and/or trans flags in location/online

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• HIRE LGBTQIA2S+ EMPLOYEES (and treat them well!)

Intake Forms

• Relationship Status: Include Partnered/Living with Partner, as well as Married, Single, Divorced, Widowed
• Also consider ‘multiple partners’ or ‘dating’

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• Gender ≠ Sex. Sex is Male, Female, Intersex. Gender can include Man, Woman, Nonbinary, Genderqueer, Agender, Two Spirit, etc.
• Assess if you actually need to know if someone is trans.
• Ask “are you transgender or someone of trans experience” as a two part question to assess for this

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• Sex/Gender ≠ Orientation. If you have orientation boxes (lesbian, gay, straight, bisexual, queer, asexual, etc.), do not place transgender here.

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• Use blanks (rather than boxes) when possible for identities allows patients to explain/elaborate.
• Example – Gender: __________________.
• If needed, use sex boxes for insurance and blanks for office use (gender, sexual orientation, etc.)
• Pronouns: _______________

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Example of a great intake form:

Avoid Assumptions!

• Not all your clients are heterosexual or cisgender

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• Remember difference between identity, expression, and behavior
• If someone says they are bisexual, but are a cisgender woman partnered with a cisgender man, it doesn’t mean their identity is any less valid!

• Ask all of your patients for names to be used and pronouns (not just LGBTQIA2S+ clients) and use them

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• Respect your clients’ identities, even if they don’t fit your perceptions (yes! There are cis gay Christian men, and Muslim trans women, and young people who know themselves to be asexual)

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• Make sure you ask for language use (i.e., when working with youth and parents: ”what language does your child use for each of you?” instead of assuming both go by mom)
• Some people may prefer using language with you that they don’t want used in front of/with parents/guardians – please respect this

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Pronouns…AGAIN

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• Remember to ALWAYS use the correct pronouns of your patients.
• If you mess up: acknowledge, apologize, and move on – don’t make it all about you
• “Hey, can you please bring those forms for him? Sorry, I mean, can you please bring those forms for them?

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Questions to Reflect on

• How can inclusivity play a role in your practice?

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• What steps are you already taking to insure an inclusive health care environment?

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• What community resources can you use?

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• How are you including LGBTQIA2S+ people in your ongoing education and assessment?

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Questions?

Contact the Trainer

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Dana Prince

Dana.prince@case.edu