Addressing Disparities and Intersecting Oppressions for Gender-Variant Individuals in Healthcare

1. Addressing Disparities and Intersecting Oppressions for Gender-Variant Individuals in Healthcare Presented by: Vaughn McLaughlin Quai Nystrom Rise Conference 2009

2. Agenda • Introduction • The Complexity of Gender • Historical Perspectives on “Mental Illness” • Brief History of Gender & Sexuality in the DSM: 1950’s to present • Socioeconomic Implications in Access to Healthcare Services • Poor Practice: What Oppression Looks Like Across Healthcare Settings • Final Discussion: As a Provider, How Might You Ally Yourself With The Gender Variant Community?

3. The Complexity of Gender "how [you] view yourself depends on the human relationships and interactions that surround [you], rather than arising from some intrinsic core sense of self.” - Emi Koyama Emi Koyama: self-portrait

4. Warm Up Exercise You are a social worker at a healthcare clinic in NYC. A transgender identified consumer enters your office for an initial appointment. You are doing an intake. • How might you prepare to see this consumer? • How might you address this consumer? • What are some questions that you might ask of this consumer? • Where might you refer the consumer for routine preventative & trans related care here in NYC?

5. Historical Perspectives on Mental Illness • History in mental health field of using diagnosis to pathologize ordinary human diversity. • in realms of race, ethnicity, sex, gender expression, class, ability, and sexual orientation • Labeling as “psychologically deviant” has inevitable civil rights and social status consequences, especially amongst marginalized communities.

6. Historical Perspectives on Mental Illness (cont’d) Benjamin Rush (“father of American psychiatry”) believed dark African skin was caused by a medical illness related to leprosy. John Money (psychologist from Johns Hopkins) developed a medical model that directed healthcare providers and parents to "nurture" intersex children into an assigned gender. Under Money’s treatment, children undergo medical interventions in the name of "psychosocial health" to make their bodies appear “normal” by societal standards.

7. Historical Perspectives on Mental Illness (cont’d) • Drapetomania:a mental illness among African slaves whose primary symptom was trying to escape slavery. • Dysathesia ethiopica:a term used to describe African slaves who destroyed plantation property, were disobedient, fought with their masters, and/or refused to work. • Anarchia:a mental illness among people who had a fervent commitment to mass participation in democracy.

8. A Brief History of Gender and Sexuality in the DSM DSM-I, 1952: Homosexuality DSM-II, 1968: Homosexuality 1973: Homosexuality is REMOVED from the DSM-II DSM-III, 1980: Homosexuality is REPLACED by Transsexualism (adults) and GIDC (children) as a clinical disorder. DSM-IV, 1994: Transsexualism is REMOVED and REPLACED by Gender Identity Disorder (covering all age groups).

9. The “Medicalizing” of Gender Expression • When facets of one’s life are controlled by medical authority - gate keeping - defining what is “normal” - scrutinizing what is “abnormal” • Happens through dominant structures - healthcare institutions & insurance companies • Legitimize or pathologize political and social beliefs. • Diagnosis & language carry connotations that influence interaction with consumers.

10. “Not Appropriate Based on the Gender of the Patient” Gynecological Care Transgender men face denial of coverage for fatal illnesses such as breast, uterine and cervical cancers, citing these conditions are acquired as a result of the “complication of the transition process or hormone therapy.” Any related treatments are “not appropriate based on the gender of the patient.” Prostate Care Transgender women are also singled out for denial of coverage for conditions such as prostate cancer because such treatments are “not appropriate based on the gender of the patient.”

11. Socioeconomic Implications: Denial of Coverage In NY state (excluding NYC), trans, GNC & GV folks have no legal protection from discrimination in the workplace, in housing, or in public accommodations. Many trans, GNC & GV folks not insured.

12. Oppression in Healthcare Service Delivery Institutional Oppression- based upon fixed social agreements, contracts and policies, i.e., hospital policies, clinic policies, clinical atmosphere, HMO/PPO policies, Medicaid, Medicare, policy making bodies, AMA, APA, etc. Interpersonal Oppression- Provider to Consumer maltreatment, etc. Internalized Oppression- that which is directed at the self or others in their community, a result of multiple oppressions. Cultural Oppression- cultural norms of intrusive questions about anatomy, lack of protection under the law, societal invisibility, ridicule, violence, etc.

13. What Oppression Looks Like: Case Examples Report issued in December 2008 Betsy Gotbaum Office of the Public Advocate for the City of New York “Improving Lesbian, Gay, Bisexual and Transgender Access to Healthcare at New York City Health and Hospitals Corporation Facilities”

14. Systemic maltreatment of trans-identified and gender-variant people, through policies, and practices. Medical schools do not train students in services for trans-identified and gender-variant individuals. Invalidating identity by requiring one to conform in order to receive services. Prerequisites to care, such as having “real life experience”. “An intersex man went to the emergency room at Lincoln Hospital. When the doctor examined him and discovered male and female sexual organs, he did not know what to do. The patient had to educate the doctor.” Institutional Oppression

15. Tyra Hunter In the mid 1990s, African-American hairdresser Tyra Hunter was in a car accident in Washington, DC. Eyewitnesses reported that rescue medics suspended treatment and made ridiculing remarks after they cut open her pants to treat her and discovered she had male genitals. Onlookers shouted at the medics until they took her to the ER, where she died.

16. Overt disrespectful or offensive language refusing services or cutting them short withholding medical information assumptions and judgments Covert body language and eye contact “scanning” lower level of professionalism “In one encounter at Jacobi Hospital, a trans woman was pre-approved by Medicaid for breast augmentation surgery. She prepped for the surgery with staff in the department. When she returned to the hospital for the actual surgery and met with the surgeon she was turned away and told that he did not perform this type of operation.” Interpersonal Oppression

17. Having adverse, self-defeating thoughts related to one’s identity. Consequence of other forms of oppression. Individuals have varying awareness of this type of oppression. Can result in acquiescence to maltreatment. “I’ve always felt weird about myself.” Internalized Oppression

18. Focus on the anatomy as an indicator of one's gender. Degraded as sexual and social deviants, pedophiles, psychotic, etc. When gender expression does not conform to societal expectations, the person is most often discarded in passive, overt or violent ways. “The medical director of one HHC facility referred to a patient as “she, he and it.”” “A trans woman was an in-patient at Lincoln Hospital for two months. She was HIV+ and had also suffered a stroke, which left half her body paralyzed. The staff would leave her soiled in her bed unless friends asked her to be cleaned. According to advocates’ accounts of this case, nurses also preached and prayed by the woman’s bedside. The patient attributed this treatment to her gender identity. The patient is currently in hospice care.” Cultural Oppression

19. Leslie Feinberg Leslie Feinberg, a trans activist, shares some of their own accounts of discrimination. The following incident occurred at an emergency room in a Jersey City in the mid 1990’s: “While battling an undiagnosed case of bacterial endocarditis, I was refused care. After the physician who examined me discovered that I was female-bodied, he ordered me out of the ER despite the fact that my temperature was above 104˚F. He said I had a fever “because you are a very troubled person.” (L. Feinberg)

20. Leslie Feinberg(cont’d) Several weeks later in a NYC hospital… “I was hospitalized with the same illness in a Catholic hospital where management insists patients be put in wards on the basis of birth sex. They place transsexual women who have completed sex-reassignment surgery in male wards. Putting me in a female ward created a furor. I awoke in the night to find staff standing around my bed ridiculing my body and referring to me as a “Martian”. The next day staff refused to work unless “it” was removed from the floor. These and other expressions of hatred forced me to leave.” (L. Feinberg)

21. Robert Eads Robert Eads died of ovarian cancer in 1999 at the age of 52 after 20 physicians refused to treat him because he was transgender. (Southern Comfort, documentary) Robert on his wedding day. Robert several weeks before he passed away.

22. Healthcare Service Delivery in NYC • Factors of racial identity, socioeconomic status and gender expression have direct impact on IF and HOW healthcare services are delivered. • Barriers to highest standards of care exist, especially in poor urban areas such as Harlem and the Lower East Side. • Consumers from impoverished communities (disproportionately communities of color) are more vulnerable to maltreatment. • Results in (1) limited access to healthcare information and (2) sub par living conditions are experienced as the norm.

23. Healthcare Service Delivery in NYC NYC’s Public Hospital System, HHC, is the largest municipal hospital and healthcare system in the country. HHC facilities are known for providing less than optimal care to mostly Medicaid recipients and the uninsured. Outside of emergency room care, wait times for standard preventative care may be up to 3 months.

24. As a Provider, How Might You Ally Yourself With The Gender Variant Community? • What Kind of System Do You Work In? • What Sort of Policies & Protocols Does Your Agency/Clinic/Hospital/School/Organization Have In Place in Working with this Community? • How Do Such Policies (or the lack thereof) Impact Your Practice?

25. Local Resources • Callen-Lorde Community Health Center • Transgender Sexual Health Clinic @ Callen-Lorde • Transgender Legal Defense & Education Fund (TLDEF) • Transgender Health Initiative of New York (THINY) • Sylvia Rivera Law Project (SRLP) • AudreLorde Project (ALP) • Gender Identity Project (GIP @ the LGBT Center) • Ali Forney Center (Drop In/Housing services) • Housing Works (Drop In/Housing services) • Streetworks (Drop In/Housing services) • F.I.E.R.C.E. (Fabulous Independent Educated Radicals for Community Empowerment) • Queens Community Pride House • Bronx Health Center’s Transgender Health Program • Bronx Community Pride Center • SAGE (Services and Advocacy for GLBT Elders) • Transgender Law and Policy Institute