Let’s Talk About Gender

1. Let’s Talk About Gender

2. Definitions • AAB – Assigned at birth. AMAB assigned male at birth, AFAB … • Transgender – someone who does not identify with the AAB sex • Cisgender – someone who does identify with their AAB sex • Trans Woman – AMAB who transitions to female • Trans Man – AFAB who transitions to male • Non-Binary – gender identity outside the gender binary • Agender – someone who has no gender identity • HRT – Hormone Replacement Therapy • GCS – Gender Confirmation Surgery • SRS – Sex Reassignment Surgery

3. What is Gender • Sex – refers to sexual characteristics of the body. Broken up into primary and secondary characteristics • At least 12 different sex chromosome combinations found so far • Differs from gender. Sex is a combination of physical attributes that are visible • People are classified based on a combination of traits, not one trait

4. Research + Social Constructionism Science + Research Social Construction Theory • Brains scan studies show that there are areas of the brain where gender identity originates • These areas are sexually dimorphic with cis women, on average, having one configuration and cis men another • Trans women tend to have brains similar to cis women even prior to HRT • Trans men tend to have brains similar to cis men even prior to HRT • HRT causes the brains to develop closer to the gender identity of the person • Social Construction states that gender exists in a specific time and place and that it changes when the context changes • Divided into gender roles and presentation • Gender roles are things you do • Gender presentation is how you present yourself to the world • Clothes, language, voice, behavior, etc.

5. Transgender People • About 1% of the population. • Nearly 20,000 in the Triangle • Nearly 100,000 in NC • Nearly 3.2 million in US • About 75,000,000 in the world • Cultures around the world have multiple genders

6. Gender Dysphoria - APA In adolescents and adults gender dysphoria diagnosis involves a difference between one’s experienced/expressed gender and assigned gender, and significant distress or problems functioning. It lasts at least six months and is shown by at least two of the following: • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics • A strong desire to be rid of one’s primary and/or secondary sex characteristics • A strong desire for the primary and/or secondary sex characteristics of the other gender • A strong desire to be of the other gender • A strong desire to be treated as the other gender • A strong conviction that one has the typical feelings and reactions of the other gender

7. Coming Out • Coming out is the second worst period of time for violence • Often, relationships are strained or destroyed. This can be a time to strengthen relationships too • It is not always fully out all at once time. It doesn’t even necessarily coincide with transitioning • People pick the right time and place to come out • Suicide rates peak during this time due to abuse and violence • In practical terms, you are always coming out • Some pass enough where they can stop coming out – “stealth”

8. Transitioning

9. Medically Transitioning • May include HRT and/or CGS/SRS as well as voice therapy • Feminizing HRT includes a “blocker” and estrogen • Masculinizng HRT includes testosterone injection or spray. • 0.00% of trans health care is covered by the State Employees Health Plan

10. Medically Transitioning • GCS/SRS includes “top” and “bottom” surgery • Top – breast augmentation or mastectomy or reduction • Bottom – vulvaplasty, vaginaplasty, metoidoplasty, phalloplasty • Other Types • FFS – Facial Feminization Surgery • VFS – Voice Feminization Surgery • Hysterectomy • Facial Masculinization Surgery • Electrolysis and Laser Hair Removal • Mastectomy is the most common procedure by far • Rarely covered by insurance • When covered, often requires 12 months HRT and RLE plus letters from a psychiatrist, the treating physician and surgeon before it can be approved

11. Social Transitioning • The purpose is to be seen as and interact with the world as your gender • This is your gender expression and role • This isn’t required but is often the most interesting • Clothing, name, voice, behavior are all commonly modified • Trans people aren’t necessarily seeking to adopt gender stereotypes but are often accused of supporting stereotypes • Many trans people are also gender non-conforming

12. Legal Transitioning • Name Change, “relatively easy” to accomplish • It’s done in the state you live in currently • Gender Marker Change on your birth certificate • Done in state you were born, 5 states where is it not possible to do so • Federal gender marker change – used to be very easy, now being rejected. Recent increase in passport revocation for trans people • Documents need to be updated at the federal, state and organizational level.

13. Nursing Care for Trans Patients

14. Pronouns • People adopt pronouns that make the most sense • They are not Preferred, they are the correct pronouns • Using pronouns recognizes and affirms their gender • If it is difficult, slow down and be more intentional about language • If you make a mistake, apologize quickly and move on • Refer to the past using the name and pronouns the patient has given • People correct themselves when misgendering a dog, it should be that easy to do it for a human being • Treat us as our gender because we are our gender!

15. Names • Our old names are often called deadnames • Names are important in the same way they are important to you • Deadnaming is the same as misgendering • Ask “Is your insurance under a different name?” • Name bracelets need to be changed to eliminate deadnames • Refer to the past using the name they have given • Calling someone by their chosen name and pronouns should be baseline respect • People easily call others by their nicknames or stage names

16. Stand Up for Your Patients! • Stand up to staff, co-workers and visitors • Don’t allow deadnaming, misgendering or other mistreatment • If you hear something speak out! • Fight back against a culture of ignorance, shame, intolerance and discrimination by creating a culture of inclusion and acceptance • DO NOT OUT THEM • I personally have been outted by staff and witnessed patient’s being outted by staff – even to non-clinical staff • If they are on HRT, they need to be on HRT in the hospital, period

17. Respect Privacy • Do not ask about genitals! • Do not ask about sexuality! • When doing SOGI collection on admission it is appropriate • Do not ask about family and friends, especially significant others • Don’t ask for their deadname or to see pics of them pre-transition • Do not indulge in your curiosity. You would not want someone to ask about your genitals, so remember to give us that respect too

18. Transphobia The irrational fear or hatred of trans people

19. Things that UNC can Do • Organizational change driven by trans people ourselves. We understand out unique needs and the rationales for them whereas cis people cannot. • That a Trans Bill of Rights is established. It is a document that explicitly codifies how trans patients and employees should be treated. A document of vision and expectations. • That trans and LGBT education be required for all staff at all levels. That this content should be driven by trans people to tell our stories. • That a trans and LGBT liaison nurse be established to help our patients. This person should be a resource for staff and an advocate for patients. • That best practices for trans and LGBT people are developed for all staff. Different positions require different educational experiences and perspectives. • That bathroom access be gender neutral wherever possible. All single bathrooms should be de-gendered. This will provide a positive and affirmative signal that UNC is a safe place. • That a culture of acceptance and affirmation is fostered. Trans employees should not fear for their jobs or expect discrimination as a consequence of coming out and being visible. • That UNC recognizes and celebrates diverse genders and gender presentations. We are a part of the human experience that should not be repressed. Queer people should be a part of media such as advertisements. • That UNC visibly identifies itself as an LGBT safe space. • That UNCs rural access facilities provide a safe place for trans patients to obtain health care including transition related interventions. That UNC leverages its state-wide foot print to bring access to those who cannot afford or are unable to travel. • That UNC’s psychiatric programs provide special training to staff on how to effectively and safely interact with trans patients. That rules and guidelines are put into place so that staff can be held accountable.

20. Policies and Procedures • I am currently researching best practices for nursing care for transgender patients • The research is pretty sparse and dominated by cis people, which contains inaccuracies • It will be a collaborative effort between staff and trans community members

21. Questions? Shae Morrigan Bardgett - Shae.Bardgett@unchealth.unc.edu