Understanding Gender Fluid, Gender Queer, Trans* & Transgender Students

1. UnderstandingGender Fluid, Gender Queer, Trans* & Transgender Students Becca Smith, LPC, CPCS Assistant Director Georgia Southern University Counseling Center

2. Cultural Humility • “Cultural Humility” is an approach that proposes change through a lifelong process of learning, including self-examination and refinement of one’s own awareness, knowledge, behavior and attitudes on the interplay of power, privilege and social contexts • Tervalon, M. & Murray-Garcia, J. (1998) Cultural humility versus cultural competence: A critical distinction in defining physician-training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117. • When incorporating cultural humility into practice, clinicians are invited to challenge their own unique set of biases and privileges that impact the LGBTQ clients they work with.

3. Be Aware!! • Practitioners need to self-examine their beliefs, values, and attitudes towards LGBT individuals to ensure that they are striving for what the client needs in order to be a successful individual. • It is crucial that practitioners check their attitudes while working with LGBT clients because even the smallest hint of negative body language or speech can affect the therapeutic process (Ryan and Futterman, 1998)

4. Say What?! • Sex vs. Gender vs. Sexual Orientation • Male/Female/Intersex • Man/Woman/Transgender • Straight/ Gay/Lesbian/ Bisexual/Questioning/ Pansexual/Asexual

5. TO SUM UP • Sex = What is in your pants • Gender Identity = How you interpret what is in your pants • Sexual Orientation= What you do when your pants are off

6. Dimensions of Gender • While our gender may begin with the assignment of our sex, it doesn’t end there. A person’s gender is the complex interrelationship between three dimensions: • Body: our body, our experience of our own body, how society genders bodies, and how others interact with us based on our body. • Identity: our deeply held, internal sense of self as male, female, a blend of both, or neither; who we internally know ourselves to be. • Expression: how we present our gender in the world and how society, culture, community, and family perceive, interact with, and try to shape our gender. Gender expression is also related to gender roles and how society uses those roles to try to enforce conformity to current gender norms. • Each of these dimensions can vary greatly across a range of possibilities. A person’s comfort in their gender is related to the degree to which these three dimensions feel in harmony. * Courtesy of Gender Spectrum

8. Queer • Think of queer as an umbrella term. It includes anyone who • a) wants to identify as queer and • b) who feels somehow outside of the societal norms in regards to gender or sexuality. • It is a fluid label as opposed to a solid label, one that only requires people to acknowledge that they’re different without specifying how or in what context.

9. Gender Fluid • Gender fluid is a gender identity which refers to a gender which varies over time. A gender fluid person may at any time identify as male, female, multigender, non-binary and/or transgender. • Gender fluid- people who feel that the strength of their gender(s) change(s) over time, or that they are sometimes agender, bigender, or may identify as gender flux.

10. Trans* or Transgender • The word “transgender” – or trans* – is an umbrella term for people whose gender identity is different from the sex assigned to them at birth. (GLAAD, 2016) • The transgender community is incredibly diverse. Some transgender people identify as male or female, and some identify as genderqueer, nonbinary, agender, or somewhere else on or outside of the spectrum of what we understand gender to be. • A trans-affirmative practice refers to a non-pathologizing approach to clinical practice that accepts and validates all experiences of gender (Austin & Craig, 2015, p. 21). • An introduction to Transgender People

11. Gender Nonconformity Is Not the Same as Gender Dysphoria • Gender nonconformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex (Institute of Medicine, 2011). • Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) (Fisk, 1974; Knudson, De Cuypere, & Bockting, 2010b). • Only some gender nonconforming people experience gender dysphoria at some point in their lives

12. Gender Dysphoria • Often with the help of psychotherapy, some individuals integrate their trans- or cross-gender feelings into the gender role they were assigned at birth and do not feel the need to feminize or masculinize their body. • For others, changes in gender role and expression are sufficient to alleviate gender dysphoria. • Some patients may need hormones, a possible change in gender role, but not surgery. • Others may need a change in gender role along with hormones and surgery. • In other words, treatment for gender dysphoria has become more individualized.

13. Transgender Transitioning- • Gender Expression • Clothes, make up, hair style, non-verbal mannerisms • Some transgender people choose not to go any further with their transition • Hormone Therapy • Hormone therapy is usually the first treatment that trans people want to have and, for some, it may be the only treatment they need • Transgender people will need to be on hormone therapy their whole lives

14. Transgender Transitioning Continued • Hormone Therapy- In trans women, estrogen has subtle feminizing effects: • Fat may be distributed on the hips. • The size of the penis and testicles may be slightly reduced. • Some trans women find that erections and orgasm are harder to achieve. • Muscle bulk and power may be reduced. • Breasts may feel tender and lumpy and may sometimes increase modestly in size. • The growth of facial and body hair may become weaker. • Male pattern baldness may be slowed or stopped, but is not necessarily reversed.

15. Transgender Transitioning Continued • Hormone Therapy- In trans men, testosterone may cause the following effects: • It promotes beard and body hair growth • Male pattern baldness may develop • The clitoris increases slightly in size • Libido may be heightened • Muscle bulk increases • The voice deepens, but not usually to the pitch of other men • Periods will stop, although there may be some breakthrough bleeding requiring adjustment of dosage • Some individuals develop acne

16. Criteria for Feminizing/Masculinizing Hormone Therapy (one referral or chart documentation of psychosocial assessment) • Persistent, well-documented gender dysphoria; • Capacity to make a fully informed decision and to consent for treatment; • Age of majority in a given country (if younger, follow the SOC for children and adolescents); • If significant medical or mental concerns are present, they must be reasonably well-controlled. Courtesy of WPATH Standards of Care

17. Referral for Hormone Therapy • The recommended content of the referral letter for feminizing/masculinizing hormone therapy is as follows: • The client’s general identifying characteristics; • Results of the client’s psychosocial assessment, including any diagnoses; • The duration of the referring health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date; • An explanation that the criteria for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy; • A statement about the fact that informed consent has been obtained from the patient; • A statement that the referring health professional is available for coordination of care and welcomes a phone call to establish this. Courtesy of WPATH Standards of Care

18. Transgender • Gender Affirming Surgery • Male To Female • FACIAL FEMINIZATION - Alteration of facial features and/or structures (nose, brow, jaw, etc.) • BREAST AUGMENTATION - Placement of breast implants • VAGINOPLASTY - converts penile and scrotal tissues into a vagina, clitoris, and labia. This procedure is usually combined with labiaplasty that further refines the labia and external vaginal area, giving it a classically female appearance. • BUTTOCK ENHANCEMENT - Shaping buttocks to more feminine contours • THYROID CARTILAGE REDUCTION - Reduction of Adam's apple

19. Transgender • Gender Affirming Surgery • Female to Male • CHEST MASCULINIZATION- designed to remove female breasts in order to create a male chest. • PHALLOPLASTY/METOIDIOPLASTY/CLITORAL RELEASE-the penis is constructed essentially using skin flaps from the abdomen, groin, or thigh. The scrotoplasty procedure uses labial tissues to construct a scrotum, into which implants can be inserted to simulate testicles. • BUTTOCK REDUCTION- size reduction and shaping is usually accomplished by carefully performed liposuction.

20. Referral for Breast/ Chest Surgery • One referral from a qualified mental health professional is needed for breast/chest surgery • Mastectomy and creation of a male chest in FtM patients: • Persistent, well-documented gender dysphoria; • Capacity to make a fully informed decision and to consent for treatment; • Age of majority in a given country; • If significant medical or mental health concerns are present, they must be reasonably well controlled. • Hormone therapy is not a prerequisite. Courtesy of WPATH Standards of Care

21. Referral for Breast/ Chest Surgery • One referral from a qualified mental health professional is needed for breast/chest surgery • Breast augmentation (implants/lipofilling) in MtF patients: • Persistent, well-documented gender dysphoria; • Capacity to make a fully informed decision and to consent for treatment; • Age of majority in a given country • If significant medical or mental health concerns are present, they must be reasonably well controlled. • Although not an explicit criterion, it is recommended that MtF patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

22. Referral for Genital Surgery • Two referrals – from qualified mental health professionals who have independently assessed the patient – are needed for genital surgery • Persistent, well documented gender dysphoria; • Capacity to make a fully informed decision and to consent for treatment; • Age of majority in a given country; • If significant medical or mental health concerns are present, they must be well controlled; • 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones); • 12 continuous months of living in a gender role that is congruent with their gender identity. Although not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional.

23. Referral Letter for Surgery • The recommended content of the referral letters for surgery is as follows: • The client’s general identifying characteristics; • Results of the client’s psychosocial assessment, including any diagnoses; • The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date; • An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery; • A statement about the fact that informed consent has been obtained from the patient; • A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this. Courtesy of WPATH Standards of Care

24. Transgender- A Real Perspective

25. Issues common in the Transgender Population • Depression and Suicide Ideation • Substance Abuse • Homelessness • Harassment and Violence • The above are compounded when they don’t have family or friend support

26. Updated Statistics • At least 22 transgender people have been killed in the United States since the beginning of 2018 • 82% of them were women of color • 64% were under the age of 35 • 55% lived in the South The Human Rights Campaign and researchers at the University of Connecticut conducted a survey: • Less than 25% of transgender and gender expansive youth feel like they can definitely be themselves at home • 72% of transgender and gender expansive youth report hearing their families make negative comments about LGBTQ people • 69% of transgender and gender expansive youth have received unwanted sexual comments • Transgender and gender expansive youth are roughly twice as likely to be sexually assaulted or raped because of their actual or perceived identities than their cisgender LGBTQ peers • Only 16% of transgender and gender expansive youth always feel safe at school • 42% of transgender and gender expansive youth have received physical threats due to their LGBTQ identity • 51% of transgender and gender expansive youth never use restrooms at school that align with their gender identity

27. Challenges at College • Harassment and stigma– 51% report feeling unsafe on campus because of their gender expression • Discrimination- the combination of anti-transgender bias and persistent, structural racism was especially devastating. People of color in general fare worse than white participants across the board, with African American transgender respondents faring far worse than all others in most areas examined. • Social Isolation & Depression- A staggering 41% of respondents reported attempting suicide compared to 1.6% of the general population • Lack of support- While non-LGBT students struggle most with school classes, exams, and work, their LGBT peers say the biggest problem they face is unaccepting families on top of regular stressors *courtesy of the Human Rights Campaign

28. Best Practices for Supporting Transgender Students • Have at least one Counseling Center therapist who has the training and experience to be able to write letters for transitioning students to access hormones. • Develop and publicize a list of area therapists who can provide trans-supportive gender therapy for students who are transitioning or who are struggling with their gender identity. • Offer a support group for trans and gender-nonconforming students. • Train front line staff to use the preferred name a student uses when signing in. • Appoint a patient advocate or have a visible procedure for trans students (as well as other students) to report concerns and instances of poor treatment. *courtesy of Lambda Legal

29. How Can You Help?? • Provide information regarding options for gender identity and expression and possible medical interventions. • An important task of mental health professionals is to educate clients regarding the diversity of gender identities and expressions and the various options available to alleviate any possible gender dysphoria. • You then may facilitate a process (or refer elsewhere) in which clients explore these various options, with the goals of finding a comfortable gender role and expression and becoming prepared to make a fully informed decision about available medical interventions, if needed. • You and the client discuss the implications, both short- and long-term, of any changes in gender role and use of medical interventions. • These implications can be psychological, social, physical, sexual, occupational, financial, and legal (Bockting et al., 2006; Lev, 2004). Courtesy of WPATH Standards of Care

30. Gender Pronouns

31. Creating a WelcomingEnvironment Example: The Counseling Center is a SAFE ZONE for individuals of all ethnicities, abilities, religions, sexual orientations, physical appearances/sizes, gender identities and expressions. • Signage • Consider the Transgender community’s “first” potential view of the providers, e.g., the website, educational materials • Post a nondiscrimination policy that includes sexual orientation and gender identity • Include LGBTQ images and language in all printed materials/brochures • Designate gender-neutral bathrooms if possible • Documentation • Create spaces on forms for “preferred pronoun” and “preferred name” • Differentiate between Sex (male, female, intersex) and Gender (man, woman, trans-man, trans-woman, agender, genderqueer) • Add a space for other so they can self identify

32. Therapy Skills • Create a safe environment for transgender clients • Assess, don’t assume, a person’s gender identity • Determine how “out” a person is and who their support group is • Help clients work through the stages of the coming out process if necessary • Use the language your clients use • Treat the presented challenge, not the person’s gender identity • Work with family members to be more accepting and supportive if necessary or if possible • Refer clients to transgender affirmative resources

33. Questions?? Becca Smith, LPC, CPCS Assistant Director Counseling Center Georgia Southern University rksmith@georgiasouthern.edu

34. Resources • Transgender Information -  annelawrence.com - Provides resources for transgender people • Trans Student Educational Resources (TSER)- transstudent.org - A youth-led organization dedicated to transforming the educational environment for trans and gender nonconforming students through advocacy and empowerment • Gender Education & Advocacy -gender.org - Focuses on needs, issues and concerns of transgender people • TransHealth -transhealth.ucsf.edu - Increasing access to comprehensive, effective, and affirming healthcare services for trans communities. • TransActive Gender Center - transactiveonline.org – Provides a range of services to empower the transgender and gender diverse population • Gender Fluid- GenderQueerid.com -The aim of Genderqueer and Non-Binary Identities is to provide awareness, information, and resources for genderqueer, non-binary, questioning, and gender non-conforming people and their allies • World Professional Association for Transgender Health (WPATH)-wpath.org – promotes evidence based care, education, research, advocacy, public policy and respect in transgender health • Campus Pride -  campuspride.org - Serves student leaders of LGBTQ and Ally campus organizations • Gay, Lesbian, Bisexual, and Transgender National Help Center National Hotline -  glnh.org or 888-843-4564 or National Youth Talkline at 800-246-7743 or email questions to info@GLBTNationalHelpCenter.org • National Center for Transgender Equality - transequality.org/ • Trans Lifeline - translifeline.org/ - Trans Lifeline Hotline: 877.565.8860 • Trans Queer Students of Color - lgbtcampus.memberclicks.net/assets/tqsoc%20support%202016.pdf • Gender Spectrum-www.genderspectrum.org/ - Helps to create a gender sensitive and inclusive environments • Human Rights Campaign- hrc.org - Civil Rights Organization