Beyond a Binary: Transgender and Nonbinary Healthcare in Michigan and Nationwide

1. Beyond a Binary: Transgender and NonbinaryHealthcare in Michigan and Nationwide Shanna K. Kattari, PhD, MEd, CSE, ACS She/Her/Hers Assistant Professor, University of Michigan Image Source: Memphis Flyer

2. Introduction • Shanna Katz Kattari, PhD, MEd, CSE, ACS (she/her pronouns) • Master’s in Human Sexuality Education (Widener) • PhD in Social Work (University of Denver) • Board Certified Sexologist (ACS) and Certified Sex Educator (AASECT) • Faculty at the University of Michigan • School of Social Work, Dept of Women’s Studies, CSHD • Intersectional research on LGBTQIA+ affirming health care access and disability/ableism • Identities: disabled cisgender White Jewish queer middle class Femme

3. Guidelines • Why are we here? • Questions: Welcome and Encouraged • Open and Honest Communication • Different Backgrounds  Different Reactions • Self Care

4. Alphabet Soup: GLBT, LGBTQ, LGBTQIA+, LGBTIQQAA, LGBTQIA2SOP…. • We are actually talking about several things • Sex • Gender identity • Gender expression • Sexual orientation • (romantic orientation)

5. Sex • This is what is assigned at birth • Male (AMAB) • Female (AFAB) • Intersex (can be assigned at birth or later in life) • Four things we use to assess 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 (everyone has a phallus; how long is it?) • Where might be some places in your life that you are required to enter your sex?

6. Gender Identity • This is who you know yourself to be • Woman • Man • Nonbinary/Enby • Genderqueer • Trans man/trans masculine • Trans woman/trans feminine • Two spirit • Agender • Genderfluid • …

7. 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 • Me? I am a cisgender women • Cisgender was coined by Julia Serano in 2006 • Based in science; trans means to go opposite directions, cis means to go the same direction

8. 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.

9. Sexual Orientation • This is who you are [sexually] attracted to. • Some examples of terms include: • Lesbian • Straight/heterosexual • Gay • Bisexual • Pansexual • Queer • Omnisexual • Two spirit • Asexual… • Romantic orientation is who you are [romantically/emotionally] attracted to. • 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 • Society tends to combine two these a lot

10. Biggest Language Note • Mirror what your patients use • Example 1: Some language is seen as outdate 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. • Some language is regional, cultural, or age specific • Example 2: Asking an older person if they identify as queer might feel hurtful, as they may have grown up with it as a pejorative term. Instead, just ask them their orientation (and then mirror it!)

11. Take a Second to Try This Yourself

12. Why does all this matter? • Transgender and nonbinary individuals face alarming rates of discrimination, refusal of care, other barriers • Michigan does not have any statewide policies protecting people from discrimination regarding gender identity and expression • Employment, housing, public accommodations, OR health care/insurance • *Note: Currently trying to wrap this into sex based discrimination, but this has not been widely discussed or tested yet • Trans/nonbinary individuals have less access to health care and face greater obstacles navigating health care systems • This increases the likeliness that trans/nonbinary individuals • Will avoid the health care system altogether • Not receive preventative care/screenings (Paps, mammograms, prostate, dental visits, cholesterol screenings, eye exams, etc.) • Are at risk for unique health concerns that go unaddressed

13. General trans/nonbinary stats • Important to note disparities to in response to stigma/discrimination not simply being transgender or nonbinary • When compared to their cisgender peers: • Higher rates of HIV and other STIs • Higher rates of substance use • Lower rates of prevention (Paps, mammograms, etc) • Higher rates of depression/anxiety • Higher rates of violence/victimization

14. MTHS 2018

15. Community Partner • Challenge: New to MI • Contacted 17 LGBTQ and trans/NB orgs • Heard anything back from three • Interest from two • Follow up and buy in from one! • ~Transcend the Binary~ • Had worked with UM Research before • Had not done CBPR before

16. Things I learned about MI • No trans inclusive policies on: • Employment • Housing • Public Accommodations • Health Care/Insurance • No extant state wide trans/NB data (other than USTS) • Very little info about trans/NB folks outside SE MI

17. Building on Existing Knowledge/Needs • TtB just finished ”Finding Our Strength/Sharing Our Strength” project • Wants to provide data to Lansing (and elsewhere) to advocate for policy change • I do health research and have background in doing health research for policy change • Decision: do statewide trans health survey • Have data for policy advocacy • Co-create trans inclusive provider scale • Better understand statewide needs of this community

18. Interdisciplinary Collaboration • Survey included questions from: • OB-GYN (Dr. Daphna Stroumsa) • Public Health/IPV (Dr. Sarah Peitzmeier) • Nursing/Sexual Health (Dr. Lee Roosevelt) • Social Work/Health Communications (Dr. Deidre Shires, MSU)

19. Challenges • New to the state • TtB has small, overworked staff/low capacity • Need to connect with hard to access community(ies) • Nay-sayers (300? Bah!) • Lots of White, young, and SE MI respondents

20. Trouble Shooting • Partnering with MORE partners! • Corktown, CGS, therapists, Jim Toy, etc. • Using member checking in and outside of MI • Focus groups, cognitive interviews, etc. • Using existing networks • Through TtB, through UM, through my new communities • Multiple recruitment strategies • Flyers, palm cards, organic online, paid online marketing • Pure grit and determination • Lots of chocolate

21. MI Trans Stats (n=660; 2018) • 38.8% report overall health as only fair or poor • 50.5% report mental health as only fair or poor • 16.8% haven’t had an annual exam in 2 years • 18.6% haven’t seen a dentist in past 5 years • 15.0% haven’t had an eye exam in past 5 years • 33.4% haven’t had a cholesterol screening in the past 5 years • 17.0% of those who are sexually active have never had an STI screening • 54.1% had ever experienced IPV

22. MI Trans Stats (n=660; 2018) • 50.3% have current depression • Additional 22.9% have had past depression • 54.3% have current anxiety • Additional 19.7% have had past anxiety • 49.8% had suicidal ideation in past year • Additional 25.1% had past suicidal ideation • 8.4% attempted suicide in past year • Additional 24.5% attempted suicide in past

23. MI Trans Stats (n=660; 2018) • Only 11.6% had insurance that covered all trans health related needs • 61.1% delayed needed health care in past year • Of those: • 16.7% did not have trans inclusive provider near them • 45.8% due to fear of gender based discrimination • 29.4% due to insurance not covering trans health needs • 11.4% insurance not accept by trans inclusive provider • 37.6% could not afford needed health care

24. MI Trans Stats (n=660; 2018) • 27.0% do not have a PCP • 31.5% of those with a PCP did not feel their PCP is trans inclusive • 69.3% have had to educate their provider on trans inclusive care • Trans related discrimination in past year: • 32.3% general health care • 29.4% in ER/ED • 28.% at mental health • 24.4% in urgent care • 22.2% at pharmacy • 15.7% at dentist

25. Trans Inclusive Provider Scale A. Passive Trans Inclusive Marketing C. Proactive Trans Inclusive Marketing B. Provider Name and Pronoun Usage

26. Trans Inclusive Provider Scale D. Internalized Trans Inclusive Knowledge and Actions F. Intake Forms E. Comfort with Trans Affirming Referrals

27. 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 exams and 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

28. 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 trans/nonbinary 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)

29. 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 • An IVF clinic that doesn’t just have heterosexual couples on their brochures/handouts • Referral lists of LGBTQIA+ (and esp trans/nonbinary) inclusive providers • Inclusive intake forms

30. Intake Forms • Relationship Status: Include Partnered/Living with Partner, as well as Married, Single, Divorced, Widowed • Also consider ‘multiple partners’ or ‘dating’ • Gender ≠ Sex. Sex is Male, Female, Intersex. Gender can include Man, Woman, Nonbinary, Genderqueer, Agender, Trans, etc. • Sex/Gender ≠ Orientation. If you have orientation boxes (lesbian, gay, straight, bisexual, queer, asexual, etc.), do not place transgender here. • 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: _______________

31. Example of a great intake form:

32. Avoid Assumptions! • Not all your patients are heterosexual or cisgender • Remember difference between identity, expression, and behavior • Ask all ofyour patients for preferred name and pronouns (not just trans and nonbinary patients) and use them. • Respect your patients’ identities, even if they don’t fit your perceptions.

33. Avoid Assumptions! • Example: Gay/bisexual men are not the only ones needing examinations of the pharynx and rectum as well as genitals • People of all orientations participate in anal intercourse and oral-genital activities. • Remember to ALWAYS use the correct pronouns of your patients. • If you mess up: acknowledge, apologize, and move on. • “Nurse, can you please bring those forms for him? Sorry, I mean, can you please bring those forms for them?

34. Treat Behavior/Bodies, Not Identity • All sexually active people with cervixes need pap smears; lesbians, nonbinary people and trans masculine people included. • Everyone with a cervix/uterus/etc (including many nonbinary people and trans men) can be susceptible to cervical/ovarian/uterine cancer. • Everyone with a prostate (including many nonbinary people and trans women) can be susceptible to prostate cancer. • Every patient should be screened for relationship/domestic violence, regardless of who they are in a relationship with.

35. Questions to Reflect on • How can inclusivity play a role in your practice? • What steps are you already taking to insure an inclusive health care environment? • What community resources can you use? • How are you including trans and nonbinary people in your ongoing education and assessment?

36. Contact the Facilitator Shanna K. Kattari Skattari@umich.edu www.ShannaKattari.com @DrShannaK 734.763.0074