Engaging Clients in the LGBT and Transgender Communities

1. SHNNY Conference LGBT Panel June 2011 Alison Aldrich, LCSW Clinical Assistant Professor NYU Silver School of Social Work Alison.Aldrich@nyu.edu Engaging Clients in the LGBT and Transgender Communities

2. Goals and Objectives • Goals • To provide an overview of the unique risks and characteristics of the LGBT and Trans Community • To provide brief overview of how microagressions in every day life profoundly impact the lives of Transgender individuals as they attempt to access services (such as housing, healthcare and substance abuse treatment) • To build skills for agency staff, supervisors and practitioners in order to work more effectively with members of the LGBT communities • Objectives • Identify and explain differences between the separate continuums of sex, gender role, gender identity, sexual orientation and basic transgender terminology • Examine and assess engagement barriers often present when working with LGBT and Trans Identified clients • Begin to define, recognize and deconstruct the destructive power of microaggressions on the emotional and physical health of Transgender people

3. Microaggressions in Everyday Life for Trans Peoplesome material extracted from Microaggressions in Everyday Life; Race Gender and Sexual Orientation by Derald Wing Sue Straight Americans need... an education of the heart and soul.  They must understand - to begin with - how it can feel to spend years denying your own deepest truths, to sit silently through classes, meals, and church services while people you love toss off remarks that brutalize your soul.  Bruce Bawer, The Advocate, 28 April 1998

4. Microaggressive Stress: Impact on Emotional Wellbeingmaterial extracted from Microaggressions in Everyday Life; Race Gender and Sexual Orientation by Derald Wing Sue • Overt hate crime represent small portion of oppression faced by racial and sexual orientation minorities • The majority of oppression faced by trans individuals are ‘micro’ which are insidious, psychologically and physically draining and often not definable, illegal or open to redress • Microaggressions are the constant, continuing everyday reality of slights, insults, invalidations and indignities upon LGBT people but particularly on trans individuals • They are perpertrated by well intentioned, moral, decent family members, friends, neighbors, co workers, students, teachers, clerks, waiters, employers, health care workers and educators

5. ‘Microaggression examples’material extracted from Microaggressions in Everyday Life; Race Gender and Sexual Orientation by Derald Wing Sue • Alicia discloses to straight male therapist that she is ‘transgender’ … the therapist responds he’s not shocked as he once had a elderly male client that said he was ‘into little boys’ • Cathy’s caseworker tells her that she’ll have to go to a men’s residential drug treatment program, because she’s ‘not really a woman’ and the other women there will be uncomfortable. • Rosa tells her caseworker to please call her “Ms. Garcia.” He replies, “Why should I? I know you’re a guy. You show me that you’ve had a sex change and then I’ll call you Ms.” • The intake worker at DV said that they could not accept a transgender woman because she would scare the women in the shelter who are vulnerable because of the violence they have endured.

6. Percived ‘Minimal Harm’ of Microaggressionissome material extracted from Microaggressions in Everyday Life; Race Gender and Sexual Orientation by Derald Wing Sue • While most of us are willing to admit harmful impact of overt bias and hate crimes on physical and emotional well being of transgender individuals • Trivializing and minimalizing microagressions by straights often appear to be a defensive reaction to feeling blamed and guilty • Studies reveal that heterosexism and sexual orientation microaggressions while trivial in nature has major consequences for the Transgender people. • They have been found to: 1. cause frustration, anger, low self esteem and emotional turmoil 2. create a hostile and invalidating day to day existence 3. perpetuate stereotype threats 4. create physical health problems 5. saturates broader society w/cues that signal devaluation of identities 6. lower work productivities and problem solving abilities

7. I’m tired of …some material extracted from Microaggressions in Everyday Life; Race Gender and Sexual Orientation by Derald Wing Sue • Wondering if the kids snickering as I entered the elevator are laughing at me … • Watching straight people with less skills get job interviews over me … • The deadening silence that occurs when the conversation turns to gender identity • Wondering if things will ever get better … • Being followed by security guards every time I enter a store • Wondering if the taxi driver really did not see me trying to hail a cab • Being ‘terrified every time I have to use the rest room on the NJ Turnpike • Having to explain why I want to be called by the right pronoun • Being told they are just not ready to have a trans person in their company • Having to explain why I shouldn’t be the object of men’s ‘sexual fantasies’ • People telling me ‘things are getting better’ • Feeling threatened when approached by a male police officer

8. Unique Risks & Characteristics of Trans Community Our right to be different is, in a deep sense, the most precious right we human beings have Lillian Smith

9. Domestic violence access scenario • Tiffany is a transgender woman who has been involved in a violent relationship with a boyfriend for the past 18 months. Recently, after Tiffany was hospitalized for the third time, she came to Housing Program seeking services and benefits in order to leave the relationship. Tiffany’s caseworker called a women’s shelter that contracts with her Housing Program to speak about placing Tiffany in the facility. Tiffany’s caseworker explained to the intake coordinator at the shelter that Tiffany’s records include her old name, which is still her legal name, Michael. The caseworker explained that Tiffany met all the criteria for the shelter. The intake worker, however, said that they could not accept a transgender woman because she wasn’t really a woman and would scare the women in the shelter who are vulnerable because of the violence they have endured. She refused to complete the intake for Tiffany. • What should have happened in this situation? • Is this a scenario of discrimination? • Should the intake coordinator have done an intake for Tiffany? • Is Tiffany’s transgender history a basis for refusing her service? • What would you do to intervene?

10. Trans-woman or trans-man?some material extracted from Gender Identity Project presentation at the LGBT Community Center • Say trans-woman or woman • To refer to a person who was assigned male at birth • And lives and/or identifies as a woman • Male  Female • Say trans-man or man • To refer to a person who was assigned female at birth • And lives and/or identifies as a man • Female  Male • Yes, this is a gross oversimplification • Best way to know is to ask • Conforms with the New York City Human Rights Law

11. What we need to know about trans-needs and barrierssome material extracted from Gender Identity Project presentation at the LGBT Community Center • What ideas or thoughts come into your mind when you think or transgender people seeking health or mental health services? • What settings do trans people seek services in? • What needs or concerns might trans people seek to address • What problems of barriers might they encounter?

12. LGBT risk factorvariables associated w/ increased health risk or concernsome material extracted from Gender Identity Project presentation at the LGBT Community Center • Multiple oppressions • The impact of multiple stigmas and problems including concurrent poverty, racism, HIV and AIDS related issues and/or other concerns • Lack of social spaces • Reliance upon the trans or gay bar scene or sex-work stroll for socialization and identity affirmation • Disconnection from family and other institutions • Family, religious and social intolerance of LGBT lifestyles • Violence • The threat and/or experience of anti-gay or anti-trans violence

13. Sex role stereotypes In particular for trans-women’s communities Community myths and lack of information Internalized shame and transphobia Social marginalization, fringe existence, survival sex Unmet medical needs Openly hostile providers Discomfort with and disassociation from own bodies Magical thinking and immunity belief Insensitive, incongruent outreach and programs Lack of targeted services Largely unrecognized and unique trans risks Trans risk factorsVariables associated with an increased risk or concernsome material extracted from Gender Identity Project presentation at the LGBT Community Center

14. Unique riskssome material extracted from Gender Identity Project presentation at the LGBT Community Center • Trans-Migrants • Many trans-people migrate to urban centers seekng to reduce isolation • Others may travel long distances to seek trans-specific services • Trans Immigrants • Nearly invisible, highly marginalized, underserved communities • Hidden Trans Communities • Partners youth, elders trans men

15. Gender non-conformity is punishedAbuse, violation and systemic violence • 60% of all trans-people have been victims of violence outside the homeGenderPAC, 1st National Study on TransViolence, 1997 • Trans-people are 71 to 162 times more likely to be murdered than the average person in the United States1 - Dean Spade, Sylvia Rivera Law Project 2 - Marcus Arana, discrimination investigator with the San Francisco Human Rights Commission • A trans-person is killed every two (2.25) days somewhere in the world, 160 persons over last 12-months (only includes reported deaths) • United States is the 2nd most dangerous country in the world after Brazil with over 1-murder per monthTransgender Europe (TGEU) and the journal, Liminalis • Disconnection from self, family, friends and community • Distortion of sexuality especially in regard • Cultural imagery as pathological & deviant

16. Sexual identityand gender identity are different thingssome material extracted from Gender Identity Project presentation at the LGBT Community Center • Sexual identity • How someone identifies their own sexuality • Sexual orientation • A pattern of emotional, romantic, and/or sexual attractions • Being gay does not mean you’re trans • Being transgender does not mean you’re gay • Sexual identity and orientation are not necessarily ‘gendered’

17. Cultural differencesImpact transgender sexualitysome material extracted from Gender Identity Project presentation at the LGBT Community Center • Cultural variance • Stigma associated with trans-identities • Predominant and stereotypical gender roles • Religious structures and importance • Legal status and gender recognition • All impact the development of • Trans identities • Brazilian Travesti, Hawaiian Mahu, Indian Hijra, Islamic Khanith and Mukhannathun, Islamic Indonesian Waria, Native American"Two-spirit“, Serbian Muzana /Albanian Tybeli - "sworn virgins”, Thai Ladyboys and Kathoey, passing women (birth assigned women who lived as men), passing men (birth assigned men who lived as women), eunuchs of many cultures

18. Gender Management, Trauma & Loss If God had wanted me otherwise, He would have created me otherwise. Johann von Goethe

19. Restroom access scenariosome material extracted from Gender Identity Project presentation at the LGBT Community Center Ellen is a caseworker who recently transferred from another residential facility. Though she is not out as having a transgender history, a rumor soon spreads that she is a “pre-op” trans-woman. Her supervisor eventually calls her into his office and informs her she must use the single stall, unisex, disability restroom rather than the women’s restroom, until she has “surgery and is a real woman.” What should have happened in this situation? • Is this is a scenario of discrimination? • How should her supervisor have responded? • What about the concerns of the non-trans women in the office • What would you do to intervene?

20. Gender identity traumaAssociated with perceiving oneself as non-normative or deviantsome material extracted from Gender Identity Project presentation at the LGBT Community Center • Developmental concerns • Problems or delays • Persistent mental health concerns • Trans people often have difficulty with relationships as a result of long term trauma • Peer rejection and/or peer isolation • One of the most dangerous aspects of a trans-identity • Peer networks can be tenuous for most trans-people • Identity trauma • Requiring to manage and repress gender identity • Childhood • Adolescence • Adulthood

21. Gender managementsome material extracted from Gender Identity Project presentation at the LGBT Community Center • Survival strategies • Trans folks spend a lot of time manage their defenses • Strategies of “gender management” • Can be both adaptive and maladaptive • Functional, though often only temporarily • Over time they can engender • Acute confusion, anxiety, depression • Family members may also be effected by ‘trans stigma’ • Potent impact on sexuality

22. Breakdown of gender management strategiessome material extracted from Gender Identity Project presentation at the LGBT Community Center • Prior to transition (pre-transition), individuals often experience behavior or features associated with trauma, anxiety and depression • May confuse and frustrate self, family, friends and providers • May be misdiagnosed as • Bi-polar disorders or Axis II disorders, especially if not “out” to provider as trans • Breakdown will often coincide with the developmental and social tasks associated with a gender non-affirming • Adolescence and puberty • Adulthood • Once acknowledged, this is often experienced as • Intense, overwhelming desire to speed transition or • Sense of powerlessness or hopelessness • May generate conflict with • Economics, age-of-consent, family and coming out needs, education, physical safety

23. InterventionA client-centered and supportive gender transitionsome material extracted from Gender Identity Project presentation at the LGBT Community Center • Respects the clients autonomy • Structured around an active relationship between client and … • Family, parent or guardian • When possible • Medical provider experienced in trans-care • When medical transition is sought • Mental healthcare provider experienced in trans-care • When sought by the client • Other elements can include • Work, school, religious/spiritual entities, other family members, peer groups, social networks, and so forth

24. Substance Abuse and Mental Health Concerns Never be bullied into silence.  Never allow yourself to be made a victim.  Accept no one's definition of your life; define yourself.  Harvey Fierstein

25. Dormitory housing scenariosome material extracted from Gender Identity Project presentation at the LGBT Community Center • Cathy is a client who who lives in a shelter. Her caseworker is working to refer Cathy to drug treatment. Cathy is a transgender woman whose records still list her as Roger and who has not be able to afford to get a legal name change or change any of her ID. Her caseworker tells Cathy that she’ll have to go to a men’s residential drug treatment program, because she’s not really a woman and the other women there will be uncomfortable. • What should have happened in this situation? • Is this a scenario of discrimination? • How should her caseworker have responded? • What would you do to intervene?

26. Substance Use in LGBT and Trans Communitysome material extracted from Center CARE Recovery presentation at the LGBT Community Center • Use substances to facilitate making connections or to maintain connection • Use substances to try to feel connected, energized, loved, or loving when that is not generally their authentic (sober) experience • Use substances to deal with hurt and pain in relationships • Also use in context of relationships with drug-using partners • To feel connected or joined through use of drugs

27. Higher Risk Factors for LGBT Communitysome material extracted from Center CARE Recovery presentation at the LGBT Community Center • Risk • Lesbian and gay men are at 2 to 3 times greater risk for alcohol and drug abuse than the greater population as well as failure to decrease use with age as in the case in the general population (McKirnan & Peterson,1989; Paul, Stall & Bloomfield, 1991) • Higher rates of abuse among women • Skinner (1994) found higher rates of drinking among lesbians than among women in a geographically matched sample (Arday, et. Al. 1993) • Tobacco • Prevalence of cigarette smoking among gay men in some studies is a high as 42% compared to 27% among heterosexual counterparts (Royce and Winkelstein, 1999)

28. Higher Risk Factors for LGBT CommunityCrystal Methamphetamine use…some material extracted from Center CARE Recovery presentation at the LGBT Community Center • A well-documented crisis especially prevalent among gay, bisexual and other men who have sex with men • Nationwide • Admissions to treatment for methamphetamine and amphetamine has increased sharply since 2004 (SAMHSA) • New York City • Studies of crystal methamphetamine use among MSM’s indicate increasing rates of use over time (Halkitis, et al, 2005) • Early 1990’s – less than 5% • 2003 – increased to a high of 60%and more among MSMs in the club and circuit party scene and rising among MSMs of color and HIV infected • Approximately one in four gay and bisexexual men surveyed indicated the use of crystal meth in the period of 6 months p0rior to the assessment in 2006 (Halkitis)

29. Best practicesdelivering health care and substance abuse prevention services for LGBT Communitysome material extracted from Center CARE Recovery presentation at the LGBT Community Center • Work from a Developmental model • Recovery from trauma always a concern • Address the impact of multiple losses • Community building is an important factor • Harm reduction using a stages of change approach

30. Losssome material extracted from Center CARE Recovery presentation at the LGBT Community Center • Loss • Major aspects of central or core identities • Loss of family and friends • Loss of professional identity • Loss or disconnection from social or class status • Loss of religious identity • Loss or disconnection from ethnic or racial identity • Recognize and acknowledge loss and bereavement • Facilitate grieving