Providing Safe, Affirming and Evidence Based Care for Transgender Persons: Part 2

Providing Safe, Affirming
and Evidence-Based Care
for Transgender Persons:
The
Basics
DECEMBER 16, 2016

Today’s Objectives
As a result of participating in today’s presentation, you
will be able to:
 Recall terms and definitions relevant to transgender
lives and culture;
 List health disparities experienced by transgender
persons;
 Identify best practices for providing clinical services to
transgender persons.
2
12/16/2016Infectious Disease Prevention and Health Services Bureau & Johns Hopkins Bloomberg School of Public Health

Today’s Agenda
 Words, Definitions, Language Usage
 Transgender Health Disparities
 Health Policy & Research Update
 Best Practice Tips
 Open Q & A
3

Intentions vs. Impact 4

Words, Definitions, Language Use
Talking Trans
5

Sex, Gender, Sexual Orientation 6
SEX
(biological)
• CHROMOSOMES
• GENITALIA
• REPRODUCTIVE ORGANS
• SECONDARY SEX CHARACTERISTICS
GENDER
(psychosocial)
• IDENTITY: SELF-CONCEPT AS MALE /
FEMALE / OTHER
• EXPRESSION: COMMUNICATING YOUR
GENDER TO OTHERS
• ATTRIBUTION: WHAT OTHERS PERCEIVE
AND RESPOND TO
SEXUAL ORIENTATION
(biological &
psychosocial)
• EROTIC & EMOTIONAL ATTRACTION TO
OTHERS

Let’s Talk About Pronouns!
 Binary pronouns
 She, her, hers and he, him, his
 (Xena ate her food because she was hungry.)
 Common gender-neutral pronouns :
 They, them, theirs
 (Xena ate their food because they were hungry.)
 Ze, hir
 (Xena ate hir food because ze was hungry.)
 Just use my name!
 (Xena ate Xena's food because Xena was hungry)
7

HIV Disparities in
Transgender Populations
8

How many trans people are there?
 Worldwide estimates
 25 millions people1
 Estimates range 0.1% - 3%
 United States estimates
 1.4 million people
 0.6% of the population
 Baltimore estimates
 1,250 people (Wisdom of the Crowd)
 912 (Service Multiplier Method)
1. Winter et al. The Lancet 2016;
2. Williams Institute 2016
9

New HIV Positive Tests among
Trans People, 2009-2011
10
 New HIV+ test results highest in
trans people
 2.4% among trans people
 0.9% cis males & 0.2% cis females
 Gender trajectory matters
 2.7% trans feminine
 0.5% trans masculine
 New HIV+ highest in trans women
of color
 54% African American
 30% Hispanic/Latina
 3-fold increase in new HIV+ tests
in trans women at 20 years
Habarta N, Wang G, Mulatu MS, et al. HIV testing by transgender status at centers for disease control and prevention-funded sites in
the United States, Puerto Rico, and us Virgin Islands, 2009–2011. Am J Public Health. 2015;105:1917–1925.
0
0.5
1
1.5
2
2.5
3
3.5
Cis Male Cis Female Trans
Female
Trans Male
13-19 20-29 30-39 40-49 50+

HIV Prevalence: Trans Masculine
 Systematic review (2012-2015)
 6 U.S. prevalence studies
 0.4% - 4.3% (n=1)
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
4.50%
5.00%
Laboratory Confirmed HIV Prevalence
Poteat et al. JAIDS 2016
Transgender MSM risk from cisgender
male partners
“I took a certain
pleasure in
informing the
gender clinic that
even though their
program told me
that I could not
live like a gay
man, it looks like
I’m going to die
like one.”
— Lou Sullivan, gay
trans activist, 1951-
1991
11

 Global meta-analysis of laboratory-confirmed HIV
(2000-11)
 United States: 22% prevalence
 34-fold greater than the general population
 Systematic review and data synthesis (2012-2015)
 Highest: 40% among trans women of color
 Lowest: 4.5% in youth (16-24 years old)
 Incidence estimate: 2.9 per 100 person-
years
Baral et al. TLID 2013, Poteat et al. JAIDS 2016
Alexis Rivera, transgender activist
Died from HIV at age 34 (2012)
Trans women who have sex with men have the
highest HIV burden of any key population
HIV Prevalence: Trans Feminine
12

Context Matters
Why such high HIV prevalence
among trans women? 13

Stigma is a Barrier to Care-Seeking
 Delay getting health care due to
experiences of discrimination
 28% delayed care when ill or injured
 33% delayed or did not try to get preventive
care
 Anticipate discrimination in health care
 52% fear they will be refused care
 73% worry they will be treated differently
 89% feel that too few health care
professionals are adequately trained to
provide appropriate care for them
14
. Grant 2011, Lambda Legal 2010

Stigma is a Barrier to Care Provision
 Denial of medical care
 19% in a US survey of 6450
 27% in a US survey of 617
 Uninformed providers
 50% had to teach their medical provider
about transgender care
 Discrimination from a provider
 70% experienced some kind of
mistreatment, eg. providers
 Refused to touch them/excessive precautions
(15%)
 Blamed them for health status (20%)
 Used harsh/abusive language (21%)
 Were physically rough (8%)
15
Grant 2011, Lambda Legal 2010

Health Policy Update
16

Changing Gender/Sex on Identity
Documents
17
Document Government
Level
Criteria
Birth certificate State Sworn statement from a healthcare practitioner stating you
have received treatment appropriate to change sex or have
been diagnosed with an intersex condition.
Driver’s License/ID
Card
State 3 letters: self, treating physician, treating psychotherapist
stating intention to undergo gender transition.
US Passport Federal A physician statement that validates that you have either
completed or are in process of treatment for gender
transition.
Social Security
Record
Federal • Full-validity, 10-year U.S. passport showing the new
gender;
• State-issued amended birth certificate showing the new
gender;
• Court order directing legal recognition of change of
gender; or
• Medical certification of appropriate clinical treatment for
gender transition in the form of an original letter from a
licensed physician.

LGBTQ Civil Rights - Maryland
 Maryland state law prohibits discrimination in employment,
housing, credit and lending, and public accommodations based
on sexual orientation or gender identity or expression.
 Anti-Discrimination Act of 2001 (Sexual Orientation)
 Fairness for All Marylanders Act, 2013 (Gender Identity and
Expression)
 Maryland public schools are prohibited from discriminating
against students based on sexual orientation or gender
identity/expression.
 They must also adhere to a statewide bullying and harassment
prevention policy that is inclusive of bias based on real or perceived
sexual orientation or gender identity/expression.
18

Reversing Decades of Health
Care Discrimination
From Maryland Insurance Administration, Bulletin 15-33, December 10, 2015
19
The formerly permissible exclusion which reads
“treatment leading to or in connection with
transsexualism, or sex changes or modifications,
including, but not limited to surgery,” which is
found on pages B49 and B50 of the 2017 benchmark
plan and originally permitted by COMAR
31.11.06.06B(32), is required to be deleted as
federal guidance has determined that this type of
exclusion is a discriminatory benefit design
prohibited by 45 CFR § 156.200(e).
Small Employer Essential Health Benefits, item 12, page 6.

HHS Final Rule on Sec. 1557
 Issued May 13, 2016 : Effective July 18, 2016
 Provides protections based on race, color, national origin, sex,
age, and disability. Protections for LGBT people come under
the category of sex discrimination, which includes gender
identity and sex stereotyping.
 Applies to all federally-supported health programs and most
health insurance and coverage, including Medicaid, Medicare,
AIDS Drug Assistance Programs (ADAP), and individual
insurance plans purchased through a state or federal health
exchange.
 Beneficiaries cannot “be excluded for participation in, be
denied the benefits of, or otherwise be subjected to
discrimination under any health program or activity to which
[the rule] applies.”
20
Affordable Care Act Fact Sheet: What the Section 1557 regulations banning
discrimination based on gender identity mean for you. Transgender Law Center, 2016

New Rules: Collection of SOGI
Data
 ACA contains language supporting the collection of sexual
orientation and gender identity data, to further research
to end health disparities (Sec. 4302).
 HHS issued new rules on Oct. 6, 2015 that require
collection of SOGI data in clinical settings in EHRs
(effective 2018).
 CMS and ONC-IT requires EHRs to allow users to record,
change, and access structured data on sexual
orientation and gender identity.
21
to a job near you…

Research Update
22

2015 U.S. Transgender Survey 23
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). Executive Summary of the Report of the
2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.
32%
8%
limited consumption of food or drink to
avoid having to use public restrooms
had a urinary
tract infection,
kidney infection,
or other kidney
problem in past
year from
avoiding
restrooms 25%
55%
health insurance
refused to cover
transition-related
surgery
experienced a problem in the past year
with their insurance related to being
transgender (denial of gender related
care as well as routine care)
N = 27,715

Research Updates
24

 Insert palm card here
12/16/2016Infectious Disease Prevention and Health Services Bureau & Johns Hopkins Bloomberg School of Public Health 25

STROBE Study: Supporting Transgender
Research and Opportunity in the
Baltimore Environment
Funded by the Johns Hopkins Center for AIDS Research
http://www.strobebaltimore.com
26

Baltimore Trans Community
Needs Assessment
27
www.baltimore
btcstudy.com
Funded by the
Johns Hopkins
Urban Health
Institute

Count Me In, Maryland!
28
Opened Sept. 2015
109 Responses with Data
0.% 10.% 20.% 30.% 40.% 50.% 60.% 70.%
Feminine
Masculine
Genderqueer
Agender
Two Spirit
Additional
Percentage
Percentage

Transgender-Inclusive HIV
Surveillance
 Voluntary “Change Your Record”
 Secured online site
 Form allows changes to multiple data variables
 Separate collection of Sex at Birth and Current Gender
 Paper version will also be available
 Local health departments
 HIV Clinics
 Targeted Health Provider Re-Report
 Request update of Sex at Birth and Current Gender for HIV caseload
 Educational component over summer (videos, webinars)
 Community
 Health providers
 Implementation
 Pilot late 2016
 Statewide roll-out early spring 2017
29

Best Practice Tips
For serving lgbtq clients
30

Ally Skills
 Deep listening
 Embracing being “wrong”
 Removing barriers
 Educating other cisgender people
 Interrupting homophobia/transphobia
 Patient advocacy
 Getting out of the way
31

Trans-Affirming Clinic
Environments
 Avoid Ma’am, Sir, Mr/Mrs/Ms
 Use gender neutral forms of address
Written gender-neutral salutation is Mx.
 Use 2-step process to determine gender identity at
intake
32
EXAMPLE NEXT SLIDE

Example: Two-Step Gender
Question
33
1. What is your current gender identity? (Check and/or circle ALL that apply)
☐ Male
☐ Female
☐ Transgender Male/Transman/FTM
☐ Transgender Female/Transwoman/MTF
☐ Genderqueer
☐ Additional category (please specify): ________________________________
☐ Decline to answer
2. What sex were you assigned at birth? (Check one)
☐ Male
☐ Female
☐ Decline to answer
UCSF Center of Excellence for Transgender Health. 2016. Available at
http://www.transhealth.ucsf.edu/trans?page=lib-data-collection

Environments
 Do not assume gender identity or sexual orientation
 How do I know which pronoun to use
(eg, he, she, they)?
 Ask politely
 What is the presenting gender?
 Echo the language you hear
 Make an effort to use the correct pronoun consistently
 Anatomical terms – what words to use
34

Environments
 Use preferred pronouns and name
 Ask for patient preference, in private, if unsure
 Include preferred name on chart and train staff
 Defer unnecessary questions and exams
 Build rapport before performing genital exams
 Avoid satisfying your curiosity
 Conduct sensitive genital exams only when
necessary
 Always explain the purpose of the exam
 Use gender neutral terms
 Ask patients what words they prefer
 Acknowledge barriers and offer solutions
 Stress of stigma and discrimination
 Limitations of medical knowledge
 Offer to find out and get back to patient
35

Improving the HIV Continuum for Trans
Women
 Barriers to Engagement & Retention in HIV Care
 Avoidance due to stigma and past negative experiences
 Prioritization of hormone therapy
 Concerns about interactions between HIV meds and hormones
 Facilitators of Engagement & Retention in Care
 Providers knowledgeable about trans-related medical issues
 Able to provide and integrate hormone therapy and HIV care
 All staff respectful and sensitive to trans issues (eg. IDs)
 Correlates of Adherence and Viral Load
 Less stress due to trans discrimination (adherence and VL)
 Adherence to hormone therapy (adherence)
Sevelius, Ann Behv Med, 2014; Sevelius, AIDS Care, 2014
36

Gender Affirmation and HIV
Care
Top 5 Health Concerns of HIV+ trans people,
in order
1. Gender-affirming and non-discriminatory care
2. Hormone therapy and side effects
3. Mental health care, including trauma
4. Personal care, eg. nutrition
5. Antiretroviral therapy and side effects
37
Deutsch 2015 (preliminary
self-report data presented
at NHPC); Positively Trans
Survey, n = 157
TW whose HIV primary care provider is also their hormone prescriber,
more likely to:
 Have an undetectable viral
 Have an HIV primary care visit in the previous 6 months

Transgender Response Team
If you share our vision of a Maryland where new HIV
infections are rare, and where transgender and
gender nonconforming children, adolescents, adults,
and their families, participate fully as equal citizens
in safe, supportive communities where culturally and
linguistically responsive services and supports are
available, accessible, and appropriate, then join us!
To find out how, contact:
Jean-Michel Brevelle
Sexual Minorities Program Manager
Prevention and Health Promotion Administration
Maryland Department of Health and Mental Hygiene
500 North Calvert Street, 5th Floor
Baltimore, Maryland 21202
(410) 767.5016 Office
jean-michel.brevelle@maryland.gov Email
38
https://sites.google.com/site/trtnetwork/

Transgender Action Group
39
 Coalition of transpeople, service
providers, non-profits, and
volunteers organized in Fall 2012,
meetings 2nd Thurs @ noon
 Outreach to trans sex workers
every 2nd and 4th Fridays, 12-4AM
 Provides
 Legal services
 Housing and employment counseling
 Safer sex materials and information
 Referrals for HIV testing and other
services
http://www.tagoutreach.net

12/16/2016Infectious Disease Prevention and Health Services Bureau & Johns Hopkins Bloomberg School of Public Health 40
Questions?

Please fill
out and
turn in your
evaluations
Don’t
hesitate to
contact us
if you have
questions.
41
Tonia Poteat, PhD, PA-C, MPH
Assistant Professor
Department of Epidemiology
Johns Hopkins Bloomberg School of Public Health
tpoteat@jhu.edu
Jean-Michel Brevelle
Sexual Minorities Program Manager
Center for HIV/STI Integration & Capacity
Maryland Department of Health and Mental Hygiene
jean-michel.brevelle@maryland.gov

Providing Safe, Affirming and Evidence Based Care for Transgender Persons: Part 2

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Providing Safe, Affirming and Evidence Based Care for Transgender Persons: Part 2