Patient/Client Advocacy F.A.Q.

As a provider, people from many different communities and walks of life access your services. As discussed in the previous section of this guide, trans people make up one population that is vastly medically unserved and marginalized within health care and social service systems today. It is up to you to think about ways to make your space more welcoming and respectful of trans people’s needs. This chapter provides examples of respectful and appropriate responses to some of the questions health care and social service providers most frequently ask when working with trans people.

Many trans people have bad experiences accessing services, so taking the steps to create a respectful environment is critical in terms of helping your trans clients access your services with ease. A power dynamic exists in the patient/client and provider relationship, and reaching out to reduce this dynamic can create the space for your clients to feel more comfortable approaching you and being honest about their lives and needs.

This chapter will cover topics ranging from proper name and pronoun usage, to demystifying transsexual narratives and stereotypes, to respectful physical examinations.

My patient/client was assigned male at birth but is transitioning to female.  At what point should I start to use female name and pronouns for this patient?

As a matter of respect and ethical service provision, you should ask every patient/client you encounter what name and pronouns they prefer. This question has no one definitive answer, and a variety of factors contribute to  pronoun and name choice. Each trans person is unique; each person has a  different way of expressing their gender and ways in which they want others to recognize that expression. For example, some transexual women prefer that you use the pronouns “her” and “she” from the very beginning of their medical transition, while others might want you to wait before using these. Some trans people use pronouns that are not gender specific.  Still others may not wish to be referred to using a pronoun at all. It is always best to ask what language is considered respectful for each individual patient/client.  Nothing should be assumed.

Trans people have different needs and wishes at different times during transition. Your patient is the expert on their situation and needs. Respecting changes that occur over time and the different needs associated with those times is important.

Also, aim to initiate a larger discussion specifically surrounding confidentiality and “outing.”  Most trans people prefer to maintain autonomy over how and when to tell others about their transition. For example, a patient may prefer that you know and use their chosen name and pronoun in private, but may not feel comfortable with that same name and pronoun being used in the waiting room.  Similarly, finding out how your patient feels about confidentiality vis-à-vis other members of your staff can be another step towards making them feel welcome.  If your patient gives you permission to reveal their identity to members of your staff or other health care practitioners, this should only be done on a need-to-know basis.

Once you have had a clear discussion with your patient, consistently following their wishes shows respect, sensitivity, and support of your patient’s situation and decision to transition.  If your patient wants everyone on your staff to use their chosen name and specified pronouns, you might also discuss with your patient the possibility of indicating this information on their file and medical records.  The chosen name should be highlighted to indicate your patient’s preference to anyone looking at the records.

Should I write a prescription in my patient’s chosen name or in their legal name?

Laws are in place that regulate how prescriptions have to be written, and many doctors feel like they don’t have the option of prescribing medications in their patient’s chosen name. In practice, many doctors have found ways of advocating for their patients at pharmacies.

Medical care coverage is based upon the health care card number and legal name. Policy and practice regarding legal versus chosen name will vary from one pharmacy to another.  Although not every pharmacy will acknowledge a prescription in a chosen name, ultimately, it should be the patient’s decision as to which name the prescription is written in, i.e. whether or not to take this risk. Here are some other options:

If your patient would like to use their chosen name and they are worried about problems at the prescription counter, you might advise the patient to consult their pharmacist and discuss the situation before attempting to get their prescription filled. They may be able to get their pharmacist to place a note in their file stating that their chosen name is valid for their prescriptions.

Another possibility is to write the first initial of their legal name followed by their chosen name. For example, S. Jean Gagnon would be a compromise for someone legally named Sylvie  Gagnon but who lives as Jean.

A third option would be to write a prescription using your patient’s chosen name and provide them with a “letter of introduction” written on your official letterhead, which explains that your patient is trans and is pursuing a course of hormonal treatment and which provides their legal and chosen names, their health care card and driver’s license information, and your signature.

Do all transgender and transexual people need counseling to come to an understanding and acceptance of their gender identity? 

Counseling is never a prerequisite for understanding or accepting gender identity.  It may nonetheless be useful in some instances. However, there are many barriers to accessing appropriate therapy for trans people:

Therapy and counseling are expensive. As a group, trans people have a high poverty rate due to many factors including discrimination in employment, job loss, and loss of support networks. As a result many trans people cannot afford counseling on a regular basis.

Furthermore, it is difficult to find counselors and therapists who have an adequate understanding of trans issues, and this can be frustrating. A trans person may, for example, end up spending large portions of their counseling appointments trying to educate the counselor about trans issues.

Some therapists and counselors don’t believe that anyone can or should “change sex.” They may spend all the counseling time attempting to make the trans person feel more comfortable in their birth sex, for example. This enforced elimination of options is never beneficial in a therapeutic setting, and is a significant barrier to trans people trying to access counseling.

Finally, for many people of all backgrounds, therapy carries a stigma. Trans people should not be required as a general rule to go through therapy in the pre-transition stages.  Self-determination and bodily autonomy are important factors in the general sense of well-being.  Making therapy obligatory reinforces the idea that transsexuals are unable to make healthy, educated choices. It also creates an additional financial barrier to transitioning that may put above-ground methods of doing so out of many people’s reach.  At the same time, it is important to try to make counseling and therapy accessible to those trans or gender-questioning people who feel they could benefit from it. Informed counselors and therapists with sliding-scale rates are valuable assets to the trans community.

What special considerations should I take concerning examinations on the genitals or breast tissue of transsexual people? (What can I do to make these exams more comfortable for patients?) 

Physical examinations can be uncomfortable for many people. For trans people, they can be very nerve-wracking experiences. By recognizing the reasons they can be particularly difficult for trans people, you can help make their experience of physical examinations more bearable.

First of all, many people are uncomfortable being seen naked.  For trans people, the vulnerability of exposure may be compounded by shame around body parts that don’t match their presenting gender. Their alienation from these body parts might make acknowledging their presence difficult.

Secondly, some trans people have had negative experiences with medical professionals, for example, being treated like an oddity, or being examined for no other reason than to satisfy a doctor’s curiosity or as a case example for medical students. Keep this possibility in mind, as it may be one of many reasons for trust to develop more slowly than you are accustomed to between you and your patients.

Below you will find two suggestions for ways you can make examinations more comfortable for anyone, regardless of their gender identity:

1) Acknowledge the difficulty of the situation. Vocalize that you realize that this may be difficult and explain the specific reason for this type of examination. For instance, “I know this may be difficult for you, but I will need you to lift your shirt so that I may examine your chest for lumps.” Use language that is respectful of their gender identity. It can be easy to forget about appropriate gender terms when examining genitals; however, conscious respect of your client’s wishes can go a long way in establishing trust. If a transsexual woman shows up and needs a routine prostate exam, do not forget to treat her as a woman throughout the process.

2) Give people privacy. Undressing can cause discomfort. For example, a transsexual man may need to unbind his chest for a breast exam, and this can be odd to do in front of someone. Be flexible to allow your patient their highest level of comfort. If they must wear a hospital gown, offer compromises like keeping certain articles of clothing on until or unless they must be removed.

These ways to make patients comfortable can be applied to all of your patients. If your patients have a positive examination experience with you they will be more likely to be honest and upfront about their health care needs and concerns.

Do all transsexual people have a history of non-stereotypical gender play from a young age? 

No. This may be true for some transsexual people, but not all trans people have telltale “early signs.”  On the other hand, a child who does exhibit non-stereotypical gender play may never question their gender identity. At a young age, children may lack the concept of gendered play.  A young boy may not be trying to communicate anything at all by trying on his mother’s high-heeled shoes.  Witnessing this kind of behaviour should not lead to assumptions about a child’s gender and/or sexuality.

A more significant indicator of transsexuality is a person’s vocalisation of the desire to or assertion that they belong to another gender than the one they were assigned at birth.  However, while persistant vocalisation can be a good indicator of transsexuality, it is also not foolproof. Many transsexuals, for many reasons, never articulate their gender identity before adulthood.  For others, only in middle age or as seniors are they able to express their trans identity.   Age at the time of disclosure does not make anyone more or less trans.

What is the relationship between transsexuality and self-harm and self-mutilation?

People make many different changes to their bodies, genitals included. Modifications may be perceived by the individual as positive revisions, tolerable variations on previously intolerable body parts, self-mutilation, or some combination of these. Medical professionals tend to label all forms of body modification as “self-harm” or “self-mutilation,” regardless of the method used, precautions taken (sometimes otherwise recognized and valued in professional surgical settings), or relative danger of the act. The blanket use of the terms “self-harm” and “self-mutilation” ignores or dismisses the ways in which people who modify their bodies label the activity. Many people find these terms condescending or judgmental.

Some people who modify their bodies use the term “cutting” to describe the act of modification. For the purposes of this discussion, we will also use the term “cutting” to reinforce it as a viable alternative word for medical professionals.

When treating people who cut, as with anything else, mirroring  how they refer to their alterations can be a way of showing respect and creating trust. Although cutting happens a lot among transsexual and transgender people, it is not a phenomenon that is linked specifically to this community. This is a population specifically categorized by discomfort in their bodies, however. Therefore, some may resort to changing their genitals in hopes to ease their pain, either through modification, or through an active desire to mutilate themselves.

Providers, when treating a trans patient who cuts, can focus on offering options for coping, or information on how to alter the body safely if that is the intention, instead of trying to stop the activity altogether. Coercive or pathologizing interventions will likely deepen any distrust of the medical establishment that already exists. People who cut will probably continue to do so in the face of such an intervention, and they will have even fewer options for medical advice, information, or assistance if their experiences with medical professionals continue to threaten their bodily autonomy.

If a transsexual person gets pleasure from their pre-operative genitals, does that mean that they are not truly transsexual? 

No, true transsexuality is not determined by the pleasure a person gets or does not get from their genitals.  “True transsexuality” can be determined only by consistent self-identification as such. Some trans experiences with pre-op genitalia are described below. Please note that all of these responses are considered “normal” and part of the spectrum of transsexual experience.

 • Some transsexuals are not at all comfortable with their birth genitals, do not get sexual pleasure from them, and wish to have genital surgery as soon as they possibly can.

Some transsexuals may not feel entirely comfortable with their genitals, but may not be able to get surgery for medical, financial, or other reasons. They may come to a limited acceptance of their birth genitals, and get pleasure out of them, all the while looking forward to the day they can have genital surgery.

Some transsexuals choose not to have their original genitals surgically altered and do get pleasure from their genitals.

Please note:  Professionals should remember that talking about sexual pleasure within a professional/client relationship should be approached with sensitivity, as it is an intimate topic of conversation.  If you are the person raising the issue,  remember to ask yourself first if you believe your client will truly benefit from discussing the topic at this time.

My patient/client says he is transsexual but he often shows up at my office using his female birth name and looking like a girl. Is it possible that he is not really transsexual? 

It is normal for a doctor who has little experience with trans people to question whether they are doing the ethical thing by providing services requested by a trans patient. One element of this questioning is to wonder whether or not the patient is “truly” trans.  At times like this, a useful reminder for yourself is that a transsexual’s identity is not necessarily related to their public presentation.

Many circumstances can make it difficult for a person to present their preferred gender full time.  Some examples of these circumstances are listed below:

• Risk: The risk of discrimination and harassment, because they may not “pass” one hundred percent, can make it unsafe for someone to exist full time in their desired gender.

• Mental preparedness: Some transexuals may not be mentally ready to be completely out about their transsexuality. Becoming comfortable with their gender identity and with the concept of being a transsexual can be a long, slow process.

• Personal circumstances: It may be impossible for some transsexuals to present full time due to personal circumstances, for example, because they fear losing their job, or because they are a minor and their parents forbid them to present in their preferred gender.

The only person who can determine whether or not someone is transsexual is the transsexual person themselves. Health care professionals who operate on the principle of informed consent, who understand the difficulties that transsexuals face, and who respect the choices that trans people make to survive day-to-day, can rest assured that they are acting in an ethical manner.

My patient/client is a refugee. Which health care and social services are covered? How can I effectively advocate for a patient/client with a precarious immigration status? 

There are many trans people living in Canada who have migrated here from other countries. They live in Canada with a variety of immigration statuses.  While some people arriving here apply for and are granted refugee status, there are still many trans people living here without legal status, and they access whatever services they can through underground channels. Sometimes, allied professionals will provide services to non-status people without a fee, or on a sliding scale, but for the most part, it is very difficult to access health care, social services, employment, or adequate housing without status.

While in general people arriving in Québec have to wait three months in order to be eligible to access health care, this policy does not apply to refugees. Once arriving in Québec, a refugee claimant can apply for the Interim Federal Health Program, which provides access to basic health care, but does not cover nearly as many services as the provincial medicare program.

For information on access to health care and social services for refugees and others living in Canada with a precarious immigration status, check out <http://www.servicesjuridiques.org/pdf/Guide_for_community_workers.pdf>.

How can I make my services more financially accessible?

Sliding scales for services can help people to access them.  Adapting your “needs assessment forms,” used to determine the rate for which someone is eligible, can also be useful.  For instance, if a youth wishes to access a counseling slot reserved for people admissible under a sliding scale and the needs assessment deems that their parents should be able to pay for the full price of counseling, it can make a huge difference to understand that this person may not be receiving any financial support from their family. As well, it can be helpful to suggest alternatives to expensive products, for instance, a generic alternative aftercare product for electrolysis.  Providing services free of charge (e.g. needle exchanges, assistance with hormone shots) as well as referrals to less expensive services can greatly aid in reducing the costs for trans people. Accommodating a client by suggesting a payment plan over a long term, as opposed to demanding lump payments, may be realistic as well.

I’ve noticed that many trans women do sex work. I am wondering if there is a correlation in between transsexuality and sex work?

The reality is that many trans people (especially trans women and travesties) are sex workers. As we saw in the chapter “Social Determinants of Health and Harm Reduction,” access to stable employment and housing is often a challenge for trans people. For some trans people, sex work is a viable job option that can provide enough money to live on. Furthermore, many trans people find supportive community as sex workers and find sex work provides a space to feel validated and desired in their chosen gender.

With that said, Canadian laws surrounding sex work often makes it difficult for people in the industry to work safely. Advocating for safer work conditions, safer sex practices, and providing resources to sex workers on the criminalization of sex work in Canada are all ways of advocating for your patient/client.

To find more information on the laws surrounding sex work in Canada, visit < http://www.chezstella.org>.

I work at a women’s shelter, and I’m concerned that allowing access to a pre-operative trans woman will make the other women in the shelter feel unsafe. What should I do?

The presence of a penis is never a legitimate reason to deny access to services. People’s experiences of gender must never be reduced to only their genitals. Trans women have experienced sexism, some are survivors of sexual violence, and many are systemically denied access to resources and services, just like other communities of marginalized women.

There are ways to put measures in place to support the needs of the trans women, while recognizing the needs of the non-trans women in your shelter.

Some ideas to move towards a trans-inclusive space could be:

• Developing policies at your shelter regarding gender identity. This could include expanding your anti-discrimination policy to include gender identity or implementing policies about housing people according to their gender identity.

• Promoting the visibility of trans women through popular education campaigns, hiring trans people as staff, or encouraging trans people to volunteer.

•  Organizing regular trans sensitivity trainings and workshops for your staff.

Trans people are disproportionately affected by extreme poverty and homelessness, and are most often denied access to the shelter system. It is important to open dialogues about trans-inclusivity, both in your shelter, and more broadly.

My patient/client is presenting signs of a mood/personality disorder, and I’m wondering what the protocols are surrounding comorbid mental health issues? Are there any mental health issues that are contraindicative to initiating Hormone Replacement Therapy or Sex Reassignment Surgery?

Current or prior experiences of mental health issues are not absolute contraindications to the initiation of Hormone Replacement Therapy or Sex Reassignment Surgery. While it is important to follow your patient/client and support them through whatever they are struggling with, mental health issues and disability should not be a basis for refusing access to trans-specific services.

—-

ASTT(e)Q does workshops and trainings for health care and social service providers. Consider organizing a training for the staff at your clinic or organization to facilitate the process of making your space more accessible and welcoming to your trans patients/clients. To contact ASTT(e)Q for a workshop, call 514.849.0067, extension 216.