A 2015 civilian survey of transgender individuals conducted by the National Center for Transgender Equality found that during the past year, 33 percent of transgender individuals who saw a health care provider had a negative experience related to being transgender. Hopefully you’re reading this blog to learn more about providing culturally-sensitive care as you move towards cultural competence. I also encourage you to attend the Defense Centers of Excellence Psychological Health and Traumatic Brain Injury Summit in September, which will include information on working with transgender service members.
Several of these suggestions were provided in 10 Tips for Working with Transgender Patients, published by the Transgender Law Center, a civilian advocacy organization. Please refer to this document for more details. While informative, this document does not provide officially recognized guidance to inform DoD policy.
Prioritize privacy. Promote a welcoming clinic environment. Do not draw unnecessary attention to transgender patients in your clinic. Regardless of how this could occur (e.g., training residents, demonstrating appropriate behavior to other staff), be consistently courteous and treat each transgender person as you would anyone else in the clinic. Also, don’t mention their transgender status to anyone who does not need to know.
Use their preferred pronoun and name. Familiarize all clinic staff in the proper use of pronouns for use with dependent beneficiaries and with service members after their gender marker has been changed in the Defense Enrollment Eligibility Reporting System (DEERS) or if the service member has received an exception to policy. It is appropriate to politely ask the patient if you are uncertain which pronoun is preferred. For example, “I would like to be respectful, how would you like to be addressed?”
Review confidentiality and documentation ASAP. Have a conversation with your patient regarding how you plan to document the assessment process, diagnosis and any subsequent sessions. Many patients have concerns regarding the confidentiality of their health information. The patient should be informed that the diagnosis of gender dysphoria is required in order to move forward with medical transition. Accordingly, other providers such as an endocrinologist or surgeon may also be involved in the treatment plan. The service member must share the transition treatment plan with the command. A conversation early on regarding the limitations of mental health care privacy as well as when it is appropriate to share information with other professionals is important to set reasonable expectations. Also, consider a discussion about how they may disclose their status to other providers as well as their command, as this is required to ensure that transgender service members are supported and that their medical needs are considered in light of readiness requirements and deployment status during the transition process.
Create a welcoming environment. Lesbian, gay, bisexual and transgender (LGBT)-specific signs, posters and patient education materials are available for placement in your clinic to let others know that the facility is transgender-friendly. Consider leaving copies of civilian and other non-DoD governmental LGBT publications in the waiting area as appropriate. A DoD-specific LGBT poster is available for download and LGBT health literature is available from the Department of Veterans Affairs and the Centers for Disease Control.
Take a trans-affirmative approach. Normalize and validate their exploration of gender identity as they determine where they feel most comfortable on the gender continuum. As you begin, focus on the distress caused by the mismatch between biological sex and gender rather than the mismatch per se. For many, treatment will include providing support for the coming out process as they inform their command and unit, as well as family and friends.
Learn more about gender identity and related terms. Gender identity refers to the basic sense of being male or female or somewhere in between. For many individuals, gender is not binary. Gender expression lies on a continuum from masculine to feminine. It is likely that their experience of gender has differed from that of most people for quite some time and that they may have explored the continuum in an effort to find where they are most comfortable.
You should be able to articulate the overlap between gender identity and gender expression as well as discern between the two. Gender identity, gender expression, assigned sex at birth and sexual orientation each exist on a continuum (learn more about key transgender terms). The American Psychological Association has provided some information as a quick-start guide to help you better understand these terms and get oriented to providing care to transgender individuals.
Both transgender dependent beneficiaries and transgender service members alike should be advised that DoD policy only recognizes binary gender; for example, clinic demographic gender can only categorized as male or female. Service members are considered their gender assigned at birth until their gender marker change occurs in DEERS, or when a service member is officially granted an exception to policy.
Learn more about transition and coming out. Coming out as transgender is very different from coming out as gay, lesbian or bisexual. For example, the physical changes necessitate coming out to more people than just close friends and family. It will be helpful to learn about a developmental model of transgenderism, such as this brief summary of Lev’s Transgender Emergence Model. This model is referenced because it includes information about the role behavioral health providers may play in support of transgender development and does not represent official DoD guidance.
Know that discrimination, harassment and victimization are salient issues for most transgender people. Many patients may need to learn skills to cope with microaggressions (slights, insults or other behaviors, which communicate hostility or negative intent based on one’s membership in a marginalized group). Many transgender service members will need to learn strategies to deal with harassment and maltreatment as well as effective self-advocacy.
Ask about the presenting problem. Don’t assume that you know what the presenting problem is. Although they may be in your therapy chair for gender-related issues, such as an evaluation for a gender dysphoria diagnosis or for psychotherapy during the transition process, they may also be presenting with anxiety, depression or any other behavioral health issues, which may or may not be related to their gender identity.
Don’t act as a gatekeeper. Many transgender service members will be motivated to seek out behavioral health services only as a means to begin medical interventions (e.g., cross-sex hormone therapy, gender affirmation surgeries), which places you in the role of gatekeeper. You will be more clinically effective if you serve as an advocate who is focused on healthy long-term outcomes.
Don’t assume the endpoint. For each individual, transition is a unique journey. Although most will engage in cross-sex hormone therapy, a number of individuals will choose not to have surgical interventions, or may limit or pace the number of surgical interventions. Maintain an open dialogue and allow your patient to define the path. You can learn more about providing care to the transgender community in these webinars.
Dr. Holly N. O’Reilly is a contracted clinical psychologist and evidence-based practice subject matter expert at the Deployment Health Clinical Center. Her specialties include the consequences of traumatic exposure as well as gender studies.
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.