Key Populations Health Service Provision Training

Session 3: Providing KP-Friendly Services for Transgender Clients

Welcome to Session 3, where we will learn to better understand transgender clients and their unique healthcare needs.

Getting Ready For This Session

  • Remember to have your workbook and a pen or pencil handy.
  • On average, you will need about 85-100 minutes to complete the session.

Learning Objectives

By the end of this module you will be able to:

  1. Define terms related to transgender persons and persons of transgender experience
  2. Discuss challenges that transgender clients face in the healthcare environment, and strategies to address them
  3. Explain attributes of gender-affirming care
  4. Describe best practices for communicating with transgender clients

Learning Activities

  • Introduction (2 min)

    In this session we will address issues that are relevant to working with people of transgender experience. We will review skills and information that will enable healthcare workers to provide sensitive, quality care to transgender clients.

  • Pre-Session Assessment (5 min)

    Let’s start off with a quick check of your knowledge and comfort about providing KP services for transgender clients. Each question will have a score for you to track in your workbook. Please track your scores as you go through this assessment and make note of any content areas that you answered incorrectly. This exercise will help in identifying gaps and areas that need more attention as you go through the session content.

    1People of transgender experience are:

    2Why are trans people at greater risk of acquiring HIV than the general population? Select all that apply.

    3Move the slider right or left to indicate whether the statement is true or false.

    A. A trans woman is a person who was assigned male at birth and identifies as female.
    B. Trans women may avoid seeking health services due to fear of discrimination and unease about the physical exam.
    C. All trans people are gay.

    4Which of the following terms are appropriate to use in association with ‘transgender’? Select all that apply.

    5Which of the following are considered transgender health issues? Select all that apply.

  • Thinking About Gender (5 min)

    Take a moment to think back to your own childhood. Answer the following questions in your workbook:

    • What is an early message that you received about gender?
    • Where did you hear this message?
    • How did it affect you?
  • What Does it Mean to Be Transgender? (3 min)

    transgender flagTransgender people are people whose gender identity is different from the gender they were assigned at birth. ‘Trans’ is often used as shorthand for ‘transgender’.

    When we're born, a doctor usually determines that we’re male or female based on what our bodies look like. Most people who were assigned male at birth turn out to actually identify as men, and most people who were assigned female at birth grow up to be women. But for some people, their gender identity—their innate knowledge of who they are—is different from what was expected when they were born. Most of these people describe themselves as transgender.

    A transgender woman lives as a woman today, but was thought to be male when she was born. A transgender man lives as a man today, but was thought to be female when he was born. Some transgender people identify as neither male nor female, or as a combination of male and female. There are a variety of terms that people who aren't entirely male or entirely female use to describe their gender identity, such as non-binary or genderqueer.

    Everyone—transgender or not—has a gender identity. Most people never think about what their gender identity is because it matches their sex at birth.

    Being transgender means different things to different people. As with a lot of other aspects of who people are, like race or religion, there's no one way to be transgender, and no one way for transgender people to look or feel about themselves. The best way to understand what being transgender is like is to talk with transgender people and listen to their stories.

  • Beyonce (2 min)

    Let’s listen to Beyonce share her definition of ‘KP-friendly’ services.

    Transcript

    Transcript

    Hello guys. Linjani [‘How are you?’ in Ndebele]? Murisei kwamuri [‘How are things on your end?’ in Shona]? My name is Zein. My preferred name is Beyonce; I’m a trans woman currently staying in Harare.

    So, to me a KP-friendly clinic is one whereby I don’t get to be treated differently from the general population. I mean, being told that there is a special chair or bench that I can sit away from everyone else. I don’t wanna feel like someone who is abnormal. Of course, I agree that I am a little bit different from all of them, and in as much as I want to be treated differently, I am not expecting hugs and kisses—but I want to ensure that the society know that we also have the right to access clinical services without being looked at differently, being judged, discriminated, or stigmatised.

    Also, I would like to be assured that I am walking into a safe space where I get to express myself. So, I think that everyone must be sensitised, from the security guard at the gate to the nurse who is going to be giving me any services that I require without being asked unnecessary questions like why are you a trans woman? Why do you have sex with another man? Those unnecessary questions they don’t just sit well with me. If you have any personal questions that you feel they are burning, and you need answers from me specifically, please make sure that when you are establishing rapport you get as much friendly as you can so that I can get comfortable with you and I can share any information that you need or you ask the person that referred me or the CF [Community Facilitator] that referred me to this place.

    Beyonce
  • Barriers Faced by Transgender Clients (5 min)

    What barriers do you think transgender clients face in accessing healthcare? Write your thoughts in your workbook.

  • Understanding Trans Identities and Issues (18 min)

    Let’s watch this short presentation given by Dr Edson Chidovi, Senior Program Manager at Zim-TTECH, to help us get a better understanding of trans identities and issues.

    This presentation was adapted from I-TECH Trinidad Key Populations Preceptorship training.

    Transcript

    Transcript

    This session, Understanding Trans Identities and Issues, reviews skills and information for working effectively with people of transgender experience.

    Let’s review our learning objectives for this session. By the end of this session, participants will be able to:

    • Define terms related to persons of trans experience.
    • Explain challenges and issues faced by persons of trans experience.
    • Demonstrate how to help trans people to access and receive effective and sensitive healthcare services.

    Now we are going to learn more about the differences between sex and gender. Let’s start with what we mean when we say ‘sex.’ The term “sex” is a classification of a person as male or female. ‘Sex’ refers to a combination of bodily characteristics, including chromosomes, hormones, internal and external reproductive organs, and secondary sex characteristics. At birth, infants are assigned a sex, usually based on the appearance of their reproductive organs. This is what is written on the birth certificate.

    Let’s move on to the term gender. Gender refers to the socially constructed characteristics of women and men, including norms, roles, and relationships. These vary from society to society and can be changed. They include attitudes, feelings, characteristics, and behaviors that a given culture associates with a person’s biological sex. It also includes the society’s expectations about how people should act, look, think, and dress as girls, boys, men, or women.

    We’ll talk about gender identity and gender expression. Let’s start with the concept of gender identity. Gender identity refers to a person's internal, deeply held sense of their gender. All people have a gender identity! Often, this is a feeling that people have as early as 2-3 years of age. For transgender people, their own internal gender identity does not match the sex they were assigned at birth. Most people have a gender identity of man or woman (or boy or girl). For some people, their gender identity does not fit neatly into one of those two categories.

    Another important concept is that of Gender expression. This refers to the external manifestations of gender, expressed through a person's name, pronouns, clothing, haircut, behaviour, voice, mannerisms, and/or body characteristics. All people have a gender expression. Society identifies these cues as masculine and feminine, although what is considered masculine or feminine changes over time and varies by culture. Typically, trans people seek to align their gender expression with their gender identity, rather than the sex they were assigned at birth.

    Let’s review again what we mean by sexual orientation. Sexual orientation refers to how a person identifies their physical and emotional attraction to others. This refers to romantic and/or sexual attraction to people of a specific gender, though this often occurs on a continuum. Encompasses attraction/desire, behaviour, and identity. Orientations can include heterosexual, gay, lesbian, bisexual, etc. Sexual orientation may describe who we have sex with (behavior) rather than an identity, i.e., MSM, WSW.

    Some less familiar sexual orientations can include pansexual, asexual, and demisexual. Pansexual means a person who is attracted to all gender identities and sexual orientations. Asexual describes a person who experiences little to no sexual attraction or desire for sex. Asexual people may experience romantic attraction, but they do not feel the urge to act on these feelings sexually. Demi-sexual refers to a person who needs a strong emotional bond or connection in order to have sex.

    Now that we understand some of the basic concepts about sex, gender, and orientation, let’s learn more about transgender people.

    Transgender (or shall we say trans) is an umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth. People under the transgender umbrella may describe themselves using one or more of a wide variety of terms—including transgender or trans. There are many other terms associated with the term “transgender.” Some people may use these terms to describe themselves, and other people may not be comfortable with them.

    Transsexual: an older term that originated in the medical and psychological communities. This term is still preferred by some people who have permanently transitioned—or seek to transition—through medical interventions, including but not limited to hormones and/or surgeries. Some people go even further and talk about being pre-op, post-op, or non-op.

    Unlike transgender, transsexual is not an umbrella term. Many trans people do not identify as transsexual and prefer the words ‘transgender’ or just ‘trans.’ Trans: used as shorthand to mean transgender or transsexual, or to be inclusive of a wide variety of identities under the transgender umbrella.

    There is a lot of diversity within the transgender community, and there are many different types of people of trans experience. Let’s review some of these together.

    • Trans woman: Someone assigned male sex at birth whose gender identity is that of a woman.
    • Trans man: Someone assigned female sex at birth whose gender identity is that of a man.
    • Non-binary, gender-fluid, gender non-conforming, gender-flexible, gender-queer: Someone who identifies as neither gender, or both genders, or a combination of man and woman genders.
    • Androgynous: Someone who exhibits a combination of masculine and feminine characteristics, or someone who is of an indeterminate sex. This relates more to gender expression than gender identity.
    • Bi-gender: The tendency to move between masculine and feminine behaviour depending on context.

    Derogatory, offensive, insulting, and insensitive terms that refer to trans people should never be used in the health facility

    One thing to note: it is always preferable to ask a person what term they prefer, when possible. The preferred term might vary from country to country, city to city, and person to person.

    There are many derogatory, offensive, insulting, and insensitive terms used to talk about transgender people that are found in many different cultures and communities. This type of language should always be avoided in the health facility, whether a patient is present or not.

    The term cisgender may also be new for many people who are new to learning about people of trans experience. Cisgender is a term used to describe people who are not transgender. It refers to people who identify with their assigned sex at birth. A more widely understood way to describe people who are not trans is simply to say non-trans people.

    Another concept to be aware of is gender dysphoria. Gender dysphoria involves a conflict between a person's physical or assigned sex and the gender with which he/she/they identify. People with gender dysphoria may be very uncomfortable with the sex they were assigned, sometimes described as being uncomfortable with their body (particularly developments during puberty) or being uncomfortable with the expected roles of their assigned sex/gender. Not all trans people experience gender dysphoria, and not all trans people wish to change their bodies.

    Gender affirmation (transition) is the process by which individuals are affirmed in their gender identity. Altering one's birth sex is not a one-step procedure; it is a complex process that occurs over a long period of time. The exact steps involved in transition vary from person to person. It may involve social changes, medical changes, and legal changes.

    Many transgender people make social, medical, and legal changes in order to affirm their gender identity. Gender affirmation can include social, medical, and/or legal changes. Some of the social changes may be telling family, friends, and co-workers; using a different name and new pronouns; dressing differently; non-permanent changes to body/appearance such as chest binding or genital tucking, etc. It could be medical such as hormone therapy, or surgical options such as chest or breast surgery, orchiectomy, hysterectomy, genital reconstruction surgery, facial feminization surgery, vocal cord surgery, and/or other procedures. They could be legal such as changing one’s name and/or sex marker on birth certificate, driver’s license, etc. as allowed by local law.

    Let’s consider an example: A transgender woman may grow her long hair, wear traditionally feminine clothing, use a female-sounding name, and ask others to use female pronouns when referring to her. She may take cross-sex hormones and undergo surgeries to align her body with her female gender identity. She may also make legal changes, such as changing her name and sex designation on legal documents if possible.

    One important thing for all providers to note is the current terminology is “gender-affirming surgery,” and not “sex change operation” or “genital reassignment surgery.” Note: when we speak of orchiechtomy we are describing the procedure to remove one or both testicles.

    Many transgender people take hormones as part of gender affirmation. Let’s review some information about hormone use. Providers should be aware that many clients may prioritize hormone therapy over other medical care, including HIV-related care and treatment. Some trans people self-administer hormones. For instance, some trans women may use hormonal contraceptives for gender affirmation. It is best for clients to take hormones prescribed by a knowledgeable healthcare provider when possible.

    Although many options are available, gender affirmation is always an individual choice. Not all trans people pursue these social, medical, or legal changes. The decision and ability to make these changes differs from person to person and depends on many factors. People who identify as trans are trans, regardless of their medical, surgical, social, or legal status. A person is transgender based on their identity, not based on their medical, surgical, or legal status. A person does not require surgery to be transgender.

    Let’s now shift to thinking about what healthcare workers can do to effectively serve persons of trans experience. Train all staff to have a basic understanding of trans people, including the importance of using clients’ chosen names and pronouns. Ensure that forms and intake processes are inclusive and welcoming for trans patients. This means allowing space for clients to indicate that they are trans, to indicate both legal and chosen name, and to indicate pronoun. Although official forms and intake processes may be difficult to change, health facilities can find ways to ensure chosen name and gender are recorded and used regularly. It is important to note that in many cases the legal/official name on a client’s records and docket will be their legal name given at birth, but providers and other staff should make a note of the client’s chosen name and use it as much as possible.

    Providers can work to use clients’ chosen names. The patient’s chosen name will often be different than their legal name. Always use a trans person's chosen name. In addition, some trans people cannot afford a legal name change or are not yet old enough to legally change their name. Trans people should be afforded the same respect for their chosen name as anyone else who uses a name other than their name given or assigned at birth (e.g., celebrities).

    It is also very important to use the correct pronouns for your patients. Use the pronouns that the patient identifies (i.e., many trans women prefer “she” even if their legal documents designate their sex as male). Pronouns may be she, he, or they. Do not assume the client’s pronouns—always ask. A person who identifies as a certain gender, whether or not that person has taken hormones or undergone surgery, should be referred to using the pronouns appropriate for that gender. If you are not certain which pronoun to use, ask the person, "What pronouns do you use?"

    Let’s review some additional recommendations for effectively serving persons of trans experience. Ensure a unisex or gender-neutral bathroom is available. Some trans patients may not feel comfortable choosing either a men’s bathroom or a women’s bathroom. Many transgender people have experienced harassment in public bathrooms. Develop a non-discrimination policy statement that includes trans patients and prohibits discrimination on the basis of gender identity and gender expression. Offer trans-inclusive and trans-specific educational materials, posters, or visuals in the waiting area.

    There are some specific expectations that are expected of and are relevant to healthcare workers providing care for trans clients. These are:

    • Maintain confidentiality.
    • Demonstrate a non-judgmental attitude and a client-centered approach.
    • Practice effective counselling skills (these are rapport building, empathy, active listening).
    • Use positive body language (both verbal and non-verbal).
    • Increase your knowledge of KPs, and their social challenges.
    • Ensure referral agencies are trans-friendly and trans-knowledgeable.

    Let’s review some of the key take-aways from this presentation.

    • Sexual orientation and gender identity are separate parts of each person’s identity, and often develop during childhood.
    • Medical or surgical status does not determine whether a person is trans.
    • Providers should be aware of the numerous stresses that affect trans people.
    • Healthcare workers should use the chosen terms, names, and pronouns for their clients.
    • Creating a safe, welcoming, and supportive environment within the health facility is an important step to providing appropriate care to persons of trans experience.
    Dr Edson Chidovi

    Self-reflection: After watching this presentation, list two concepts shared in the presentation that you will incorporate into your work.

  • Providing Gender-Affirming Care for Transgender Clients (5 min)

    What do we mean when we say ‘gender-affirming care’? Typically, when we talk about gender-affirming care, we are referring to services that are delivered in a way that recognises and supports an individual’s gender. It involves treating them with dignity and respect. It includes both medical care and mental healthcare, and is delivered in an age-appropriate manner. Gender-affirming care is client-centred and treats people as individuals, with the goal of fostering better health outcomes.

    Many trans people make changes to their name, pronouns, and physical appearance to affirm their gender identity. This process is sometimes called transition. A person’s gender affirmation can include a variety of changes. Which changes are made, and when those changes are made, will differ for each individual person. Gender affirmation may involve:

    • Name and pronoun changes
    • Hairstyle and clothing changes
    • Gender-affirming hormone therapy
    • Gender-affirming surgeries
    • Changes in voice
  • Transgender Client Healthcare Needs (10 min)

    transgender womanIn addition to the gender-affirming medical care they require, transgender people have primary and preventive healthcare needs that are similar to those of the general population. Depending on an individual's history of gender-affirming care, primary and preventive care may require special considerations. Transgender patients often experience discrimination in the healthcare setting and lack of access to medical personnel competent in transgender medicine. This results in lack of access to preventive health services and to timely treatment of routine health problems.

    Healthcare worker awareness of specific transgender health issues and needs[1]

    Source: Transgender HIV Health Services Best Practices Guidelines, San Francisco Department of Public Health, 2007

    Healthcare workers should develop comprehensive knowledge of health and social needs among transgender clients. They should be able to talk to their clients about a range of health and social issues that impact their clients’ overall well-being, including:

    • Hormone therapy, including underground street hormone use and trends
    • Gender confirmation surgery
    • Appearance modification, such as use of silicone injections
    • Tucking and binding
    • Gender identity disclosure with partners or other individuals in the client’s social network
    • Mental health issues, such as depression and suicide
    • Medication adherence
    • Substance use issues
    • Partner disclosure of HIV status
    • Categories of potential sexual partners (primary, casual, anonymous, sex work partners), each with differing risk behaviours, and the ability to discuss these behaviours with patients/clients
    • Prevention of HIV transmission and other sexually transmitted infections (STIs)
    • Domestic violence and hate-motivated violence
    • Sex work
    • Discrimination and stigma
    • Self-esteem issues and self-efficacy issues
    • Homelessness
    • Referral networks
  • Physical Examinations for Transgender Clients (10 min)

    nurseThe physical[2] examination for a transgender client should be appropriate for the client’s anatomy, regardless of gender presentation, and without assumptions about their anatomy or identity. Sensitivity is required when taking a client’s history; it is important to keep in mind that your client may have had prior negative experiences within the healthcare setting, including discrimination, or physical or emotional abuse.

    UCSF Gender Affirming Health Program, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016. Available at transcare.ucsf.edu/guidelines.

    When conducting a physical exam, providers should use a gender-affirming approach, including referring to the client by their correct name and pronouns throughout the visit. This may also include using general terminology for body parts or asking clients if they have a preferred term that should be used. An examination should cover only those body parts that pertain to the reason for a specific visit. For example, examination of the genitalia is not appropriate in the context of a visit for an acute upper respiratory infection.

    Secondary sex characteristics may present on a spectrum of development in patients undergoing hormone therapy, dependent to some degree on duration of hormone use and age of initiation. Transgender men may have facial and body hair growth, clitoromegaly, increased muscle mass, masculine fat redistribution, androgenic alopecia, and acne. Transgender women may have breast development (often underdevelopment), feminine fat redistribution, reduced muscle mass, thinned or absent body hair, thinned or absent facial hair, softened, thinner skin, and testicles that have decreased in size or completely retract. Clients who have undergone gender-affirming surgeries may have varying physical exam findings, depending on the procedures performed, approaches used, and occurrence of complications.

    Special considerations for a vaginal exam in transgender women

    The anatomy of a neovagina created in a transgender woman differs from a natal vagina in that it is a blind cuff, lacks a cervix or surrounding fornices, and may have a more posterior orientation. As such, using an anoscope may be a more anatomically appropriate approach for a visual examination. The anoscope can be inserted, the trocar removed, and the vaginal walls visualised collapsing around the end of the anoscope as it is withdrawn.

    Special considerations for conducting a pelvic examination with transgender men

    The pelvic exam may be a traumatic and anxiety-inducing procedure for transgender men and other trans-masculine persons. Transgender men are less likely to be up to date on cervical cancer screenings, and tend to have a higher rate of inadequate cytologic sampling. It is essential to make clear to the laboratory that the sample being provided is indeed a cervical Pap smear (especially if the listed gender marker is "male") to avoid the sample being run incorrectly as an anal Pap or discarded. The use of testosterone or the presence of amenorrhoea should be indicated on the requisition.

    Other special considerations

    Binding of the chest to create a masculine appearance may lead to skin breakdown or other complications of the skin. Clients may be hesitant to remove the binder for a physical exam. Appropriate, sensitive history taking and education about safe binding is recommended for all trans male patients.

    Tucking of the testicles and penis may lead to hernias or other complications at the external inguinal ring or skin breakdown at the perineum. Thorough and sensitive history and education is recommended for all trans women.

    exclamation point

    Remember that it is important for clinicians to build rapport, and to clearly explain the reasons for asking sexually explicit questions and performing various parts of the exam. Here are some tips for building rapport with transgender clients:

    • Assure confidentiality.
    • Convey the routine nature of risk assessment questions.
    • Ask open-ended questions.
    • Reinforce healthy behaviours.

    For more information, read the ‘Tips for Building Rapport with Transgender Clients’ job aid.

    Keep in mind that individuals of trans experience are often misunderstood by members of the community, and more so by healthcare workers. Their preferred gender identity and expression are sometimes shun upon as they are thought to resemble deviance from social norms. The stigma is commonly worse in public health facilities that offer services to everyone, not just KPs. Sensitivity and acceptance are essential in the provision of care. Above all is the need to respect their human rights.

  • Clinical Services for Transgender Clients in Public Health Facilities in Zimbabwe (7 min)

    healthcare workerWhen a transgender person comes in for healthcare services, the following clinical issues should be addressed. (As mentioned earlier, develop a rapport with the client before jumping into the clinical assessment, or you may end up pushing the client away, and they may not feel comfortable being truthful.)

    The clinical issues to be covered are:

    Refer to Promoting Health for All: Participants Handbook For Healthcare Providers Focusing On Key Populations for more details on clinical care.

    Make sure that you provide information about risk reduction during the visit, especially with those clients who are HIV-positive. Some of the main messages to cover on risk reduction are:

    • Emphasise condom use with partner; explore strategies for increasing condom use.
    • Partner notification and testing.
    • Affirm good adherence to ART and stress the importance of ARVs; explore disclosure of HIV status with sex partners and family.
    • U=U (Undetectable = Untransmittable): with sustained undetectable viral load, HIV cannot be passed to partner(s) via sex.
    • HManagement of STIs and the importance of adherence to treatment.
    • Discuss concerns regarding gender transition.
    • Discuss possible patterns of isolation in relationship (often this may look like controlling behaviours that keep client away from friends and family).
    • Provide referrals as needed for additional services, including intimate partner violence, mental health, and peer support.
  • Sly (10 min)

    Sly is a 23 year old trans woman who is HIV-positive. She receives healthcare services at her local clinic. Today she has come to pick up her ARVs; as she waits for services, she confides in one of the KP community facilitators (CF):

    My experiences taking ARV pills is we take our pills from public facilities so everyone can see that we are the ones who [are taking the] pills. And some nurses, they call each other and say, ‘Come and see, that gay is here! He has come to take his pills!’ As I enter the gate, the security guard looks at me with a talking eye. The patients in the clinic queues talk behind my back, saying ‘is this a man or woman?’ I feel so uncomfortable when the reception staff look at my clothes and start talking to each other with eye contact. The pharmacy assistant looks straight into my eyes as he is dispensing drugs to me. I also struggle to use the males toilet as other users would be waiting to see if I will take out a penis or what. Sometimes I wish the ground would just swallow me up. Those are some of the experiences we face.

    After Sly has left the CF goes to tell the sister in charge (SIC) what was shared with her.

    1What should the SIC do when she hears about how Sly was treated at the facility? Select all that apply.

    2In a situation where a client like Sly feels mistreated by facility staff, what course of action do they have?

    3What can facilities do to make services more friendly to transgender persons? Write your response in your workbook.

    Sly returned to the clinic the following week for a meeting with the SIC. She was scared about what the sister had called her in for. As she waited in the reception area, she was pleasantly surprised to see the staff at the facility warmly greeting her. She wondered: Was this some kind of trap? The sister came through within a few minutes and asked Sly to follow her to her office. She welcomed her warmly to the facility and reassured her that what they were going to discuss would stay strictly between the two of them. Sly shared her feelings about the treatment she was getting at the facility. The sister apologised on behalf of her staff for the unfair treatment that Sly had been receiving. She told Sly that she had had a meeting with her staff, and they are committed to providing quality and friendly services to both her and to others who are in her circumstances.

    Sly felt comfortable enough to share her story with the sister how it is not easy being a trans woman:

    My boyfriend says he’s not comfortable roaming around the neighbourhood with me as people will start to suspect him too. Sometimes he slaps me and says ‘behave like a man’. Yeah, sometimes I really feel if I become a full woman I will get the respect from him, but these things are not easy, and you know…’

    4When Sly shares about the abuse she is experiencing, what should the SIC do? Select all that apply.

    5What measures can help in improving staff attitudes when working with transgender persons and other key population groups? Select all that apply.

  • Strategies to Overcome Barriers that Transgender Clients Face (5 min)

    Earlier in the session we identified a number of barriers that transgender clients may face when accessing healthcare services.

    In your notebook, list three strategies that you can employ to overcome some of the barriers mentioned (such as avoiding seeking primary healthcare services because of fear of discrimination or stigma, unease about the physical exam, lack of legal protection, and mental health issues such as depression, trauma, and substance use).

  • Communication Tips for Working with Transgender Clients (10 min)

    It is not possible to know someone’s gender identity based only on their name, their appearance, or the sound of their voice. Using the wrong name, pronoun, or gender can cause embarrassment and humiliation for anyone, not just transgender people. Men with high voices are often called ‘ma’am’ on the phone, and women with short hair are often addressed ‘sir’. For transgender people, being misgendered like this is common, and can be very distressing. To help prevent communication mistakes with clients, the following strategies[3] are recommended:

    Source: Affirmative Services for Transgender and Gender-Diverse People--Best Practices for Frontline healthcare Staff. National LGBT Health Education Center, 2020
    Use the client’s pronouns and chosen name

    A chosen name is the name a person goes by and wants others to use in personal communication. Many trans people have a chosen name that is different from the name on their insurance, medical record, or identification documents. Pronouns are the words people use in place of a name. Examples are she/her/hers, he/him/his, and they/them/theirs. It is good practice to politely ask. For example, you can say,

    • ‘I would like to be respectful—how would you like to be addressed?’
    • 'What name do you go by and what are your pronouns?’

    Once you know a patient’s pronouns and chosen name, make sure to always use them when talking with and about that patient. While asking for pronouns and using new pronouns may feel strange at first, it gets easier every time you do it.

    Don't guess!

    Even if you regularly collect pronouns and chosen names, there will be times when you do not have that information. In these cases, it is best not to guess a person’s gender identity and possibly get it wrong. Instead, you can avoid using words that assume gender. Here are some examples:

    • Instead of asking ‘How may I help you, sir?’ ask ‘How may I help you?’
    • Instead of using Ms. or Mr., use a person’s first name, or first and last names. For example, instead of saying ‘Ms. Moyo, please come with me’, say ‘Anita, please come with me’, or ‘Anita Moyo, please come this way’.
    • If you’re not sure of the client’s chosen name, say ‘Hello, we’re ready for you now. Please come this way.’
    • Instead of saying ‘She is here for his appointment’, say ‘The client is here in the waiting room’, or ‘Dr Dube’s patient is here.’
    Apologise for mistakes

    Mistakes happen. If you do slip, you can say something like,

    • ‘I’m sorry for using the wrong pronoun/name. I didn’t mean to be disrespectful. What name do you go by and what are your pronouns?’
    • ‘I apologise. I’m still learning. Let me try again.’

    It is not necessary to give long apologies, just be honest and open. Occasionally, a patient will have a very negative reaction to being misgendered, even after an apology. Remember that many transgender people have experienced extreme discrimination and trauma, making it challenging for them to trust others. Try to stay calm and not take their reaction personally. A thoughtful second apology can go a long way towards changing the client’s experience.

    Never refer to a person as ‘it’

    Referring to a person as ‘it’ is incredibly rude, as it is practically the same as denying they are a real person.

    doctor with stethoscope on plush heartHere are some tips for respectful, responsive communication to keep in mind when working with transgender clients:

    • Stay relaxed and make eye contact. Speak with transgender clients just as you would speak with any of your other clients.
    • Avoid asking unnecessary questions. Some people are curious about what it means to be trans and want to ask questions. However, like everyone else, most trans people want to keep their medical and personal lives private. Before asking a transgender person a personal question, first ask yourself:
      • Is my question necessary for their care or am I asking it out of my own curiosity? If it is out of your own curiosity, it is not appropriate to ask.
      • Instead think about: What do I know? What do I need to know? How can I ask for the information I need to know in a sensitive way?
    • Do not gossip or joke about transgender people. This should go without saying, but joking or gossiping about someone’s identity, appearance, etc., should not be tolerated.
    • Protect confidentiality. Only discuss a client’s gender identity with those who need to know in order to provide appropriate care. This is consistent with privacy policies concerning all clients.
    • Always use the correct name and pronouns of clients, even when they are not present. This will help maintain respect for the patient and help other staff members learn the patient’s preferences.
    • Create an environment of accountability. Don’t be afraid to politely correct your colleagues if they use the wrong names or pronouns, or if they make insensitive comments. Creating an environment of accountability and respect requires everyone to work together.

    You can read more strategies in the Best Practices for Communicating with Transgender Clients Cheat Sheet.

  • Action Plan (5 min)

    In your workbook, list actions (at least two or three) that you will take to improve how you provide services for transgender clients. Additionally, list any resources you will need and who will help, and set a goal date for the change to be implemented.

  • Post-session Self-Assessment (5 min)

    Now that you have completed this session, let’s take time to check your knowledge and comfort about providing KP-friendly services for transgender clients. Please track your scores as you go through this assessment, compare them with your pre-test scores, and make note of any content areas where you answered incorrectly.

    1People of transgender experience are:

    2Why are trans people at greater risk of acquiring HIV than the general population? Select all that apply.

    3Move the slider right or left to indicate whether the statement is true or false.

    A. A trans woman is a person who was assigned male at birth and identifies as female.
    B. Trans women may avoid seeking health services due to fear of discrimination and unease about the physical exam.
    C. All trans people are gay.

    4Which of the following terms are appropriate to use in association with ‘transgender’? Select all that apply.

    5Which of the following are considered transgender health issues? Select all that apply.

  • Summary (3 min)

    In this session we reviewed what it means to be a person who is of the transgender experience. We discussed some of the unique barriers they face in receiving healthcare services, and we shared some strategies to address those barriers. We defined some of the terms that are used in the transgender community and identified clinical services needed for prevention, care, and treatment of STIs and HIV. Additionally, we reviewed tips to help build rapport, and best practices for communicating with transgender clients.

  • Resources
    Title/Source File
    Tips for Building Rapport with Transgender Clients Click to open file.
    Operational and Service Delivery Manual for the Prevention, Care and Treatment of HIV in Zimbabwe Click to open file.
    Best Practices for Communicating with Transgender Clients Cheat Sheet Click to open file.