Nov. 14 – Nov. 20 is Transgender Awareness Week! GLAAD describes this week as a time to “help raise the visibility of transgender and gender non-conforming people, and address the issues the community faces.”
The transgender patients and clients we serve at Central City Concern are a valued part of our vibrant community, but they also face a number of unique barriers. According to CCC Associate Medical Director of Primary Care, Dr. Eowyn Rieke, people who identify as transgender are more likely to have difficulty finding employment and accessing housing. This, of course, increases the chances they become homeless and live in poverty, which is often how they end up as CCC patients.
Roran Everheart, an urgent care medical assistant at our Old Town Clinic, adds, “There is an overriding fear of being outed and ending up on the street. There’s a fear of violence.”
Our mental health providers also see a relationship between people who struggle with questions about their gender identity in isolation, and mental illness and substance use disorders. “Oftentimes we see that someone’s gender identity struggles play such a role in their mental illness that we actually see a relief of symptoms when people can make steps toward living the life that they believe is rightfully theirs,” says Erika Armsbury, Director of Clinical Services at our Old Town Recovery Center. “And the same goes with substance use—we see people who use substances as a means to manage whatever it is they are struggling with around who they are with respect to gender.”
Roran, who identifies as trans, understands some of this firsthand. “I wasn’t able to transition until I got into recovery,” he shares. “Gender identity is so complex. When you’re trying to figure out what your gender identity is, it’s a strain on your mental state. From my own experience, it’s hard for me to imagine how hard it must be for someone who is also homeless, addicted, and also trying to transition.”
These are the very real issues that affect the transgender community we serve; they matter profoundly to us. We also know CCC must continue working to extend the values of equity and inclusion to more and more people. In fact, increasing equity is an explicit part of our organization’s strategic plan.
In that spirit, CCC—particularly our health services—has taken steps over the last year to make our agency is more trans affirming, trans inclusive, and responsive to the experiences of transgender individuals. Staff members formed working groups. They held meetings, brainstormed, and prioritized. They consulted with our own health care consumers and colleagues.
Since that call to action, CCC’s health services have made significant advances to address the unique issues our trans patients and clients experience.
Within the past few months, every single CCC staff member across our primary care, mental health care, and substance use disorder programs has gone through a “Trans 101” training to provide an understanding of the basics. The information covered in these trainings was intended to demystify trans issues, as well as to learn how to be an ally and interact with transgender patients in appropriate, sensitive ways.
However, Eowyn emphasizes that this is not about cultural competence; instead, it’s about humility. “Competence implies that we who don’t identify as trans ‘get it.’ Instead, we’re working toward a culture of humility as it relates to gender identity—recognizing that there are great differences at play here and that we need to be humble about our assumptions.”
Old Town Clinic primary care providers received additional training on the basic medical care of transgender patients. In a separate two-session training, mental health providers at Old Town Recovery Center learned about working with transgender patients during the transition process, as well as their responsibilities related to writing assessment and approval letters for patients hoping to transition.
“We want to be sure out providers are on the same page,” Erika says. “[Providing letters] is something we want to offer our patients consistently, but it’s important for us to improve our larger understanding of trans issues because, for us and our patients, the letter isn’t the ultimate goal, nor is it the end of their journey.”
Providing CCC health staff with information doesn’t just benefit them. It’s also a way to take a common burden off our trans patients. As Roran says, “Having to train your doctor to be trans aware can be so exhausting.” Staff members who are aware of trans patients’ experiences drastically reduces the chances of retraumatizing patients with insensitivity and judgment. Instead, calling back to CCC’s goal of cultural humility, Erika says, “Even if we aren’t experts, we know enough to be open and accepting. We honor their experiences and all the things they come to us with. We can show that we want to work with them to tease out the severe mental health hardships while also supporting them around their gender identity.”
Transgender Support Group
Patients of Old Town Clinic and the Old Town Recovery Center can now find a community of support, thanks to a new group co-facilitated by Roran and Shanako DeVoll. Though in its early stages, Roran sees great potential for the group, named “Chrysalis.”
“A lot of our clients are pretty isolated in their lives,” Roran says. “When you start to navigate your gender identity without supportive family or friends, it can be lonely to not have that sounding board. This group gives them a chance to meet other people who identify as trans.”
The hour-long support groups make room for organic conversation to talk about struggles and victories, resources, and relevant topics. Roran and Shanako co-facilitate, but the group itself is largely client-led. It begins open for anyone for two meetings, then closed for the following three months to give the group time to develop a sense of community and trust. After, the group open up again. That sense of trust, Roran says, is imperative to our clients.
“Many of our clients face mental health and addiction challenges. There are already lots of groups out there for trans people, the feeling is that many of them feel cliquish. Clients with mental health challenges may not be able to navigate the social cues at larger, more established groups, so having someone like Shanako, a mental health professional, on board is great.”
Roran hopes to see the support group thrive. Early signs show interest is high, and people appreciate this opportunity to find an accepting community. “I hope that people want to come back all the time and that this first group will invite their friends to this awesome group they’ve discovered.”
Adapting Electronic Health Records
In a health care setting, it’s easy to forget infrastructure and technology can carry the same biases and blind spots that we seek to mitigate. Thankfully, CCC health services didn’t forget, and instead spearheaded substantive changes to our Electronic Health Records (EHR) system to, as Eowyn says, “reflect this culture change of becoming more trans affirming and inclusive that we’re working to embed within the organization.”
The most immediate and noticeable change is the banner when one pulls up a patient’s record. There, at the very top, is now an area that shows the patient’s pronoun and preferred name. Though small, this change will help staff interact much more appropriately in the way that the patient identifies.
The EHR system will also help health care staff ask appropriate questions related to gender identity and sexual orientation, in both content and word choice. Staff members performed hours of research to learn about best practices for asking these questions, then adapted it to CCC’s culture to be even more inclusive than what the current body of research suggests. The goal, according to Eowyn, is to structure these questions in a way so “as many people as possible have a place to feel like they belong.”
Better, more inclusive questions means gathering better, more inclusive responses. This, ultimately, will help CCC health services track how we are serving our transgender patients as a whole. In that vein, an OHSU Doctorate of Nursing student is planning a period of focus groups and one-on-one interviews during which trans patients and clients can provide direct feedback about how CCC is doing and how we can continue to improve.
Keeping the Trans Community Visible
Finally, CCC will continue to be intentional about talking about trans issues, whether internally within the CCC community, or externally with partners and constituents. (Even this blog post is part of that effort!)
According to Erika, “The more we talk about [trans issues], the more we see it, and the more we work with people who identify as trans in a safe, open, and aware way, it will have a ripple effect in the public.”
Knowing that, CCC will continue to bring stories of our trans patients, as well as the work we do to, as Erika says, “give people an opportunity for people to live as they see themselves.”