Creating a safe environment for trans populations in physio

This is the first of two blog posts which reproduce articles from the Canadian Physiotherapy Association's excellent recent "Diversity in Practice" issue of their news magazine Physiotherapy Practice. A huge thank you to the authors and the CPA for permission to post this here.

On considering your role in creating a safe environment for trans populations in physiotherapy.

By Katherine Harman, PT, Ph.D., Associate Professor, Physiotherapy, Vice Chair Senate (Student Affairs), Dalhousie University, CPA Member since 1981; and Greyson Jones, Dalhousie University, Sociology and Social Anthropology, Graduate Student.

© Canadian Physiotherapy Association, Physiotherapy Practice, Diversity in Practice, Volume 7, No. 2, 2017.

At a recent event about transgender concerns on campus, a speaker presented themselves as male, and stated that on other days, their felt gender was female. They talked about binding (the common practice of compressing breasts used by some trans men to create a flatter chest), and how painful it is. Our purpose with this article is to help physiotherapists better serve the transgender community by providing information about trans health and the potential impact of binding.

Look around, and you may be surprised by the dominance of binary gender classification in our world… it is everywhere in signage, language, literature, our physical world… People are defined as pink or blue, male or female, the sports world is (almost) completely constructed that way, and to be sure, health care is no different. Think about the forms you have your patients complete, the questions that you ask as you conduct your intake interview… Our world is framed this way. In this article, we use a case study to place some of the issues we want to convey into a clinical setting.

Leslie, a 22-year-old university student, has presented at the physiotherapy clinic with a referral to have neck pain that has been present for four months assessed and treated.

In your initial interview, you observe that Leslie has a very stiff appearance, holding their head fairly still, rounded shoulders and a protective type of posture. Leslie is wearing baggy clothes, has a strained, painful facial expression and eye contact is fleeting.

You think “all of this could be explained by a fairly straightforward neck strain.”

You learn that Leslie has been studying hard, is in the final year of an undergraduate degree in neuroscience and that studying has become more difficult with the neck pain. Medications are necessary to cut the pain to allow longer periods of study, and the other medication that Leslie is taking is testosterone. No other health conditions are noted. Other things you have observed which may be relevant: heavy acne, repeated pulling of sleeves over wrists and hands, semi-agitated state.

You think “the stress of school could definitely explain the anxiety; perhaps it is going to be fairly straightforward muscle strain that will improve with a bit of passive treatment, some stretches and addressing study postures and routines”.

You ask Leslie to take off the shirt so you can do a neck examination. Leslie refuses, and makes a move to leave, ending the session… 

Transgender people often terminate a health care encounter when they feel uncomfortable with the health care provider. This turning away can lead to a disconnection with the health care system and loss of needed services, leading to undiagnosed illnesses and untreated, painful conditions.

Definitions and background

This Genderbread Person (Killerman & Bolger, 2015) helps convey some key aspects of sex and gender. Gender identity (how one ‘identifies”) and gender expression (the way someone presents themselves) are different. Also, male-ness and female-ness are portrayed as not on opposite ends of a “sex” line. Instead, they have distinct entities, and one person can have parts of each. The Genderbread Person image illustrates that gender identity and expression are also different from sexual orientation (attraction). It may not be immediately obvious, but the strong desire to become the other sex stems from self-identity, not sexuality. (Breger, 2005)

Typical diagnostic criteria state that people who identify as transgender experience a mismatch, an incongruence between the sex they are assigned at birth and their gender identity. Doctors generally determine birth sex by the baby’s external genitalia, and that predicts their socialization. However, people internally identify as male, female or elsewhere on the gender spectrum (or ‘queer’).

Leslie is a university student. University-aged people are more likely to be in transition than any other age group. That is due to developmental factors. For both gender conforming and nonconforming youth, gender identity usually develops in early childhood. This identity evolves from childhood into adolescence and adulthood, and not necessarily in a predictable way. For example, a child who is gender nonconforming or who experiences gender dysphoria may or may not identify as transgender as an adolescent. However, if gender dysphoria persist into adulthood, it is likely that that individual has practiced different forms of social transition, such as using a different name or changing their style of clothing. (Guss et al., 2015)

Gender-affirming surgery is an irreversible intervention and considered the final phase of medical gender transition. The timing of the procedure can be problematic for youth as, the patient should be of legal age for consent and have lived continuously for 12 months in the identified gender(Guss et al., 2015). For Leslie, they are taking masculinizing hormone, this can explain the heavy acne. Another thing we need to consider is that there are some phases of medical transition that are covered by insurance and many that are not. Your patient might be using testosterone obtained on the street, or binders that can cause physical harm.

Prevalence data

Recent estimates suggest that as many as 1 in 200 adults may be trans (transgender, transsexual, or transitioned); in Canada that is ~720,000 people. A survey of trans Ontarians found:

• 30% were living in their birth gender

• 23% were living in their felt gender (59% had identified trans in the past 4 yrs.)

• 42% were using hormones (Scheim & Bauer, 2015)

The Canadian Trans Youth Health Report found that almost half of trans youth used walk-in clinics for their health care and Emergency Care Departments also serve a large part of their health care (Veale et al., 2015). Physiotherapy is a primary health care service; this direct access may favour our service for trans people.

Barriers to health care

As with other vulnerable populations, multiple studies have demonstrated high prevalence (20-70%) of serious discrimination in health care. It has been reported that health care professionals have: refused to treat or touch, used excessive precautions, used harsh or abusive language, been physically rough or abusive or blamed the patient for their health status. (Ellin, 2016; Lambda Legal, 2010; Veale et al., 2015; Bauer et al., 2014) Many end their health encounters before they receive the treatment that they are seeking, avoid the doctor’s office altogether, postpone getting health care and delay or don’t seek preventive care because of their past experiences with doctors. (Veale et al., 2015; Bauer et al., 2014) In a recent British Medical Journal article, a consulting psychiatrist from Charing Cross Gender Identity Clinic decried his colleagues. Dr. Barrett explained that prescribing cross-sex hormones is effective treatment for gender dysphoria, and many of his colleagues refused to provide prescriptions. He recounted their explanations “concerns about it being dangerous (it isn’t), difficult (it isn’t), expensive (it’s not particularly)” against “deeply held Christian beliefs” or that “we are trained to treat illnesses, not to change nature” p. 1694 (Barrett, 2016). Leslie might have experienced these barriers, as the neck pain has been present for a long time (four months).

Mental health

With gender dysphoria, a significant part of the transgender experience, the estimate of 60-62% trans people with depression is not surprising. (Rotondi et al., 2011a; Rotondi et al., 2011b) The social experiences of trans youth likely contribute as well, as studies have found more bullying and physical fights than non-trans students and the fear of being hurt or bothered at school, missing school and dropping out also predominate. (Veale et al., 2015; Guss et al., 2015) The gender dysphoria can lead to even more serious mental health concerns: more than 50% hurt themselves without wanting to die, 65-75% considered suicide, 22-43 % attempted suicide and 10% tried 4+ times (Veale et al., 2015; Bauer et al., 2014). Leslie’s agitated state, the repeated pulling on long-sleeved shirt may be covering evidence of cutting.

You have made Leslie feel comfortable enough to continue with the examination… Leslie says that they do not wish to show their body below the neck. You provide a “johnny” shirt, and when you come back in the room Leslie has it very tightly wrapped. They are wearing a binder, what should we know about them?

Binding

There are many kinds of binders, available on the internet or for sale at stores such as Venus Envy (http://venusenvy.ca/). Wearing a binder can help with gender dysphoria, but it is not without risk. Many youth will use less expensive and potentially harmful materials such as ACE bandaging and duct tape. In an effort to present themselves convincingly and consistently, the recommended eight-hour limit for binding is often disregarded. Also, many trans men never have top (breast reduction) surgery and will wear a binder for years. In the absence of research on the impact of binding, we turn to testimony on blogs and sites such as Wenus. Prolonged circumferential chest compression is painful, and other impacts on health are significant. Musculoskeletal and cardiovascular consequences of binding include bruised and fractured ribs, costochondritis, spinal pain, muscle atrophy, infection, pneumonia, collapsed lung, impaired blood flow, shortness of breath, skin blistering and bleeding.

Leslie wears a binder while studying on campus, long hours sitting; the binder might be contributing to their neck pain. One of our immediate thoughts might be to recommend stopping binding.

But if Leslie follows this advice, Leslie might not attend school, leave their apartment, see their family or friends. If we are judgemental (about the practice of binding) Leslie will likely not return for more physiotherapy. Instead, having a better understanding of the practice and the potential health impact of binding will put you in a better place to provide useful information and education. The first encounter sets the tone… “Hello, my name is Katherine Harman, I prefer to be called Katherine, how would you like to be addressed?” For health records and billing reasons, a person’s birth name is what appears, but they may have another name preference. Names are very personal and it is the way we recognize each other individually. With trans people, names might change frequently, as it is an external reflection (expression) of their felt gender. Listen and ask how someone would like to called.

Creating a safe place for your trans patients goes beyond them trusting you. Many physiotherapy clinics are small, with little privacy offered, and physiotherapists are very accustomed to working physically with peoples’ bodies. However, someone with gender dysphoria may be uncomfortable with their own body, and more sensitive than other patients to touch and exposure. So, seeking ongoing permission to touch, explaining what is going to happen next and paying more attention than usual to your patient’s response to treatment would enhance Leslie’s confidence in you and will help you conduct a proper assessment.

Feelings of safety can be enhanced by the environment as well. Trans youth reported among the least safe places for them are washrooms and change rooms; (Veale et al., 2015) gender-defined places where disrobing happens. There are more single gender-neutral washrooms in public places now. Is there something about the washroom/ change room facilities, or single assessment rooms where you work that can be changed? Katherine has a Dal Ally poster on her office door that signals that her office is a safe place. She also had a window put in her office door so that even if the door is shut to discuss sensitive topics, inappropriate behaviour would be visible from the outside. The rainbow is a recognized symbol of the LGBTQ community (T- for transgender). What could you do in your clinic or marketing of your services that signals welcome?

What to do about the binder you ask? There are no studies. My thoughts about this include: counseling to remove as often as possible, perform upper extremity and neck exercises (ROM, flexibility and strength; particularly to reverse the adopted posture when wearing the binder), perform specific strength and mobility exercises for the thorax, and pay attention to skin health. There are likely others.

Lots to think about! One trans man took his own action about creating a safe space. When Rafi Daugherty went to the hospital for the birth of his first child, he wanted hospital staff to be prepared for what they were about to see—a man laboring in bed—so he posted a sign on the delivery room door. “I am a single transgender man having my first baby,” it read. “I use he/him/his pronouns and will be called ‘Abba’ (Hebrew for father) by the baby.” (Birkner, 2016).

Terms/Definitions: This list presents many of the terms you might encounter when reading or discussing trans health issues. (Guss et al., 2015)

Cross-sex hormones Use of feminizing hormones in an individual assigned male at birth, or masculinizing hormones in an individual assigned female at birth.

Female-to-male (FTM)   Individuals assigned female at birth who identify on the masculine spectrum and may undergo gender affirming medical treatments to masculinize their body.

Gender dysphoria An individual’s affective/cognitive discontent with the assigned sex. Refers to the distress that may accompany the incongruence between on’s experienced or expressed gender and one’s assigned sex.

Gender identity An individual’s internal identification as male, female, or elsewhere on the gender spectrum.

Gender nonconforming/ gender atypical An individual whose gender identity, role, or expression is not typical of individuals with the same assigned sex in a given society and historical era.

Gender queer A term which may be used by individuals whose gender identity and/or role does not conform to a binary understanding of gender as limited to the categories of male or female.

Gender role Personality, appearance, and behaviour traits that society designates as masculine or feminine.

Male-to-female (MTF) Individuals assigned male at birth who identify on the feminine spectrum and may undergo gender affirming medical treatments to feminize their body.

Sex Biological indicators of male and female, such as sex chromosomes, gonads, sex hormones, and internal/external genitalia.

Gender affirmation surgery (sex reassignment surgery) Surgery to change primary and/or secondary sex characteristics to affirm a person’s gender identity.

Transgender Adjective to describe a diverse group of individuals who cross defined categories of gender.

Transsexual   Term to describe individuals who seek to change or have changed their primary and/or secondary sex characteristics through medical interventions (hormones and/or surgery) with a permanent change in gender role.

Transition Period of time when individuals change from the gender role associated with their sex assigned at birth to a different gender role. The nature and duration of transition are variable and individualized.

Katherine is an Associate Professor at Dalhousie University and a Dal Ally (Dal Allies exists to support students, staff, and faculty of the Rainbow community by encouraging respect and diversity. http://www.dal.ca/campus_life/student_ services/health-and-wellness/lgbtq.html).

Greyson is a transgender man, graduate student, advocate for transgender health and an active blogger, who manages the Tumblr.com site Wenus, where ~12,000 people go to discuss trans issues.

Reference List

Barrett, J. (2016). Doctors are failing to help people with gender dysphoria: conservatism in treating trans people in primary care is unacceptable. British Medical Journal, 352(March 30), i1694.

Bauer, G., Scheim, A. D. M., & Massarella, C. (2014). Reported Emergency Department avoidance, use and experiences of transgender persons in Ontario, Canada:  results from a respondent-driven sampling survey. Annals of Emergency Medicine, 63(6), 713-720.

Birkner, G. (2016). Jewish transgender man gives birth and embraces life as a single ‘abba’. Retrieved from Jewish Telegraphic Agency

Ellin, A. (2016). Transgender patients face challenges at the hospital. Retrieved from New York Times Guss, C., Shumer, D., & Katz-Wise, S. (2015). Transgender and gender nonconforming adolescent care:  psychosocial and medical considerations. Current Opinion in Pediatrics, 27(4), 421-426.

Killerman, S., & Bolger, M. (2015). The Genderbread Person v2.0. Retrieved from its pronounced METRO sexual Lambda Legal. (2010). When Health Care Isn’t Caring: Lamba Legal’s Survey of Discrimination Against LGBT People and People with HIV New York: Lambda Legal. Retrieved from www.lambdalegal.org/health-care-report

Rotondi, K., Bauer, G., Scanlon, K., Kaay, M., Travers, R., & Travers, A. (2011a). Prevalence of and risk and protective factors for depression in female-to-male transgender Ontarians: Trans PULSE Project. Canadian Journal of Mental Health, 30(2), 135-155.

Rotondi, K., Bauer, G., Travers, R., Travers, A., Scanlon, K., & Kaay, M. (2011b). Depression in male-to-female transgender Ontarians:  results from the Trans PULSE Project. Canadian Journal of Mental Health, 30(2), 113-133.

Scheim, A., & Bauer, G. (2015). Sex and gender diversity among transgender persons in Ontario, Canada:  Results from a respondent-driven sampling survey. The Journal of Sex Research, 52(1), 1-14.

Veale, J., Saewyc, E., Frohard-Dourlent, H., Dobson, S., & Clark, B. (2015). Being Safe, Being Me: Results of the Canadian Trans Youth Health Survey Vancouver: Stigma and Resilience Among Vulnerable Youth Centre, School of Nursing, UBC.

© Canadian Physiotherapy Association, Physiotherapy Practice, Diversity in Practice, Volume 7, No. 2, 2017.