Caregiver

Respectful Service Provision: An Overview

When we asked service providers who work closely with our communities if they had any advice to pass on service providers who were less familiar with intersexed and trans issues, many said, "People are just people. Treat everyone the same".

This is true in some ways. Trans and intersexed people and our family members don't want to be singled out, made to feel like freaks, or otherwise treated as abnormal. We also don't want to be perceived as a homogenous group, stereotyped, or otherwise have our individuality removed from us.

However, we often do have specific and unique concerns relating to service provision. While some intersexed and trans people prefer that their status never be mentioned unless it is absolutely necessary, many of us appreciate those service providers who make the effort to indicate that they are aware of some of the basic issues, and that they are willing to learn more in order to improve the quality of services provided to our community.

Many of the general strategies you use to provide services that are respectful of other kinds of diversity will be useful in determining how to provide services in ways that are respectful of sex and gender diversity. We hope you will find the following suggestions useful in thinking about what specific strategies might help you in your work with our communities.

Learn More About Our Communities

- Take an active role in educating yourself, rather than expecting your trans and intersexed clients and their family members to educate you. (See our Intersexualism and Gender Identity Disorder pages for an overview of trans and intersex issues.)

- Know that there is no one experience: there as many different genders and physiologies as there are individuals. Other issues can affect an intersexed or trans person's experience, such as culture, disability, age, economic status, and religious

faith.

- Learn more about the variety of cultural and spiritual perspectives on gender; the protocols for culturally respectful communication about gender, physiology, and sexual orientation; and other aspects of cultural diversity that affect the relationship between you and your clients.

- Encourage your clients to make informed choices by providing them with resources and educational materials. This includes informing them about your ethical code of conduct and conflict resolution/complaints procedures, their human rights, and options outside the services you can provide.

- Not all intersexed and trans people are aware of resources or transition options, or are clearly decided about what they want to pursue. They may need your assistance to determine what they would need to be able to make well-informed choices, and to explore the benefits and drawbacks of different options.

- Many trans and intersexed people struggle with issues around sexuality, including sexual practices. If you are uncomfortable talking about sexuality, make an effort to find someone who can provide your clients with the services they need. Avoid making clients feel embarrassed for bringing those issues up (even if you don't feel comfortable openly addressing the issues).

- Find out what types of services are available for your intersexed and trans clients and their family members. Avoid defaulting to places like the Vancouver gender clinic to meet all service needs; encourage your client to consider gender clinics as only one option, and to become aware of other options as well.

Maintain Confidentiality

- Respecting confidentiality and using correct names and pronouns is an important yet simple means of supporting intersexed and trans people, and, as with other types of confidentiality, is a fundamental requirement for ethical service provision.

- While some trans and intersexed people are not concerned about others knowing that they are intersexed or transgendered, most prefer to maintain autonomy over decisions of when and how to tell people.

- Outing can result from overtly telling others, or by inadvertent use of incorrect gender pronouns or previous names in the presence of others. If you need clarification around what pronoun or name to use, do not ask in front of others; move to a private location.

- Even if an intersexed or trans person explicitly gives permission to reveal their identity to others, this should only be done on a need-to-know basis, and not to satisfy curiosity. Similarly, it is not appropriate to share information about an intersexed or trans person's body unless it is medically necessary to do so.

Respectful Language

- Using correct names and pronouns goes beyond confidentiality and indicates your recognition and validation of a trans or intersexed person's identity. These details count and have meaning.

- The words used to describe sexual orientation can be inadequate to describe intersexed and trans people's relationships, because they are gender-specific and don't account for changes in gender or physiology over time. If you are confused about a client's sexual orientation, consider whether you need to know this information, and if so, gently ask for clarification.

- Listen to what term(s) your client uses to describe their sense of self, and follow their lead. If you are unsure, ask what they would prefer.

- Language is very important. It's also important not to get so focused on the details that you lose your connection with your client. Don't let anxiety about getting the language "perfect" interfere with being present, approachable, and communicative.

Respect Clients' Boundaries

- It is not helpful to push trans and intersexed people and family members to pursue or reject any particular options, even if you think they are in denial or lacking perspective.

- Requests for information about a trans or intersexed person's body, sexual preferences, or transition status should only be made when it is directly relevant to the service you are providing, and should be asked in a professional and courteous manner.

- While it may, at times, be appropriate to share one's own experience with gender, intersexuality, or a trans or intersexed friend or family member, as with any other type of self-disclosure this can become a burden if the client feels you are looking to them for support or information. When you are motivated to share personal information, ask yourself whose needs will be met by doing so, and go slow.

Support Our Relationships

- Support trans and intersexed people in building and maintaining relationships outside of the relationship they have with you.

- The support systems of intersexed and trans people and their families often fail, and they often require help in maintaining them. Checking in regularly during transition a particularly stressful period for both the person going through the change and the people in their lives helps ensure that people are well supported.

- Friends and family can discourage intersexed and trans people from seeking services, and vice versa. It may be helpful to invite people to talk about how seeking service provision is affecting their relationships.

- This guide includes a section on family issues. Family members may find it helpful to learn more about some of the common experiences family members share (as well as information about what their loved one is experiencing).

Support Our Relationships

- Support trans and intersexed people in building and maintaining relationships outside of the relationship they have with you.

End Discriminatory Workplace Practices

- If you witness discrimination against a trans or intersexed client or family member in your workplace (by volunteers, staff members, other clients, or anyone else), it is your ethical and legal responsibility to address that discrimination. It can be helpful to talk with an intersexed person, trans person or family member about the general climate in your workplace, and to ask them if they would feel comfortable with you doing _____ (fill in the blank with whatever action you would take) should discrimination arise. It is not helpful to refuse someone service because you are afraid they will be treated badly by others; human rights law explicitly prohibits this type of discrimination.

- Expand existing anti-harassment and diversity policies to protect and be inclusive of intersexed and trans people. Encourage other agencies and professional peers to do this.

- When screening clients for group participation, remember that the potential discomfort of other participants is not grounds for refusing service to an intersexed person, trans person, or family member. This is as inappropriate as refusing service to a person of color because another group member is racist. This type of discrimination is explicitly banned by human rights law.

- Change policies and procedures that force intersexed and trans people to conceal their identity or prohibit diversity of gender expression. If a trans or intersexed person wants to cross-dress while receiving services, that is a reasonable request, as long as the type of clothing they wear is appropriate for a service provision setting.

- Avoid displaying symbols only of the dominant culture (such as Christmas decorations), assuming that "family" is the equivalent to the nuclear family of parents and children, or other practices that are insensitive to the diverse cultures of your

clients.

- Support trans and intersexed clients who are elderly or who have disabilities to explore issues relating to their bodies and sexuality, as you would with any other client.

A Simple Solution to the Bathroom Issue

Some spaces in society are reserved for women or for men. Intersexed and trans people may find themselves unable to access either kind of space with safety and dignity. The most obvious example of this is the public washroom, which is the cause of much fear and anxiety among many trans and intersexed individuals and limits accessibility to all public services.

Some key services, such as shelters and transition houses, are similarly divided. Intersexed and trans people may not be able to make use of them, either because access is refused outright or because it can only be accessed at too high a price outing oneself as trans or intersexed, or presenting as the "acceptable" gender/sex.

The question of what to do about gender-based services is complex. There is a simple solution to the bathroom issue: if you have single-user washrooms, remove "male" and "female" signs on the doors. There is no need to differentiate single-user bathrooms on the basis of sex/gender.

Reduce Barriers to Accessing Services

Physical Barriers

- If you are unsure how to modify your office space, entrance, or washroom to increase physical accessibility, contact one of the local disability rights.

- You can offer sessions in a client's home or in another location that is physically accessible.

Language Barriers

- When you need to talk via phone with a client who is Deaf, Hard or Hearing, or has difficulty speaking, ask if they would like you to arrange TTY/TDD access for both of you. Although the Message Relay Service provided by Telus is confidential, revealing private information (such as gender, physiology, or sexual orientation) not only to a service provider but also to the Message Relay Service operator can be overwhelming.

- Subsidize translation of material relating to intersex/trans issues into languages spoken by your client group.

- Let all your clients know that you can make large print copies of any written materials (copier enlargement features make this simple to do).

- If your organization hosts community events, subsidize the costs of ASL interpretation.

Avoid jargon and acronyms in your print materials and when talking with clients.

Financial Barriers

- Reduce your fees for people who have low incomes.

- Help your clients find out what coverage is available through the Medical Services Plan, or if subsidies are available from the Ministry of Human Resources (CA).

- Offer to help find services that are free or less costly than those you provide.

- Offer home visits if this will help with travel and childcare costs.

Geographic Barriers

- Geographic barriers are related to other factors such as physical accessibility of transportation and cost of services. Reducing these obstacles can reduce geographic barriers.

- Ask clients if traveling to a service will be feasible. If not, make an effort to find an alternative, rather than leaving it up to the client to figure out a way to manage.

- Explore fears around asking for time away from work or school. Because intersexed/trans people are vulnerable to discrimination in employment, many are reluctant to ask for time off (even when it is within their rights) because they are afraid it will be a reason to be fired or laid off.

- Find out what options are available for travel and accommodation subsidies. Explain what needs to be done to get these subsidies.

- If clients are traveling to the gender clinic, let them know they can ask that appointments with different clinic staff be scheduled consecutively, so that they are not waiting for hours between appointments.

- Help clients gather information they need to travel: maps, accommodation options, etc.

What About the Societal Barriers that I Can't Change?

Even when systemic barriers seem beyond your control as an individual service provider, you can help by:

- asking clients what they would need to participate in a program or service, and finding out if potential referrals are accessible

- being honest with your clients about the limits that exist

- supporting clients to express their frustrations

Reach Out as a Service Provider

Make an effort to reach out to trans/intersexed people and their family members, instead of putting the onus on them to raise issues with you.

- Display pamphlets and other reading and visual materials that have intersexed and transgendered content. Include trans and intersexed content in educational materials that you produce.

- Let people know you are aware of discrimination against intersexed and trans people and their family members, and that you are concerned that this history of discrimination may affect how they feel about seeking services in general, and your services in particular.

- Inform clients that you are committed to making your services respectful of gender and sex diversity, and encourage clients to offer suggestions on how to live up to that commitment.

- Recognize your power as a service provider. Ask trans and intersexed clients if they have any fears about how they will be treated by you fears about being outed, reactions to incongruities in gender presentation (the difficulties of "passing"), stigma around diagnosis, refusal for approval of surgery, etc. Addressing these issues helps people to feel understood, and makes it easier for you to find out if there are things you are doing that may inadvertently be hurtful to your clients.

- If you need to stop seeing an intersexed or trans client or family member, offer to assist in finding a replacement. Because it is challenging to find a service provider who is aware of issues faced by trans and intersexed people, and building rapport with a new service provider can be a time-consuming and tiring process, intersexed and trans people and family members may not feel they have the energy to search on their own.

Remember: It's Not Always About Gender or Sex

There are many reasons that intersexed and trans people and their family members seek services. We are complex people and our gender and sex are only two aspects of our being. While some people may be unable to articulate that they are struggling with issues relating to being trans or intersexed, it is annoying and invasive to have service providers assume that every issue somehow relates to being intersexed and trans. This can manifest in overt or subtle forms, such as:

- assuming that relationship problems, substance use, self-harm, or various physical ailments stem from being trans or intersexed, when this may be only one of a myriad of contributing factors, or a non-issue

- refusing addiction or mental health services on the grounds that staff are not qualified to deal with issues of gender transition, intersexuality, etc.

- pushing a person to work through "unresolved" issues about gender or physical sex

- expecting an intersexed or trans person to disclose information about being trans or intersexed in settings where that information is not required, or asking inappropriate questions about a person's transition status or body

"I was having problems with my vision and hearing and went to a walk-in clinic that I had visited a few times previously. My file there indicated that I was born female and that I had been on testosterone as part of gender transition.

After examining my eyes and ears, the doctor, who had never seen me before, asked me if I intended to pursue genital surgery. Startled, I stammered that I didn't think that the appearance of my genitals were relevant to my symptoms.

He chastised me for withholding information that he felt could be relevant to my situation, remarking that, "If I couldn't tell him things he felt he needed to know, he might not be able to help me".

Humiliated, I burst into tears. The most important thing to me in that moment was getting out of there, but I did manage to tell him that I thought his curiosity was inappropriate, and that even if he did need to know, questions about genitals should always be asked in as tactful a manner as possible.

To his credit, he apologized, which was more than I expected. But I would never go back there again, even if I was really sick. The more times things like this happen, the harder it is to seek any kind of medical help. When I'm sick, the last thing I want to have to worry about is having to educate a doctor. Sometimes it's easier just to wait it out and hope that I get better on my own."

Commonly Used Terms

The language used to describe members of our communities is continually changing, as people become better able to articulate the similarities and differences in our identities and experiences. There are many ways in which trans/intersexed people describe their sense of self, and it is difficult to define terms precisely. We offer these descriptions as ways of understanding some of the ways in which people describe themselves, not as a way of labeling anyone.

TWO-SPIRIT is a term used by some indigenous (First Nations) people to describe themselves in a way that is closer to their cultural construct of sex/gender/sexuality than the dominant Western view. Many of the languages of indigenous nations of North America include specific terms for gender and sexual diversity; some indigenous people may use both the general term Two-Spirit and the culturally specific term from their own language to describe themselves.

CROSSDRESSERS enjoy wearing clothing that is considered appropriate for the 'opposite' gender (i.e., someone born male wearing a skirt; someone born female wearing a full suit and tie). Some prefer to do this privately, while others enjoy publicly presenting crossdressed. Some crossdressers appreciate being referred to in the gender associated with the clothing they are wearing (regardless of their sex), while others have a gender identity unrelated to the clothing they are wearing. Because clothing is strongly defined by culture and class, what is considered "crossdressing" in one context may not in another; for example, Scottish men who wear kilts are not considered to be crossdressing, because their clothing is in line with what is considered the norm for men in their culture.

DRAG KING/QUEEN refers to those who crossdress in a showy or campy way, often for theatrical purposes and often to caricature famous men or women. 'Drag' is a term that is often associated with gay or lesbian communities; some people who perform professionally outside gay/lesbian communities prefer the term 'female/male impersonator'. While some drag kings and queens may self-identify as transgendered, many do not, as their own sense of gender identity is not affected by their performance.

TRANSSEXUALS have a gender identity that is not congruent with their body. They typically experience discomfort with the disparity between their physical bodies and their sense of self, and seek to modify their body through hormones and/or surgical procedures in order to bring their body closer to their gender identity. Most transsexuals want to be perceived as the gender that is congruent with their identity, regardless of what physical changes they have pursued.

BI-GENDERED people identify and/or express two genders, much as bilingual people can express themselves in two languages.

PAN-GENDERED people identify and/or express the many shades of gender. Multi-gendered is another way to describe this.

MTF (or M2F): Male-to-female. Generally used to refer to anyone assigned male at birth, but who identifies or expresses their gender as a woman all or part of the time.

FTM (or F2M): Female-to-male. Generally used to refer to anyone born female at birth, but who identifies or expresses their gender as a man all or part of the time.

INTERSEXED people have physical bodies outside the relatively narrow chromosomal, genital, hormonal, or other physiological ranges associated with 'male' or 'female'. People may be born intersexed, or may become intersexed as a result of an accident or medical intervention (e.g., gender transition). Intersexed people may identify as trans because they have experienced transphobia, because they feel intersexuality falls within the umbrella "trans", or because they are, in addition to being intersexed, crossdressers, bi-gendered, etc. Other intersexed people do not identify as trans. Keep in mind that there are over 600 different intersexed conditions and that as many as 1:100 individuals are intersexed.

For a more thorough list of gender terms, see:

http://www.survivorproject.org/

http://www.ftm-intl.org/Wrtngs/ftm-words.gary.html

Family Issues: An Overview

The following section is intended to give an overview of some of the conflicts that can exist within families due to transgender issues. Family is not solely the nuclear family unit of spouse and children, but includes any of the people that intersexed and trans people have deep relationships with: for some it may be adoptive or birth parents, siblings, grandparents, grandchildren, aunts, uncles, or cousins; for others it may be chosen family friends, lovers, partners, housemates, neighbours, community peers or others that are a close part of a trans and/or intersexed person's life. As you read the descriptions of concerns of partners, parents/guardians, siblings, and children, consider how these might be similar or different to the people in your own family, whatever the makeup of your family is.

In reading, please keep in mind that just as each intersexed and/or trans person's experience is unique, there is no universal experience of family members. Given that we focus on the tensions that can exist between trans and intersexed people and family members, we should point out that many family members are encouraging and supportive, and that some take a strong stand in helping counter the internalized shame and embarrassment that many intersexed and trans people feel.

Some people may have known all along that their loved one is intersexed and/or trans; others may be completely surprised to find this out. Responses upon disclosure range from excitement to disgust, depending on an individual's perspectives, their relationship with the trans/intersexed person, and their cultural beliefs about gender and sex diversity. Most trans and intersexed people spend at least part of their life (and many live their entire lives) closeted, keeping their gender identity, gender expression, or intersexuality a secret from others. A primary reason for many is a fear of family breakup.

"I had to risk the love of someone I dearly loved and wanted to be with, to make the change. Why did I? Because I simply had to become the person I was, that I was willing to give up most everything else to be with my partner but not my personhood, that I would suffer mentally and physically if I continued through to my deathbed internalizing the conflict between my inner self and the expectations placed on me by my environment. I was also sustained by a belief that our relationship could be even better if my internal conflicts were resolved. Our attempts to seek professional assistance together were met with blank stares and dead air, with one notable exception a local gynecologist who with his wife treated many transsexuals simply told her to leave me, that it never works out. She wasn't interested in leaving but wanted support for staying."

Reprinted with permission from 'TransForming Community:

Resources for trans people, intersexed people, and family members

Transcend Transgender Support & Education Society, 2001", their online version is at: http://www.transgender.org/transcend/guide or by e-mail at transcend@islandnet.org

PO Box 8673, Victoria, BC V8X 3S2

Tel: 250-413-3220

Fax: 250-479-3836

Organisation Intersex International

Guidelines for Service Providers