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Deconstructing the Gender Binary in Mental Health ...
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Presentation and Q&A
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Hello and welcome. I'm Shereen Khan, Social Work Expert for SMI Advisor and Senior Director of Workforce and Organizational Development at Thresholds, Illinois' oldest and largest provider of community mental health services. I am pleased that you are joining us for today's SMI Advisor webinar, Deconstructing the Gender Binary in Mental Health Services. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now, I would like to introduce you to the faculty for today's webinar, Dr. Lisa Rosano. Dr. Lisa Rosano is Associate Professor in the Department of Psychiatry at the University of Illinois at Chicago, UIC, serving as Deputy Director for the Department's Center on Mental Health Services, Research and Policy, and as Director of Graduate Studies at the UIC College of Medicine. For nearly 30 years, she has conducted research, evaluation, and education programs dedicated to improving the health, wellness, and community participation of people with mental health conditions. Dr. Rosano has served as Principal Investigator, Co-PI, Site PI for projects from a diverse array of funders, including SAMHSA, the National Institute on Disability, Independent Living, and Rehabilitation Research, the National Institute of Mental Health, and the Patient-Centered Outcomes Research Institute. Her portfolio includes funded programs examining health disparities, medication adherence, service intentions for individuals with co-occurring physical and behavioral health conditions, translating evidence-informed practices for new target populations, and addressing the education and training needs of the integrated behavioral health care workforce. Her research and educational contributions have been recognized with awards, including those from professional associations, community advocates, and the University of Illinois. Currently, Dr. Rosano is Principal Investigator for a five-year Federal Disability Rehabilitation Research Program, focused on health literacy, and Co-Principal Investigator for a Rehabilitation Research and Training Center on Health and Function. In addition to her academic appointments, Dr. Rosano is Vice President for Research at Thresholds and Co-Chair for the American Psychological Association's Task Force on Serious Mental Illness and Serious Emotional Disturbance. Welcome, Dr. Rosano, and thank you for leading today's webinar. Thanks so much, Shireen. I really appreciate it, and I just want to say how grateful I am to SMI Advisor and the whole team for putting this presentation together. I have no disclosures to report. I will note that some of this research has been supported both with medical students and grants to our center at UIC. Here are the points that we hope to cover in this presentation in terms of deconstructing the gender binary. I will say that this discussion is going to highlight what I think are some distinct challenges in terms of working with this population, and I think that's something that all of us here will probably recognize, is that this is an area that is continuing to evolve at a really, really fast pace. And so the things that we say today are things that we may see evolve, and I think some of the data that we're going to talk about today really represents that. Here are the learning objectives in terms of this presentation, and then I think a place to start would be to go over some terms. I'd like to say that my inclination is to use as much person-first intersectional language as I can. I've endeavored to go to these communities and read and learn about them to ensure that I use person-first language. I will apologize in advance if at some point I'm not as exacting or I might use a term that someone is less likely to be familiar with, but I do think language is important, and I do think language around this group of individuals is particularly important. So, where to begin? The truth is we begin with sex, and in sex what I mean there is what we are assigned at birth, primarily genetically or maybe what we see during an ultrasound prenatally. This is generally determined, again, genetics or external genitalia, but in some cases, and this is important to remember, individuals are born as infants in an intersex type of category where they don't have well-defined external genitalia that present as defined male or defined female. That's a really important concept because based on this, even at birth, individuals who are intersex may be assigned one sex or the other based on that presentation. That population has an entire experience developmentally both biologically, socially, and emotionally that can be very distinct, and so I think while we may talk about some concepts of intersex people, that would be in and of itself an entire component of treatment of a population, so I just want to say that. When we talk about gender, we really start to talk about the appearance and more socially constructive cultural types of nuance, and what we have in gender is both cognitive constructs in terms of our identity as well as our roles or our behavioral constructs of how we either display or act within that gender construct. I think the thing that's important here is that sex and gender primarily as our approach has been a dimorphic kind of construct because you're one or you're the other, and that's really come from sex research, and the important part about sexual dimorphism in humans is that this is something that really comes from our neurological composition. It's really driven from the fact that we are dimorphically reproductive as humans. We have dimorphic gametes, but the question is whether these organic and biological functions really translate to our social and emotional and even cognitive structures. Here is where I'll introduce the notion of sexual orientation, which is a very separate construct from sex or gender, and this is really the emotional connectiveness that people identify in terms of their sexual orientation. I will tell you here that what we might consider the more traditional terms of heterosexual, gay, lesbian, and bisexual are terms that many people, even within this community, don't necessarily identify with as compartmentalizing, as limiting, and so there are as many terms as you can see here for people regardless of their sex, regardless of their gender or gender identity that leads them to how they might identify their sexual orientation. So what are we really revealing with gender? Sex creates a foundation for gender, which then provides us with behavioral and cognitive frameworks, which are really scripts when you think about it. So when we have a party or we have an event where we identify people and say we're going to reveal gender, I would contend not entirely cynically, we're actually having a sex reveal party, which is probably not terminology that most people are going to want to use with an infant, but when we identify that we're having a person of one sex or the other and we now associate it with particular behaviors, particular colors, particular attitudes toward that individual, we as a culture are defining the script that goes along with that sex. What's really important for that is that we often set some of these things into play even before humans are born. Many gender reveal parties happen before infants are born, and so we're already telling people this is how you might approach this human. What I think is important about that is if you look at human development from a perspective, say, of birth to 22 or 24 months, we are in a primarily sensory motor state. We don't have big cognitive structures about what it means to be male or female. We're trying to push up on our elbows. We're trying to sit up with our core strength, and when you think about the developmental milestones, processes, and needs of human infants from birth to a period of time, they are not so sexually dimorphic because what human infants need is not necessarily going to be separate based on sex or gender at that age, so this is something to consider. We see this in probably the earliest research in gender, and so these behavioral and cognitive constructs started to come to life in the 1970s, and you see a lot of momentum around women's studies, around feminist psychology, cultural aspects of psychology and psychiatry, and what we have is an approach to gender and gender constructs that still, to some degree, are dimorphic, but they're orthogonal, and by that, what we have here in, say, BEMS research is the notion that just because you might endorse something that's traditionally a behavior or a state associated with a man or masculinity, it does not mean that you can't necessarily endorse something that might be more typical of femininity. Now, what's an issue here is that BEMS construct felt you could be high or low on both, you could vary based on your own sex, and so you see here in the table, if you're low on both, you might have an undifferentiated gender role, or if you're high on both, you have what we would call an androgynous gender role, and what I think is so interesting about androgyny is typically that term is applied in, kind of misapplied, because when you see somebody who doesn't have a distinct gender one way or another, you might think, hey, that person looks very androgynous. In truth, that concept would be that they're highly in reflecting both masculine and feminine things. The other thing that I think is important about attribution and the social and cognitive constructs of gender in the dimorphic state is that here you can see the list of items for masculinity and femininity. When you look at these items, it's interesting how they came up with them. I don't know why having, you know, love of a child over on the femininity side isn't something that you wouldn't see over as representing masculinity, and so endorsement of these characteristics not only would define your gender role, but endorsement of these characteristics can sometimes lead people to consider cross-sex behaviors, and in fact, it is the attribution about cross-sex behaviors where you see the most stigma. Think about the attributions of what we might consider an effeminate man or a masculine woman. Typically, we're going to make attributions based on sexual orientation, but there can be very negative attributions, at least historically, about people who step out of their own sexist gender role and might endorse or practice into the gender of someone else. We also see that there are some inherent social characteristics when we have to give a gendered adjective to certain people. When we have to say someone is a male model or a female pilot, we're suggesting that the construct of pilot or the construct of model is inherently gendered, and so if a person isn't in that construct, we need to give that gendered adjective to ensure that we understand it. So cognitively and behaviorally, we have very well-defined scripts, and it's these scripts which sometimes can create tension for people in terms of how they identify and how they want to display themselves and display gendered behaviors. This has led us to a conversation about what are these gender identities, and where we find ourselves now is in three bigger categories, and I say bigger categories because I think these are fluid categories, and I don't necessarily think in another couple of decades we might even be using these terms. When we refer to an individual as cisgender, that would be a term to apply to an individual whose gender identity and concept of their gender role is measured as sameness, let's say, with their sex. So if you're born a female and you have female reproductive genetic material and female reproductive systems, you identify as a woman, you might be considered a cisgender person. What's important about that, and again, an example of the intersectionality of sexual orientation, cisgender people can be lesbian. Cisgender people can be gay. Men, for example, where they don't have discontinuity, let's say, between their sex at birth and their gender identity. Transgender individuals, regardless of their sexual orientation, are typically individuals who have a gender identity which would be the other to their born or their biological sex. For many individuals now, to identify as transgender would mean that they are transitioning from a state of being one gender to living their life as the other gender, and I'll say more about that later in the presentation. The important thing is that they are making a movement, perhaps medically or surgically or in whatever way they identify, to then live and present as the other gender. Gender non-binary and non-conforming individuals have, as a community, adopted the term NBs. And so when I use the term NB, I just want to be certain that everyone recognizes that this is a term within that community that many individuals as gender non-binary have chosen to define their experience. The gender non-binary or non-conforming person does not necessarily look at their gender as having to be equitable or balanced with their sex. At the same time, that person may not have a desire to transition or to present in a really constructed or compartmentalized way as the other gender. They want to operate in whatever gender space in terms of the attributions or behaviors that they find most acceptable to themselves without some kind of marker that it would be more indicative of a female person or more indicative of a male person. We also have people who, you know, they might identify as genderqueer or agender, where the queerness of gender is that people don't really want to place themselves in one group or another or individuals who are moving between two genders. Agender people really think of themselves as individuals who have characteristics of both male and female people and move, you know, equally between those. You also have people in the agender group who don't necessarily embrace the idea of sexual dimorphism at all and that there are only two genders or not mixed genders for people in terms of that intersectionality. Gender fluidity is something that we see among people who, again, are going to move kind of freely between these two constructs without a lot of feeling that they have to be in one particular compartment or the other. The idea of gender fluidity, I think, though, still inherently has some component of the sexual dimorphism because you need the two poles to move between masculinity and femininity. So in that regard, some of these terms have, again, set up this dualism that if you're more of one thing, you can't necessarily be the other thing, which has moved away from that construct that we saw in the BEM literature, which looked at masculinity as freely moving things that were not dependent on, if you move more positively toward one, you are moving more negatively toward the other. Now, this brings us to a conversation of where gender and gender fluidity might be in mental health. What's very important for us as practitioners to remember is that individuals who move freely or express their gender in perhaps what might be considered non-traditional ways do not necessarily indicate that they have any type of psychiatric illness, any type of negative mental health manifestation, and really any type of psychopathology at all. What's important is that gender is a lifelong process. In fact, one of the things later in her own life as a researcher, BEM was studying gender across the lifespan and found that gender was not static and that as people aged and their parental or social, marital, even work roles changed, their gender roles changed along with that. People operating with some gender fluidity may find it helpful to describe themselves in this way because it reduces the stress of them having to take a side and then somehow then feeling like if they change their mind or they change their emotional state, that they somehow are moving away and that creates stress for them. I wanted to take a moment to also mention that in neuroscience, people are starting to identify that the idea of sexual dimorphism from a gender perspective might be a much older paradigm than we realized. And what you can see here in these data is a summary that, you know, luckily for us, neuroscience has progressed to a point where we can take much more intricate and functional images of brain operation, not just snapshots of brain operation or even brain architecture. And what we find in neuroscience is that gender is starting to look like a very diffuse and distributed type of neurological energy within the brain and that we don't really have these polar sections of particularly gendered activities in so much as we have human activities that have been assigned to gender. So while we typically think of women as having, you know, particularly left brain language kinds of things, language is in the left side of the brain for most everybody, whether we're female or whether we're male. What we're seeing in these studies is that concepts around gender are actually distributed throughout the brain. And when you look at people and you compare brain structure and function, even if people are trans or gender non-conforming, their brain behavior looks much more like people with the same gender identity than it looks like people who have the same sex exclusively. I think this is also very important research because in addition to identifying brain function with regard to these cognitive constructs, as many of you might know, they're looking at these types of brain mosaics in treatment of mental health. There's been some research, for example, in brain mosaics of depression and that there's clusters of cells that operate throughout the brain. And so as we look at even mood states or, you know, other types of functioning, I think it's an excellent opportunity to look at the parallels of how the same cognitive space might be taken up in how we form ideas about gender and how our brain really operates with regard to gender. But as we move forward, we're learning that it's a much more complex neurological process than we used to think, or at least that we knew to this point. So what does this mean for us as providers working with people who don't necessarily fit into this binary structure? Well, one thing I can tell you is some of their experience starts very early, and so what we see here, if you look at adverse experiences like ACEs studies, particularly among people in schools, we see a lot of social and emotional trauma, as I will call it. Harassment not only by peers, but also by teachers, and what's interesting about this is some of these data actually show that some of the more intense isolation or some of the more stressful and negative feedback is actually to younger people, because the compartmentalization of people in younger grades of school based on gender is even much more strict than what you might see as you progress into high school or later in the years. All of these ACEs are also important because, again, you're going to see stress responses, and what I think is important about mentioning adverse childhood experiences is not only both hormone, neurological, and then ultimately immunological effects. We see these underpinnings from ACEs types of experiences across all types of mental health and mental illnesses, and we know that individuals with at least four or more ACEs are going to experience depression, they might experience anxiety, they might experience substance abuse at a higher rate than individuals in the general population or without the ACEs, so I just want to remind everyone these are also happening not just necessarily from the day-to-day stressors, they could be happening directly as related to stressors and trauma based on gender identity and people who have experienced that directly for their gender identity. In the DSM, we've had a mixed review, I guess as I would say. You know, the history of gender and the DSM has not always been a very positive one, and in fact I think it's interesting because not only until DSM-IV do we see replacing that transsexualism kind of term with really talking about gender and identity and that cognitive structure and the discontinuity between the ideas we have about our own gender and the ways that we present ourselves or the expectations even of the attributions about gender, but what we do see is an enormous, and I feel, you know, as a practitioner, a particularly meaningful paradigm shift in DSM-V with gender identity disorder being eliminated and moved to a gender dysphoric type of category. And you can see, you know, I'm not a diagnostician, but what's really important is that the distress that people feel in their experience of their gender, less so of it being other, but more so in their social acceptance from people is really what causes the anxiety and stress among people from perhaps a psychiatric perspective. The other thing that's important is that DSM-V has taken the stance of just saying transparently gender nonconformity is not in and of itself a mental disorder, and I think historically we can look back and, you know, whether it's psychiatry or psychology, a lot of behavioral science, that's not necessarily the case. The important thing is that we look at the stresses and, as we might see in a clinical setting, the ego dystonia for people who have experienced or have gender identity disorders. Usually that is going to be a defining criteria, is some form of ego dystonia or tension, stress, that is going to come from that experience of their gender identity. The other thing that's important is that people have really taken, again, a developmental perspective, which is essential in this population. Younger children, people, I guess I should say, they are children, are starting to identify with gender differently, and so DSM-V has tried to make some refinement of children's experience of their gender throughout that process compared to what might be adults, because children, you know, developmentally could change in ways that perhaps adults may not. So among individuals who choose to transition, DSM-V has also given an opportunity to classify individuals because they have transitioned from one gender to the other, and they're living as the other, and that post-transition is really, excuse me, important, not only, I think, for their mental health, but the identification from a psychiatric perspective that you would not necessarily still have gender dysphoria because you have transitioned to the gender of your choice, and by living and being accepted in that gender, a lot of that stress and dystonia would, in fact, have resolved itself. Now, that's not always necessarily the case, but, you know, supportive gender-affirming treatment would typically find ourselves here, where individuals, because of transitioning and because of being able to live their lives in the gender of their choice, they have a lot less stress and trauma and feelings, but, you know, again, whether they still need mental health support is a very, very individual type of question. In the broader mental health spectrum, again, we don't necessarily see psychiatric illness driving gender dysphoria, but what we do see are some symptoms related to feelings of gender incongruity, and what most people will report in those early stages are things like mood liability, suicidal ideation. Most of these things would probably not qualify as personality disorders, and that's probably because they are so intimately and concretely linked to the discontinuity the individual might experience with related to gender. The other thing that's important is that this focus of treatment is not necessarily related to their gender variance. When people in the non-binary space come for psychotherapy, it's either to help support them in making decisions about their gender versus them coming into a therapeutic environment and us trying to talk them out of what their gender identification was, and in a lot of spaces, that was the initial approach to people was, you know, how can you reconcile the gender you are versus how can I support you in living a free gendered life or in having some form of gender fluidity or non-binary life. That said, what you will see, like other individuals with serious mental illness or even common mental disorders, is we see a lot more medical comorbidity, and I think that we can come up with lots of reasons why. One, fundamentally, is if people are living in an immunosuppressed or an inflamed state from trauma or stress or anxiety, they are going to be more susceptible to medical illnesses overall. This is a pervasive issue. With all individuals with serious mental illness, no reason to think that an individual in the non-binary space who experiences that type of stress wouldn't also be vulnerable to these types of issues. We also see some very alarming social types of experiences for this population. 41% of non-binary individuals in population-based studies will report that they've attempted suicide. That rate is 25 times the rate of the general population, at least based on surveillance, credible surveillance data that I can find. We see higher rates of substance use, but then we also see a lot of people being denied treatment in mental health clinics and being turned away from even standard community mental health clinics. When you look at the risks for suicide, and I've cited the Trevor Project here, which has some very enriched and gender-affirming programs that are available to people, particularly around things like suicide, you can see these really alarming effects, not only among individuals with gender types of non-conformity, but we also see some intersectionality here with the GLBT population. And so really, whether people are experiencing gender discrimination or stigma, or whether it's related to their sexual orientation, we can see that there are some really alarming things that are happening. The other thing that I think is particularly notable here is that younger children who are sexual or gender minorities, ages 7 to 12, are almost twice as likely to have attempted suicide. And I think if we look at connections between, you know, those adverse childhood experiences, where we see high rates of social isolation, high rates even from teachers or peers of stigma, it would make sense that younger children of sexual or gender minority would be much more vulnerable to mental health phenomenon that would lead to suicidal ideation or even attempts of suicide. And so whether or not this is directly connected to things like depression or anxiety or other mental health states has not really been well established. Most of this research would talk about the social stressors, athesis type, adverse experience types of stressors, that would be most likely to be driving these types of experiences. We also see that veterans, particularly in the GLBT community, and you know, without digressing into a more political conversation, there have been changes even within the last five to six years about whether individuals are accepted in the military who are trans or gender non-conforming versus whether they are. These are stressful events for this population. And so even among veterans who have a well-defined health care system around them, at the same time that can be an environment that can be a little tricky. One thing I will tell you is that all of the Merrick training agencies and entities that are on the East Coast as well as throughout the country for veterans have taken a various sort of stance on gender and GLBT for our veterans and have done a lot of fellowships and material around supporting veterans who are sexual and gender minorities. So if we look at serious mental illness, our hospital and community-based studies would tell us that we see the types of mental disorders that we would see in the general population. Anxiety, depression, schizophrenia, other psychosis, the mental health disorders. We did some research at our Center for Mental Health Services Research at the University of Illinois, and this is a small student paper that I've done with a person who is now a psychiatrist and child psychiatry at Harvard. She was interested in how trans and gender non-conforming individuals felt about their providers. And what I thought was interesting and included here today was that the patient experiences that we saw in terms of feeling like they could speak with providers was definitely influenced by their mental health states. And these were not necessarily diagnosed mental health conditions. It was more their experience of stress, anxiety, and depression. And we found that, you know, obviously if you're having more anxiety about talking about your gender, you're going to have less satisfaction in working with providers. The other thing that we found was that age was a really significant predictor. And I bring this up because older individuals who have lived in a gender non-conforming state often have a very different developmental experience than younger individuals who live in a more accepting environment, perhaps. More of their peers may be more open to gender non-binary individuals or fluidity, whether it's gender or sexual orientation. Many people who are cisgender, in theory, might identify as queer as allies to people in the community. And so this differential effect that we see across the lifespan and across how we interface with providers based on our mental health can be very meaningful. So I guess this is my way of saying that regardless of where you find yourself with an individual who might be gender non-conforming, think about the stress, anxiety, and depression they might be experiencing, even if that's not necessarily their primary diagnosis or the reason you found yourself working with them. It's something that's probably going to affect their engagement and certainly going to affect whether or not they feel like you are someone that they're going to have confidence in as a provider. With more serious mental disorders, I think it's really interesting because we see gender fluidity and schizophrenia is almost a century old. If you had told me they had written Metamorphosis Paranoica Sexualis back centuries ago about people having transient gender experiences, I probably wouldn't have believed you. But here we are and that people with schizophrenia will have this. The important thing about people with schizophrenia who experience psychosis or might experience delusions is that gender fluidity for them is a very different and perhaps transitory state. And a lot of the research has shown that as you improve treatment for individuals, you're going to see them actually resolve those types of conflicts. We also see more representation of non-binary individuals in autism spectrum disorder. This is a new area of research in that people are starting to look to see whether the gender demands are not necessarily embracing the gender demands, are part of the experience of some individuals who might be on the spectrum, or how the experience of being assigned one or the other gender might fit into that experience. This is also, again, very new research, but from a developmental perspective, it's something that most people are seeing in slightly older individuals. I would see teens or youth and young adults who are presenting or have been living with an autism type spectrum disorder. So we have chronic comorbid medical diagnoses. The important thing to think about this is that some of these will be related to, if they have a social aspect of transitioning, we spoke a little bit about that, but then some of the medical aspects. Again, in addition to mental health treatment, depending on where the individual is in their own gender, they might be doing puberty suppression therapy. This would be something you'd more likely see in a child. Hormone therapies, testosterone and estrogen, are more likely to be seen in individuals who have gone through a secondary sex characteristic development and are probably going to be transitioning, and then ultimately some people may choose to have reconstructive surgeries. It's extremely important to remember that not all people who transition are going to have lots of surgeries or ultimately elect to have all the types of surgeries that might be considered gender-defining. These are complex procedures, very personal decisions, and you may encounter individuals who present very different ways, maybe using hormone therapy, not elected to have a surgery. Again, you're going to have all of these different areas which are going to vary for individuals that you'll have to speak with them about where they are and really what their goals are. Some of the things you're going to see is what, regardless again, you may be using hormone therapy or you may be choosing to have surgeries down the line. These are some of the things that individuals who are trans or gender non-binary might engage in doing because they want to present themselves not only behaviorally but in life as in a form that might be more fitting of themselves or might fitting of the gender that they identify with. But I think this is a good set of examples of the kinds of things that individuals will do. I think what's important about this is it creates issues if you have to undress in a school setting, you have to undress in a clinical setting, there's certain amounts of disclosures that you would have to make if you're doing any of these types of things to change your appearance. Puberty suppression therapy, as I mentioned, would be something that you use in a young population. It's going to be something that can, you know, typically help people with gender dysphoria. It can be very complicated and one of the things that we've learned is that puberty suppression therapy can be very sensitive. So if an individual, for example, is considering a gender surgery down the line and they do puberty suppression therapy, they may have to think about whether limited development of their secondary sex characteristic is going to affect their opportunities for surgeries down the line. And so not only would you think about the benefits or struggles of doing this type of therapy medically and emotionally for a young person, but in addition to how it might make them feel now, you do have to have some kind of forecast about how it might make them feel if they have some decisions they're going to want to make down the line. The therapies that we're mostly going to see, obviously, estrogen and testosterone therapies. Some people will elect to preserve gametes in the event that they want to transition now, but they also want to have some reproductive opportunities later. You'll see speech and voice therapy, particularly for people in terms of how does a woman sound or how does a man sound. And then there's a list of some of the surgeries that some people might elect to do. And again, very personal decisions. Some of them actually may also be driven by whether the person has access and resources to the health care that would support that. Key things to keep in mind if you're working with people who elect to transition is hormone therapies should always be supervised, obviously, by a physician. And some people will use injectable silicone. This is something that's more likely to be used by male to female individuals who are transitioning. It can be very damaging. One of the health risks to this population out in the community is using silicone that has not been injected by a physician or professional. You see high rates of STIs, other infections, hepatitis C from people who get kind of, I hate to say, who get underground types of silicone injections or other things. The higher rates of substance abuse are particularly going to be seen in drugs of choice. The one thing that I think I would say from the literature that would be most important for us as practitioners, and I would say this is true of all individuals with serious mental illnesses, we should be much more assertive on what we're doing about tobacco and nicotine. Not only are they deadly, as we know, but if individuals are using some hormone therapies, smoking can actually be even more dangerous to them than if they were not. And so these were things, you know, obviously in the long-term health of the population, we do see higher rates of drinking, higher rates of all the recreational drugs, and slightly higher rates of smoking in the population. And then finally, STIs, whether they are the general ones that you would see, again, you'll see higher rates of hepatitis C because you see some related to injectable silicone, but also some individuals who are still using injectable drugs. We do see enough seriousness in terms of STI and HIV, particularly that we've designated a day for a transgender HIV testing day to help individuals who are trans have more visibility in that community and identify and really address that risk. It's not easy for people to come in for services with us, and so one of the things I think we should be mindful of is where do we stand as practitioners, and I think that's a great way for us to turn to this discussion now in the final parts of this presentation. These data are alarming to me, not only as a person in community mental health, but as an individual who works at a college of medicine, and I see a college turning out medical students and residents all the time. These are issues that each of us probably has to take a stand in terms of being an ally, creating gender-affirming environments, and really addressing what should be evidence-based practice guidelines. These are the things, not only in terms of patient needs, but our own provider competencies that we should probably be really focusing on in concerted efforts, and here are ways that we really need to do that, and if we were going to put these compartments together, these would be the areas that I think are the critically important ones. Obviously, what we're doing today is foundational knowledge, and we're learning more about the population. We're learning more about evidence-based risks to the population. We're trying to identify evidence-informed services that are functional for the population, but we also want to think about this in a complex matrix, not sexual orientation, gender identity. These are not monolithic types of ideas, and not only do they vary within their own concepts, but again, that intersectionality, not only of sexual orientation and gender identity, but of race, of socioeconomic status, all the social determinants are in the intersection of how gender and sexual identity are going to come out for people. We as providers have to be very fluid and open in our own minds for that. How can we recognize stigma and discrimination, and certainly exposure to violence, even exposure to microaggressions? People making comments about someone's appearance, any of the kinds of things that we often hear about gender non-binary people, that they don't fit into a category. These are things that even within clinical settings that we experience, and we have to take an aggressive stand on. Two areas where we really have to push the population forward are work and housing. I say that because it's really hard to recover and be a well person if you don't have a stable place to live, and you don't have a lot of resources. What you can see here is that work and housing can be really unsafe places for people who are non-binary. Mistreatment at work can be one of the hardest ones. People have asked questions to other staff, to myself, to my own staff, about either sexual orientation or gender identity. A staff person reported to me that they have a picture from their wedding. They happen to be two women, and one of the women is wearing a dress, and one of the women is wearing a suit. As far as I know, they both identify as cisgender people, but a staff person asked them, how did you decide who wore the dress in your wedding? That's not really a question that we ask cisgender people or heterosexual people. How did you decide clothes for your wedding? Those kinds of microaggressions are things that people will experience. We also see that there's a lot of discrimination in housing. I would say personally that turning the policy on individuals who are trans in the military is probably a good foundation for reducing some of the discrimination and exclusion of trans and gender non-binary people in the world, but again, that's a beginning. We have to adopt some developmental lifespan approaches. I've said this throughout the presentation, that it is essential to consider where your patient or your client is in their own age and developmental process. If they are prepubescent, that's going to be a consideration. If they are post, if they are older, do they want to transition? Do they not? Lots of questions that you could ask people. Some of the ways that they will answer will change over time, and so this is an ongoing fluid conversation. One of the ways you can do that is to use this gender-referentive lifespan approach or what we call GALA. What we see in GALA as a psychotherapeutic model are some really, I would consider, basic level tenets. We have, how do we promote trans-affirmative care? It's the same question of how do we promote recovery-oriented psychiatry? How do we promote self-determination? We look at intersectionality throughout psychiatry. What's your experience of race in your mental illness or any component of your mental illness? That would include gender. It certainly would include gender identity. Everywhere that I think we've seen successful gender-affirming programs, we see interdisciplinary approaches. What we're trying to do as providers, obviously, I think develop our own gender literacy. I think building resiliency is a given, but some of these other things are ways that we can help engage people who have a gender identity or a process in their own relationship, sexual orientation. Whether or not it's our own, it doesn't have to be our own to create a gender-affirming type of environment. One environment I'll just quickly mention here is a place in Full Transparency I've done research with, which is Chicago Health and Social Service Agency. What we see here is that most individuals at this agency, which was primarily an AIDS service organization, found that they needed a safe space for trans people where they had trans providers, they had transgender clinicians, they had gender non-binary staff. All of the things that you see here, drop-in center, the housing, the health, all of it is operated from a perspective of trans and gender-affirming care by trans and gender-affirming people. We've seen dramatic improvements in this particular community, and especially in engagement of people in the population in these services. We've talked all morning about foundational knowledge. Here we find ourselves with assessment and intervention. Obviously taking multidisciplinary approaches to people and providing gender-affirmative care. Your organization rates. What do you already do that you feel is culturally mindful, and what could you do to increase that cultural mindfulness or intersection, if you will? One of the areas that I brought, which I think is the place to start, is look at your electronic health record. Are you in the gender binary? Is there an other? Do you track other? Do you use other? If someone's transitioned while at your program, are you moving to using their name of choice now versus still listing them as other? Many of these things become really complicated and often negative experiences for people in treatment, whether it's in community mental health, whether it's with their primary care providers. All kinds of systems here you can see, and from the provider perspective, why it's complicated in electronic health systems, not only in terms of managing patient and clinic flow, but how you build things and at the back end of your system, what's required on the basis of gender. Then finally, we find ourselves where IMO is the most comfortable, which is research, education, and workforce training. One would be that we absolutely need more research on gender nonconforming populations among individuals who are transgender, and I would say we need to start those studies even in childhood or among young individuals, examine this intersectionality, and then really prepare our multidisciplinary workforce, which I'm, again, proud to say SMI Advisor has taken a very impressive stance on that. I really thank you and thank the team for that. It's also important to not necessarily look at transgender or gender as a simple independent variable. I think we've identified the limitations of that based on race, the limitations of that based on biological sex, and so that's something that we really need to work with our researchers to move their mindset forward in terms of that type of analysis. Here's some more model programs and providers that I can recommend. They have excellent clinical programs. They have excellent materials that are available to individuals. Almost all of them are evidence-informed materials, and then here, I'll just say thank you and turn things back over to the team at SMI Advisor. Thank you, Lisa. That was such an interesting and informative presentation. Before we shift into the Q&A, I want to take a moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org. Now, we'll move into the Q&A. If you have any, please go ahead and submit those now into your questions box over on the side. Lisa, most of it is about what do we actually do with the information, so first, a place to start us off is if you are not a person who identifies as LGBTQIA plus or N and B, are you able to provide treatment successfully to people who do? That's a great question, Shereen, and I think I would say yes, and the reason I would say that is we as individuals, whether we're in psychiatry, psychology, or even medicine, we provide a service or supports to our patients and clients without necessarily having experienced those things ourselves. That would be great if we had more, and I would advocate strongly for more gender non-binary and trans visibility of practitioners across the spectrum, but we can't always guarantee that, and so I think that means that we as a workforce have to identify how we are allies because not everyone who is even gay or lesbian can find a gay or lesbian provider, and do they need one? It probably helps with the identification of experience, but I also think it's important for us to ask those questions in another context, so for example, is there an expectation that a gynecologist or an OBGYN provider has to have children to understand their patient? Most people would say no, but they have to have sensibilities about patient needs. They have to have sensibilities and openness to what their patient wants, and they really have to be that advocate because they're there to help the patient make informed decisions about their health and their long-term care, and that's where I think the space we would find ourselves in, in terms of becoming allies to the population. Great, so then what can you recommend that people can start doing right now in their individual practice in order to be more inclusive? Is there anything, we talked a lot about systemic, which there's a few questions about that as well, but is there anything people can start doing right now to make their practice more inclusive? One would be to, you know, talk with your own staff about comfort level. One thing is, and just terms, you know, what do people mean? You know, just because a person is GLBT or GLB doesn't mean they're T and vice versa. The other thing is to ask people what they need. Ask them how they identify. Ask them what you, how they want to be addressed, what they want you to call them. The other thing that I think most people will tell you is they're open to, and I think this was in one of the slides in the literature, but most people say that they have to be agents of health literacy and information to their physicians. And so whether you're a physician or any practitioner, be open to something that your patient knows about their experience that they could tell you, but then really be honest about what you need to know, what you're trying to find out for them, and I think even when you make, you know, mistakes and you use a pronoun or you ask a question that really isn't the most informed, the person is going to appreciate the fact that you're engaged with them. Frankly, I think most of the principles of self-determination in recovery would apply to how you would approach a person in terms of gender identity. You know, ask them those same questions you would ask any individual about their recovery. So then to take it more from an individual perspective into that systemic area, so we have some people who are asking about what can be done in terms of education and education system from an early age, or do we know of anything that is being done? You can start there and then I'll ask another area. You know, yeah, in terms of early education and things like that, that's a really tough question because people vary. One of the things that I would tell you is an interesting way you could approach this is if you look at sex education, naturally and nationally, but the reason I say sex education is because a conversation about gender and gender identity would come under that. There is no consistency across the United States about sex education, and not only the requirements of what you have to tell people from state to state. And so some consistency there might be useful in terms of having some foundational knowledge about what every group should know. The other thing would be to remember many, many individuals are starting to experience stigma or isolation in childhood, and so our addressing how we feel and express ourselves has to come much earlier in our lives. And so to find ways to not only do education of provider systems, but some relationship to even our education systems and how we work with, you know, young people and students who are gender non-conforming or identified, I think would be extremely important. So those would be two things that I would say. I also say push your legislators. You know, why isn't, you know, gender identity, I believe, is now included in things like the EEOC and other types of protections, and, well, they should be. And so, you know, does your organization have an assertive position on gender? Does your community have one? Does your mental health board have one? All of those are places where you can do some good in terms of moving forward concepts of gender or opening up a dialogue about it. This could be actually both as an individual and system level. So somebody is asking about the jail systems, and so it's particularly as people who identify as transgender. So are there any recommendations you have from a systemic perspective about what needs to be different there, and then if there's any individual on how to work with people who are housed, you know, in an incorrect, as we would say, an incorrect, you know, sex group? That is, you know, that's a really tough question. So whoever you are, whoever asked that, I applaud you because you're in a system where you've got some extreme challenges. You know, justice systems and jails are really, really tough because there is a fundamental idea that, you know, someone has done something that needs accountability, and because the accountability is foundational there, people are not always interested in, you know, accountability doesn't always have to be nice. And so I think that it's hard because I think that, you know, people who are transgender are going to be vulnerable to violence, vulnerable to other kinds of things within correctional or jail types of settings. But at the same time, I think there's a big paradigm shift that would probably have to happen within those types of settings. What I would say, though, is that I feel like justice settings, jails more maybe than prisons, and certainly I think this could be my bias for Cook County Jail here in Chicago, I admit that, have taken and really understood how much more mental health need there is in prisons and jails and correctional settings. Hopefully, that larger framework of positivity, mental health, trying to address trauma, trying to reduce re-traumatization within those settings would then apply to these populations. Because you know, I think this person probably is well understands they're very vulnerable in these, so I don't have a great answer for that. But you know, I could probably make a recommendation. The person I would recommend that you could ask that type of question, we could follow up with, would be a person like Linda Teplin at Northwestern University, who would be an authority, I think, on that type of system. Great. Thank you. Yes, that was a tough one, but I thought I'd throw it in there for you. Okay, so I think that's all we have time for the Q&A, so I apologize to people that we didn't get to your answers. So thank you again, Lisa, for presenting today. It was very informative, very important, and as Lisa mentioned, there'll be a lot more, hopefully, on this topic coming up, not just from SMI Advisor. So if you have any follow-up questions about this or any other topic related to evidence-based care for people with serious mental illness, our clinical experts are now available for online consultations. Any mental health clinicians can submit a question and receive a response from one of our SMI experts. Questions are free and confidential. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics, from school-based mental health through the opioid epidemic. Thank you again for joining us, and thank you to Lisa, and until next time, take care.
Video Summary
The video is a webinar titled "Deconstructing the Gender Binary in Mental Health Services" hosted by SMI Advisor, an initiative aimed at helping clinicians implement evidence-based care for those with serious mental illness. The webinar is led by Dr. Lisa Rosano, an Associate Professor in the Department of Psychiatry at the University of Illinois at Chicago. She discusses the challenges faced by individuals who do not conform to the gender binary and how mental health services can support them. Dr. Rosano explains the concepts of sex, gender, and sexual orientation, and highlights the importance of language and person-first intersectional language when discussing gender identity. She also discusses the intersectionality of gender identity and mental health, emphasizing the need for a gender-affirming and supportive approach to care. Dr. Rosano also explores the role of electronic health records in creating inclusive environments, and encourages healthcare providers to ask patients about their gender identity and preferred pronouns. Finally, she discusses the need for more research, education, and training on gender nonconforming populations, and provides recommendations for providers to create more inclusive practices.
Keywords
Gender Binary
Mental Health Services
SMI Advisor
Lisa Rosano
Gender Identity
Intersectionality
Person-first Language
Inclusive Care
Electronic Health Records
Inclusive Practices
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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