Last week I gave a talk on patient care practices for transgender, gender-fluid, and non-gender conforming patient populations. The following guidelines are based on my own experience treating these patients. I’m not the definitive expert, but I believe I have enough experience to provide some insight on creating safe space for these patients should you transgender, gender-fluid, and/or non-gender conforming patients seek you out for care.

Internal attitudes

This is huge and drives every other topic below. If you have ambivalent feelings about gender, sexual orientation, or other social factors in this realm, no matter how you try to reach out to the LGBTQ, gender-fluid, and non-gender conforming community, your attitude and beliefs will probably show. Do some soul-searching and find out what internal beliefs and prejudices are at play before you go any further.

Even if you’ve already done this internal soul search, your staff (should you have one) needs to dCatsTCMNotes.com - Gender is fluid, much like yin and yang.o the same and you probably need to incorporate this into your sensitivity training with them on a regular basis to make sure you are all on the same page.

Gender, after all, is much like yin and yang. Everyone has their own dynamic mix and that can change as a person moves through their life. See the beauty in the whole, no matter the mix of gender yin and yang.

Website

A patient’s first encounter with you often begins before they walk in the door. They might hear about you from a friend or family member, which is always the best first point of contact if the friend/family has great things to say about you. Then they will probably go online and check you out. Take a look at your website. What does the imagery, color choice, and wording say about your practice? Do you mention transgender, gender-fluid, or non-gender conforming concerns? Do you talk about what you can offer for this population of patients? How did you language that? Does it sound like you know what you’re talking about, like you are a friendly place to be for these patients? If you don’t know, you’re going to need a few external pairs of eyes that belong to people outside of your usual circle. Don’t be afraid to ask for feedback.

Forms

CatsTCMNotes.com - Transgender patient supportDo you ask about gender on your forms? If so, do you have the usual M/F check boxes? If so, you’re not really welcoming transgender and gender non-conforming patients.

Here are some options to consider about your forms: 1) Make the question optional, especially if you have online forms that can be filled out.

1) Make the question optional, especially if you have online forms that can be filled out.2) Just don’t ask. Ask what you really want to know – should I call you Doctor? Reverend? Miss? Mrs.? Mr.?

2) Just don’t ask for gender. Ask what you really want to know:  should I call you Doctor? Reverend? Miss? Mrs.? Mr.?

3) Whether you use paper or online forms, if you feel you need to ask about gender, how bout giving them a blank (or text field if you’re doing online forms) so they can supply their own answer?

4) If you’re going to ask about gender, please ask about the pronoun they prefer as well. It might be she, he, they/their, or something entirely different like “ze.”

By the way, Unified Practice is the only EHR software I know of at the time of this writing that actually offers gender options other than M/F.

Bathroom signs

trans-restroomTo be truly inclusive and create safe space, you have to extend that to your bathrooms. Many acupuncture spaces are small businesses and may only have one bathroom for the whole practice. This makes it easy: relabel the bathroom as “All Gender” or just “Bathroom” if you don’t want to have the alt-right bathroom police breathing down your neck.

This gets a little harder if you have a space that has multi-stall traditional M/F bathrooms. Instead of writing the whole article, check this out:
http://www.uua.org/lgbtq/welcoming/ways/bathrooms

Cost considerations

I’m not asking you to compromise your cost, but do consider that the cost of changing one’s body to match their internal gender is a very expensive process in the United States. Other countries (hello, Australia!) have much saner policies about this and it’s not nearly as prohibitive from a financial standpoint.

I offer sliding scale rates for people who need it, but state my standard rate as $85 USD/session. If people can easily pay the $85, they do. If they can’t, it’s nice to offer a lower cost option for transgender patients.

As an added bonus, if they love you, they will send their friends, which translates into higher patient volume. You might even consider a sliding scale day or two in your practice, which will impact your bottom line less so you can keep doing what you do without going broke.

Build your communication vocabulary

Even if you happen to be transgender or gender-fluid, you might need to build your vocabulary to communicate more inclusively (insert Caitlyn Jenner reference here). That takes reading about gender identity, how gender identity differs from birth gender assignment and sexual identity, and gender identifiers. There are a few references to get you started in the Reference section below. Reading is a great start, but you actually need to converse with people who fall outside of the gender normative spectrum.

It’s like learning a language: if you let people know you are learning and are open to being educated, you will generally be warmly accepted. Note that I said “generally.” Transgender and gender-fluid folks have been treated very badly and might be cautious or prickly.

CatsTCMNotes.com - Transgender and Gender Queer Clinic practicesBear in mind that it’s very dangerous not to fit into the boxes society builds for all of us. Those who don’t fit into the norm are viewed as a threat to people who do cram themselves in those boxes. It scares them to see someone acting in ways that stand out and small minds tend to bully. Transgender, gender-fluid, and gender non-conforming people have been targets of small-minded bullies, so they might be very cautious about interacting with you. Of course, if they are coming to you for treatment, they’ve already decided to tentatively trust you as a safe zone. You can probably ask for constructive criticism and education more easily than you could in a random public encounter. Patients can point out your hidden attitudes faster than you can discover them yourself.

Of course, if they are coming to you for treatment, they’ve already decided to tentatively trust you as a safe zone. You can probably ask for constructive criticism and education more easily than you could in a random public encounter. Patients can point out your hidden attitudes faster than you can discover them yourself, which can be very helpful in building your own inclusivity.

Also, remember to ask what pronoun a person prefers if you don’t ask it on your forms. Put it in your notes and get used to using it. Pronouns may change as your patient begins to embrace their gender identity. I’ve treated several FTM (female to male) patients who began the patient/practitioner relationship with me as “she,” and later asked me to mark them as M in their charts and refer to them as “he.” I have several patients who prefer “them/their” and choose not to identify with a specific gender. Be willing to flex your thinking. We aren’t all M’s or F’s. (As a matter of fact, most of us are somewhere on a line between these extremes, but most people I’ve encountered don’t seem comfortable talking about that.)

All of this being said, your patients are not your personal Google, so do not treat them as such! They are coming to you for services, not the other way around! I’ve swapped treatment services with other body workers who seem to want to pick my brain more than give me a massage, acupuncture, or Reiki session. If find that annoying. Your patients would too.

Clinically relevant information

Many but not all gender non-conforming, gender-fluid, and transgender patients have some level of body or gender dysphoria. If you feel female inside but have a penis, that can generate some serious ambivalence about one’s genitalia resulting in some reticence about discussing certain body parts or having certain areas of the body touched. Regardless, there are some things you need to talk about and data you need to gather to give a good treatment. Find ways to become comfortable with this and to explain why you need to know.

Surgical history

Surgery of any kind leads to scarring, blood stasis, qi stagnation, and often a deviation of the channel(s) in the area. Pain or numbness can result, both of which are reflections of the qi and blood stasis/stagnation. As you well know, acupuncture and herbal medicine can help with all of this. Take time to educate yourself about top and bottom surgeries and surgical methods. Think about what channels are likely to be impacted and how that will affect internal organ systems and meridian function for both primary and tendino-muscular/sinew channels.

I would strongly suggest you learn Balance, Master Tung, scalp, and auricular acupuncture methods to treat these areas without actually needling into the affected tissues. There are ethical reasons as well as reasons related to your patient’s emotional and physical comfort.

Pre-surgery
If your patient is pre-surgical there is a lot you can do to boost immunity, qi flow, and blood flow in advance so that there is a lower risk of post-surgical infection, inflammation, and scarring. Yunnan Baiyao and herbal medicines like it taken several days prior to and for a week or more after surgery will help reduce bleed-out during surgery, bruising, scarring, and will speed post surgical healing in ways that border on the miraculous.

You can also down-regulate stress and anxiety prior to surgery, leading to greater emotional comfort. Going into surgery calm instead of frightened also speeds healing and gives your patient a better prognosis.

Some patients have to have laser hair removal/electrolysis on areas of skin that will be used for grafts or that will be grafted. To grossly understate it, this is a painful process. You can help reduce this pain as well.

Though it isn’t specifically acupuncture, you might also let patients who are going to undergo general anesthesia that some people have a pretty profound depression after surgery. Personally, every time I’ve had surgery for several weeks afterward I experience a deep depression and sense of hopelessness that feels bottomless. Knowing that this might happen and is transient really helps me endure it.

Post-surgery
After surgery, you can use Master Tung, Balance, distal, scalp and auricular points to treat blood and qi stasis/stagnation and tissue inflammation. You can also treat skin graft pain and lessen the appearance and size of scarring. Constipation is a problem for a lot of people after surgery and you know we can help with that. You can also treat the depression that might occur post-surgically. It really helps to use auricular points to boost Liver, Kidney, and Lung function to help detox the body as well.

Chest binding

FTM patients and patients who prefer to present to the world more masculinely will often bind their chests either by wearing compression shirts or by wrapping them in ACE bandages. Any bound tissue suffers from qi and blood stagnation. Some patients will bind so extremely that they suffer cracked or broken ribs. Patients who don’t identify with their breasts are also prone to poor posture in an attempt to hide them. That leads to loss of neck curve and neck pain, as well as lower and upper back pain because the curve of the back no longer has the spring shape the muscles evolved to support.

Hormone therapies

trans-hormone-therapyTestosterone adds yang to the body while estrogen adds yin. This affects the internal organ function in ways that are acknowledged by both biomedicine and Chinese medicine. Acupuncture and herbs can balance this out more smoothly.

MDs often want patients to stop smoking, lose weight, improve heart health, and control diabetes prior to starting hormone therapies. You can use all of your learned methods to help in these areas.

You can also help mitigate the side effects of hormone therapy and the associated hormonal changes just as you would in a patient who was experiencing them as part of their inherited biology. Some side effects you could see include:

1) Acne. Damp, heat, and blood heat often generated by early testosterone therapy. You might also see a colder type of acne – bumps without the yellow and red heads – in estrogen therapy, but that’s more rare in my experience.

2)  Personality changes. Your personality is largely a function of your internal chemistry. Hormone levels are a big part of that. Treat it just like you would in any other person. Look for an increase in Liver qi stagnation, Heart/Kidney disharmony, and Spleen qi deficiency, etc. Treat what you see to help balance your patient.

3) High blood pressure. You might see pressure changes with both testosterone and estrogen therapies.

4) Migraines

5) Gender pain. Testosterone therapy in FTM patients causes clitoral enlargement, which can be rather painful. (I’m understating this…)

6) Yeast infections. Often resulting from estrogen therapy, but can happen with testosterone too as the heat and damp increase.

7) UTI’s. Same reason as the yeast infections, but can also be stress increasing heart fire, transferred to the Ttaiyang channels of the Small Intestine and then to the Bladder.

8) Baldness. Can happen with both testosterone (surprise! now you’re bald like your dad!) and with estrogen supplementation, but also as a result of Liver blood deficiency.

9) Osteoporosis.

10) Lowered sex drive. Mostly from estrogen therapy, but also happens in patients taking testosterone who have changing gender preferences or a lot of stress.

11) Cardiac complications. More likely with estrogen therapy.

12) Breast cancer and lactation. Again with the estrogen.

You can help with cancer prevention. Patients who take Pure Encapsulations M/R/S Mushroom formula and herbal therapies like this can lower their risk of cancer when on estrogen therapies.

Menstrual history and function

Do your masculine identifying and FTM patients want to talk about this? Probably not. But it’s incredibly relevant. All of the usual TCM questions, concerns, issues, and therapies will apply here. You already know how to do this!

Safe sex and multiple partners

You probably know all about this too. The same stuff applies to cis-gender (people who comfortably check the M/F box) people too.

Stress

This. Is. Huge. If you identify with the gender you were assigned at birth, especially if you happen to be straight (goes double if you happen to be white and living in the USA), you have little to no idea what it’s like for non-gender conforming, gender-fluid, and transgender people. The risk of physical attack is constant, so PTSD and hypervigilance is common. Bathroom safety is virtually non-existent outside of a patient’s own home and it’s getting worse in the United States. Job discrimination is now legal again in many locations, so the likelihood of a non-conforming person losing their job is higher than it has been in some time. Family alienation is common as well. More parents seem to be able to accept a gay or lesbian child than they can when a child finally allows themselves to identify with a gender that they weren’t born with. I know a number

Family alienation is common as well. More parents seem to be able to accept a gay or lesbian child than they can when a child finally allows themselves to identify with a gender that they weren’t born with. I have a number of transgender friends who first identified as gay or lesbian and then were able to admit that they actually had a gender dysphoria. This means they have to come out all over again. That also means they might have to embrace a different sexual orientation than they had before. MTF (male to female) patients might have identified as straight before the gender identity change and now identify as lesbian. FTM (female to male) patients might have identified as lesbian and now have to think about what it is going to be like to lose that community now that they identify as straight. This can throw families, marriages, and partnerships into a tailspin from which they might not recover.

For all of these reasons and more, suicide is a very real risk for transgender, non-gender conforming and gender-fluid people.

transgender-quote

Safe Space

Finally, the last time I talked to a group of people about this someone asked me what I meant by safe space. Safe space is that spot you go to where you feel like you can be totally yourself and don’t have to hide anything. Creating safe space means the wording, the look, and the feel of the place you create makes people feel “at home.” For me that means I don’t use table paper because it feels too clinical

For me, that means I don’t use table paper because it feels too clinical. My treatment table is soft enough to relax into, but firm enough to feel supportive. The wording I use on my forms is as inclusive as I can possibly make it. The drawings I use in my forms are non-gendered so that anyone can mark the areas of pain or discomfort they feel without referring to genitalia or breasts. I don’t even ask about menstruation or men’s health on my forms, though I do ask verbally in my intakes and follow-up visits. The sign on my bathroom just says “Bathroom.” The office furnishings are comfortable and living-room like. I give people space to talk if they want to, both for their comfort level and for my own diagnostics. (You can learn a lot about someone based on how they talk about their family and living situation!)

I create safe space by allowing people room to talk about sexuality, gender dysphoria, the options and risks of top and bottom surgery, and more. When your patients feel safe and accepted for who they are, regardless of what’s going on with them, your treatments will be more effective and your patients will aspire to better and better health.

Resources

This is just a starter pack. Don’t stop learning!


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