It's all about busting stereotypes and assumptions; acquiring new terminology and pronouns; and adapting intake forms to include trans-sensitive, bi-gender, and gender-fluid awareness. Those of us in the gay community see many issues confronting trans clients, which resemble stereotypes we faced a couple of decades ago in society and among our teachers in Asian medicine. I addressed such issues in a past column, "There Really is No Room for Sexism."1
Recently I attended the Central Texas Transgender Health Coalition conference at Austin Community College specifically for health care professionals and then interviewed colleagues in acupuncture, ABT, endocrinology, massage therapy, and psychology. They all stressed the importance of dropping preconceptions about gender identity, and health issues, by avoiding generalizations and clumsy vocabulary.
Some discussed discrimination and violence experienced by trans clients. Several workshopped trans-sensitive issues with employees to avoid a situation where a transgender woman who booked an appointment for a PSA (prostate-specific antigen) exam was asked by the receptionist, "Ma'am is this for your husband?" A transgender man spoke about booking an after-hours appointment with an OB/GYN for a pap (pap smear) test, to avoid being the lone male in a waiting room full of women. Referrals to trans-sensitive physicians and practitioners are essential. Everyone praises UT Southwestern Medical Center's Parkland Hospital in Dallas for opening a special OB/GYN clinic for transgender men, and a special clinic for gender non-conforming clients.
Understanding The Basics
Get familiar with politically correct terms - she, her, hers, he, his, their, they, them or ze, xe, hir, hirs, or leave a blank space for a client to add a pronoun or title of their choice. Be open to bi-gender or genderqueer clients expressing gender fluidity and the pronoun "they." The University of Vermont was one of the first colleges to validate this third gender.2 Add the gender neutral Mx to titles (pronounced mix or mux). Use transgender man or FTM, or trans man (not "transman"). Use transgender woman or MTF, or trans woman (not "transwoman").
Michelle Martin LMSW, field clinician with Austin based Samaritan Center for Counseling, said a good question to ask is, "What was your gender assigned at birth?" This might be necessary for insurance or medical reasons. Similarly, she includes separate lines on her intake forms for assigned gender and identified gender, and separate lines for preferred pronouns. "I cannot tell you how important this is," she said, adding, "Sex and gender are two different things—this was not understood until recently—the trend for centuries was to conflate sex and gender. Sex has to do with anatomy. Gender has to do with identity."
The GLAAD media reference guide pinpoints defamatory terms such as tranny, she-male, he/she, it, or shim, and advises health practitioners to avoid labels like deceptive, fooling, masquerading, posing. Similarly, avoid making comments like, "but you were so pretty as a girl, why do you need to change?" as someone said to FTM folk-pop musician activist Jaime Wilson in the New York Times.3
Equally vital to avoid assumptions about who transgender individuals date or marry. Some remain with spouse and children. Some MTFs date straight guys. Some date straight women. Some FTMs date other FTMs. A young transgender couple in Ecuador (MTF and FTM) broke all preconceptions by conceiving a son, featured in a BBC TV documentary.4
Intake Forms & The Body Diagram
If your intake forms include body outlines for clients to depict areas of pain, injuries, and surgeries, avoid stereotypes like beefy guys and curvy women. Add all shapes, ages and sizes along with gender-free profiles and back views. Niklas Brochhagen, Shiatsu Therapist, a transgender man, and my TA at Shiatsu Zentrum Edith Storch Berlin Germany, added, "It's good to encourage clients to define their own bodies by drawing their own scars, breasts, chest outline, genitals—but only if they feel comfortable doing this."
If it's not relevant, therapists are discouraged from asking personal questions about gender reassignment. Contrary to popular myths, most trans people never get full gender reassignment surgery. Hormone therapy is the common denominator. Partial surgery for transgender men may just involve mastectomies with or without hormone therapy. As with any post mastectomy, swimming and weight training help regain upper body strength.
Brochhagen stressed the importance of working on those scars to break down scar tissue—or to teach clients to do this for themselves to enhance flexibility. Matt Nolan, a Texas based medical massage therapist and teacher, and a transgender man, is amused by questions colleagues ask when massaging his scarred torso. Has he had open heart surgery? Or, breast cancer?
Nolan experienced "both menopause and adolescence" when he first started hormone therapy a couple of decades ago. Now Nolan knows he's due for his monthly "testo hit" from his primary care physician when he feels weepy a week before.
Valerie Espinosa MD, an Austin based endocrinologist, said her group practice requires clients to undergo a psychological evaluation first before embarking on hormone therapy. Generally, the jury is still out on the evaluation necessity. And, as with FTM clients requiring referrals to a sensitive OB/GYN for check-ups, she said "all MTF trans individuals should be under the care of a primary care physician who check PSA and performs annual digital rectal exams," even though suppressing testosterone with high doses of estrogen, may lessen the likelihood of prostate enlargement, she added.
My Observations
Austin based acupuncturist Alighta Averbukh works with Rebecca R., a 21 year old transgender woman whose "moods are all over the place" with estrogen. I asked how she balanced Rebecca's mood swings without subduing estrogen. "I do predominantly Dr. Tan style acupuncture. I treat by pulse to balance the whole system, and don't do much in the way of yang stimulation," she said.
Recently Averbukh needled "Spleen 6, PC6, Liver 2,3, St 36, 42 and LI4," she added, "if Rebecca's emotional symptoms are intense, I use window to the sky points, or color gels on the needles." Rebecca has been advised to avoid bananas as "potassium can block estrogen."
Swiss trained pediatrician and AOMA trained acupuncturist Isabelle Chen-Angliker worked with Jay L. in the process of MTF transition. Jay L. experienced an array of psycho-emotional problems but Dr. Isabelle warns against anyone assuming all these problems are trans-related, which they are not.
Austin based child and adolescent psychologist Deborah Lyons works with youths in transition and said even though her clients can access an abundance of information online, there comes a moment where they need "one-on-one" counseling. Sometimes they seek her advice for family problems or depression. It's only after several sessions that discussions may open to gender or gender non-conforming issues. Dr. Deborah's emphasis helps them feel comfortable with the gender identity stirring within themselves.
References
Ferguson PE. There Really is No Room for Sexism. Acupuncture Today, April 2015.
Scelfo J. "A University Recognizes a Third Gender: Neutral." New York Times, 3 Feb 2015.
Hagwood A. "Meet Jaime Wilson, a Transgender Activist with Guitar in Hand." New York Times, 26 Jan 2018.
Crellin O. "The transgender family where the father gave birth." BBC News, 23 Sept 2016.
As modern medical standardization continues, the field of traditional Chinese medicine has the advantage of comprehensive personalization. For rare or complex cases, deeper consideration of constitution is invaluable. Proper constitutional assessment, especially with first-time clients, can guide desirable and predictable outcomes. This leads to a higher rate of return, and greater trust between you and your patient.
Though the creation of a financially sustainable, health-promoting model feels far away today, we are casting a vision for a full return on health, believing that this compels us to keep one foot firmly rooted in caring for the sick and the other foot firmly founded in maintaining health. Shifting from a fee-for-service model to value-based care using a phased approach is paramount.
Traditional Chinese medicine and the Vedic traditions both offer rich frameworks for understanding human health, emphasizing the balance of physical, mental, and spiritual aspects. The concept of "souls" or spiritual components in TCM, namely Hun, Po, Shen, Yi, and Zhi, bears significant similarities to the yogic concept of koshas. Their similarities and differences provide insights into how these systems contribute to holistic health practices.
