This month, we've asked two long-time providers of services to the transgender community to share some insights based on their experiences working with this population.

HIPS: Creating a Welcoming Environment for Transgender Clients

Since 1993, HIPS has been providing a range of services to individuals who engage in street-based sex work.  The Washington, DC-based agency strives to provide harm-reduction, advocacy, and community engagement services that are respectful and non-judgmental. Through its work on the streets, HIPS reaches transgender individuals who are engaged in sex work. Over time, these services have been expanded.

"We opened our services to all transgender people," says Cyndee Clay, executive director. "There was a need and we were effective in our work with this population."

Critical to engaging transgender individuals is the creation of an environment that is welcoming at multiple levels-from the clinical staff to the receptionist. This population regularly faces misunderstanding, discrimination, and stigma and may have had negative experiences in the past as they have sought services. All staff receive basic training on how to sensitively interact with transgender patients-such as what pronouns to use and calling the client by his or her preferred name (not necessarily their legal name).

HIPS takes a holistic approach to their clients' health care needs. Often, transgender patients are seen in the context of HIV and the focus is on their sexual health. Clinical providers should be knowledgeable about transgender health as well as HIV, since patients often report having to educate their health care providers about transgender health care. However, it is also important for providers to treat the patient as a whole person - and not just assume that the patient is coming in for a trans-specific health issue.  This is especially important as the medical home model becomes more prevalent. 

For HIPS, the first step in linking a client to health services is an assessment to determine the client's needs and learn about their prior experience with the health care system.  If the client has had a bad experience with a specific provider, they may not follow up on the referral.  Working with each client on an individual level and figuring out what will work best for them is essential. HIPS works with several different providers so clients have options.

The individualized approach is important because significant access barriers to health care exist for transgender individuals.  To facilitate access to and retention in care, Cyndee emphasizes the use of specific strategies.  First, it is essential to recognize the legacy of discrimination and stigma and that our culture can be very hostile to transgender individuals. Because they have so many challenges in their lives-housing, employment, mental health issues, etc.-health care may not be their top priority. Working within this framework, HIPS seeks to create a community of providers around clients that offer a complete range of health care and social services. Not only do the services need to be available but the providers must offer a welcoming environment. All staff need sensitivity training (i.e., Transgender 101) to ensure that transgender clients feel they belong. Even better is to hire transgender employees-not just to work with transgender clients but throughout the agency.

"Nothing is more powerful than to see someone with similar experiences," says Cyndee. "They send a message that transgender people are not only accepted but valued."

Community Healthcare Network: Focus on Communication

"With this population it is even more important to treat each person as an individual and to make no assumptions," says Dr. Luis Freddy Molano.

Dr. Molano is Vice President of the Infectious Diseases and LGTBQ Programs and Services at the Community Healthcare Network (CHN) in New York City.  In his nine years with the program he has learned that the only way to learn how a person identifies is to let him or her tell you.  Working with transgender individuals involves a lot of listening. But to get to the answers, providers must also know how to ask the right questions.

From initial contact with a new client, staff seek to identify the complete range of the client's needs-such as their health care needs beyond HIV and their current living condition.  A critical element of the approach is to ask the client if he or she would like a "family member"-either biological, extended, or adopted-to be involved in care. Not only do these family members provide support, they can also serve as an additional point of contact should the client be lost to care.  Since CHN offers comprehensive health care services, approximately 90 percent of family members come to access health care at the clinic. This helps strengthen ties with family members.

At their initial appointment, clients are introduced to the entire clinical team (e.g., nutritionist, social worker, and mental health provider).  Emphasizing that support services are integrated into the care model and establishing an initial rapport helps lay the ground work for ongoing communication.

While it is important for providers to be good listeners during their one-on-one interactions with clients, CHN also seeks to gain feedback from clients at a systemic level. Gaining client input is critical at the developmental stages as well as on an ongoing basis-whether it is a single person within the clinic that can listen to clients' concerns or through other mechanisms. For example, CHN was able to reduce the no-show rate by extending clinic hours until 7:00 pm after learning from patients that they did not want morning appointments.  CHN also learned from clients that many do not have regular access to phones and contact numbers change frequently. Contacting clients through Facebook for reminders about appointments and support groups has proven much more effective.  Having transgender people on staff is also an effective way of gaining input about the needs of this population.

To ensure that staff is well prepared to hear the concerns of their transgender clients, Dr. Molano stresses the importance of training.

"During the training, it is important to acknowledge that there may be some level of discomfort on the part of staff," says Dr. Molano. "This acknowledgement allows you to work toward addressing it. By listening to staff concerns, you can learn if more sensitivity training is necessary."

Dr. Molano also recommends involving transgender individuals in staff training. In addition to the training, Dr. Molano stresses that a clear set of policies and procedures that address bias and provide a guide of how staff should interact with transgender clients is critical.

"The policies and procedures will hold people accountable," says Dr. Molano.