JoAnne Keatley: This is a panel presentation and the first member of the panel is Andrea Pasillas, who's with UCSF Stimulant Treatment Outpatient Program. Andrea is the Intake and Outreach Coordinator and a Substance Abuse Counselor for the Stimulant Treatment Outpatient Program in the San Francisco General Hospital and UCSF Department of Psychiatry.

Andrea Pasillas: Thank you very much. I also wanted to mention that today is also Cinco de Mayo, so Viva la Raza. [viva, yeah] Cinco de Mayo, this is a big day for me, I'm third generation Mexican American and a Chicana. And, you know, I've wondered. I've said what kind of philosophical thing can I make of this because I thought, Gee, this whole workshop is on Cinco de Mayo. I thought, well actually I see some real connections here. Where I feel a sense of empowerment, especially because I see so many transgendered women, and some transgendered men here at this conference as presenters -- which has been a big shift. When I first got involved in these types of workshops and forums five years ago, the transgender persons were there strictly as consumers, as clients, as patients. You know, there is a big power differential there. So today a lot of us are here as peers of with other care providers, which I think is really important.

I want to talk about certain issues that relate much to cultural competency. I think it's really been important that we've had a lot of presenters discuss cultural competency. So what I want to find out is that there's a real power differential. There's a real power differential here in the City, and has been historically. It's no surprise to me, it's no coincidence that most of the transgender women we've seen here are women of color like myself. Most of the HIV care funded programs receive care money to have services specifically for LGBT communities. However, it's been only the agencies from the communities of color that have actually provided transgender specific programs, such as API wellness Center, Brothers Network, Latina Agencies. And there's a reason for that. Because in this society we have a power structure where if you're heterosexual white male, you're pretty much at the top of the heap. Women, even, you know, white women are gonna make less, doing the same work, make less money, have less resources, less power.

So if you're a transgendered woman, you know, you're down, your're way down here on the bottom of the power structure. You have less power politically, economically, in terms of employment, education -- you have much less resources. So what that means is it's very difficult for us to get a lot of our needs met in terms of health care, mental health services, substance abuse treatment; and of course, medical services is a big issue here -- as a lot of people have spoken about. Now add to that, if you're already at the bottom of this economic scale here in the power scale, go to the fact that you're, you're Latina, you're Asian American, or you're African American -- it's gonna take you even a little bit lower. We've heard a lot of talk today about being culturally competent and sensitive towards the person's gender identity. How is that possible when a lot of care providers are still not really comfortable working with someone who is Black, or Latino or Asian? So put on top of that that they are transgender identified and it's gonna -- there's a lot of distance between the client and the care provider.

And there is a need, I think, for resources. It really amazes me how sometimes people call me for information and resources. I will fax them over some copies that I've made, and I will give them a lot of tips and say -- and I always say, all you need to do really is look on the Internet. How many people here have a computer at work or at home? It's amazing how many calls I get. "I don't know anything about resources for transgenders. I don't know anything about this. I don't know anything about that." Use your computer. It's an excellent resource.

So one of the things that has been shown in a lot of studies for marginalized populations to increase a person's, a community's awareness, or an agency's awareness is to have some kind of training manual. I know I work for UCSF, and I think a lot of other employees that work for UCSF and Department of Public Health -- when you first start you're given a manual. You're given information about if there's an earthquake, what do you do? If there's a bomb threat, what do you do? Right? And you've gotta read that stuff, and you gotta cite it. You've gotta let your employer know that you've read this stuff. So why don't we get training manuals about how to work with marginalized populations -- African Americans, Latinos, Asian Americans? Why don't we get manuals and guidelines about how you work with a transgender client? It doesn't, doesn't make sense to me. Because that's not really a priority, historically. And until there are enough people that are going to recognize this lack of equality and say, "You know, we really need to push for some type of training manuals. We need to push for more education." That's what's really gonna give programs and agencies the impetus to actually get these resources done, and the trainings done, and get the manuals and the resources available. And not just available for staff, but make it a requirement for care providers who work with the transgender community.

I'm gonna talk a little bit about my experiences as a care provider. I've had some really invasive questions during job interviews. I've actually, you know, gone all the way through the interview process and all of a sudden the Program Director wants to meet me. And the only question the guy has is usually, usually the Program Director is a male, and will say, "Well, you know, you're qualified, you have the educational background, and you have the experience and the skills; but frankly I don't know if our staff or our clients are ready to work with one of your kind." And it's not just a one time thing, it's happened to me probably three or four job interviews. And I thought about -- I thought what if, what if I were just another Latina, what if I were Jewish, would somebody say, "I don't know if our clients or staff are ready to work with someone who's Jewish, or somebody who is Black?" Those questions used to come up. So that's actually part of a job interview process for a lot of transsexual women. In other words it was made clear that it's my responsibility -- if people are uncomfortable, and have phobias working with someone like me, then I'm gonna have to resolve the problem. Because the agency employers don't feel capable of resolving that type of conflict.

I want to talk about substance abuse programs also. In residential and outpatient treatment programs, there aren't any transgender specific residential or outpatient substance abuse programs. The transgender clients are usually mixed in with the other populations. This has long been a concern, not just for the care providers, but for the transgender persons that are receiving treatment services. There's often been a lot of hostility generated towards the transgender clients. Some -- because a lot of the women want to be placed in women's programs, women's groups, women's residential programs, and there's been a lot of resistance to that. And what it boils down to is that it's the care provider's responsibility to make sure that the environment is safe for all clients. And that's not always the case, not often the case for transgender persons. It's the care provider's responsibility to make sure that the -- that every client feels safe and welcome in an environment, whether it's a hospital clinic, outpatient program or residential substance abuse treatment program. There's a lot of unreasonable fears that are projected onto transgender clients in substance abuse treatment programs. I've heard things such as well the women aren't, the women won't feel safe with a man in the group. The women are afraid that the man is going to attack them. And it's just -- a lot of these things are projections.

Years ago when the Civil Rights Act of 1965 was signed into effect by President Johnson, many people in this nation said our nation's not ready to have blacks in Colleges such as Alabama. The United States is not ready to have Blacks integrated with White troops. So there's still this question here that really gets in the way of adequate services for transgender people. A lot of care providers and agencies and individuals feel that we're just not ready, you know. We need more time, we're not ready. So when are people ever ready? The bottom line is I don't believe that people are ever completely ready to make these changes. So we just have to push ahead. There's always going to be that resistance. But that's because we all have our own cultural biases. I have mine. We all have them. But it's important that we sit down, and if we look at transgender persons more as whole beings, more as people, and get past the gender identity things, they start to see all these other qualities. Not just the problems that we all have, but also the strengths and resiliency that transgender people have. Transgender people have a tremendous amount of resiliency. You've heard about all these obstacles that we are confronted and we have to overcome. But yet, you know, a lot of us are still here and we're still standing. So, I guess I'll pass it on to the next presenter.

JoAnne Keatley: Actually we're gonna have five minutes of questions for the individual panel members. So does anyone have questions of Andrea? We will also have a question and answer period at the end of the panel presentation.

Audience Member: Andrea, are there any programs in San Francisco that are specifically designed for the transgender community?

Andrea Pasillas: They are, but they're not substance abuse specific programs. And that's what I was addressing. Well, actually there are some agencies that are designed as services providing for the care of the LGBT community. But most of them, if not all of them, do not have transgender specific programs. They don't have transgender specific groups. They don't have transgender care providers that are really culturally sensitive. [applause]

JoAnne Keatley: So our next Presenter is Barbara Anderson, Ph.D. LCSW, Center for Special Problems and Private Practice. Barbara is a licensed Clinical Social Worker and Sexologist. She has a private practice in San Franciso and is Coordinator of Gender Identity Treatments Services at the Center for Special Problems, a mental health agency which is part of the San Francisco Department of Public Health. I'd like to introduce you to Barbara Anderson. [applause]

Barbara Anderson: You know, I used to be five-four and now I'm five-two, and if I get any shorter, I will be under this podium. The topic that I picked to talk about was one in which -- if mental health services are indicated, a physician might like to know what to look for, so that they can make an appropriate referral and where they can make that referral. But I do want to say that all transgender people do not need mental health services. That is not the point of my talk. The point of my talk is when they need services how to access them.

I want you to know in the back and up front I brought a piece of paper like this, which is a report of a study that indicates that a non-clinical sample of transgendered people have the same rate of mental disorders as the general population. So anybody who needs any evidence to support the fact that transgender people do not per say need mental health treatment, I hope you'll pick one of these up.

So now I'm addressing primary care physicians who may be wondering whether it's appropriate to refer a certain client for a mental health session, or an evaluation, or for ongoing treatment. One indication for referral is your patient's expressing the need to understand or make sense of their feelings or behaviors. Questions like why do I cross-dress? Am I in the wrong body? Am I the only one who feels this way? Am I gay, perverted, sinful, or mentally ill? These suggest, of course, the need for support and information about the phenomenon of transgenderism. Unlike other conditions, such as phobias or schizophrenia, I don't think there's a really great need for the patient to understand the nature of that illness. There's more of a need for them to be treated for that illness, whether or not they understand why they have a phobia or what causes schizophrenia.

On the other hand, I think that people who have gender identity disorder really need information about this in order to develop the confidence and self-esteem to allow them to make decisions about the rest of their life. If you as a physician become aware of a patient who is isolated, complaining of loneliness, seems to have no one to talk to, please consider a referral to a mental health provider. Some transgendered people, again, some, have an extraordinarily difficult time connecting with others. Their histories often indicate early relationship problems with rejecting parents and peers, leaving them in adulthood without the supportive network of a loving family, or the skills to build friendships as adults. In addition to psychological counseling, inclusion in a support group would be very helpful. And a mental health person could help a physician find that.

Another reason you might want to refer a transgendered person for psychological treatment is the fact that they may need a care manager, or a case manager to oversee the process of preparing for a life change which may or may not proceed all the way to sex reassignment surgery. This might include referral to resources, such as electrologist, legal advice, counseling on family or employment matters, social and educational organizations, even clothing stores friendly to the transgender community.

We also discuss HBGDA's Standards of Care with clients who seek hormonal treatment and surgical procedures. And we explain the reason that a mental health evaluation is required prior to receiving the desired procedures.

Helping clients deal with discrimination and victimization is an important function of the gender counselor. With increased comfort with their gender issues, clients often begin a tentative exit out of the closet before they make a presentation that is really passable. Poor clients have an even harder time due to the cost of cosmetic procedures and products. We provide psychological support to help them deal with cruelty and unfairness until they develop the skills to avoid these responses from others. Further into therapy when self-esteem is higher, we encourage clients to be advocates for themselves and for other transgendered individuals. And we refer them to politically active groups seeking equal rights for this population.

One of the most challenging patients you may treat is the transgendered person whose health is so compromised either by STDs or chronic illnesses which have been exacerbated by inconsistent health care, prostitution, homelessness and conditions resulting from unsupervised hormone use, that sex-reassignment surgery may be medically contraindicated. A gender specialist is equipped to help these individuals to find ways to minimize their gender dysphoria, while they also manage medications and possibly face the consequences of life threatening diseases.

The addicted patient may benefit from mental health counseling as well. There is a great deal of drug abuse and substance abuse in this community, possibly because of the pervasive shame and guilt that these people have around their condition; and alcohol and drugs become a convenient way to help them quell the pain that they feel so much of the time. In counseling we help them understand the necessity for addressing their substance abuse problems as well as their gender concerns.

A person might need help about -- with decisions about disclosure. How do I tell my spouse, my parents, my children about my gender issues? How do I tell my boss, my co-workers, my customers? What are my rights with regard to custody, visitation, transitioning on the job? We do, if not have the answers, we can help find the answers in a way that we're much more used to doing than a primary care physician would be.

Post-operative adjustment may present a problem to clients. They may be dealing with cosmetic disappointments. Or some people who have surgery move. They want to start over again and have a fresh start, and then they find themselves isolated in a community where they have no connections.

Lastly transgendered people suffer from the same variety of mental disorders that the general population suffers from. And they certainly shouldn't be denied treatment, or their disorder shouldn't, their mental disorder shouldn't be laid to the fact that they're transgendered. They also suffer phobias, personality disorders, etc.

I'm just going to whip ahead to tell you how you might begin to find somebody that you could confidently refer a transgendered patient to. I am the coordinator of the Gender Identity Treatment Services at the Center for Special Problems. And we welcome seeing transgendered people who would benefit from individual therapy, from psychiatric medications, and from case management. There's also a loose association of gender specialists in the private practice sector. And I or Lin could help you understand what, how we work, and how to locate us. So I think at that point before you throw me off, I'll just graciously leave. There's another piece of paper -- I can't believe I did this in pink and blue -- what was I thinking of? This pink one tells about the services provided at the Center for Special Problems. So I'm probably down to about two minutes of questioning and then at the end you can ask all of us questions.

JoAnne Keatley: Actually you do have five minutes for questions.

Barbara Anderson: Okay.

JoAnne Keatley: So are there any questions for Dr. Anderson?

BA: I've said it all. Oh.

Audience Member: Just a real basic question. Does the client need a referral from an agency to go to the Center for Special for Special Problems? Or is it a drop in basis?

BA: No. They do. They need to go through the Community Mental Health Services Access Team, and there's a central number, and it's on this pink sheet of paper. And a client, once he or she says what the nature of his concern is, would probably be referred to us.

Audience Member: Hi. I'm vaguely confused in that I'm hearing two different citations about emotional distress. The study that was cited this morning had something like half of the respondents depressed, and then the study you're citing is saying that the numbers are roughly equal to what would be called the general population. Could you clarify at all?

BA: Okay. Yes if you have a hammer, everything looks like a nail. And I absolutely have a belief that transgendered people are not per say mentally disordered. So it took no time at all for me to find a study that proved my point. Now, I know that there must be people in some other conference who are gonna tell you how terribly sick these people are, and they need years and years of treatment. And I guarantee you that they will find a study.

Audience Member: I'm not saying that transgender people are per say. I'm saying the study that was cited this morning I believe said that something like half of the respondents were coincidentally depressed. And that doesn't sound like what we see in what we would call general population.

BA: Okay, this was a non clinical population. What was --

Audience Member: [inaudible]

BA: Okay, all right. I can invite you to look at this and maybe look at it more closely will explain.

Audience Member: Maybe you could look at what was presented this morning.

BA: Okay. Maybe we should get our act together. Okay.

JoAnne Keatley: Any other?

Audience Member: Given that you recommend that all transgenders have some sort of mental health evaluation prior to starting hormones, and --

BA: Not so, I don't -

Audience Member: You don't agree with that position, okay.

BA: No I don't. HBGDA doesn't require it, and I don't think that it's necessary. HBGDA has its conditions and I am a HBGDA member, but I think three months of a real life experience is sufficient.

Audience Member: Okay. So would you -- is the Center for Special Problems, however, available to primary care providers to do a psychological assessment on someone?

BA: Mm-hm.

Audience Member: Even though there's not a clear mental illness present.

BA: Yes, yes.

Audience Member: And how would that referral be made, through the Access program?

BA: The client would call the Access Team and talk about what the nature of the concern is. There has to be a concern. You wouldn't just refer a person here. But the person could say that "I need an evaluation" and we would do that. Where we run into difficulty is writing a letter of endorsement. That requires, that puts us in an awkward position. But we would send you a report. Are you speaking as a primary care physician?

Audience Member: Yeah, I'm a primary care provider.

BA: We would send you a report saying that these were our findings, and it would be your conclusion whether to proceed.

Audience Member: I work at Dimensions which is the Queer and Questioning Youth Program at the Castro Mission Health Center, and we have quite a large clientele of transgender youth. Do you have any specific programs available for youth?

BA: I don't, but I think I know a private practitioner -- does, Luanna -- there is a person known in the community who has a specialty in that area. At the Center we don't treat youth. Everyone has to be 18. I think we'll hold the rest of the questions so that we can -- okay because we will have 20 minutes after we all speak, and so these questions will be dealt with.

Audience Member: Excuse me. Okay, this is not a question but a comment. I just thought, I didn't necessarily hear you say this, but I feel like there's a danger in associating transgender community with drug use. And I want to minimize the fact that there is drug use in this community, as there is in all kinds of communities, because I think America is a drug addicted society, period. But I think it, I mean, you know, anyway. I just feel like we need to be cautious with that because in certain communities the drug use may be more visible or more preeminent, just as certain factors, you know, regarding access and education. But there is communities where drug use is rampant, I suppose the use is more private so we don't see it, you know? And I think that there's is very easily a tendency to associate certain behaviors with this population.

BA: Thank you. I'm glad you didn't hear me say that.

JoAnne Keatley: So our next presenter is Lin Fraser and I gave her introduction this morning, so if you would just welcome Lin Fraser.

Lin Fraser: I would just like to know how many mental health professionals are out here? Oh great! Because most of what I want to talk about relates to psychotherapy, although it applies to primary health providers as well. I want to give an overview of transgender identity development as a way to give understanding of the clinical issues that come up in psychotherapy.

But first I want to talk a little bit about sort of global issues. James Green talked about a lot of those in his talk today. But the kinds of things that keep me and other specialists like me in the field for as many, many years as I have because it's such a fascinating condition, and -- but the -- So, what is my, what approach works best in my experience and why? And this is in therapy. For me as we're learning today, we listened to transgender voices, which have been until relatively recently discrepant with the literature. And I've been looking for a theory in therapy that works and might help and not harm that encompasses the tremendous variation in the TG experience. And that takes into the account for me the development of the TG identity. Non-pathologizing, but depth oriented and consistent with my own personality, and I think that's important. So for what for me works is a Jungian Psychodynamic approach which is depth oriented, coupled with feminist relational, which is egalitarian and very interactive. And that takes into account connection and relationship, which is the key aspect, because for the majority of transgender people don't have as much opportunity as others to develop skills and connection because their self is hidden.

So what sustains me are the people. It's very stimulating, and there's tremendous variety. The people as clients -- I think as we've seen today -- are thoughtful, hardworking, resilient, funny, appreciative, adaptive, interesting, and willing to participate in their own therapy. They taught me everything. Very, very willing to participate and tell me what they need. Very stimulating intellectually. The whole issue of gender role variation and the freedom to express self without gender straightjacketing is right here. The issue of individuation in a real sense, grappling with basic issues. We get to develop new theory. Get to be active in civil rights. Get to work with the media, do teaching. Get to study many fields -- anthropology, sociology, medicine, surgery, endocrinology, and the ongoing question at two levels: what can we learn from this population that is useful for the non-TG world? I think a lot of us are learning that today. And what specifically is useful to help TGs?

Issues and questions -- what is the basis of identity, sexual orientation? What is a self? How does it develop? What is needed to develop a self? What is the importance of the body in developing a self? A mind in developing a self? The interplay of gender identity, gender role, sexual orientation -- which is first? Gender identity or sexual orientation? What's more important? Mind or body -- self or body? Questions concerning the interplay of mind body, self body, nature or nurture, unitary and non-unitary self. Is the unitary self important? Role of biology and hormones, effect of culture on gender. And the whole question of the binary system and it's relation to gender. What about the theory of the third gender? On and on and on. These are all questions. We don't have answers, but we're questioning.

So how do you help? Look at the developing gender identity. How does identity develop? What's needed for an identity to develop for all of us? Two things in terms of psychodynamic theory -- the concept of mirroring. People see you and reflect back who you are. And then the idea of practicing -- going out and being that person that is mirrored back. The transgender person gets neither of those growing up. In terms of the key, the key needs for identity to develop do not occur in a transgender person. So what happens to the young transgender person growing up is they're continually dealing with the interplay of two selves -- one that's secret, and one that the culture is mirroring. You can imagine how confusing that might be. No one can see them. And that is crucial to develop a self. So they're negotiating this parallel development of a true self that's internal. They're developing it themselves in the constructed self. Then when they start coming out there is an adult body, usually, that -- and the wisdom of an adult, with this adolescent that's emerging with adolescent hormones. So you're dealing with that, too. That's very confusing. So the two things that are necessary in psychotherapy and they are necessary for all of us, is to develop a self in relationship and to develop an autonomous self. Imagine if you're trying to do two of those at the same time -- juggling them. One hidden, one mirrored, and then when you come out [excuse me] the one that people are starting to see is an adolescent self, or the one that you're feeling is an adolescent self in an older body.

So the therapy process along this path is where the task of the therapist or the primary health provider is to see the person. You may be the first person who has ever really seen, seen the true self and validated it and mirrored it, and helped the person in terms of the practicing.

What transgender people tell me is that most of them felt very shy and isolated growing up and developed the self alone. Feelings of loneliness, fear, isolation and stigma, sense of craziness, alienation, and the beginning of shame and guilt. We've heard a lot about that today. Because the world doesn't mirror the self-concept back. Adolescence is a very difficult time because the body is a betrayal. What happens in adolescence, with the hormones kicking in, but they're the wrong hormones. So what happens to a lot of transgender people is that they become almost disembodied. They develop their minds, but not their -- there's no connection between the mind and the body. And so imagine having a sense of not having, not being connected to one's body. There's a continued parallel development as an adult and in adulthood or younger -- it's getting, people are coming in to get treatment earlier and earlier, and I think the role of the Internet is really helping in terms of identity formation for people. Because you can get mirrored and practice the authentic self on the Internet.

So the role of the therapist is mirroring and practicing. But also asking the hard questions to the adult self -- is this right for you? Because in my practice anyway, the transgender identity is not always healthy. For some people who have Obsessive Compulsive Gender Dysphoria, the outcome may be better to be bi-gendered, or in some cases to stop cross-dressing completely. And I'm going into more Psychodynamic Theory here, but in some cases it is a defense in my view and in my experience. But this is not true for the majority of people, but it is true for some, and we need to pay attention to that. That in some cases -- and a therapist is -- in long term therapy it's more likely that that can emerge in the relationship.

So the major task is finding out what is the true or authentic self. So the major task is the development of authenticity, capacity for truth telling and, in terms of self in relation, development of empathy. I'll stop there. Questions?

Audience Member: What, if any, experience have you had regarding family dynamics of patients [inaudible]?

LF: Mm-hm. I think that's a very, very good question. I think one of the things that's very important to understand is there are different pathways to the cross-gender identity. And in some cases, it's not difficult to see the role of the family. I've seen numbers of male to female transgender people who report lack of touching in their family of origin. And so what they report experiencing is that they go to clothes as a transitional object as a way for comfort. And in Jungian terms we call in the [Auraboris?] -- I mean all in one. And when I say that to a group of male to female transgender people, I invariably get a lot of feedback that "That is my story." The other family dynamic I hear -- and also Holly Devor write a very, very large and tremendous scholarly work on FTMs. And what she found was that many FTMs -- their bodies had been intruded upon and so -- by either family members or other people. And she speculated about what impact that might have on the developing gender identity. But you see it's very, very complex how the cross-gender identity develops. And it's an individual -- I always look at it individual, each individual. And in Psychotherapy, you know, really if there's a safe container in which some memories emerge -- I've seen a lot of abuse. Now these are people who come to therapy, and so their memories emerge. That's a little bit anyway.

JoAnne Keatley: Other questions?

Audience Member: In terms of the emerging visibility of transgenders it seems there's a lot of parallels to emerging visibility of gay people, and how do you see change for the future?

LF: Well, that's a wonderful question. How do I see change? What I'm hoping to see is that the culture won't polarize, and that what will happen is that with more and more visibility there will more acceptance of the spectrum of gender role variation which is what we're talking about, I think in terms of the transgender person, anyway, and what people are threatened by. When I talk in San Francisco, I have a lot of hope. But I don't necessarily feel that elsewhere. I don't know. What, how do you feel?

Audience Member: Just the whole concept of role models? For gay people, and I'm thinking of myself -- just to see other gay people in the media, and having protection, it's like an expanding quantity of people. There's like a threshold which makes it easier once you see it. Does that apply -- do transgenders when they meet other transgenders -- does that help?

LF: Depends upon how much internalized transphobia is going on. Because I have many people in my practice who have a very conventional upbringing and are part of the conventional world. And what they say is they don't identify with other transgender people, and they want to pass as men or women, and want to identify in the straight world. Now in the younger communities I think that's different. I think many transgender people identify as queer, and are comfortable with that, and are part of a whole movement, and that's very empowering. But that's not everybody. So I don't know. I hope. It's been five minutes I think, isn't it time for -- not yet?

JoAnne Keatley: One more.

BA: One more, okay.

Audience Member: Hi. I'm actually FTM but I know a lot of people who are were in the Holly Devor studies. One of the FTMs she completely misrepresented what they said to her to fit her views of FTMs, and you have to look at the population statistics, of incest and sexual assault and sexual abuse within female bodied people to begin with. And that's high to begin with.

LF: Right. And that's very important information. I really do want to stress that I do not know the etiology of this condition. I have really tried to see if I can find patterns, and the question was asked, and I'm trying to find something, but thank you.

Audience Member: I just wanted to say something. It's not a criticism.

LF: Yeah, no, I appreciate it. I didn't hear it that way.

JoAnne Keatley: Okay, so this next segment is actually gonna be for the panel. And so if there are questions for the Panel?

Audience Member: This was a question that I wanted to ask actually when the Community Panel was on. And maybe you all can help me out, too. It seems the only place to fit. One of issues that always concerns the non-TG community is toilets. And it always seems to come up. The military was very concerned about gays in the military, and the issue was always showers and people being together. How is that dealt with, and at what point do we introduce -- does that become a concern, or is that dealt within the community?

Andrea Pasillas: I had a lot of experiences with that issue as a staff person, as a counselor trying to resolve those conflicts. The only thing I do know is I've learned from my experiences at the women's restrooms, we have stalls. You close the door. You don't stand in front of a urinal. And I have been in -- before my transition -- I've been in, when I was using male bathrooms, women would go in there, so I'd close the door. I think a lot of it is more about a person -- what's going on in the inside of a person, their own prejudices and some of the unrealistic ideas about just how much of a threat is this that there's a person in the stall next to me that I can't see and my door is locked? This person may or may not have a penis, and it could also be this person may or may not have a vagina. So some people will really take that and run with it. But I don't recall of any incidents of rape or violence being, being documented around this issue. I think it's a lot of social theories.

And I just want to add I remember once years ago I was instructed -- I had just started a part time job and the supervisor instructed me. And he said, "Well you're transgender so you have to go into the men's bathroom." And I looked at him and I said, "Excuse me, I'm a post-op. You don't send postoperative women, transgender --" And then I thought -- I was angry and I was also humiliated because I felt why did I have to say that? I mean, so I violated my own privacy, but I was damned if I did and damned if I didn't. So it's a real sensitive issue, and I think a lot of times the concern is more about the person, the person's fears which are often unrealistic. Well, how does the other person feel? Do they feel safe? Are they afraid of being maybe attacked or jumped by somebody. Because they may or may not even be transgender persons. I know a lot of butch lesbians that have gone to the restrooms, and then because of their presentation it's assumed that they're male to female. And they receive just as much hostility as a transgender female.

Audience Member: I'd like to add just on the issue of bathrooms. I think one of the things that Larry Brinkin actually can address is the San Francisco policy about bathrooms. There are some City guidelines, and I think that would be a good question for Larry.

LF: Is he here?

JoAnne Keatley: He'll be here. He's presenting.

LF: I would like to say though that many people don't drink anything all day because they want to avoid having to use a restroom. That's all.

Audience Member: I wanted to ask Dr. Fraser for a -- talking about the part where you know, when you transition, I was 25 when I had this transition -- and yet I went through the adolescent phase of experiencing myself probably for the first time when I was on hormones. So it was a totally different process. While my body was older, my spirit was much younger and going through the puberty and the whole thing. So I think it's different when you're transgender and you have to feel and release your gender identity that's been bottled up for so long, so it's a different experience. And as far as bathrooms go, I've been asked, "Which bathroom will you be using at jobs," and stuff. And I ask them "Which bathroom do you go to? And then that's the one that I'll be using." So I think that kind of solves the problem [laughter]. You know, if you just -- so like that it makes a difference in how you're perceived. [applause]

Audience Member: This is more on toilets. The general, this is an issue when you're educating, you're counseling a transgender person. In Silicon Valley, and I'm in the Palo Alto area, companies that have someone that transitions on job. Some of the companies will be reasonable and let a person who's transitioning male to female use the women's bathroom. Some will uphold the law that they can't use that bathroom until after they've had surgery. The company will sometimes work out a bathroom on another floor for the person to use, and not the same floor. That is discriminatory, but the general kind of general rule that's followed is whether the person's had surgery or not had surgery. And that's not only Silicon Valley, but other companies in the US. It's an issue that company's call about. Which toilet are they to use?

JoAnne Keatley: Thank you.

Audience Member: When I was going through my transition, I was working for Pacific Telephone in San Jose. And what they had to do is every time I wanted to go the bathroom they would have a girlfriend go with me and stand outside the door until I finished.

Audience Member: I'd like to follow up on the issue I raised earlier this morning about accountability and quality of care. Barbara, I have through the intake at the Center for Special Problems, and I've seen the otherwise pretty good forms. The [inaudible] readable forms and so forth. You got a start on a good questionnaire, but as I told you one-to-one I think it needs some work. But -- in fact I think it needs a lot of work. So my question for you and for Lin and for maybe Andrea, maybe the group at large, is what's actually happening on keeping evaluations on both your assessment of what the quality of service has been and the assessment, and is any of that data being gathered so we can have some common -- some analysis on the community at large?

Barbara Anderson: We're always responsive to our client's feedback. We do meet, the staff meets regularly and we do revise forms as they -- as people bring to our attention areas that are inadequate or offensive. I don't know that we're really in a position to do this study about how satisfied people are with our forms. As a private practitioner I use very little paperwork, but what more I use -- I'm very interested in what people say. So thank you for your suggestion, Jennifer, and I would welcome you putting something in writing that could really be brought to a staff meeting and be considered in a way that it should be.

Audience Member: I will!

Lin Fraser: I also have very little paperwork. I work with some people -- I do take a lot of notes with the fantasy that someday I will be able to utilize it in writing and to write about this issue in terms of what people tell me. But at this point I've only done a dissertation on the topic. So I am -- would certainly be responsive to feedback, but I have very little form to, in my practice.

Andrea Pasillas: I'm kind of jealous of these people with little paperwork. I work with UCSF I have tons of paperwork. [laughter] When it comes to demographics, you know, I have the CFDS [?] Episode Summaries, and the Care forms, State forms, it goes on and on. It's interesting we just have a standard CFDS [?] form that has something about transgenderism. But it's very limited in it's definition -- are you either transvestite or are you transsexual? It doesn't go into matters such as drag king. There's not a lot of stuff [inaudible] that breaks down the community.

What I wanted -- this is a good time to bring up -- a few people have brought up the matter of demographics about the reporting, the self-reporting. And I recently started participating on the Cultural Competency Committee at the Division of Substance Abuse [inaudible]. I was volunteered. And on the front page by my name it said they wanted to know my gender identity and it says male, female, transgender, other. And there's a separate page where information that is about a person's sexual orientation, such as gay, lesbian, bisexual, heterosexual is on a separate page where it says anonymous staff information. So one of the problems that I had with that, and I brought it up -- was that why do I have to make the choice to make this anonymous statement, as opposed to it has to be right next to my name with the Division I work with, the people I work with, the Department I work with? And you see a lot of people feel differently. I feel differently about it than some other people do. But the point I was trying to make is that it should be my choice if I want to make this part of the paperwork that goes in my file that people in my Department have access to. Or I mean, why don't I have the option of putting it on the form where I can retain my anonymity? So again, you know, it's not designed to satisfy all transgender people.

Audience Member: I had a short thought. Right now transgender care is very much provider driven, and when you get around to doing it better, then we will get something better. And right now we are basically powerless. We take whatever we can get. And we try to work the system. It's not going to get better until we have the data. So we can make a, we can make a focused effort to be active and create public policy changes, funding changes and so forth so that, so that we can actually feel empowered to control what kind of care, what is really appropriate for us.

Audience Member: I just want to make a comment that it's very comforting to know that there are agencies out there that are providing this service........[coughing] And especially, I think it should go beyond the health care and mental systems. It should be going, like we mentioned already, to prepare the workforce after transition -- training, education [inaudible] and better grooming standards. And I think it's great and we need to work more on that and [inaudible] our community will be feeling pride instead of shame. And of course [inaudible].

Audience Member: A lot of times the in the transgender community the transgender person himself has no problem with their self image. It's their, the people around them, perhaps their parents. Is there any program or procedures for getting those people to your services? [applause]

Lin Fraser: Good question. That's a wonderful question. I spend a lot of time with families. And at least those of us who have been in the field for a long time, have -- and it's easy to access over the Internet too -- or via other resource agencies around the country. You can get the names of people, around the world actually, with familiarity with transgender issues to refer, if the family isn't local. But I would say that what happens often times is that the transgender person has spent a lifetime struggling with this issue in secret. And when he or she comes out it's a tremendously liberating experience, but it's the beginning of pain for other people in your life who didn't know about it. And for many family members they had no awareness or didn't know the degree of your gender condition. So for them, they're dealing with a loss, in their -- how it feels to them -- they're dealing with a loss. So what happens in therapy is we spend a lot of time talking about how best to approach individual other, other people who may be feeling very badly. Or dealing with very a profound image shift in their loved one -- you the transgender person. And it takes time. And often times family work is very, very helpful. And education. And there are resources available, plenty of resources; but I just want to remind transgender people that, once again, often times to people around you -- this is new information. And it's painful information. And over time it can be celebrated -- not always.

Barbara Anderson: At the Center for Special Problems we do see relatives, and significant others, and adult children -- in the interest of the primary client. And similarly in private practice I work with families as well.

Andrea Pasillas: This is a similar issue to add to our policy of treatment and recovery. How do we get their family members into treatment? That can be a very difficult process, because why should I go to Anonanon, or why should Alanon? I'm not an alcoholic or a drug addict. I don't have a problem, they're the person with the problem. And there's a lot of pain involved, and one of the benefits of going to substance abuse treatment for those people that do have a substance abuse problem -- and I think a lot of transgender people will feel the same way as I do about this, is you can start to build another family. And a lot of people in this country build families through their support groups, for example, Narcotics Anonymous and Alcoholics Anonymous. Because there they are able to give a lot of support. And it's not just around the drinking and using. It's about the reasons why people drink and use -- the shame and the guilt around gender identity, the loss of being rejected by society and being rejected by your family. So there are some types of support groups. And they don't specifically have to be some type of gender support group.

JoAnne Keatley: We only have time for one more question.

Audience Member: Well, first a quick comment, and then a question. My comment is I think that toilet thing would be resolved if we'd all agree to be neat and put the seat down and anybody can go into any room. [laughter, applause] Having grown up with brothers. My question has to do with charting, and this actually may be more for the transgender people in the room then the panelists necessarily. But as a doctor, I'm used to leaving a lot of things out of my charts, because charts get in the hands of insurers and employers and they're not just medical records anymore. They're much more public records then you like to think. So, I often leave out people's HIV status. I leave out that people are in recovery -- all sorts of things like that, because that's very private information. So I'm concerned about -- is it appropriate for me routinely list or not that someone's transgender. I realize I have a lot of very relevant medical implications, but I'm wondering if it's a piece of information that's so potentially mis-usable that we should not routinely include it. And that would be one of my concerns about -- in my intake sheet I don't ask people whether they're gay or straight, because number one, I'm concerned that some people might not be comfortable telling me that before they've met me. But number two, again this isn't a private document. So I'm curious how either other practitioners feel about it, or how transgender people feel about that?

Audience Member: Actually, could I make a quick comment in response to that, as well? And it's about the issue of people of transgender status being in the medical charts or not. And there's an issue that a number of people have brought up around how the City and County of San Franciso counts AIDS cases. And where we currently do not have very much information at all on the number of diagnosed people with AIDS who are transgender individuals. And one of the reasons is the main way we get that information is by looking in medical charts. So if people's transgender status is not in there, it makes it very difficult for us to know how many people living with AIDS are themselves transgender. So the more that that is in medical charts -- I realize that there might many reasons why people don't want that in their medical chart -- but, you know, if we're advocating to add and to count the numbers and to report transgender for HIV and AIDS, then it does need to be in the chart so it will show up. Thank you.

Audience Member: I just want to say that that's an issue that's larger than San Francisco and is an issue throughout the country, so....

Bob Teague: And this might be an appropriate time to comment on another project that the ADDC is doing. And that is actually funded out of the same chunk of money that this conference is funded out of. And that's a protocol development for primary care chart review. It's part of a Quality Management Process Training that we're putting together for Title 1 and Title 2 funded providers. So I would be very interested in talking with any of you individually further who would like to get involved in helping us develop chart review protocols that would be more useful in gathering this kind of information. Because that is another Quality Management Training piece that we are actually working with DPH to develop.

Andrea Pasillas: I wanted to respond briefly to that question.

JoAnne Keatley: All right.

Andrea Pasillas: I understand, I really do understand, the necessity of the documentation and identifying clients that are transgender and HIV positive. It's really critical for funding for one thing. But what let's not be lost in is the client's right to privacy. We do, you know, you have to respect the privilege of right to privacy. And I think what's always worked best for me is to ask the client, to educate them. This is -- these are the pros and cons, these are the benefits and the cons of you providing us with this information. Let the client make an educated choice. Let them know what their rights are, and let the client decide. All too often the decision is made by the care providers, because they feel it's more important for them to have that information and have it documented someplace. It is personal information. It's something -- if you can talk to your patient about it -- if she trusts you, or he trusts you, you're more likely to have them say go ahead and put it down. But you have to some trust and rapport with that patient.

Audience Member: Hi, I'm also a doctor that takes care of a few transgender people. And one thing in my chart, is I have a separate page of information that is not to be copied, forwarded, sent anywhere. And tell me about your substance abuse, you know, anything and it's left on that page. And then when it comes to dealing with whether or not to identify -- it is a discussion with the patient about like, you know, where they're at, and what's going on with them, and how they identify that -- what their driver's license says and where they're going with things. Because we recently came up with the -- trying to get someone surgery for breast reduction, and it was very ambiguous. And when the person went to the surgeon -- he said, "You know, you don't have enough back pain blah, blah, blah....." And then a half hour later call me back. "I think I might have made a mistake. I think it was a guy, and, of course [inaudible] I'll do that in a hot second and insurance will cover that. But, you know, I just, I have to ask you, what's the gender?" And I'm like, oh the records. And the insurance was listed as a female. And, you know, so I have patients who their gender identity matches their insurance. So things go through for that, and things get documented in such a way that it supports them. So there's a little bending of the truth that goes through. But I think it has to be an open conversation with the client.

JoAnne Keatley: Thank you. One more comment.

Audience Member: Clever charting you can get insurance to pay for things insurance does not want to pay for.

JoAnne Keatley: Okay, so that's -- thank you very much to the panel. [applause]