Gender Affirmative Care Clinic: An Overview.

Transgender healthcare is an evolving multispecialty field including medical and social domains catering to the needs of a specific subset of population presenting with gender incongruence, differences in sexual development/orientation, requiring care rather than cure. Delivery of transgender healthcare is done through gender friendly healthcare facilities, which are designated as "gender affirmative care clinics (GACC)." The primary purpose of the gender affirmative care clinic is to be the "one stop solution" for a person seeking affirmative care. The main objective is to facilitate care with compassion and prevent/mitigate dysphoria. The components of the GACC should include reception cum front office; affirmative mental healthcare department; affirmative medical, surgical, and sexual healthcare department; diagnostics, legal, and ethics department, as well as inpatient care. The GACC should be preferably located in a place that is easily accessible to the community members and has an "open plan." Association of Plastic Surgeons of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).

Introduction

Transgender healthcare is an evolving multispecialty field transecting the medical and social domains to cater to the needs of a subset of people who present with gender incongruence, differences in sexual development/orientation. 1 Majority of these individuals have very poor health-seeking behavior due to their past unpleasant experiences at healthcare facilities. Delivery of transgender healthcare is done through gender friendly healthcare facilities that are designated as “Gender Affirmative Care Clinic (GACC).” 2 The GACC addresses the medical and social needs of this subset of individuals under one roof. This article gives an overview, touching on the need, purpose, components, and the layout of the GACC.

Why do we need a Gender Affirmative Care Clinic?

The nonconforming person, being a minority in a largely cis oriented world, is wary of the healthcare setups. 3 The mistrust is reinforced by their past experience of negation of their narrative and denial of the basic human right of availing the benefit of the advances made in the medical field to live in harmony with all human forms as their desired true selves, enjoying equal opportunity and privileges, just as those granted to the cis majority. 4 As the medical fraternity recognizes and endorses the diversity of gender identity and supports the call for affirmative care, it becomes pertinent that changes be made to cater to the needs of this subset of society. 5 Unlike the cis majority, they are not patients, even though, the delivery of care needs to be done by a trained and skilled “Gender Affirmative Care Team (GACT).” This team should comprise gender friendly and gender knowledgeable healthcare professionals, social scientists, legal and ethical experts, at healthcare facilities equipped with state-of-the-art, cutting-edge technologies. The need for “GACC” arises from this unique requirement. Proximity to and integration with services provided by gender friendly specialists and super-specialists, mental health professionals, physical and vocal therapists, medical and surgical affirmative care providers, legal and social workers, community members, and support groups is a pre-requisite.

What should a Gender Affirmative Care Clinic do?

The primary purpose of the GACC is to be the “one stop solution” for a person seeking affirmative care, and the primary objective of the staff is to facilitate care with compassion and prevent/mitigate dysphoria. 6 The GACC should maintain records pertaining to the medical and social transition, serving as the interface between the National Council for Transgender Persons, the State Transgender Welfare/Empowerment Board, Ministry of Health, Ministry of Social Justice, and the individual. The GACC, in addition to being the training ground for refinement and enhancement of skills of the professionals working in the field of transgender healthcare, should also collate data for undertaking research in this evolving field to improve the quality of care being delivered.

What are the Components of the GACC?

The components of the GACC are discussed in the following text.

Reception cum Front Office

The reception is by far the most important component of the gender clinic. This will be the first contact point for the person who more often than not, is negated, ostracized, scared, uncertain, carrying the baggage and scars of the internal and external battles, to seek validation of their narrative and discovery of their true selves. Who they meet and how are they received will have a long-lasting impact on their journey. 7 8

Staff

Staff deployed at the reception has to be carefully chosen, qualified, and very well trained. The reception should ideally be staffed by members from the community.

The staff deployed at the reception should have good communication skills and be well versant with the

Transgender Persons Protection of rights Act & Rules

Documentation procedures both for medical and social transition

Counselling services

Protocols for medical and surgical affirmative care

Trauma care services

Legal help, ethical care, and grievance redressal services

Help lines and contact details of governmental and nongovernmental agencies providing social support/financial aid/avenues for professional growth

Gender-friendly accommodation/hostels/paying guest facilities

Gender friendly transportation services

Local self-help and support groups

The Layout and Design of the Reception

The layout of the reception has to be welcoming and comforting. Keep in mind that the person approaching the clinic for care, based on their past experiences of healthcare facilities, is likely to get triggered by the language used or behavior of the staff. They may feel overwhelmed in an authoritarian environment wherein they face uncomfortable questions, feeling rushed and compelled to fill out officious appearing documents and forms. Hence, an “open design layout” is preferred. Herein the entry to the facility leads to a spacious waiting area with comfortable seating arrangements permitting sitting in small groups in a relaxed atmosphere. The amenities area and washrooms should be adjacent to the waiting area and all signage to be gender friendly. Gender-neutral washrooms, display boards of gender friendly organizations, self-help groups, parent support groups, pictures and displays highlighting the achievements of members of the community so as to showcase role models worthy of emulation. Helpline numbers and information regarding redressal of grievances should be readily available and exhibited. The reception counter should be positioned on one side. The staff should not restrict themselves to standing behind the reception counter. Instead, as far as possible, approach the individual, welcome them, and sit with them in the waiting area. The staff should use gender friendly language and should display their name and pronouns. They should allow the individual time to understand the nature and need of the documentation and should not rush them into filling up of forms.

Documentation

A two-step documentation should be followed with the affirmed gender and preferred name being recorded and displayed on all forms and communication with staff of the gender clinic whereas the assigned name and gender be mentioned along with the affirmed gender and name only in records required to be maintained by the hospital. All records to be kept confidential and care taken to not “out” the individual without their consent. All records to be centralized and information to be shared among staff on a “need to know” basis. 9

Designated Person-in-Charge

One member of the team, preferably from the community, to be designated as person-in-charge who will assist the individual by arranging consultations with the various departments. This ensures that the discomfort arising out of meeting a stranger on every visit to the clinic is avoided. The person can go directly to the professional entrusted with their care thus reducing waiting time and unnecessary interactions that may trigger dysphoria. 7 8

Affirmative Mental Healthcare Department

This forms the backbone of the gender clinic and would be manned by a mental health professionals trained in transgender healthcare. 7 8

The staff would be responsible for monitoring the progress of the individual before, during, and after transition. They need to take steps to prevent the onset of, or mitigate, dysphoria throughout the medical and social transition process.

They would also be required to give letters of recommendations for advanced care by specialists. This is in accordance with the protocols or as decided by the gender affirmative team in consultation with and consent of the individual. In case the individual is a minor, then consent of the guardians is required.

They would address mental health issues related to substance abuse and high-risk behavior.

They would also be actively involved in resolution of posttraumatic stress disorders, self-harm, and suicide prevention measures.

They would also take on the role of “Trans-coach” teaching coping skills and generating positive role models for the individual to emulate.

They would also take on mentorship of community workers and school counsellors helping develop the outreach arm of the gender clinic.

Number of members would depend on the population being served. However, each unit should have a clinical psychologist, a counsellor, and a social worker.

Affirmative Complementary Care Department

This department of the gender clinic caters to techniques, which enable the individual to pass as their true self. The staff deployed will assist the individual in choosing clothes, makeup, body language, proper use of binders, tucking, etc. to help them pass. It is desirable that most of the staff deployed in this department should be community members. 7 8

Affirmative Voice and Communication Department

Voice modulation and communication training given by the speech therapist reduce dysphoria in the individual. It also reduces the need for surgical procedures. Hence, a separate department to cater to this need is made a part of the gender clinic. 10 11 A speech therapist and a communication expert will be in charge of the department and services of an ENT specialist will be sought for special cases. 7 8

Affirmative Medical Care Department

This part of the gender clinic would have the heaviest footfall. Persons of all ages seek care beginning in the pretransition phase, extending way beyond the transition phase of their lives. This would cater to the medical aspects of transgender healthcare encompassing the primary, secondary, and tertiary care needs. These needs are provided by the general practitioners as well as specialists from the field of family medicine, pediatrics, endocrinology, geriatrics, and preventive healthcare including cancer screening and management of lifestyle disorders. 7 8

Reproductive and Sexual Healthcare Department

This is a very important department requiring specialists from gynecology, urology pathology, and cytology working together. This not only needs support of cutting-edge technology and specialized infrastructure but also special counsellors. They, in turn will, assist the individual to tackle sexual health issues and make the decisions regarding preservation of ova and sperms for future fertility needs. 12 13 14 Sexually transmitted infections remain a major concern and hence this department needs to work in tandem with the National AIDS Control Organization for provisioning of condoms, antiretroviral therapy (ART), as well as pre-exposure prophylactic treatment. 15 This department would, like the affirmative surgical care department, need wards for procedures requiring admission and close monitoring. This department maybe colocated with the affirmative surgical care department for optimum utilization of trained staff, equipment, and resources. 7 8

Affirmative Surgical Care Department

The affirmative surgical care department is the most sought after facility not only by persons with gender incongruence but also by people with differences in sexual development/orientation. It is staffed by reconstructive surgeons, gynecologists, urologists, anesthesiologist, specialized nursing staff, and physical therapists trained in the field of transgender surgery. This department should ideally be housed on a separate floor. Consultation chambers, wards, pre- and postprocedure rooms, operation theaters, and recovery rooms should also be present in the same area. In addition, separate waiting areas for attendants and family members/guardians need to be provisioned. 7 8

Legal and Ethics Department

This department is manned by legal experts and social workers. They need to be well versant with the Transgender Persons Protection of Rights Act & Rules and the documentation procedures for both medical and social transition. They would ensure social justice and support for the individual by becoming the link between the individual, State Transgender Board and the National Transgender Council. 16 17

Pharmacy

A well-equipped pharmacy catering to the medical and surgical needs of the individuals visiting the gender clinic should be located close to the waiting area. In addition to the hormone preparations being prescribed by the professionals, the pharmacy should stock dilators, binders, tucking tape, prosthesis, and implants too. 7 8

Diagnostics Department

A well-equipped laboratory with trained staff and an ultrasound machine with a sonologist should be available at the gender clinic. 18 19 20

Layout of the Gender Affirmative Care Clinic

The GACC should be located in a place that is both accessible to the community members and close to the affiliated tertiary care hospital. However, it should have a separate entrance and exit from the said hospital. An “open design” of the facility is preferred so that each department is easily accessible from the common waiting area with minimal mixing of individuals seeking different services. Separate staff entrance is desirable and so are separate entry and exit points to and from each department. Use of designated corridors and a unidirectional flow plan for the movement of the individuals seeking care will prevent mixing of individuals seeking different services. Keeping the above in mind, a suggested layout is as under (not to scale) ( Fig. 1 ).

Fig. 1

Layout of Gender Affirmative Care Clinic.

In a multistorey building, the reception complex, legal and ethics department, pharmacy, diagnostics department, affirmative mental healthcare department, affirmative complementary care department, affirmative voice and communication department, and the affirmative medical care department should be on the ground floor of the GACC. The reproductive and sexual healthcare department and the affirmative surgical care department may be colocated or be on separate floors with shared procedure rooms and operating theaters/rooms. In a larger setup, one may have a separate floor accommodating the administrative wing and the training complex including a seminar hall for the conduct of gender education classes and training sessions for staff and sensitization of general public.

Conclusion

Its time, India reconnects with its cultural heritage of acceptance of diversity, unshackling itself from the oppressive draconian laws (reminiscent of the colonial era. 21 22 Empowering the LGBTQAI+ community through the recently introduced transgender persons

Protection of Rights Act in 2019 and aligning with the current medical evidence to implement the International Classification of Diseases (ICD)-11 is certainly a step forward. Setting up of gender affirmative care clinics is a felt need for delivery of holistic healthcare without fear of stigmatization to this hitherto neglected and ostracized vibrant subset of our society. It is the basic requirement for them to live with.