Cultural Competency

Abstract

As an outcome of the lack of cultural competency about transgender and gender-nonconforming populations, transgender people have experienced significant barriers to full access in many spheres of society and have consequently experienced discrimination, harassment, and violence (Grant et al. 2011). Cultural competency refers to the ability to understand, communicate with, and effectively interact with diverse populations, and it can be measured by awareness, attitude, knowledge, skills, behaviors, policies, procedures, and organizational systems. Culture is defined as “the integrated pattern of thoughts, communications, actions, customs, beliefs, values, and institutions associated, wholly or partially, with racial, ethnic, or linguistic groups, as well as with religious, spiritual, biological, geographical, or sociological characteristics” (Office of Minority Health 2013). Cultural groups can include people who share racial and ethnic affiliations, linguistic characteristics, generation, geographic residence, socioeconomic status, physical ability or limitations, sex, sexual orientation, gender identity and expression, and other characteristics, and they can be population groups that share a defined set of cultural expressions and expectations. Transgender cultural competency is imperative across the board for improved health, social service, legal, faith-based, employment, and educational outcomes.

The phrase “multicultural competence” first surfaced in a mental health publication by psychologist Paul Pedersen in 1988, a decade before “cultural competence” came into popular use. While health care institutions were the first to promote the concept of cultural competency, and undoubtedly continue to be the most common field that recognizes the need, all fields can benefit from a cultural competency perspective. Behavioral health, public health, social services, educational institutions, criminal justice, law enforcement, faith-based organizations, government services, employers, and other organizations, businesses, and institutions can certainly improve their knowledge, skills, behaviors, policies, and procedures to create a welcoming and nondiscriminatory environment for transgender and gender-nonconforming individuals and families.

Rather than a body of knowledge that can be learned in an afternoon workshop, training series, or course, cultural competency is a lifelong process of engagement. Critiques of the concept of cultural competency highlight concerns that people sometimes view the work as short term or that power imbalances are not examined, instead preferring the term “cultural humility,” which emphasizes self-evaluation and nonpaternalistic approaches (Tervalon and Murray-Garcia 1998).

Indeed, intersectionality, or multiple systems of oppression and discrimination (Wikipedia 2013a), exists for many transgender people. Systematic injustice and inequality occur not just based on gender identity and expression but also within overlapping experiences of race, gender, socioeconomic class, ability, sexual orientation, health status, linguistic capability, migration, and other characteristics. Transgender cultural competency requires recognition and commitment to genuinely understanding and working to address the multiple parameters that impact so many transgender lives. Within this framework of intersectionality, transgender cultural competency involves an understanding of terms, identities, and concepts associated with transgender and gender-nonconforming communities, including utilizing culturally appropriate language and behavior for addressing and working with transgender populations; broadening understanding of the myriad socioeconomic, health, and legal issues that transgender people face; and developing and implementing culturally appropriate systems and service approaches for working with transgender individuals and families.

Cultural competency issues are addressed worldwide through many avenues for an array of audiences. In 2000, the US Department of Health and Human Services, Office of Minority Health, first introduced the National Culturally and Linguistically Appropriate Services (CLAS) Standards — fourteen mandates, guidelines, and recommendations for health care organizations to develop language access services and organizational systems for more culturally competent care (Office of Minority Health 2001). Since the original CLAS Standards focused fairly exclusively on racial and ethnic diversity, LGBT-specific CLAS standards were later developed independently to recommend that substance abuse organizations (but transferable to other entities) implement the following: LGBT-inclusive policies and procedures, LGBT training as part of larger diversity training, LGBT-inclusive forms and oral language used in assessment and interventions, a welcoming and inclusive climate, and linkages with local LGBT resources and communities so that appropriate referrals can be made for LGBT clients (LGBT Constituency Committee and LGBT TRISTAR 2008). In April 2013, the fifteen Enhanced CLAS Standards were released with a much broader definition of culture (including gender identity and sexual orientation for the first time) as well as an expanded approach to the intended audience beyond health care institutions (Office of Minority Health 2013).

On a global level, approaches to transgender cultural competency issues are informed by the economic situation, legal issues, and whether there is a historical cultural framework for understanding trans and gender-nonconforming people. Organizations in their respective locales as well as such far-reaching organizations as Global Action for Trans Equality, University of California, San Francisco, Center of Excellence for Transgender Health, American Jewish World Service, and others are working to support trans human rights around the world. Many countries are addressing transgender cultural incompetence in health care. In Kampala, Uganda, where it is illegal to be gay or associate with gay people, with trans people considered to be “gay” (Wikipedia 2013b), activists are working to ensure that trans people are not turned away from the emergency room at the local hospital and that they can establish relationships with doctors who are willing to treat them (Kopsa 2012). The organization Gender DynamiX in Cape Town, South Africa, is working to improve competence in the police force (Gender DynamiX 2013), while South Africa, Chile, several European countries, and others are educating government agency workers who handle identification changes (Shlasko, pers. comm., August 2, 2013). In Argentina, where the 2012 landmark Gender Identity Law enabled trans people to change their identification documents without medical intervention and access transition-related care through public and private health insurance, the organization Nadia Echazú works to improve trans access to education and employment beyond the sex industry (Baird 2013). In locales such as Thailand, India, Pakistan, and the Yucatan region of Mexico, where there is an indigenous tradition of gender diversity, stigma and marginalization persist throughout society, yet not the level of cultural incompetence at which providers are unaware of the existence of trans people. Finally, in locations with dire economic conditions, where basic survival is paramount and primary health care is not available to poor trans people, health care institutions are not necessarily the first priority with regard to addressing cultural incompetence. Indeed, approaches vary around the world, with Europe relying almost exclusively on a medical model, while much of the global South relies on a human rights model (Shlasko, pers. comm., August 2, 9, 2013).¹

It is essential for health service providers (including medical, mental health, substance abuse, and other public health professionals), government agencies, educators (preschool, K-12, and college level), and others to understand the complex array of identities and expressions that transgender and gender-nonconforming people represent. This includes people who identify as male or female as well as people who identify as something between or beyond male and female. It is also important to understand the various ways in which trans and gender-nonconforming people want to be addressed and to be equipped to successfully navigate appropriate name and pronoun use. Also key is the ability to respectfully obtain this information when it is unclear what is appropriate and to recover gracefully when a mistake is made.

Trainees in transgender cultural competency benefit from a firm grasp of social and medical transition, including the routes and barriers to transition-related care for transgender and gender-nonconforming people. It is important to understand how underlying factors of low socioeconomic status, limited health care access, lack of family acceptance, partner and community discomfort, discrimination in employment and housing, legal challenges, and medical conditions including HIV/AIDS can make medical transition challenging to pursue. Indeed, the lack of coverage for transition-related care under most health insurance plans for what are often cost-prohibitive procedures contributes to significant financial hurdles.

In the United States, many jurisdictions prohibit discrimination based on gender identity and expression in public accommodations such as health services. Organizations, government services, and educational institutions can develop trans-inclusive policies and procedures to identify, respond to, and appropriately serve this population. They can update their written forms to ascertain and document transgender status; implement trans-inclusive policy for gender-specific environments including restrooms, locker rooms and shower facilities, housing accommodations, dress code, support groups, and urinalysis; and develop clearly written nondiscrimination policies that specifically protect against discrimination based on gender identity and expression. Systems should be in place to address grievances and poor-quality treatment so that staff persons can receive additional training and/or appropriate sanctions if necessary.

School district policies for accommodating trans and gender-nonconforming students, such as the one developed in Toronto, Canada, recommend systems that emphasize dignity, respect, privacy, safety, and curriculum integration in educational settings free of bullying, harassment, and discrimination (Toronto District School Board 2011). In addition, K-12 schools can support students with transgender family members through celebration of diversity of all kinds, staff training, and LGBT affinity groups. Colleges and universities can support transgender and gender-nonconforming students by incorporating transgender issues into the curriculum across fields and providing trans-affirming academic, social, medical, and mental health programs. A resource has recently been developed to document trans-inclusive policies and practices at American college and university campuses (TONI Project 2012).

Many are confused about how to navigate social interactions and work with individuals with complex, nonbinary identities. They may work with transgender clients, patients, and students with multiple concerns such as immigration issues, limited dominant language capability, cross-cultural differences, unemployment, unstable housing and homelessness, mental health concerns, substance abuse, HIV/AIDS, hepatitis, and other medical conditions, to name a few. Challenging scenarios can be addressed by researching Internet resources, developing effective partnerships with colleagues who serve this population, and getting training from experts in the field of transgender cultural competency. With awareness, compassion, attention to knowledge and skills development, and a commitment to updating organizational systems, health service providers, educators, government agencies, law enforcement, faith-based organizations and others throughout society can build the capacity of their organizations to create nondiscriminatory service environments for transgender individuals and families.

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