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5 Sexuality Research & Social Policyhttp://nsr c.sfsu.edu alking,Gawking,or Getting It Done:Provider Trainings toIncrease Cultural and Clinical Competence for Transgenderand Gender-Nonconforming Patients and ClientsAbstract: is article presents a set of preliminary policy recommendations regarding competencytrainings for health care providers to improve service delivery to transgender and gender-nonconformingclients. These recommendations are based in part on a program evaluation of trainings conducted inthe northwestern United States in 2005Ð2006. Using a mixed-methods approach, the evaluationassessed the effectiveness of 3 competency trainings administered by a nonprofit health education andoutreach organization serving lesbian, gay, bisexual, transgender, gender-nonconforming, andquestioning people. Quantitative data indicated that the trainings were effective in transferring knowl-edge. Qualitative data confirmed this finding and elicited a number of themes about providersÕexperience of the trainings and their posttraining questions about interacting with transgender andgender-nonconforming patients and clients. The authors propose policy recommendations to guidecurriculum developers and trainers in developing content and structure and to facilitate implemen-tation of lessons learned in trainings at an agency- or organization-wide level.Key wohealth disparities; LGBTQ; LGBT; training; Transgender 101; cultural competence; qualityIn the past decade, an increasing number of publica-tions have focused on transgender health (Israel & Tarver,2003; Lombardi, 2001; Xavier, Hitchcock, etal., 2004).research on this topic has been sparse, it is clear that trans-ulation (Dean etal., 2000; Minter & Daley, 2003; Xavier,part of providers about how to deliver competent care tothis problem (Minter & Daley; Xavier, Hitchcock, et al.).is a perpetually evolving term and,evolved from within these communities. Generally,tinuous, or more complex than that for the gender toAlthough nontransgender individuals alsoAddress correspondence concerning this article to Christoph Hanssmann, 2641 1/2 NW 64th Street, Seattle, WA 98107. ; Darius Morrison, 312 25th Ave. S., Seattle, WA 98144. E-mail: Seattle, WA 98195. E-mail: Sexuality Research & Social Policy, Vol. 5, Issue 1, pp. 5Ð23, electronic ISSN 1553-6610. © 2008 by the National SexualityResearch Center. All rights reserved. Please direct all requests for permissions to photocopy or reproduce article contentthrough the University of California PressÕs Rights and Permissions website, March 2008 SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 16 defined as those whose bodies, genders, or behaviors fallcompetence in serving transgender and gender-writing, we do not know how many such trainings arerecent publications have called for increasing providertransgender and gender-nonconforming patients andCultural Competencein the late 1980s to help meet the mental health careIsaacs, 1989). Since that time, cultural competence hasthose with limited English language proficiency, immi-grant or refugee status, and barriers due to race orethnicity. Such trainings have gained acceptance inCross etal. (1989) originally defined cultural com-policies that come together in a system, agency, or amongpopularity. In contrast with the definition set out by Crossetal. (1989), the expansion of cultural competence cur-wide approach„the core educational content shiftedprimarily to the provider-patient interaction (Betancourt,Three review articles (Anderson etal., 2003; Beachetal., 2005; Bhui, Warfa, Edonya, McKenzie, & Bhugra,2007) discussed the lack of comprehensive evaluationascertain how many trainings take a system-wideCross etal. (1989): The system-wide approach is no longeresbian,Gay,Bisexual,Queer,Transgender,andGender-Nonconforming Issues andompetence Trainings(Corliss, Shankle, & Moyer, 2007). Trainings that educatenonconforming individuals are even less integrated.developed educational strategies to increase quality ofhealth care to lesbian, gay, bisexual, transgender, gender-conforming, queer, and questioning individuals. Although such trainings are known by a variety of names,to generally refer to trainings that aim to increaseservice providers competence in delivering care to2 We used SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 17 One of the main challenges in administering culturalto LGBQ and transgender or gender-nonconforming peo-integrate it into practice (Bonvicini & Perlin, 2003; Corlissetal., 2007; Feldman & Goldberg, 2006; Israel & Tarver,bisexual, transgender, and queer (LGBTQ) health ishealth care because their identities are highly medical-der identityŽ (Spade, 2003, p. 16). This state of affairs isin part due to the fact that the clinical psychiatric diag-sis of gender identity disorder has been based have been„and, to a large extent, continue to be„too narrow. Thesespecific, unique concerns of transgender and gender-nonconforming individuals are seldom given enoughBased on existing standards of care (Meyer etal.,2001), therapists and health care providers are expecteda useful tool, the dominant standards of care are fraughtgender-congruent legal identification, employment,and housing. Because mmedical transition„and, thus, who will have access togender-congruent services„providers must have atalternatives to such gatekeeping systems. Some pro-lines or recommendations that increase transgenderng individuals degree of self-determination in seeking care (Lev, 2004; Tom WaddellHealth Center, 2006). Nevertheless, in the absence ofsuch services, access is still a problem for people who docal assistance that is specific to their gendered appearance,they still face a number of challenges associated withducted to date (Bockting, Robinson, & Rosser, 1998;Landers, & Lawrence, 2005; Xavier, Bobbin, etal., 2004)demonstrate a profound lack of access to care. Barriers toof which create additional barriers to gaining access to care(Clements etal., 1999; Kenagy; Xavier, Bobbin, et al.). Aetal., 2005) found that providers who see transgender2005; Sperber etal., 2005; Xavier, Bobbin, etal., 2004),Such trainings not only can familiarize health care 4 Many individuals who seek hormones or surgeries tochange their appearance to achieve a desired gendertransition.However,transgender and gender-nonconforming communities usetransitionvery broadly, not exclusively in terms ofusing medical intervention to change ones appearance. SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 18 gaining access to care but also can provide a context inwhich providers can improve their skills at deliveringcare exist at every level in health care delivery (from insur-desk staff), the system-wide approach advocated by Crossetal. (1989) is appropriate.viduals. Nevertheless, Transgender 101…style trainingsseem to overlap in content and approach, providing sev-cultural competence education (Cross etal., 1989) may besimilar needs but whom the provider perceives as not fit-Egli, Baker, & Kassekert, 1997) and examined the tensionimportance of refection, uncertainty, and a focus on2007). Building skills to cope with ambiguity serves acurriculum developers and trainers, as well as a depth ofcommitment from health care organizations, agencies,this writing, we found no articles about evaluations ofways that curriculum developers and trainers can buildeffective trainings for use in health care settings and offersrecommendations for health care clinics and organizationsthat aim to increase quality of care to transgender andesearch Background and ContextFrom April 2005 to September 2007, the authorssmall-scale community-based program evaluation of aadministered by a local nonprofit health agency inSeattle, Washington. The primary author undertookgram in public health. Researchers also included acommunity research team comprising four transgenderwill be presented in detail in another publicationtence in providers who deliver care to transgender patientsseries from a local community organization 5 Making this distinction is generally considered an impor-tant aspect of trainings because transgender communities 6 The name of the organization has been omitted to protect SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 19 variety of programs, most of them focusing on educationtrainings regarding provision of care to lesbians andcurriculum by adding content about gay and transgendertraining curriculum using information from clinical pub-lications and feedback from community members.the organization began fielding requests from providersfor more information about transgender and gender-(an alternative term for gender-nonconforming) healthThe organization does not actively publicize the train-The trainings, ranging in duration from 1 hour toabout health disparities in transgender and gender-extent to which this could take place. Each of the train-ings finished with a question-and-answer session. One ofthe trainings, which was longer in duration, included anintersecting identities (gender in context of race, class,mention or discussion. Regarding barriers to care, mainThe study used a mixed-methods approach toticipation in the trainings was associated with an improve-ment in self-assessed knowledge about cultural andtransgender individuals. With qualitative data collected in= 9) with providers who com-pants recall about the training (4…30 days after training)?;(b) What do they feel they learned from it?; (c)Whatquestions remain for them after the training?; and (d) Inwhat ways do they feel prepared to implement knowledgethey learned in the training, and what steps have theyteam with connections he made as a result of his mem-bership in the transgender community. All of the members the range of gender identities that veer away from expecta-orthat male and female are mutually exclusive genderumbrella but distinct from transgender, intersex conditionsdifferentiated from transgender identity (although some SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 110 and all were familiar with the organization that offered thein part to measure knowledge that the research team feltsurvey to determine whether providers gained knowledgetence have been published. The research team developedsuring cultural competence regarding race, ethnicity, andscales from the Cultural Competency Self-Assessmentto address issues that pertain to caring for transgender andorder to capture data about providers communicationstyle and self-assessed bias„topics the CCSAQ does notaddress„the researchers also developed an additionalsubscale, called Cultural and Clinical Competency inTransgender Health Provision: Self-Assessment, usingthat emerged from data and a priori codes developed fromPrimary codes that were developed a priori were spe-Open codes that emerged from participants answers toopen-ended interview questions included Provider Setting,esearch Resultsrespondent between pretraining and posttraining, theQualitative data were used primarily to confirm quan-ticipants were generally very impressed by the training andparticipants fell under three main categories: (a)(b) Provider Settings, and (c) Identified Training Needs.the training centered on terminology, the presence of athe availability of medical or clinical information.the training. Most also commented on having a trans-(afemale-to-male transgender individual) or to a transnity connection as they gained information. However,these training components presented unanticipatedproblems. Some of the participants quotations illus-curate or incomplete understandings about transgender 9 The researchers included the three authors of this article,as well as two additional researchers who were members of SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 111 and defined them as being a forming this role through the use of clothing, makeup, or both.from that of [A transvestite] either identifies themselves as femaleor feels female sometimes, [but is] a malehas maleversa. As opposed to a transgender person who Icating that the respondent equated the desire to physicallyeffect on her use of patients or clients preferred pro-a context in which transgender or gender-nonconformingnontransgender and so would fail to receive culturallytransvestites or cross-dressers„a distinction in which distinction in whichoffice, andƒyou can get a good sense thatƒits either afemale dressed as a male or a male dressed as a female.ŽThe researchers saw this response as indicative thatthis participant missed a key point: Transgender andgender-nonconforming individuals use language and ter-minology very differently depending on social or geo-danger inherent in presuming gender identity basedin terms of the peo- 11 Use of correctly gendered pronouns (according to thesubject), such as him/he, her/she,significant to transgender and gender-nonconformingpeople, who perceive the correct use of such pronouns as anindicator of being seen, recognized, or affirmed in theirgender identity. Failing to consider pronoun preference orconsistently using incorrectly gendered pronouns (again,according to the subject) is likely to cultivate distrust andfrustration on the part of transgender and gender- Although such distress may not occur for all transgenderand gender-nonconforming individuals, many have a dis-comfort or disconnection with areas of their bodies associ-ated with what, for them, is the wrong gender„breasts,vagina, uterus, or ovaries for male-identified individuals, forexample, or testes, penis, or SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 112 sionary manner, providers understandings of termsclients to describe and define their own identities as theyciated hearing from the perspective of a transgender indi-someone educate you but have not walked in therich and it helped people feel, oh, that this is real andrich and it helped people feel, oh, that this is real andFTM, that was the first time that it struck meknow, this is what an appointments going to looklike, and this is what a transgendered person looksIm sure my jaw just dropped to the table! Justit was not at all who I was envision-And because I guess I wasnt really thinkingthere was a large female-to-male population, I wasmore thinking of male-to-female.understanding of transgender identity (to includemasculine-identified transgender and gender-transgender person looks like with another, equallyOne of the participants expressed a desire to seeOne of the participants expressed a desire to seeƒlike, this is who yourpatients are, and this is who were talking aboutƒImean pictures sounds so, like, animals in a zoo.gendered appearance is directed toward transgender andgender-nonconforming individuals. The participantbased on race and ethnicity as barriers to care. Greater lev-experience intersecting oppressions. However, qualita-It didnt occur to me during the training, I wasntthinking, like, what if it was an African Americanor an Arab American. I wasjust thinking the whole time, like if a transgendercultural differences.ticipants independently formulated action steps inresponse to learning about such barriers even though SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 113 insurance companies policies regarding transgenderindividuals. Insurance companies generally excludehormones and surgeries from coverage and at times havetransgender status (Israel & Tarver, 2003; Minter & Daley,advocate: We [providers] could send petitions toinsurance companies that we contract with saying that wefeel this is a very important issue.Ž Another provider com-struggling with how to accomresponded very well to the discussions and the interac-tive aspects of trainings but less well to an entirely lecture-style format. A participant in one of the longer trainingssee games, demonstrations, or activities in addition toQuantitative data analysis is promising in terms ofshowing an increase in cultural and clinical compe-tence in health care delivery to transgender and gender-issues of internal reliability), whereas others have to doconfirmed our initial findings about the effectiveness ofgaps in the curriculum (delivering effective care tomarginalized members of these communities, interac-The relatively small shift in overall change in scorefrom pretraining to posttraining (0.6 point) may beattributed to the limited length of the training, to the mostlyvided only once. A recent meta-analysis (Mansouri &cal education (CME) courses showed positive correla-tions between the size of the effect and the length of theare more effective than those that do not (Mansouri &Lockyer). The observed effect size in this evaluation mayalso be attributed to a possible selection bias. Becausetrainings are offered on demand, organizations thatrequest them may be more familiar with LGBTQ issuesthan others, which could attenuate the overall change inhave the opposite effect on overall change in score fromarea of cultural competence in general, can be used toand thus guide future curriculum development.Participants in the training described learning a greatabout language, connection with communities, and accessput them in a position to advocate for transgender andticipants independently developed specific plans of actionwith regard to advocacy. We found this outcome to be par-viewed clinical and cultural competence as existing beyond SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 114 nonconforming communities. We concluded that, in par-ticular, providers were ill equipped to deliver quality careto two major groups: (a) transgender and gender-gaps in skill set and knowledge are disturbing; the likelying individuals will benefit from providersunderstanding, we discussed some of the reasons whystanding of the variations in appearance, expression, iden-Thesemisinter-pants previously held beliefs, stereotypes, or assumptions.We thought that the creation of a shared language andunderstanding via training was important, and interviewdefinitions as bounded and exclusive when, in fact, thevariation within transgender and gender-nonconformingcommunities may have stemmed from a lack of effective-nicity. The vast majority of training participants identifiedas White; we surmised that participants assumptionsare not able to get cost-prohibitive medical treatmentassigned the gender at birth with which they currently iden-tify) or to people who present a relatively conventional gen-der identity are not providing competent care to the diverseindividual demonstrated not only that she conflated trans-treat individuals not generally perceived as the genderoppression of transgender and gender-nonconforming both within and outside of these communities. Healthphobia and racism (as well as classism and sexism, insome cases) therefore experience an even greater challengeand of being uninsured are extremely high (BostonPublic Health Commission, LGBT Health, 2002).tionalized racism (Jones, 2000), which centralizes dom-inant cultures and renders marginalized groups invisiblenot necessarily considered the implications of racialnonconforming people; therefore, these providers wouldindividuals mayface.Despite the importance of cultural competence indelivery of care, some scholars in this field (Taylor, 2003b) SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 115 students received specific cultural information about thisgroup, they were more likely to believe that Aboriginal peo-animals in a zoo.Ž Here, she articulated the tensionand the danger of indulging excessive curiosity. We echoedbenefit providers without reinforcing an increased scrutinyA number of scholars and practitioners in the field ofcultural competence (Betancourt etal., 2003; Cross etal.,affect behavioral change if they are not met with structuraland systems-based change. Despite the lack of concreteevaluations demonstrating this conclusion, the argumentin favor of a system-wide approach makes logical sense:ulations is most effective using such an approach becauseinteractions with multiple individuals and agencies is char-portive care delivery is then primarily the responsibility ofin the domain of provider-patient clinical encounters. Wefelt that in addition to cultivating skills and knowledgeassociated with provider-patient interaction, a set of well-curriculum developers and trainers must exercise someorganizations in which they work. Therefore, we also pro-Transgender 101…style curricula.olicy Recommendationsliminary. At the same time, Transgender 101…stylechange and increased quality of care. Transgender101…style trainings also overlap to a greater or lesserpetence in general, may be relevant in considering the pol-We will discuss policy with regard to trainings at twolevels: (a) with regard to training curriculum develop-tional implementation of knowledge gained fromshould be incorporated in health professional schoolCurriculum DevelopmentA number of aspects of curriculum developmentnonconforming patients and clients. We based these con-competence education (Chrisman, 2007; Cross etal.,munity research team in our evaluation project gener-ated about aspects of provider knowledge vital to a positivethat providers will gain in the course of the SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 116 2.Offering information that is relevant to providersGiving providers tools to prepare them forinteraction with a wide variety of gender-6.Providing information about resources and com-professional development and in clinical interac-7.Developing expectations or action steps designednificant gaps remained. We thought the training could beimproved by developing a set of specific learning objectivesthe training. These objectives should be made explicitatthe beginning of the training and should be addressedCurriculum developers should have a good under-standing of what clinical information providers need most(and whether it may vary by audience) and should ensuregeneral lack of research about transgender primary healthCross etal. (1989) introduced the term and defined it as involving a system-wideapproach. Training curricula, even if focused on directprovision of health care and the patient-provider inter-provides context in the clinical encounter and becauseCurriculum developers and trainers can play a cen-transgender and gender-nonconforming communities.educational theories of praxis, curriculum developers(Freire, 2000; Knowles, 1980). By centralizing andmembers of transgender and gender-nonconformingcommunities experience, curriculum developers canProviders depth of knowledge about health care pro-but nonetheless should understand some of the basic clin-ical needs and barriers to care (Feldman & Goldberg,2006). Curriculum developers should consider these fac-will deliver care to transgender patients or clients. At min- SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 117 but also give them information to pass on to patients andongoing information or guidance. Curriculum developersCurriculum developers should be explicit in devel-oping trainings as a component, rather than an endpoint,about how clinics, agencies, and organizations canCross etal. (1989) discussed the importance of involvingof them have been developed by or in cooperation withtransgender or gender-nonconforming individuals„andevaluate training programs to ensure that goals and objec-tives are being met. In addition, they must ensure that cur-Community collaboration in curriculum develop-Educational approach. part by scholarship in cultural competence that argued forcross-culturally rather than giving them formulas, scripts,or recipes. Reducing cultures or communities to onespecific experience can be tempting, but such an approachis harmful because each individuals experience of cultureand identity (including gender identity) is unique andTo adopt a cookbook approach is too reductive: Suchbut also fails to cultivate their trust in a clinical encounter,Members of the community research team suggested anumber of ways„some of which are currently in use bysome Transgender 101…style trainings„in which trainingsintroduce the concept of gender fluidity and the depth andparticipants about how they fit or do not fit gender stereo-Community research team members generally thoughtfocusing on transgender experiences. The former allowsquality, accessible care for these communities. The latteris more likely to cause participants to come away from thetraining with a narrower understanding of supposedly pro-totypical transgender or uals because it is impossible to truly represent the breadthQualitative data from the training evaluation revealedsome of the unanticipated effects of using specific,nonconforming individual leading trainings. Although wedo not deem it necessary to eradicate these componentsfrom trainings, we certainly recommend that curriculumgoals and messages of the trainings. Curriculum devel-gender-nonconforming groups and communities include SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 118 Organizational Implementationto sustainable improvements in quality of care if they arechange and support. Although trainings are key in pro-interact with transgender and gender-nonconformingindividuals, organizational and agency policies serve asthe bridge to action and implementation. The key ele-ments of implementation are as follows: (a) agency- orAgency- or organization-wide focus. Cross etal.of issues with health care coverage, and directors andboard members should have enough knowledge to informor organizations would benefit from considering the edu-ment instruments, interviews, analyses of patientAn important component of needs assessmentcare delivery agencies and organizations assume thatexperience challenges in gaining access to care are some-how to blame. Cross etal. (1989) have pointed out thatapproach also ignores the ways in which a lack of orga-nizational self-reflection contributes to maintaining orsetting up barriers to quality care.Community engagement. nonconforming individuals is to create relationships,partnerships, and alliances with a wide variety of orga-nizations, groups, and coalitions that centralize thesegroups and communities. Cultivating sustainable part-build and maintain connections with groups and com-munities that already have experience with transgenderand gender-nonconforming individuals, enables them tobuild trusting and mutually enriching relationships withsuch groups, and opens up an avenue of communicationand collaboration. Of course, care should be taken tomake these relationships equitable and mutually bene-and organizations to view transgender and gender-framework. Recognition of communities capacity to makewith a solid grounding in SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 119 For such partnerships to be most effective, theseconnections must be with organizations, groups, andconnections need not and, in fact, should not be limitedneeds of the transgender community meets on a quar-terly basis; the People of Color Against AIDS Network(n.d.) runs an HIV prevention, support, and discussionamong these groups, transgender and gender-nonconforming individuals are generally considered to bemedically underserved (Dean etal., 2000; Feldman &tions leading to underemployment, homelessness, andencounter a number of specrelated barriers to gaining access to health care. Forexample, the dearth of health agencies and organiza-tions that deliver clinically and culturally competentwho seek a medically assisted transition, individualsmay encounter a number of barriers ranging from exces-coverage exclusion or prohibitive cost of surgeries orAssociation, 2001). Even structural and environmentalpresenting barriers regarding access to care, includingno provisions for usable restrooms, lack of training forfront desk staff, and absence of discussion or protocolregarding medical charting for transgender or gender-important role in reducing or eliminating these barriersto care, both within the agency or organization and morebroadly. At the least, agencies and organizations shouldinthe course of a needs assessment, the agency orhelm of medical and legal gatekeeping regarding trans-tion. In this context, health care providers can play alarge part in drastically reducing far-reaching barriers tocare that not only can increase quality of care but alsononconforming individuals. We highly recommend thatany plan of action for advocacy be conducted in collabo-tions, and groups that are familiar with all of thepetence can be fully assessed only by those who use its ser-vices. Therefore, it is vital to integrate patient satisfactionit should involve meeting a minimum standard of patientModels for Training and ImplementationOne of the reasons that transgender and gender-der and gender-nonconforming groups„specifically,individuals who desire a medically assisted transition andmake a commitment to improving quality of care andhealth outcomes for alltransgender and gender- SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 120 those seeking medical transition) are in a position to seta precedent in health care practice. Our recommenda-Resspective, this framework includes specific and detailedwith regard to transgender health care. This list is anA variety of health clinics and organizations providetransgender-specific care. The Tom Waddell Health Center ), the Mazzoni Center in Fenway Community Health in Boston ( national organizations„such as the Transgender Law and ), the SylviaRivera Law Project (http://srlp.org ), Transgender at Work( ), Transgender HealthEmpowerment (http://www.theincdc.org ), and the NationalCenter for Transgender Equality (http://www.nctequality der andunemployment, lack of access to legal documents, immi-gration policies, and homelessness.Overview of Recommendationsecommendations for Trainers and Curriculum Developers1.Consider limiting coverage of definitions and ter-constitutes clinically competent care (give concreteclinical guidelines); (b) what constitutes culturallypatients or clients in a positive, supportive way);(c)what are the main barriers to care and how canproviders address them; and (d) how can providerscommunity organizations, groups, and coalitions,and what can be gained from such partnerships.3.Providers desire to see or hear from transgenderaccomplished in a number of ways. For example,trainings can incorporate a film showing trans-transgender individuals speaking about their expe-riences with health care providers. It is important SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 121 mity„in other words, inclusiveness in terms ofrace and ethnicity, choice to pursue hormone orentation, religion, size, gender, geographic area,and so on„so as to avoid leaving them with a pic-ture of the typical transgender individual.Hospitals,and Health Organizations Seeking Training and Education1.Prior to training, make connections with com-munity groups, organizations, and coalitions that3.Prior to training, develop a vision and level ofquality of care to transgender and gender-After training, develop an agency- or organization-resources, and plan follow-up training or educationfor local, statewide, or national policy advocacy.5.Maintain partnerships and continue to deepen6.Include items specific to the experience of trans-anism of quality assurance.currently face a number of barriers to getting quality healthrecommendations„for developers of training curriculum,as well as for organizations, agencies, and clinics„can guidethe integration of sustainable provision of quality care foreffective means of increasing access to quality care for indi-grate them more broadly.cknowledgmentsmembers of the Community Research Team, whichtion to the authors). 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(2004, August). overview of U.S. trans health priorities: A report by SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 118 Organizational ImplementationCross etal.how to blame. Cross etal. (1989) have pointed out that SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 119 nonconforming indmedically underserved (Dean etal., 2000; Feldman &inthe course of a needs assessment, the agency orModels for Training and Implementationder and gender-nonconforming groups„specifically,health outcomes for alltransgender and gender- SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 117 but also give them information to pass on to patients andongoing information or guidance. Curriculum developersCurriculum developers should be explicit in devel- SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 117 Cross etal. (1989) discussed the importance of involvingtransgender or gender-nonconforming individuals„andnumber of ways„some of which are currently in use bysome Transgender 101…style trainings„in which trainings SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 118 Organizational Implementationto sustainable improvements in quality of care if they arechange and support. Although trainings are key in pro-interact with transgender and gender-nonconformingindividuals, organizational and agency policies serve asthe bridge to action and implementation. The key ele-ments of implementation are as follows: (a) agency- orAgency- or organization-wide focus. Cross etal.of issues with health care coverage, and directors andboard members should have enough knowledge to informor organizations would benefit from considering the edu-ment instruments, interviews, analyses of patientgender-nonconforming patients and clients. At minimum,An important component of needs assessmentcare delivery agencies and organizations assume thatexperience challenges in gaining access to care are some-how to blame. Cross etal. (1989) have pointed out thatapproach also ignores the ways in which a lack of orga-nizational self-reflection contributes to maintaining orsetting up barriers to quality care.Community engagement. nonconforming individuals is to create relationships,partnerships, and alliances with a wide variety of orga-nizations, groups, and coalitions that centralize thesegroups and communities. Cultivating sustainable part-build and maintain connections with groups and com-munities that already have experience with transgenderand gender-nonconforming individuals, enables them tobuild trusting and mutually enriching relationships withsuch groups, and opens up an avenue of communicationand collaboration. Of course, care should be taken tomake these relationships equitable and mutually bene-and organizations to view transgender and gender-framework. Recognition of communities capacity to makewith a solid grounding in SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 119 For such partnerships to be most effective, theseconnections must be with organizations, groups, andconnections need not and, in fact, should not be limitedneeds of the transgender community meets on a quar-terly basis; the People of Color Against AIDS Network(n.d.) runs an HIV prevention, support, and discussionamong these groups, transgender and gender-nonconforming individuals are generally considered to bemedically underserved (Dean etal., 2000; Feldman &tions leading to underemployment, homelessness, andencounter a number of specrelated barriers to gaining access to health care. Forexample, the dearth of health agencies and organiza-tions that deliver clinically and culturally competentwho seek a medically assisted transition, individualsmay encounter a number of barriers ranging from exces-coverage exclusion or prohibitive cost of surgeries orAssociation, 2001). Even structural and environmentalpresenting barriers regarding access to care, includingno provisions for usable restrooms, lack of training forfront desk staff, and absence of discussion or protocolregarding medical charting for transgender or gender-important role in reducing or eliminating these barriersto care, both within the agency or organization and morebroadly. At the least, agencies and organizations shouldinthe course of a needs assessment, the agency orhelm of medical and legal gatekeeping regarding trans-tion. In this context, health care providers can play alarge part in drastically reducing far-reaching barriers tocare that not only can increase quality of care but alsononconforming individuals. We highly recommend thatany plan of action for advocacy be conducted in collabo-tions, and groups that are familiar with all of thepetence can be fully assessed only by those who use its ser-vices. Therefore, it is vital to integrate patient satisfactionit should involve meeting a minimum standard of patientModels for Training and ImplementationOne of the reasons that transgender and gender-der and gender-nonconforming groups„specifically,individuals who desire a medically assisted transition andmake a commitment to improving quality of care andhealth outcomes for alltransgender and gender- Although such trainings are known by a variety of names, SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 16 defined as those whose bodies, genders, or behaviors fall SEXUALITY RESEARCH & SOCIAL POLICYMarch 2008ol. 5, No. 16 Cultural CompetenceCross etal. (1989) originally defined cultural com-Cross etal. (1989), the expansion of cultural competencewide approach„the core educational content shifted pri-Three review articles (Anderson etal., 2003; Beachetal., 2005; Bhui, Warfa, Edonya, McKenzie, & Bhugra,Cross etal. (1989): The system-wide approach is no longeresbian,Gay,Bisexual,Queer,Transgender,andGender-Nonconforming Issues andompetence Trainings 1 Although such trainings are known by a variety of names,the authors will use either Transgender 101or Transgender101…styleto generally refer to trainings that aim to increaseservice providers competence in delivering care totransgender and gender-nonconforming individuals.2 We used transgender trainingand transgender 101 assearch terms.in the specific context of serving severely emotionally