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Answer to the StreetsDeveloping accountability in transgender careNotes for Healthcare and Social Service Providers |
this text as pdf |
Transgender people access all sorts of social services, health care and other resources. Too often trans people face severe discrimination, ignorance, inadequate care and disrespectful treatment from all sorts of institutions. Thankfully, things are beginning to change. Transgender health clinics have opened in several cities. A few organizations have developed special outreach and support programs to help meet the needs of transgender people. Many social service and health agencies, in Philadelphia and around the country, have begun to realize the need to make their work more substantively respectful and inclusive of trans people. These are exciting and positive developments, and reflect both of years of hard work by trans people and our allies and a growing openness and thoughtfulness among healthcare and social service professionals. There is a great deal to say about developing or changing a program to better meet the needs of trans communities. Each city and each agency has a different history to contend with, and many trans people come with different pressing concerns. This text addresses one often overlooked and particularly crucial component to programs that effectively meet the basic needs of trans people: developing structures of responsible accountability to trans people themselves. It is written for health care and social service professionals. Accountability is a difficult and crucial concept. By using the word, I am referring to who social service and health workers answer to - who has a real say in defining our work, who has control in structuring programs and who really has a chance to be heard in how things work. At most agencies, workers answer to supervisors, administrators and executive boards. Usually, there are concrete mechanisms in place to assure some level of further accountability to funding sources. Government agencies, foundations and health insurance companies all have various means of checking, regulating and partially managing the programs they fund. Unfortunately, trans people rarely run foundations, governments or insurance companies. Transgender people don't often head up agencies or work in administration and management of social service institutions. The rare times that trans individuals do become incorporated as staff with real control over programs, they are often of a different social class and background then the majority of trans people receiving services. Without major changes in society, there will continue to be an unbalanced relationship of control: the communities receiving services don't run the programs they access. What are ways, then, that we can all - as people accessing services, as social service and healthcare workers, as administrators - help develop structures of accountability to communities most in need of support? This is a huge question, and this text seeks to just begin to open up a discussion around one of many crucial facets: care for transgender people. This text does not provide a basic introduction to transgender issues. It should be read alongside Down to Basics: An Introduction to Transgender Issues, for Healthcare and Social Service Providers. It is also a companion text to Keeping It Real: Transgender Inclusions in Safe Sex Education. Both are available by emailing michelle@deadletter.org.uk. Most of the ideas of this text were taken from other authors. In particular, I wish to acknowledge the remarkable text Disloyal to Feminism: Confronting the Abusive Power and Control Within the Domestic Violence Industry, by Emi Koyama. It's available through her website, eminism.org. The Need for Accountability There are many pressing reasons for developing structures of program accountability to transgender communities. Perhaps the clearest is assuring program effectiveness. Any one of several needs assessments around the country clearly document how poorly social services are addressing the needs of poor transgender people. Less well known, however, is the grim reality of how many programs designed to meet those very needs end up not being effective. While there is little clear documentation, there is a substantial weight of scattered anecdotal evidence of education, health and service programs supposedly designed with transgender people in mind grossly alienating the very people they are designed to serve. Many programs end up simply not substantively helping anyone improve their lives. There are many reasons for such failures, and among the clearest is an absence of accountability. Without strong relationships between an agency and transgender people, without transgender people incorporated into the planning process, and without means of feedback and response by transgender people themselves, it seems almost inevitable that a program will go astray of providing the most effective, substantive care possible. Along with adequate funding, program stability and skilled workers, real participation and control by trans people is a crucial component to an effective program serving trans people. Beyond any easily measurable notion of meeting program goals are deeper issues of ethics, politics, empowerment and self-determination. The oppression of transgender people in our society daily robs most trans people of real control over our bodies, our lives and our communities. Without access to decent medical care, adequate housing and employment or safety on the streets, trans people are often unable to exercise real self-determination. It's this lack of control, created by transphobia, racism, poverty and other forms of oppression, that takes the true toll on the well-being of trans people. Developing an effective program isn't just about giving someone a room or a prescription - it's about finding real ways of empowering people to have control and self-determination over their own lives and bodies. Doing our work as social service and healthcare professionals has to be rooted in a commitment to self-determination. Developing means of programs to be accountable to trans communities, especially poor trans people and trans people of color, is among the valuable means of doing our work in empowering ways. Forms of Accountability There are many possible means of developing accountability between an agency and marginalized trans people. Each one has advantages and costs. Evaluating between strategies has to be specific to the needs and history of each program and population it serves. Here I'll briefly outline a few interconnected strategies. Take accountability seriously, even when it's hard. None of these strategies work, if we don't start by setting accountability as a clear priority. It can be very difficult to cede authority and control to people who you might not like, you might not get along with, and you might not agree with. Answering to someone has to mean something even when it isn't easy, comfortable or simple to do. By setting structural accountability as a real goal, agency professionals are opening themselves up to criticisms, negative feedback and the potential anger of people who have been disrespected time and time again by too many agencies. Establishing a program-wide commitment to accountability, and to whom and how, is a great place to start to change this reality. Listen to clients. This is probably the simplest and most valuable recommendation here. Nearly all programs see trans people at some sort or another. When you are working with a trans person, listen to what to they say. This couldn't be overemphasized enough. Many service workers dismiss trans people as pushy, demanding, judgmental or angry -- all statements that lead to a provider no longer listening. By listening to our clients and patients in each and every interaction, and taking seriously what they say, we can begin to shift our programs to better demonstrate respect and dignity. Develop substantive grievance procedures. Listening in one and one interactions with trans clients and patients is crucial. But sometimes this isn't enough - sometimes a relationship between an individual provider and client is so bad that communication has broken down completely. In some cases, a client might still be interested in working with an agency or program, even if they don't feel heard by an individual provider. In these cases, it's crucial to have a strong grievance procedure in place. If someone feels offended by their doctor, their case manager, or any other worker, they should know clearly to who and how they could report it. When someone does choose to report an incident, they should be heard and taken seriously. At the very least, clients often deserve an apology and the chance to work with a different individual. Sometimes a far more extensive reevaluation of training and program organization is in order. Ultimately, as an industry we should begin to develop a system of independent grievance procedures. A client should be able to go to an independent body when they have frustrations with their treatment at a particular agency, and this body should have real power in advocating for a client and forcing institutional changes across the industry. Currently, I knew of few such structures, but their development is crucial for long-term industry accountability to clients and patients. Support substantive consumer feedback groups. Listening to clients can take many forms. It could be one-on-one, or it could be more collectively organized. Many organizations have consumer feedback groups, where a group of clients sit down together and answer questions openly evaluating the effectiveness of an agency programs. A few things can go along way to making such a group work. First, by attending a consumer feedback group a client is doing an agency a favor - not the other way around. Clients should be adequately financially compensated for their time and energy. Pay the people who attend. This could also encourage participation of clients who don't otherwise have time available. Other things can also assure better access - holding groups at various times, offering free childcare and transportation, and having some groups specific to a particular community, like a transgender feedback group. Above all, these groups mean nothing if they aren't listened to. The feedback generated in such a group should be taken very seriously and lead to real organizational changes. Without such substantive response, these groups can too easily become a tokenized insult to people's time. Develop needs assessments and focus groups. Needs assessment can be qualitative or quantitative surveys of a people in a community to better document their needs. Focus groups are often a component to needs assessments. They collect together a group of people to discuss their needs, demands and experiences with social service or healthcare agencies. Needs assessments can be quite helpful in developing a program that responds to people's real needs, and to document the value of a program for funding sources. Unfortunately, there is often a dramatic disconnect between the language, tone, and form of needs assessments and the communities they target. For instance, many of the needs assessments I have seen for transgender people ask their sexual orientation (straight, gay, bisexual, etc.). Without further explanation, however, it can be quite difficult to interpret what this means, as for each transgender person these terms might signify a very different set of relationships. While agencies should definitely continue to do needs assessments, there are a few suggestions that might help out a bit. One, incorporate trans people into the process for developing a needs assessment, so that it's intelligible to the individuals being targeted. Compensate individuals for the time they spend participating in an assessment. And, most importantly, make sure than the information generated is taken seriously. I have filled out far too many surveys where the results ended up having little impact. If you can't deliver with real services, there are better ways of spending everyone's time than asking a lot of questions. Think about who is not at the table. Throughout all levels and aspects of an agency's work, think about who is the room, who is speaking and who is getting heard. In doing a needs assessment, consumer feedback groups, staff hiring, administrative promotion, board appointments or any other space created within an agency, it's crucial to think critically and carefully about who is not at the table, who is excluded. It can take some time and work in finding out about how these exclusions take place, but doing so is an invaluable piece of developing real accountability. This is a huge issue, and could consume an entire essay. To touch on only a few components to this topic: Which trans communities are being included in a survey? Which are not? Can people with kids or no transportation come to this meeting? What are an agency's hiring practices? Who has gotten fired? Who doesn't get promoted? Which individuals have been excluded or not invited to a group? Why was this done? Addressing these questions critically can go a long way to an agency beginning to open itself up to hearing the real needs of trans people. Incorporate trans people in agency processes. The next three suggestions involve incorporating trans people into various positions within an agency. There are a few general considerations to take seriously for all of these suggestions. Think carefully about which trans people are being included, and which are not. Often, for example, trans people are included who share a lot culturally with those doing the hiring, or who have particular forms of social privilege. It's not only crucial to incorporate people who identify as trans into the process, but also trans people who have strong roots, connections and relationships with the specific communities of trans people being served. Often this calls for hiring trans people of color and poor trans people, and people who are actively respected and known in specific communities. This need should be balanced against the value of involving trans people who bring forms of professional expertise. Trans people are often selectively included or excluded based on 'difficult' we are perceived to be - how easy or comfortable it is to hear what we might have to say. Trans people who have harsh or critical things to say are often the most important people to be at the table, but usually the least likely to be invited. None of these suggestions mean anything, however, if an agency doesn't substantively listen to and respect the trans people who are involved. A token person who is ignored might make an agency look good, but it's a long way from substantive accountability. Incorporate trans people into program development. One of the most valuable and crucial times to involve trans people in agency process is when programs are first being developed. This can be a time when feedback will have the biggest impact, and hence is the most important time to involve trans people who will ultimately benefit from a program. Even if a program is not specifically designed around transgender care, trans inclusion in the planning can help assure that it is inclusive and valuable for trans communities. Again, this involvement of trans people in the planning has to involve really listening to and incorporating the feedback they might bring. Hire trans people on staff. Trans people are far more likely to trust and value a program that hires trans people on staff. These individuals should ideally bring both professional expertise and substantive relationships with the specific communities being served. Balancing the two is tricky, but implementing affirmative action supporting the hiring of trans people of color and working class trans people can be a place to start. By having trans people on staff, a program provides individuals who can act as liaisons between communities and programs. They might be an individual that trans people are more likely to trust with their own needs or frustrations with an agency. And, it's worth saying, such hiring is a means of a program giving another concrete form of support to trans people: employment. Just hiring a token, however, is not enough: multiple trans people should be hired, and they should be taken seriously as valuable staff with important input. Promote trans people into administrative positions. Within every agency, there is an imbalance of power and control between administrators and staff. Even having trans people on staff is no assurance that they have any say in how programs are developed and implemented, or how funding is allocated. Not only should trans people be hired, they should also be actively involved in making hiring and firing decisions, budget plans, funding strategies and overall program development. These administrative positions can and should involve trans people in all aspects of this process. While there are many agencies around the country who hire trans consultants or outreach staff, few provide trans people substantive means of making administrative decisions. When they do, these trans people are usually white and upper class, and not connected to trans communities most in need of services. Support self-organization. All of these suggestions involve work an agency does in involving folks in various ways into its process. Ultimately, however, developing real accountability between trans communities and providers depends on establishing new institutions and networks that are not under the supervisory control of social service agencies. Agencies can also take steps to support whatever forms of independent, autonomous self-organization staff and clients might start. Among the many examples of such forms of self-organization are consumer unions, consumer-run advocacy groups and staff unions. For each, agencies should do whatever they can to support this work. If a consumer union or consumer-run advocacy group begins to form, an agency can help by providing them with meeting space, work space and other forms of material support. In keeping with the value of autonomous self-organization, this support should continue and agency's should listen even if a group becomes very critical of an agency's policies. Administrators, management and executive boards can also help by supporting, recognizing and honoring agency staff unions. Staff have the right to organize collectively to advocate for their own needs and demands, especially when these needs run counter to administrative agendas. Often non-administrative staff are far closer to clients needs. Staff unions can be crucial to establish an independent, accountable voice to call for institutional accountability to marginalized communities, like trans people. Advocating for increased funding for programs accountable to trans people. As social service professionals, we all know too well how quickly a great program dies without funding. We can all work to advocate for increased funding for transgender care and for those agencies taking these issues seriously. Many social service organizations are dependent on other, larger institutions for funding -- like foundations, and government agencies. By documenting and pushing these institutions to take transgender issues more seriously, we can begin to bring in more resources for agencies demonstrating responsible accountability to trans people. Respond to criticism. I've made a point several times here that is worth repeating again. Everyone one of these suggestions can be easily sidetracked by agency professional's simply not listening to criticism. No matter how many trans people are involved, if they aren't heard when it counts their participation doesn't count for much. Criticism can be hard and harsh, and as professional we have a moral obligation to hear it out. For each of us, we need to work to see that we are able to take criticism without taking it personally, and without silencing or marginalizing the critical voices. Hearing criticism has to be followed with real response - commitment to creating real, concrete institutional changes that reflect people's input. Rethinking Care Transgender people have a particularly awful and painful history in trying to access social service and medical care. Ridiculed, dismissed and disrespected by the very people who are paid to help us, many trans people have little trust for professionals. Even now our healthcare is overwhelmingly controlled by people who act as gatekeepers to care, robbing trans people of the right to self-determine our own bodies. The absence of accountability is particularly dire and brings unusually severe consequences in the lives of poor trans people. Few professionals recognize and honor the rights of trans people to self-determine their own medical care or receive respect across social services. By taking a stand, changing the way your agency works and developing real means to be accountable to trans people, it's possible to have a positive and lasting impact on trans people's lives. We all have a right to control our own lives. We all have a right to receive dignified care from institutions that are ultimately accountable to the people they serve. These issues of accountability are far from isolated to transgender people and trans issues. All poor people in our society have to spend a lot of time in spaces not controlled by the people using them, like workplaces, rented homes, housing facilities, hospitals, social service agencies or prisons. In building a future committed to democracy, respect and justice, we can begin by reforming our institutions to answer not only to the government or a foundation, but also to answer to the real communities on the ground that can use the help. In making our society humane and decent, it's time we began by making sure our work answers to the streets. |