A Guide for Community Clinic Organizing and Advocacy
Thank you to the many community members, providers and allies who have led the effort to expand access to quality health care for transgender and gender non-conforming people in California.
We are grateful for the work of Gender Justice LA (formerly FTM Alliance of Los Angeles) and the Community Clinics Campaign; Community Health Partnership, the TransPowerment Program and St. James Health Center in Santa Clara County; the Humboldt HEALTH Council; Tri-City Health Center and Lighthouse Community Center in Alameda County; Lyon-Martin Health Services; and The Center of Excellence for Transgender Health at University of California San Francisco.
Special thanks to the individual activists, advocates, and allies who helped increase awareness about the health care needs of transgender people, especially Daniel Gould, Hannah Howard, Ignatius Bau, Tiffany Woods-Bodine, Patricia Kevena Fili, Danielle Anderson-Castro, JoAnne Keatley, Karin Fresnel, Cecilia Chung, Berkeley City Council Member Darryl Moore and countless others.
Credit for this publication goes to the writers and editors who negotiated an ever-evolving environment to make this vision a reality: Donna Cartwright, Kara Desiderio, Jamison Green, Maceo Persson, and Jason Tescher.
This report was made possible with program support from The California Endowment and the California Wellness Foundation.
TLC is also grateful to those who have supported our economic empowerment and health work over the years, including the Horizons Foundation, Open Society Institute, Evelyn and Walter Haas, Jr. Fund, Liberty Hill Foundation, David Bohnett Foundation, Gill Foundation, Kicking Assets Fund of the Tides Foundation, Small Change Foundation and the Rainbow Endowment.
© 2012 Transgender Law Center
Transgender Law Center
870 Market St., Suite 400
San Francisco, CA 94102
Design and Layout by Design Action Collective and Wing Poon
Purpose of this Guide
The purpose of this guide is to provide transgender people and allies with information and tools so that we are better equipped and more empowered to change the health care system to meet our needs. We use the word transgender as an umbrella term that encompasses gender non-conforming people and everyone whose gender identities, expressions or behaviors are not those traditionally associated with their birth sex.
The challenges that transgender people face in accessing comprehensive, affordable and respectful health care are well-documented, but there are few resources for those who would like to make real systemic change. While some people have had success advocating for themselves on an individual basis, there is still a great need to make broad changes in the way transgender people receive health care.
In this guide, we look at four case studies where transgender community members and allies have made real, positive changes for transgender patients in community clinic settings. From commitments to open transgender clinics to improvements in the quality of existing care, it is clear that change can take many forms. In each case, advocates used strategies that were well suited to their circumstances. We examine each case to extract key lessons, best practices, tips and tools that you can use to improve access and quality care in your community.
Organizing for Transgender Health Care: A Guide for Community Clinic Organizing and Advocacy is a publication of the Transgender Law Center’s Health Care Access Project and is a companion guide to our publication, How to Start a Transgender Clinic(1), a guide for advocates and service providers about the logistics of launching transgender- inclusive health services.
(1) Transgender Law Center, 2009
Who Is This Guide For?
This guide is intended for anyone who wants to change the way community clinics offer care for transgender people. Whether you are a community member, ally, policymaker, health care provider, or clinic administrator, you will find useful lessons and promising practices to start organizing for transgender health care in your community.
What Is in This Guide?
This guide provides a brief introduction to transgender health advocacy and organizing and offers a range of ideas to help you with your efforts. It features stories from Los Angeles, Santa Clara, Alameda and Humboldt Counties in California. Finally, the appendices include sample agreements and other tools useful for planning and implementing policy advocacy efforts.
Why Organize for Transgender Health Care?
All human beings have a right to live healthy and happy lives in which their gender identities and expressions are fully accepted. Safe and affordable health care is preventative care! It allows us to stay healthy throughout our lives and helps us detect chronic illnesses early.
Unfortunately, many people struggle every day to meet their basic health needs. Often they cannot find an affordable insurance plan that fits their circumstances. For transgender people, such difficulties are frequently made worse by the ignorance and discrimination of insurance companies and medical providers.
Health access and economic status are closely tied. In 2008, Transgender Law Center surveyed transgender Californians, asking questions about their employment, housing and health care status. The resulting report, The State of Transgender California, revealed the following troubling statistics. Among 648 respondents:
- 30% postponed care due to disrespect or discrimination from health care clinicians;
- 42% postponed care because they could not afford the medical care they needed; and
- 26% of those who postponed care reported that their conditions worsened as a result.(2)
(2) Transgender Law Center, 2009
When transgender people access medical care, they often encounter discrimination and ignorance. Many providers are unaware that some kinds of sex-specific care, such as pap smears for transgender men and prostate exams for transgender women, are still necessary for many transgender people. In such situations, lack of knowledge and cultural competency can lead to undetected cervical or prostate cancer. To make matters worse, health insurance plans often explicitly exclude transition-related care such as hormone therapy and gender reassignment surgery. The inability to obtain care can have serious effects on the safety, economic stability and mental health of transgender people.
Transgender people must often pay out-of-pocket for the cost of hormones, mental health therapy and transition-related surgeries, and they may not have access to safe and affordable medical providers for this care. For many people, these additional health care costs are staggering. Given high levels of unemployment and poverty among transgender people and the high cost of health care, some transgender people find that the street economy is the only feasible way to finance their health care needs. For many, accessing less expensive care from unlicensed practitioners carries serious risks.
So why is organizing necessary to change this reality? Organizing is a way to build community and long-term results. The actions that an organized group of people can take are powerful and influential for not only the larger community but also decision- makers. Similar to the way unions gain recognition as representatives of workers for a particular business, community organizing groups can gain recognition as key representatives of particular communities and can leverage their power to create lasting change.
What Is Transgender Health Care?
Transgender health care is culturally appropriate primary care, including access to sex- specific and transition-related procedures. Like everyone, transgender and gender non-conforming people need access to quality primary care that encompasses health maintenance, disease prevention (such as screening for common conditions like cancer and diabetes), and diagnosis and treatment of acute and chronic illnesses. Overall primary care also incorporates health promotion, risk reduction counseling and referrals for other health and social issues, including mental health services, housing, and employment. For many transgender and gender non-conforming people, access to sex-specific care and transition-related care is a unique and critical element of primary care.
The American Medical Association asserts that transition-related care is a vital part of primary care for transgender people (see Appendix I for the language of that resolution).(3) Additionally, two recent survey reports: The State of Transgender California(4) and Injustice at Every Turn: (a report of the National Transgender Discrimination Survey)(5) have demonstrated that transgender inclusive health care can profoundly increase quality of life for transgender individuals.
More community clinics are improving their capacity to serve transgender patients.
(3) American Medical Association, 2008
(4) Transgender Law Center, 2009
(5) Grant, Mottet, & Tanis, 2011
For transgender people who transform their bodies to align with their gender identity, access to safe hormone therapy and/or surgery is critical. Providing competent transgender health care requires that providers understand the different ways transgender individuals can approach medical transition. Even health care providers who are competent in administering transition-related services may mistakenly assume that all their patients have the same goal – to transition from one gender to the other. In reality, each transition is different and unique.
Competent transgender health care includes sensitivity to identities that transcend the binary of male and female as well as recognizing that social transition, hormonal therapy and surgery are often independent parts of an individual’s transition. In addition, while some transgender people do not need mental health counseling or therapy, some find it very helpful before, during, and/or after transition; as a result, access to mental health care is also important.
Why Community Clinics?
Community clinics provide excellent opportunities to advance transgender health care. Not only do they serve a large portion of the transgender community, but their missions generally include providing care to under-served and low-income populations. Community clinics are a crucial resource for transgender people seeking safe and affordable health care – including access to transition-related hormones and referrals to social services.
Although community clinics have the potential to serve as medical homes for many transgender people, they often need additional training and support to develop the specific clinical skills or sensitivity needed to serve transgender people competently. Providers seldom receive adequate professional training in the specific needs of transgender populations and may lack cultural sensitivity or awareness.
Over the past decade or so, many groups have organized efforts to change how community clinics serve transgender patients. The commitment of community clinics to improving access to health care makes them a natural ally to our communities. While great strides have been made, there are still many opportunities to improve the ways community clinics serve transgender people.
How Do We Make Change?
By organizing for transgender health care access, we can make meaningful change in our communities as well as work to build the foundation for better practices in the medical industry. In order to meet these goals, we need to understand the power of policy advocacy, community organizing and the processes they both involve.
Policy advocacy is about influencing those who make decisions. Often when we think about influencing decision (policy) makers, we think of elected officials – our city council members, county supervisors, school board members, or state legislators. But policy is also made by government agencies, nonprofit organizations that operate community clinics, homeless shelters, and other social services. Regardless of whether policy decisions are made by elected officials, nonprofits, or others, we want to create and implement policies that help transgender people access health care.
There is a wide range of approaches to policy advocacy, including influencing policymakers by organizing people to display strong support or opposition to a particular policy. For example, in our case studies, some advocates organized broad community support, while others drew upon a small number of key individuals who had existing relationships with decision makers.
Another approach to policy advocacy includes developing messages and delivering them to decision makers. In another one of our case studies, a town hall meeting was used to deliver a message about the health needs of the transgender community. That meeting spurred a city council member to lead a fight to expand the city’s employee benefits to include transition-related care.
These are just a few examples of how to enact policy change, and these approaches are most often combined and tailored to meet the needs of the specific policy goal.
What is Policy?
Simply put, a policy is a set of principles that are meant to govern the actions of a group, organization, or government. All organizations – from small to large – have policies they use to guide their decision-making. When people envision changing policy, they often think about laws passed by governments. However, policies are decided and implemented at many different levels. Nonprofit boards of directors and staff, government bureaucrats, hospital managers, and many others create policies for their organizations that have intended and unintended consequences for the people they serve.
For example, the board of directors of a nonprofit clinic might create an LGBT nondiscrimination policy. The staff, then, affects the results of the policy because they are in charge of its day to day implementation perhaps by creating more trans-friendly intake procedures. State and County governments also develop and clarify policy that is then put into operation by government agencies and departments.
Policy advocacy is when we try to influence the development, passage and implementation of these policies.
Community organizing, sometimes called grassroots organizing, is a bottom-up approach to making change. Community organizing mobilizes individuals so that they can use their combined power to make change. It is a long-term strategy that builds relationships between people so that they can work together. While short-term advocacy wins are important, the overall goal of community organizing is to do something that results in the group being taken seriously by people in power (policymakers). Organizing requires constant development of leaders and organizers. A sustainable movement often depends on the ability to:
- Grow a greater number of savvy transgender community leaders;
- Increase the number of transgender community members and allies ready to act and become leaders;
- Train leaders to become organizers; and
- Generate respect among key decision makers.
Policymakers will seek out the expertise of groups that have organized this way. Groups doing community organizing should be able to identify existing problems, mobilize to fix them, and continually rally support for their goals.
Advocacy and Organizing: What’s the Difference?
Community organizing and policy advocacy are related, but they are not the same thing. Policy advocacy focuses on affecting a particular change. Community organizing focuses on building the capacity, power and participation of a community in order to make that change. Organized communities do participate in advocacy efforts, but as you will see in our case studies, policy advocacy can take place without a fully organized community. Sometimes a few well-placed individuals can impact policy. However, a long-term, stable movement requires both types of activities.
Advocacy Model: How We Make Change
The chart below shows the organizing and advocacy process commonly used by Transgender Law Center. The process doesn’t always happen in this order, but our case studies show that these are important elements that can improve the likelihood of success for many organizing efforts. Think of it like a recipe – start with it as written and then, as you move forward, experiment to meet your needs and tastes!
Initiating Group or Individual:
There are many ways that advocacy efforts get started, but they almost always begin with some sort of initiating, or start-up, group. That group might be a nonprofit organization, an existing group working on policy change, or a group of community members reacting to an event or issue. Sometimes, though, it just takes one person with a vision to get things started!
Identify a Policy Issue:
An existing policy or practice (or lack thereof) can be the cause of problems for transgender people trying to access quality and medically necessary health care. An issue detailed in one of our case studies was the lack of any local healthcare providers available to prescribe transgender patients with hormones. In another situation, a group doing health-related work focused on the absence of a county-wide nondiscrimination policy covering gender identity and expression. Choosing an issue that is meaningful to the community is critical.
Research and Policy Analysis:
Once you have selected an issue to address, it is important to learn as much about it as possible so that you can create a specific policy goal. Researching policy requires identifying how and why the policy (or problem you are trying to fix) came into existence, how the policy or practice is implemented, and who (specific individuals or organizations) is in a position of power to change the policy and fix the issue. Analyzing the policy environment is also important. Understanding how decisions are made, what the timelines are for making decisions, and who influences their development is helpful in creating an advocacy plan. Appendix II includes a tool that lists helpful questions for analyzing your policy issue.
Choose a Policy Goal:
A policy goal is a simple statement that clearly describes a specific change in your community. For example, the policy goal, “The Bayside Community Clinic will open a once-per-month transgender clinic,” lets people know the end result of the actions you want to take. A policy goal is more specific than a policy issue. Articulating a clear policy goal will allow you to begin planning strategically to change or create a policy.
To decide on the most effective policy goal, it is necessary to understand the people and organizations which will implement or monitor the policy – a county health department or nonprofit group, for example. Appendix III includes a checklist used to help decide on choosing your policy goal.
Develop a Strategy:
Achieving a policy goal can be as simple as holding a meeting with a key decision maker who already agrees with you. In other cases your goal may require collecting local stories of discrimination, setting up a town hall meeting or writing a series of letters to the editor of your local newspaper.
Successful strategy development requires understanding your target person or audience and knowing what will influence them. When thinking creatively about how to approach them, it is important to create an advocacy strategy that identifies key messages aimed at influencing your target. Message development – anticipating what stories, spokespeople and arguments will be most persuasive for your audience – helps keep the goals very clear and allows the group to speak with one voice. Appendix IV includes a sample tool that you can use to help plan your advocacy strategy.
Build and Execute the Plan:
Eventually you need to put some detail into your strategy. Developing a plan includes selecting roles for the group and its partners, defining your advocacy activities (letter writing, meetings with elected officials, etc.), setting a timeline, and putting together a list of the resources you will need to carry out your plan.
Evaluate Success and Monitor Changes:
After you have achieved your goal – or even if you haven’t – it is important to figure out what worked and what did not during your effort. What was successful? What actions were least effective? This information will help you plan your next effort.
Even well-planned policies can be implemented poorly and result in little or no change. Groups often build into their plan the ability to monitor and revisit the policy to make sure it’s actually doing what it is supposed to do. For example, did transgender education for clinic staff result in better experiences at the clinic for transgender patients? Monitoring and evaluating your success is as important as getting your policy change in the first place.
In the Real World
In reality, advocacy efforts are not usually as cut-and-dried as our model. In the end,
however, taking into account all the factors that we have discussed will help you develop
an effective plan. In the next section, we examine four case studies where transgender
communities have stood up to advocate for better health care at community clinics.
Each effort had its own strengths and challenges.
Standing on the Shoulders of Transgender Advocates
Four Case Studies
The quest for safe and affordable transgender health care has been made possible through the passion and hard work of advocates throughout the state, especially in Los Angeles, Santa Clara, Alameda, and Humboldt Counties. With their determination, they have shown us that it is possible to successfully advocate for transgender health care and that there are many different paths to achieve it.
Below are stories from different communities in California. Each story highlights the successes and challenges that advocates faced in pursuing their particular path toward better access to care.
Los Angeles – Grassroots Organizing and Advocacy
FTM Alliance of Los Angeles (FTM Alliance) sponsored a support group for transgender men, their families, friends, and significant others, named Guy’s Chat. Through that effort, leaders noticed that health care was a frequent topic of discussion. As former organizer Daniel Gould told us, “people were asking questions like, ‘Where do I learn about hormones or sexually transmitted diseases?’ and, ‘How do I find a doctor?’” He concluded that, “It was clear that some people didn’t understand how to explain the physical differences of their transgender bodies to the clinical care workers that they saw. And sometimes people experienced very rude and humiliating treatment when they approached clinics and/or hospitals for basic or emergency care.”
In 2003, this group began its health advocacy work by conducting a survey to learn more about the health experiences of the local female-to-male (FTM) transgender community. Based on the results, they developed training programs for the community, with topics such as “How to Speak to a Doctor,” “What is Mental Health Care?” “What to Expect from a Mental Health Practitioner,” “What Are your Health Care Rights?” and “Understanding Primary Care.”
The workshops helped the organization identify a core group of leaders from Guy’s Chat and other transgender support groups who were thinking beyond their personal needs — they were interested in changing the system so that transgender people’s health care needs could be properly met in a supportive atmosphere.
The group discovered an abundance of diverse expertise within the community along with a tremendous need for transgender people to tell their stories. As the core group expanded, participants recognized that while they had experience organizing events and other one-time activities, they had no long-term campaign experience. This led them to Organizing for seek help from professional organizing experts.
FTM Alliance partnered with the Transgender Law Center to leverage the strengths of both organizations, and together they launched a campaign to organize the community to increase access to transgender-inclusive care through community clinics. Both organizations brought strengths to the table – FTM Alliance brought the energy and experiences of its members to drive the campaign, while Transgender Law Center brought staff resources to help with strategic planning and grant writing. Together they secured funding to hire an experienced organizer from within the transgender community, and the Community Clinics Campaign, known as C3, was born. C3 used a storytelling process to mobilize community members and engage two local clinics in efforts to improve access and quality of care for transgender patients. Members learned media advocacy skills and organized community members to tell their stories in YouTube videos.
The advocates and organizing staff engaged community members in a number of ways by providing food at every meeting to using an open planning process to make sure that all members were involved every step of the way. For example, trainings were integrated into every C3 meeting, providing members an opportunity to learn about campaign strategies, media advocacy, and coalition building.
Using these tactics, the community-wide team identified two targets clinics that served many low-income transgender people: BAART Beverly and the Los Angeles Gay & Lesbian Center (LAGLC). BAART’s Beverly Clinic provided basic services to transgender patients, but had limited capacity and no clear connection to the transgender community. The LAGLC was applying for its status as a Federally Qualified Health Clinic (FQHC), and advocates saw the potential to integrate transgender-specific services into their newly emerging clinic. C3 organizers identified potential allies within both facilities and worked to determine their priorities. Allies from BAART Beverly and the LAGLC attended various C3 meetings where they shared their priorities with C3 members. These meetings resulted in commitments to set up meetings between agency leadership and C3.
In both circumstances, after several months of relationship building, the respective clinics and the advocates were able to propose partnerships (see Appendix V) that included:
- The creation of transgender-specific outreach brochures;
- Cultural competency trainings provided by C3 members;
- Collaboration on clinical protocols that enabled clients to access hormones through the clinic;
- Adoption of a harm reduction care model for the clinic; and
- Improved referrals for care and services not provided on site.
After securing these commitments and working with the clinics, C3 faced an even greater challenge – budget cuts. Scheduled budget reductions for specialty clinics threatened to eliminate the transgender clinic at BAART Beverly. Building on their previous relationships, C3 advocates identified two Los Angeles County Supervisors with whom to open dialogue about the cuts. First, they found a supervisor whose interests and history included supporting health care and under-served populations. Second, they identified the supervisor representing BAART Beverly’s district. They scheduled meetings and educated the supervisors about transgender health care needs.
After C3 members made compelling presentations about the needs of the transgender community, the supervisors redirected funds to support BAART Beverly. This is a great example of collaboration between an allied agency and the community. The benefit of the relationship flowed both ways – the community received better services and the clinic had community allies to call on.
Finally, in 2009, leaders from the C3 campaign decided to build a relationship with the senior health deputy of the Los Angeles County Supervisor serving District 1. At a meeting with the deputy, C3 members learned that federal funding was going to be used to increase health care access for high-need and underserved communities. The senior health deputy encouraged the C3 leaders to find a clinic that could apply for the funding, and the C3 members turned to BAART Beverly. BAART Beverly in turn applied and received the stimulus money, which was designed to expand transgender health services to South and East Los Angeles County through a mobile health van program. Meanwhile, LAGLC agreed to open a transgender clinic upon receipt of its FQHC status, hired a transgender lead physician (Dr. Maddie Deutsch) to staff the program, and started providing primary care, including access to hormones, in late 2009.
What Did They Win?
BAART Beverly sustained and expanded services for transgender people, including access to hormones;
BAART Beverly received federal funding to provide care throughout South and East Los Angeles counties;
The LA Gay and Lesbian Center opened up a primary care clinic for transgender people;
All management and frontline staff at the Los Angeles Gay and Lesbian Center attended cultural competency trainings;
The LA Gay and Lesbian Center created gender neutral bathrooms in their buildings; and
The C3 campaign developed a positive relationship with a health deputy in L.A. County.
What Did We learn?
One factor that led directly to successful outcomes for C3 is that they continuously engaged the community through surveys, education, leadership development and group decision-making. While this involved more work and required bringing in additional organizing expertise, it resulted in a more engaged community and a focus on issues that really mattered to the community.
Because organizing requires a considerable (and often unplanned for) investment of time and resources to educate and empower individuals, C3 experienced tension between those who felt it was important to teach organizing skills (process) and those who were eager for results (product). Process-oriented people were interested in teaching organizing principles and techniques, going slowly so that everyone could track what was happening, and making decisions by consensus. Results-oriented people wanted to implement the strategy, secure an agreement from the clinic, and move forward.
The lesson learned is that organizers should try to find ways to build long-term capacity while making sure that short-term projects get done. It is also important to introduce new and less experienced members to community organizing principles and strategies outside of larger planning meetings. Ideally, more experienced participants can mentor others in support of long-term capacity building.
In addition to the challenges people faced having a variety of skills and priorities, class tensions existed among the members of the group. Organizing within transgender communities requires a deliberately inclusive approach to ensure that voices of different classes, races, ethnicities, and gender identities can sit around the table and make decisions as equals. For example, leaders who are not familiar with the challenges that low income transgender people face may develop strategies that don’t reflect the community’s needs. Different experiences bring different strengths, and it is important to recognize and value them all. In order to address tensions, C3 used multi-racial and mixed class teams among meeting leaders and project teams to foster relationships and strengthen results.
Lastly, staff turnover was a setback to the C3 group. The campaign ran for a few years, and various organizers staffed the project. To be sure this doesn’t have a negative effect on your effort, make sure that staff organizers working on the project document and share information with other staff and group leadership so that turnover doesn’t set back your work.
In spite of these challenges, C3 continued to carry out its health access work for five years. Although the formal C3 collaborative ended in 2009, Gender Justice LA (formerly FTM Alliance), an organization that encompasses a broader social justice mission for transgender and gender variant populations, continues to monitor the changes made at BAART Beverly and the Los Angeles Gay and Lesbian Center. Gender Justice LA plans to re-launch the C3 campaign in East Los Angeles in 2012.
Santa Clara – Small Group Advocacy
Another style of advocacy was used in Santa Clara County, where a few people with strong relationships with the public health system and existing clinical services established a transgender-inclusive health care clinic.
Throughout her life, Danielle Castro, a transgender Latina woman, had trouble accessing health care. Danielle knew she was not alone – many other transgender women in her area were experiencing similar issues. A friend referred her to TransPowerment, a county health program housed at Community Health Partnership created to reduce HIV infection and transmission among transgender people and their partners. Having discovered her passion for this work, Danielle applied to become a health educator at the Community Health Partnership, and was hired as a trainer by the Pacific AIDS Education and Training Center (PAETC) through their Minority AIDS Initiative funds. Because of her understanding of the transgender community and social service systems, Danielle was able to help TransPowerment connect through targeted community outreach with lowincome transgender populations and started a multicultural support group.
Shortly after the support group got started, TransPowerment received a grant from PAETC that focused on training clinic staff on providing services for Latino men who have sex with men (MSM) and other minorities, including transgender women. Danielle understood the need for health care outreach among this group and worked to become an excellent trainer with the guidance of JoAnne Keatley, PAETC Minority AIDS Initiative Program Manager. She also started as a trainer alongside Jen Shockey, a public health professional and San Jose AIDS Education and Training Center Program Coordinator who provided HIV & STD preventation trainings at targeted San Jose clinics. Together they conducted clinic trainings, during which they took note of which doctors seemed to be most interested in providing transgender health care.
At St. James Health Center, a primary care clinic in San Jose, they found physicians who were very interested in serving the transgender community but lacked sufficient knowledge or experience to feel comfortable doing so. Danielle enlisted the support of community leaders and professionals in transgender health, and together they provided trainings that improved the clinical and cultural competence of clinic staff, and increased the clinic’s transgender patient volume from 2 to 20 in a single year.
Meanwhile, Danielle’s support group grew in number and reputation and eventually became a transgender community advisory board for St. James Health Center. The partnership between the TransPowerment Community Advisory Board and St. James Health Center helped create and ensure a welcoming place where transgender people, and especially low-income transgender Latinas, could get health care services and support.
What Did They Win?
- The Community Health Partnership expanded the TransPowerment program;
- Doctors who work with the county health care system were trained on transgender cultural and medical competency;
- Advocates established a successful referral process so that more low-income transgender people could start accessing services; and
- The support group started by Danielle later became a transgender community advisory board for the program.
What Did We Learn?
In Santa Clara County, programs like TransPowerment were already in place to provide a stepping-stone for further advocacy. Although the policy results were similar to those in Los Angeles, community organizing was not used as a strategy to advocate for policy change. While this doesn’t change our advocacy model, it shows us that the initiating group doesn’t always have to be large.
Danielle was well positioned to make considerable change while maintaining a strong grassroots connection with the community. She was able to identify missing pieces of the puzzle and fill in the blanks by building relationships with providers. Her ability to make the necessary connections between people, provide enthusiastic encouragement, and finally step aside and let others’ energy, community spirit and professional commitment carry them forward made this work successful.
Community involvement was also crucial and took the form of support groups, advisory groups, and clinic patronage. Unlike in Los Angeles, this involvement came later in the process. The Santa Clara County community was ready for change — it just needed the catalyst provided by a few dedicated people to put the pieces together.
Alameda – Advocacy by an Existing Group
Throughout the years, advocates in Alameda County worked extensively with elected officials to pass non-discrimination ordinances and helped shape non-discrimination policies to protect transgender people. In 2007, local community members, building on the gains of previous efforts, took on another policy goal: to improve access to health services for the transgender community throughout the county’s health system. They leveraged the relationships they built with elected officials and the community to demonstrate strong public support for meeting transgender people’s health needs.
The two primary advocates, Tiffany Woods, Transgender Program Coordinator at Tri-City Health Center, and Patricia Kevena Fili, former Executive Director of the Lighthouse Community Center, faced some uphill battles, including a limited capacity to organize the community. They did not have the resources to hire a paid organizer, so their project was entirely volunteer-run. Tiffany noted that, “The community wasn’t really ‘organized’.” Without having one point person to manage the project’s work, their ability to involve the broader community was limited.
Alameda County is a large county that has high needs for LGBT-friendly social services but limited resources.. The county not only lacked LGBT services but also had no representation of LGBT identified politicians in city and county seats. The invisibility of transgender people was a barrier in getting the word out about organizing meetings. To combat this, Tiffany and Patricia utilized their strengths and existing positions in the community to leverage different parts of the organizing. Tiffany worked on community organizing through outreach activities with her program at Tri-City Health Center, TransVision. Patricia tackled political organizing through her existing relationships with legislative offices and the Lighthouse Community Center.
The advocates understood that their limited capacity prevented them from engaging in a grassroots campaign like C3 in Los Angeles. They did not have as much time to conduct a needs assessment or to pull together monthly meetings. “There was a sense of urgency, because so many people were busy with other things and didn’t want this project to drag on,” recalled a local advocate.
The advocates decided to focus on holding an informal public meeting, otherwise known as a town hall meeting, to generate interest and publicity. The meeting was planned to address the need for transgender health care and the benefits of establishing local transgender specialty clinics in Alameda County. Both Tiffany and Patricia made personal invitations via phone and in-person visits to city and county elected officials and clinic administrators. Advocates hoped that a large turnout with moving testimony would influence county officials to get the needed clinics established. Key talking points were developed and given out ahead of time to pre-selected speakers to help them prepare and ensure that all point areas were covered and not duplicated.
In July 2007, elected officials from several cities in Alameda County, as well as state officials, attended the town hall meeting, which was held in a donated auditorium, to hear testimony from a variety of stakeholders. Physicians and psychologists spoke about the needs of their transgender patients. Community members testified about their experiences trying to access culturally competent health care. Some told stories about the hardships they had suffered as a result of insufficient or insensitive care. Clinicians discussed their capacity to offer transgender-specific services.
The advocates came prepared. They presented a five-year implementation plan to improve services for transgender patients throughout the county, including the resources needed and approximate costs anticipated. The plan also included targeting three clinics in different areas of the county, Berkley Free Clinic in the North, Alameda County Medical Center in Central county, and Tri-City Health Center in the South. The elected officials were grateful for the information and said they felt inspired and motivated to help.
A Berkeley city official was so inspired by what he learned at the meeting that he took it on himself to work toward transgender-inclusive health insurance coverage for Berkeley city employees. He also supported efforts to expand services for low-income transgender people at the Berkeley Free Clinic, a clinic that had a history of providing some services to the transgender community.
The advocate’s work also resulted in an agreement from Alameda County Hospital to train Emergency Department physicians in transgender cultural competency. Additionally, Tri- City Health Center’s specialty program TransVision, which had previously provided only HIV-related care and prevention services to transgender people, expanded its services to include primary health care. This entailed hormone administration, the creation of transgender primary care protocols, and trainings for their providers on transgender health care.
As the California budget crisis began to impact health clinics, Tri-City Health Center was forced to eliminate TransVision. Advocates went back to the drawing board and shifted their focus to integrating transgender-specific health care services into other health care settings to ensure that transgender people in Alameda County could get competent care. Guided by research that showed large numbers of Alameda County transgender residents accessed care through emergency rooms, they chose to build on their existing relationships with emergency room staff at Alameda County Hospital. Working together, they implemented ongoing training sessions with emergency room physicians that covered cultural competency and trans-specific medicine.
What began as response to a setback became an opportunity to not only provide a positive experience to Emergency Room physicians and patients but also to build a long-term training program that could be used at other area hospitals. Also fortunately, additional state funding was found five months later and TransVision was refunded again. During the crisis, TransVisio continued to serve their transgender clients through the primary care clinic, and worked with the clinic administration to create the capacity to provide a transgender specific day.
What Did They Win?
- Advocates deepened existing relationships with Alameda County elected officials and allies;
- A Berkeley city official made trans-inclusive health care a reality for city employees and committed to supporting a local clinic’s efforts to provide health care for low income transgender community members;
- Tri-City Health Center in southern Alameda County expanded its primary health care and developed clinical protocols to be inclusive of transgender health care needs; and,
- Alameda County Hospitals trained all emergency room staff on transgender cultural competency and medicine.
What Did We Learn?
Groups can leverage existing relationships to move a policy agenda even when larger scale community organizing isn’t a viable strategy. Two community leaders were able to organize enough local attendance at the town hall meeting to have an impact, and they were able to use existing relationships with elected officials to their advantage.
We’ve learned that our stories are critical to our efforts. The Berkeley City Council member who took on the health care issue as his own was inspired to do the right thing based on stories he heard about how difficult quality health care access can be for transgender people. In fact, the telling of stories can often be more moving than recitations of facts in policy advocacy work.
Preparation is essential. When the advocates approached the elected officials, they came prepared with a well-researched five-year implementation plan that included options and pricing. Elected officials often look to the community for such research and specific proposals. Come prepared, think ahead, and do the research!
Finally, when faced with a change in the political and economic climate, victories are still achievable.
Humboldt – Organizing and Advocacy in Rural Areas
Organizing and advocacy for transgender health in rural settings can be very different from efforts in urban and suburban settings. For transgender people living in rural areas, access to services may be limited and there are probably fewer opportunities to build new support systems than might be found in urban areas. However, organizing in smaller communities can often make a big impact.
The health needs of individuals living in rural areas, like Humboldt County in Northern California, are unique and challenging. Disparities in disease prevalence, lack of diversity, and access and coverage for the underinsured and uninsured all become more complicated. Many social and economic challenges unique to rural areas, such as lower wages, fewer jobs, increased risk of poverty, and lack of educational opportunities, impact healthy living. For the transgender community in Humboldt, these challenges were even harder to navigate due to gender identity-based discrimination, lack of provider sensitivity, and the medical field’s overall lack of awareness of transgender health.
A dedicated group in Humboldt County with support from local organizations was able to establish a transgender health care clinic. It started with a couple of local transgender community members connecting with the Transgender Law Center and becoming active in statewide advocacy efforts. Not only did their presence put Humboldt County on the map as an area in need of better services, but it also allowed them to connect and organize their local community around statewide issues.
While these leaders were building community in Humboldt, the Transgender Law Center and Lyon Martin Health Services, an LGBT community clinic in San Francisco, created Project HEALTH (Harnessing Education, Advocacy and Leadership in Transgender Health), a collaboration that works to improve access to transgender health care throughout the state of California. Project HEALTH was designed as a provider-community partnership to provide technical expertise to clinics and other medical providers in order to increase capacity to provide care to the transgender community. As part of the initiative, Project HEALTH organizes “HEALTH Councils” composed of transgender people, allies, and service providers. The councils focus on changing local policy to improve transgender health in their geographical areas.
In early 2010, Project HEALTH and local leaders created a Humboldt HEALTH Council by recruiting community members and allies interested in transgender health care. With eight folks on board, they held a retreat to learn about policy advocacy and chose two policy projects to work on.
The first project was to amend Humboldt County’s local non-discrimination ordinance to include gender identity and expression, putting it in compliance with California state law. The council also decided to address the lack of transgender health care by organizing to establish a regular transgender clinic at Open Door Health Center, the local community clinic. Finally, the group decided to raise its visibility in the community by creating a successful transgender meeting and discussion group at a local café.
To amend the County’s non-discrimination policy, the Humboldt HEALTH Council drafted policy language and presented it to both the County’s Human Rights Commission and the Board of Supervisors. The group received positive feedback, and the county government moved to add gender identity and expression to its non-discrimination policy.
The HEALTH Council also made significant progress on their “access to care” policy goal by securing an agreement from Open Door Health Center to establish a monthly transgender clinic.
Project HEALTH started by initiating a relationship with Open Door to train its staff and providers, improve services and connect the clinic with the local transgender community. Through this process, a medical provider was identified who had a great reputation in the local HIV-positive and LGBT communities as well as some minimal experience with transgender patients. He was a great resource and an ally to the movement. Although his enthusiasm was critical for success, Project HEALTH and the HEALTH Council began to realize that Open Door’s large size made it difficult for patients to navigate the system and find culturally competent staff and providers. They separately requested a meeting with management and leaders at Open Door but were told that the need was not great enough to establish a separate transgender clinic.
After a year of relationship building with Open Door Health Center, Project HEALTH and the Council planned another meeting with the clinic management to assess goals and next steps. A Humboldt HEALTH Council member who was a lifelong patient at the clinic spoke to the management about the difficulties of navigating its services. He talked about the need for support groups, hormones access and better primary care. Project HEALTH staff also spoke about the medical and legal importance of providing culturally competent care to all of their local under-served communities. The management of Open Door was moved, and they committed to launching a monthly transgender clinic. Further demonstrating their commitment, they also established a planning committee that includes Project HEALTH staff and Council members.
What Did We Win?
- A county non-discrimination policy protecting gender identity and expression;
- An agreement from Open Door Health Center to expand its services to include a monthly transgender clinic;
- An organized and vibrant community group; and
- A regular group gathering that helps the community be visible and organized.
What Did We Learn?
Because community organizing is a resource-intensive process, tapping into existing community networks gives an advocacy effort a valuable head start. In Humboldt County, a few community leaders served as the initial organizers and recruited community members and organizational support. Having a mix of committed community leaders and Project HEALTH staff allowed their projects to keep momentum and stay organized.
Local communities know their own needs best, and bringing a community voice to the table helps providers hear firsthand about these needs and how they are affecting the community. In the face of limited data on health disparities in the transgender community, we often face questions regarding need. Human faces, local surveys and stories are critical to advocacy efforts.
In rural communities, local clinics need to build and maintain their reputations. Local transgender communities can partner with clinics to extend goodwill. By having a visible organized community in Humboldt, the community has created opportunities for further training and has stimulated local interest.
The first section of this guide described a broad framework for policy advocacy. Next we learned about the remarkable efforts by four local transgender communities that organized and achieved significant improvements in accessing culturally competent health care. Now, we hope to put this all together and highlight some of the promising practices that emerged from each case study, identifying critical skills and information that will help you best reach your goal. We will take an in-depth look at the following organizing techniques:
- Building your core team
- Building membership
- Identifying allies
- Choosing your issue
- Identifying targets
- Talking about your issue
- Following up effectively
Building Your Core Team
The four case studies teach us that it is critical to have transgender and gender nonconforming community members leading policy advocacy efforts. Genuine and diverse transgender leadership helps ensure that solutions meet the needs of the community and signals to decision makers that the group is serious.
The size of the groups varies, and the strength of people’s commitment was far more important than the size of the group. Some successful efforts have a consistent group of 15 to 20 advocates while others have a group of 2 to 5 members.
It is important to have a diverse group of people as your core team of advocates. Special efforts should be made to authentically include people who are historically unrepresented, including people from different socio-economic and racial backgrounds. Many lowincome communities and communities of color within the transgender communities face additional cultural and financial barriers in accessing health care. Make sure that your outreach is intentionally inclusive of people with varying experiences, taking into account race, class, age, and gender.
Additionally, because the transgender community experiences ongoing stigmatization and marginalization, many community members may not be accustomed to negotiating for resources. You may have to build your team’s communication skills and build confidence before you can effectively approach clinics, elected officials or the media. Training on meeting facilitation, strategic communications and media advocacy can be especially helpful.
Organizing doesn’t stop once a core group is established. One way to ensure a vibrant group is to continually expand participation. New organizers have the ability to bring different resources, connections and fresh ideas and will aid in sustaining your group through the often inevitable dropout or burnout of members.
Many organizations expend considerable energy and resources on flyers, phone calls, emails, and postcards to recruit members but achieve limited results. In the end, organizing is all about building one-on-one relationships with people. A good organizer will, for example, seek out those with deep roots in the community, build a relationship, and ask, “Who else do you think I should talk to?” A good recruiting prospect is someone who:
- Is a leader who is well connected and widely respected;
- Has the capacity to be involved; and
- Has the motivation necessary to act and has self-interest in the issue.
Leveraging existing relationships is a great way to recruit new advocates. People are more likely to listen and engage if someone they trust suggests that they talk to you; a reference is always better than a “cold call.” When reaching out to potential members, the goals of the conversation include:
- Developing a stronger relationship;
- Discovering the ‘motivation to act’ of the person and their organization;
- Discovering if the person or group has a mutual interest with your group; and
- Clarifying the next action step and discovering other prospects.
Before contacting a potential member, keep in the mind the following steps to ensure an effective conversation:
- Who we are
Offer what makes you qualified to do this work
- Why we are meeting
Communicate the purpose of the group
- Getting to know each other
Introduce yourself with more detail and allow them to tell you about themselves
- What they can or will do
Share common goals and dreams for this work
- Explore what they can offer or what they are good at
Share common skills and interests
- Next steps
Communicate the next steps around engaging them
Who else do they know who might be a partner for the group?
Thank them and follow up on your conversation.
A strong core group will build this recruiting method into all networking opportunities. Regularly identifying activists with motivation and leadership potential will build the strength of a core group.
Another recruitment technique is building relationships by visiting known community gathering spots. Be sure to include partners and families of transgender people, whose lives are closely intertwined with their transgender loved ones. Also, don’t be afraid to think outside the usual boundaries of your own experience and reach out to people you don’t know.
Building Your Membership
In addition to having core advocates that drive the project forward, you may also need to recruit volunteers who are not part of the core team but who will volunteer for a single event or action. Volunteers are typically different from your core group of members, but there’s always potential for volunteers to become core members.
Strike a balance between breadth and depth when it comes to volunteer recruitment. By breadth we mean using recruitment tactics that will reach the biggest number of volunteers. By depth we mean using recruitment tactics that typically reach fewer people yet tend to engage volunteers more meaningfully.
Recruitment tactics that have the strongest chance of deeply connecting with people tend to take a greater amount of time and capacity, therefore decreasing the overall number of people you can ask to get involved. Often efforts that reach the largest number of potential volunteers do not involve direct conversations. Blogs, listserves, and email may be less effective because they are less likely to connect deeply with people.
On the next page you’ll find three volunteer recruitment strategies that are most effective when they are combined.
- In-person recruiting involves reaching out to everyone you know who is committed to your group’s cause. Seek out places where you’ll find transgender people and where you can have conversations. This might be in a social group, a bar in your community, a support group, an LGBT organization, or a welcoming religious congregation. Consider writing a recruitment script and practicing it to make your ask clear, concise and strong.
- The Internet is a vibrant virtual community for transgender people. We use it to learn about and share our transgender/transitioning experiences. It is also a great place to meet other transgender community members and allies, especially when we live in communities with sparse resources. The Internet provides a great way to reach out to a large potential pool of volunteers, but Internet asks often produce limited results. The most used methods for recruiting over the Internet are e-mail invitations and through social networking sites. You can also post on blogs and community calendars as a recruitment tactic, but this alone may not produce the results that you are looking for. Blogs and community calendars can be most useful as reminders for your volunteers or people you are recruiting.
- Phone banking is an effective way to recruit volunteers. Telephone contact makes it possible to have high-quality conversations with individuals and directly ask people to get engaged in your cause. ‘The ask’ itself may not be as powerful as if it were done in person, but it is still strong, and you can often reach a lot of people in a relatively short time. One person phoning can usually dial 60-90 numbers in one night and will typically get four to five people to commit to an event or action. This is tough work, and the results depend heavily on whom you are calling and what the requested action is. When you create your phone list, think about all the people that you know who are transgender or who care about transgender health care. There are many levels of sophistication for making and tracking calls. Keep it simple; if you are calling a list of 10 people, you may not need to track your results on a spreadsheet. If a few people are calling a few hundred potential volunteers, you want to track them carefully so that people don’t receive multiple calls. Tracking it this way also allows you to make notes that another person can follow up on.
Recruiting for What?
It is always important to have a clear ‘ask’ when recruiting new members. If volunteers feel valued, useful and respected, they’ll likely come back. We’ve included some important recruiting tips:
Identify Allies: Who and Where are They?
We can’t do this work alone! We often have friends or contacts who are part of community groups, who work at clinics, or who know elected officials who care about equal access to health care. These friends can advocate with us for change and may help us map our path.
As the case studies show, allies have opened doors, and it has been important for us to find them, whether they are in community clinics, in government or in other organizations. In addition, other LGBTQ, health and social service organizations are natural allies – they often have the capacity to assist in our efforts by helping us make political and financial connections and providing other resources for our efforts.
Setting the Table
Internal dynamics are the interactions and interpersonal relationships between members of your group, and these dynamics are as crucial to your group’s work as any opposition you may encounter. Ensuring participation from the transgender community is critical. Many transgender activists have experienced meetings in which they are outnumbered and disrespected. It is important to set clear and respectful roles when inviting nonprofits and other organizations to join your group.
A way of setting clear and respectful roles is to encourage those who have more power or influence to take on a supporting role instead of a leadership role. At the same time, community members can acknowledge the value of the contributions that clinics, elected officials and other organizations bring to the table. An explicit conversation to clarify roles is helpful as the group moves forward.
Many of us are clients at community clinics, and we may have some connections to the clinics where we are advocating for policy change. Perhaps we are seeing a great, supportive doctor, or we may have built a relationship with a particular nurse or front desk staff member. Sometimes these people can be our best allies. Talk to them about your concerns; they may help connect you to an administrator in charge and even start advocating for our issues.
As is the case with the general population, policymakers – who often influence funding for health and human services – vary widely in their familiarity with transgender people. Many elected officials have never met a transgender person, or are unaware that people they know are transgender, so it is important that we begin fostering relationships with fair-minded politicians who can serve as our allies – especially since they may have the power to bring public resources to your issue.
Start developing these relationships by setting up meetings between elected officials and transgender constituents. You can discover their attitudes toward transgender people and issues and educate them about the experiences of transgender communities.
Political parties often have LGBT affinity groups for their members, so check to see if one is active in your area or county. Such groups can be a great place to meet other active community members who care about your issues and who can serve as your allies with political leaders. Appendix VII contains a list of Do’s and Don’ts when visiting a policymaker.
Other Community Organizations
There are many community and social service organizations that also care about issues of economic justice and health care. In fact, they may be advocating around similar issues, and they can be valuable partners. Seek out opportunities to meet with these organizations to learn about their priorities and to understand how you can help each other.
Choosing Your Issue
Organizing and building membership is key to having an effective group, but in order to be a successful group, you must have a clear idea of what you want the group to accomplish. Being thorough in choosing your issue will help you prepare for the road ahead and achieve your goals.
While we’re all familiar with our own personal experiences, in order to advocate for change it is important to seek out and understand the experiences of other transgender people in your community. Take stock of the state of health care conditions for all transgender people so that your group can more easily identify gaps in services. Conducting a health needs assessment can be a valuable step. See the Transgender Law Center’s How to Start a Transgender Clinic(6) for more information on conducting needs assessments and for sample needs assessment surveys. Also helpful might be Injustice at Every Turn: A Report of the National Transgender Discrimination Survey(7) and The National Transgender Discrimination Survey Report on Health and Health Care,(8) where you can find a range of data to support your policy advocacy.
(6) Transgender Law Center, 2008
(7) Grant, Mottet, & Tanis, 2011
(8) Grant, Mottet, & Tanis, 2010
If you live in a smaller community, you do not need to survey large numbers of transgender community members to legitimately understand your local health care needs. If you are part of a group of less than 10 advocates working on this issue, you can start with your own experiences. As transgender community members, we bring our own expertise to this issue.
Make sure you are gathering individual stories as well as facts and figures. Needs assessments and surveys are a key component of understanding and explaining facts about your constituency and its needs, while personal stories add strength to your arguments in a way that will motivate your targets and allies to make a difference.
Common Targeted Issues
After you identify the challenges that transgender people face in accessing health care in your community, it is time to define the specific policy change you are trying to achieve. For example, if community clinics cannot afford to add an extra evening clinic for transgender patients, your policy goal could be to advocate for additional funding from the county Health Department. Be specific! If you don’t have a particular goal that you are working toward, it can be difficult for your allies to understand how they can be supportive. Here are some examples of specific goals for policy change at community clinics:
Cultural competency training:
Community clinics are often staffed with wellmeaning people who want to serve the community to the best of their ability. When it comes to treating their transgender patients, however, there is often a medical and cultural gap between transgender patients and medical providers because medical schools and medical training seldom address transgender care. Clinic-wide sensitivity and cultural competency trainings can go a long way to help already open and wellintentioned community clinic staff better serve transgender and gender non-conforming patients.
Inclusive intake, medical forms and Electronic Medical Records:
As transgender people, we often have a difficult time talking with our doctors about our bodies and our gender identities. If our first point of contact with a provider is an intake form that asks us to check F or M, it can create a sense of discomfort from the start. Working with your community clinic to alter forms so that they allow options for patients to self-identify their gender and sexual identities can make transgender people feel more welcome in accessing services at a clinic and can go a long way in making that first appointment a more relaxed, candid and confident experience. (See How To Start a Transgender Clinic).9
Like anyone else, transgender people need to find a “medical home” where they can receive primary care. Identifying a local community clinic that can provide culturally and medically competent primary care to transgender community members is critical. There are different types of community clinic. Some provide primary care services to a general population over a geographic area like a county or a city. Others may provide care for specific populations, such as HIV-positive people, or may emphasize particular types of care, such as reproductive health care. These clinics may be open to providing primary care for transgender people, especially after learning about the needs transgender people have.
Hormones can be an important aspect of transgender people’s health related needs but can often be costly or inaccessible. Even when clinics are already providing primary care to transgender people in the region, they may or may not provide hormones. It is worth asking those that do not provide hormone treatment to add this service. Sometimes there are clinics that are not providing complete primary care but that may still be a good provider for hormones. For example, a local Planned Parenthood group might be willing to offer hormones along with other reproductive and primary health care needs if they are asked.
Funding for transgender health services:
When you talk to clinic staff about providing new programs for transgender patients, one issue that will likely come up is the lack of funding. Clinics may have resources in their own budgets that they can allocate to new programs, or current funding streams that may cover transgender care; however, if this is not the case, you may want to work with the clinic to identify new sources of funding. Better yet, helping an existing clinic to integrate transgender-specific health care into its primary care practice is sometimes a way to minimize cost increases for both the clinic and the patient.
Analyzing the Policy Environment
Taking into account the policy context that exists around the issue you have chosen helps you to decide if your policy change is achievable and helps to prioritize possible strategies. There are many questions that a group should explore when deciding what policies to pursue and how to go about doing so. What individuals and organizations make decisions, the history of the issue, and what other groups have an interest in the issue are a few of the factors that will influence your approach. Appendix II is a helpful tool for analyzing these factors.
9 (Transgender Law Center, 2008)
Making a Decision
There are many areas where we can affect change, so where do you start? You should choose your goal based on your research about your community’s needs and/or the opportunities that present themselves. For example, you may decide to advocate for staff training at Site A because you consistently hear complaints about how people are treated there, or you may focus on starting a transgender-specific clinic at Site B because your ally has a relationship with the Medical Director.
Is the policy issue meaningful to the majority of your community? Do community members care about the issue?
Is the policy issue moveable? Does it have enough potential political support to see progress?
Is the policy manageable? Is it something that can be completed with your current capacity and resources?
There is a balance to be set between biting off more than you can chew and not aiming high enough. Both can limit your impact! If your proposed policy project is meaningful, moveable and manageable, then you are off to a good start.
Now that you know the policy you’ll be organizing around, it is important to identify the people you are trying to influence (targets). Targets are the one or two specific people who can ultimately make the decision to implement the change you are trying to achieve. For example, if you want a clinic to include hormone therapy in its primary care services, the director of the clinic may be your initial target. It is helpful to identify people who can influence the decision-makers.
In our Los Angeles case study, for example, advocates found an ally to help them identify the decision makers in the organization. The targets they identified had the authority to approve workshops, transgender-specific outreach materials, and hormone administration. In Humboldt County the group identified the County Board of Supervisors as their primary target because the Supervisors have the authority to amend their county’s non-discrimination ordinance. The group identified the local Human Rights Commission as their secondary target because of the influence that the Commission holds over the Board of Supervisors. Properly identifying targets is critical to your efforts.
Talking About Your Issue
It is important to develop a clear and concise message that is easy to understand and is targeted toward the decision maker or a group that can influence the decision maker. Here are some quick tips:
Develop a Specific Ask
Whether it’s a community clinic director, a county commissioner or a state representative, make sure that your targets understand clearly what you are asking them to do. For example: “Will your clinic support our community members by providing primary care to transgender people?” To do this, you’ll need to develop a key message.
Develop Key Messages
A key message is a concise and persuasive statement about your advocacy goal. It says what you want to achieve, why you want to achieve it, and how you will achieve it. Because its purpose is to create action, it must also include the specific action that you want the target to take.
It is important to keep your message(s) simple. Leave the details to supporting documents and follow-up conversations that will happen when you negotiate the details. Your message should be simple and clear enough so that anyone who hears and agrees with it can easily repeat it to someone else – which is exactly what you want them to do.
Characteristics of Effective Messages
The effectiveness of your message depends on a number of factors. Your messages should be:
Is the message simple, understandable, and easily repeatable?
Does the target feel that the message speaks to them?
Is their personal stake in the issue obvious? Can they sense the negative consequences of not taking action and the positive consequences of acting?
Does the message convince the audience to take action? Does it tell them what to do?
The effectiveness of your message also depends on the when, where and how:
The messenger is often as important as the message itself. It is important to choose an individual or organization that the audience finds credible and will respond to.
The timing of an activity can enhance or detract from your message. Your message can be drowned in a sea of other news on any given day. If you know that this is a possibility, you could hold off on releasing new “news” until it has a chance of being heard.
It is important to deliver a consistent message to your target audience through a variety of channels over an extended period of time. Messages will not be absorbed by audiences and influence their opinions overnight. Therefore, delivering the same message in different ways in order to increase your impact is essential. Messages for the media should be concise.
Know Your Audience
Whether your audience is the director of a nonprofit clinic, or a member of your county’s Board of Supervisors, you should communicate your message in a way that is appropriate and effective. To do this you need to have a sense of what they know already and of their attitudes on transgender and broader LGBT issues. This will allow you to find ways of presenting points that make sense to them and that build on the familiar.
Make the Case
Make sure that you have facts that illustrate that there is a need in the community for the changes you are seeking and that policy change is needed in order to achieve the desired goal. For example:
“Did you know that the Transgender Law Center conducted a survey of almost 650 transgender Californians and found that 42% of respondents delayed seeking care because they could not afford it, and 30% of respondents delayed care due to discrimination or disrespect that they had received previously?” Statistics in the transgender community can be hard to come by because there are very few reliable sources of data. Don’t allow your target to use the excuse of limited data to deny your request.
Back Up Your Claim
An issue never becomes more real than when you are looking into the eyes of someone who struggles with it. As you learned in the case of Alameda County, a Berkeley City Councilman was moved to take action because he had met, heard, and listened to the stories of his transgender constituents for the first time. Your personal stories are the face of your issue, so make sure that you help your volunteers and advocates develop personal stories that will strengthen your claims and back up your request. For example: “My primary care doctor was disrespectful to me when I tried to see him, right here in our town. So, I have not gone back to get the Pap smear and other tests to understand what is wrong me. Instead I just live with this pain on a daily basis.” Appendix VI includes step-by-step instructions and tips for developing your story.
Put It Together
Now that you have framed your specific ask and have facts and personal stories to back it up, it is important to weave them together into a powerful story that ends with a request. For example:
“I am here today to talk about transgender people’s need for safe and affordable primary health care. Did you know that the Transgender Law Center conducted a survey of almost 650 transgender Californians and found that 42% of respondents delayed seeking care because they could not afford it, and 30% of respondents delayed care due to discrimination that they had previously experienced? “In fact, my primary care doctor was disrespectful when I tried to see him, right here in our town. So, I have not gone back to get the Pap smear and other tests to understand what is wrong and why I am experiencing a lot of pain. Instead I just live with this pain on a daily basis. It has affected my work because I have to stay home frequently, and I am very afraid for my health because I still don’t know what is causing my pain. I need somewhere to go where I know my doctor will treat me with respect and where I can afford the care. “Will your clinic support our community members by providing primary care to transgender people?”
Follow Up Effectively: How Can We Make Sure That the Changes Occur?
It often takes persistence to create change, so it is crucial for advocates to stay in touch with their targets and constituents. After you’ve won a policy change, it is a good idea to check in periodically with your decision makers and people in the community to see whether the change is working. Establish a schedule for checking in with clinic administrators, public health officials who have provided support, and any elected officials who attended your meetings or helped facilitate the changes you have achieved. Keep to the schedule, and check in regularly to see whether there are any problems you might be able to help solve or success stories that you can pass along to others. Be sure to check in with community members, too, especially those who served on your committees or helped your project in any way. See how they are feeling about the project and its results and be sure to pass along any success stories to them. Let them know that their efforts mattered. That’s one of the most important things you can do to help develop your own community’s self-esteem and self-confidence.
We are standing on the shoulders of dedicated and passionate transgender community leaders who have shown us that we have the power to create change in our communities – including those who led transformative change in Los Angeles, Santa Clara, Alameda, and Humboldt Counties. Each community took a different path and achieved a different victory. However, each community achieved its goals by working together with transgender community members, allies, social service providers, and elected officials. We also know that there are many other remarkable efforts and even more leaders ready to step up and organize for transgender health care. By working together and developing productive relationships with allies across the spectrum of politics, medicine, and social service organizations, you too can achieve success. It takes commitment, dedication, and time – sometimes years. But it can be done. We’ve proven that we can do it and that you can do it. It doesn’t take a professional policy advocate to make change; we all have the power to make the change we want to see for ourselves and for our communities. The best person to improve health care for your community is YOU!
American Medical Association Statement
AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Introduced by: Resident and Fellow Section, Massachusetts Medical Society, California Medical Association, Medical Society of the State of New York
Subject: Removing Financial Barriers to Care for Transgender Patients
Referred to: Reference Committee A
Whereas, The American Medical Association opposes discrimination on the basis of gender identity1 and
Whereas, Gender Identity Disorder (GID) is a serious medical condition recognized as such in both the Diagnostic and Statistical Manual of Mental Disorders (4th Ed., Text Revision) (DSM-IV-TR) and the International Classification of Diseases (10th Revision),2 and is characterized in the DSM-IV-TR as a persistent discomfort with one’s assigned sex and with one’s primary and secondary sex characteristics, which causes intense emotional pain and suffering;3 and
Whereas, GID, if left untreated, can result in clinically significant psychological distress, dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death;4 and
Whereas, The World Professional Association For Transgender Health, Inc. (“WPATH”) is the leading international, interdisciplinary professional organization devoted to the understanding and treatment of gender identity disorders,5 and has established internationally accepted Standards of Care6 for providing medical treatment for people with GID, including mental health care, hormone therapy and sex reassignment surgery, which are designed to promote the health and welfare of persons with GID and are recognized within the medical community to be the standard of care for treating people with GID; and
Whereas, An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID;7 and
Whereas, Health experts in GID, including WPATH, have rejected the myth that such treatments are “cosmetic” or “experimental” and have recognized that these treatments can provide safe and effective treatment for a serious health condition;7 and
Whereas, Physicians treating persons with GID must be able to provide the correct treatment necessary for a patient in order to achieve genuine and lasting comfort with his or her gender, based on the person’s individual needs and medical history;8 and Whereas, The AMA opposes limitations placed on patient care by third-party payers when such care is based upon sound scientific evidence and sound medical opinion;9, 10 and
Whereas, Many health insurance plans categorically exclude coverage 1 of mental health, medical, and surgical treatments for GID, even though many of these same treatments, such as psychotherapy, hormone therapy, breast augmentation and removal, hysterectomy, oophorectomy, orchiectomy, and salpingectomy, are often covered for other medical conditions; and
Whereas, The denial of these otherwise covered benefits for patients suffering from GID represents discrimination based solely on a patient’s gender identity; and Whereas, Delaying treatment for GID can cause and/or aggravate additional serious and expensive health problems, such as stress-related physical illnesses, depression, and substance abuse problems, which further endanger patients’ health and strain the health care system; therefore be it
RESOLVED, That the AMA support public and private health insurance coverage for treatment of gender identity disorder (Directive to Take Action); and be it further RESOLVED, That the AMA oppose categorical exclusions of coverage for treatment of gender identity disorder when prescribed by a physician (Directive to Take Action).
Full text, references, and related AMA resolutions available for download at www.transgenderlawcenter.org
Analyzing Policies Worksheet
|Step||Questions To Explore||Notes|
|Identify Key Actors and Institutions||· Who makes direct decisions about the issues you identified?|
· Who can influence the decisions of policymakers?
· Are policymakers and those who can influence them interested in the issues?
· What resources do they have?
· What opinions do they have in relation to the policy issues you are considering?
|Analyze the Policy Environment||· How do people get involved in policy decisions concerning the issue you’ve identified?|
· Where are key decisions on these policies made and who controls those decisions?
· Is the policy a priority for the organization making the decision?
· What does the political environment look like and might there be changes coming that could affect your issue?
|Summarize Your Findings||· What are the direct causes of the problem you identified?|
· What policymakers’ actions led to the problem?
· Why have policymakers taken these positions?
|Identify Options for Policy Change||· What changes would give you what you want?|
· What are your best options for policy change?
· What will happen if nothing is done?
· Which policy solutions are likely to attract significant support or face significant opposition?
· Who should take the lead on bringing the policy solution to the attention of policymakers?
Checklist for Choosing an Issue
A good issue is one that matches most of these criteria. The issue should:
- Result in a Real Improvement in People’s Lives
If you can see and feel the improvement, then you can be sure that it has actually been won.
- Give People a Sense of Their Own Power
This builds both the confidence to take on larger issues and loyalty to the organization.
- Alter the Relations of Power
Building a strong, ongoing organization creates a new center of power that changes the way the other side makes decisions.
- Be Worthwhile
Members should feel that they are fighting for something about which they feel good, and which merits the effort.
- Be Eventually Winnable
The problem must not be so large or the solution so remote that the organization is overwhelmed. People must be able to see from the start that there is good chance of winning, or a that there is a good strategy for winning.
- Be Widely Felt
Many people must feel that this is a real problem and must agree with the solution. It is not enough that a few people feel strongly about it.
- Be Deeply Felt
People must not only agree, but feel strongly enough to do something about it.
- Be Easy to Understand
It is preferable that you don’t have to convince people that the problem exists, that your solution is good, and that they want to help solve it. In general, a good issue should not require a lengthy and difficult explanation.
- Have Clear Advocacy Targets
The target is generally the person who can give you what you want. A more difficult issue might require several targets.
- Have a Clear Time Frame that Works for You
A priority issue should have a beginning, a middle, and an end.
- Be Non-Divisive
Avoid issues that divide. Don’t pit different constituencies against one another.
- Build Accountable Leadership
- Set Your Organization Up for Future Advocacy Work
- Have a Pocketbook Angle
Issues that get people money or save people money are usually widely and deeply felt.
- Be Consistent with Your Values and Vision
The issues we choose to work on must reflect our values and our vision for an improved society.
Outlining an Advocacy Strategy Worksheet
|Step||Questions to Explore||Notes|
|· What policy issue is critical for addressing|
the issue you identified?
· What policy change is your best option for
a significant impact?
· Is the issue “winnable?”
· Do opportunities exist for working with
others on this policy issue?
· What are the potential risks? Are they
worth it, or not?
|· Who are potential target audiences (who|
can help you bring about the change you
hope to achieve)?
· Who has the authority to make these
changes? Who are potential audiences?
· Who has the greatest ability to influence
the decisions of your primary audience?
Who are the secondary audiences?
· Which primary and secondary audiences
will you select for your advocacy initiative?
|· What should your policy project|
· Who will make that change and by when
will it be achieved?
· Can you clearly articulate the final
|· Which other organizations, groups, and|
individuals are concerned or already
working on the same policy issue?
· Do coalitions exist?
· How can you contribute to the efforts of
other organizations and how can they
contribute to your group?
· Are there advantages and disadvantages of
forming alliances with them?
|· Are there any organizations, groups, or|
individuals that oppose the proposed policy
· What threat do they pose to your success?
· What can you do to reduce the influence of
Sample Proposal & Memorandum of Understanding
[Clinic Name] & [Project Name]
[Local Collaborative] invites [Clinic] to partner with us to increase access to transgender health care in [Your Area].
- Create a mutually beneficial relationship
- Local Collaborative] partners support [Clinic]’s commitment to provide people with cost effective, comprehensive health care
- [Clinic] helps address the unmet health care needs of transgender adults – an under- served, historically low-income population
- Advocate for increased and sustained clinic funding
- Increase access to primary medical care and other health care services for transgender adults in [Your Community] through [Clinic]’s clinic and community linkages
Short- and Mid-Term Objectives
Memorandum of Understanding – Create a 6-month MOU to define the partnership, identify the scope of services, and create media and funding strategies
Sustained Scheduled Dialogues – Schedule quarterly meetings between transgender community members and key [Clinic] administrators to engage the target population as a resource for the clinic
Target Marketing – Create and distribute a brochure to market [Clinic]’s existing services to the transgender community
[Clinic] Transgender Health Program – Begin rolling out comprehensive system of care in [Date]
• Primary care services
• Transition-related services and referrals
• Culturally competent care
• Community advisory board
Vision for the [Clinic] Transgender Health Program
We envision high quality, culturally competent comprehensive health care services that meet the primary and transition-related health care needs of transgender adults. Ideally this model would include:
Comprehensive Primary Care
General primary care services, including substance abuse treatment and genderspecific services such as pap smears, pelvic exams, prostate exams, breast exams
Access to hormones
- Male to Female (MTF) – oral hormones and injections, such as anti-androgens, Spirolactone, Estrogen, and Progesterone
- Female to Male (FTM) – testosterone in multiple forms, such as intro-muscular injection, gels and patches
- Laboratory tests, including monitoring of liver function and lipids
- Referrals to Transgender Specific Adjunctive Services
- Pre-surgery physicals
- Mental health services, including support groups, psychology and psychiatry
Transition-Related Care based on Informed Consent Model
Formal transition-related protocol with range of options. To build positive communication with the transgender community, we recommend [CLINIC] develop a protocol that honors a range of transition options that addresses a client’s needs regardless of hormonal or surgical status.
• Require that clients receive appropriate education regarding transition in order to
make informed decisions about their own transition
• Provide educational materials for both MTF’s and FTM’s
- Ongoing staff training for administrative and clinical staff
- Community Advisory Board
- Transgender-friendly environment
Inclusive intake and treatment forms
Gender neutral bathrooms
Multilingual forms and facility signs
[LOCAL COLLABORATIVE] is eager to help [CLINIC] implement this vision for quality, comprehensive transgender health care. To this end, we can connect you with transgender health experts, provide free training and technical assistance, support evaluation efforts, and advocate for increased funding.
[Should Appear on Letterhead]
[City, State, Zip]
Dear [Contractor Name],
This proposal outlines the prospective relationship that the [Local Health Care Compaign] would like to initiate with [Clinic] to help develop a program for competent transgender health care. We are excited that you are open to working with us to expand your range of services for more extensive transgender-specific care.
[Local Group] envisions a mutually beneficial relationship in which the transgender community’s health care needs are provided for and [Clinic] has the support needed to secure stable funding for transgender health care.
We envision a formalized partnership with a sustained scheduled dialogue between [Local Group] and the [Clinic] administration. This kind of social mechanism will allow [Clinic]’s transgender health program to grow and flourish while maintaining a discourse to keep the trans community involved in the clinic and to use the community as a resource. Below are some goals for a transgender health program at [Clinic] that we would like to help you develop over the next six months.
Primary and Transition-Related Care
Develop a formal transition-related protocol. These are guidelines for medical treatment specific to transgender health and wellness and should include an Informed Consent process. Informed Consent requires that the client receive appropriate education regarding transition in order to make informed decisions about their own transition.
Provide comprehensive primary care that includes access to hormones. For transgender people, hormone therapy is an essential part of primary care. Appropriate primary care for transgender people on hormones also includes: pap smears, pelvic exams, breast exams and laboratory tests for liver function and lipids. We would be glad to provide clinical resources that can assist your providers to develop primary care guidelines for transgender people.
Referrals to transgender specific adjunctive services such as surgeons, mental health services and support groups.
Enormous disparities in health care impact the transgender community primarily because of a lack of cultural competence on the part of administrative and clinical staff in medical settings. Issues such as identity documents, bathrooms, pronouns and clinical documentation standards can be complex and confusing for some providers. By ensuring linguistic and cultural competence, [Clinic] will set the standard for quality transgender care in [City or County]. To this end, we ask [Clinic] to:
Commit to on-going staff training for all staff members who come in contact with transgender clients/patients.
[Local Group] can provide training and materials to help [Clinic] staff use language and terms that are appropriate for the transgender community.
Develop policies and practices that promote a transgender-friendly environment. Attached is a summary of the issues described above with greater detail about these specific proposals. If you have any questions, please do not hesitate to contact
[Contact] at xxx-xxx-xxxx.
[Community Advocate’s Signiture]
[Community Advocate’s Name]
[Community Advocate’s Title]
Developing Your Personal Story
- Describe who you are, where you are from, and where you work or if you are unemployed.
- Describe a situation that has occurred or an issue that you’ve experienced in a health care setting that is related to your transgender identity. The example can be negative (i.e. the inability to get proper care) or positive (i.e. a great experience with a doctor).
- Have you experienced discrimination? Either in a health care setting or in employment?
- Have you had a hard time accessing health care because of your gender identity or expression?
- How did this experience impact your health?
- Making Your Story Friendly
- The ideal personal story will only be 30 seconds to a minute long and free of too much “trans lingo.” Re-word your story to cut down its length. You should always develop or refine your story with your target in mind. Your story should also follow these guidelines:
- Identify yourself, where you live, and what you do for work. If you’re speaking with your elected official, make sure to let them know that you are their constituent.
- Keep your message simple and free of unneeded information. Make sure that all details are relevant and important.
- Keep the message personalized. Do not make generalizations for the entire transcommunity (i.e., “ALL transgender people feel discriminated against at work”). Use “I” statements to make sure your story is personalized (“I feel that this issue is very important,” “I feel that trans people face discrimination at work due to transphobia.”)
- Do not include language that your target may be unfamiliar with without explaining it. This includes words like “genderqueer” or “cisgender,” acronyms like “QPOC” or “PFLAG,”” and abbreviations like “FTM.”
- If this is a relationship-building meeting, do not bring up specific actions that you want the legislator to take a position on. This might cause the target to dismiss your issue. It is important that they hear your experiences as a transgender person.
- Include how your story would improve or change with the realization of your ask (i.e. trans inclusive health care legislation, etc).
Visiting a Policy Maker
Be prepared. Know what you want to say. Refer to your talking points. Make sure your story makes a point! You don’t need to be an expert. Your job is to put a human face on the problem. And if you don’t know the answer to a question, offer to have someone follow up.
Practice! Keep your statement SHORT.
Arrive early. Then be prepared to wait! All policy makers’ schedules are subject to change.
Meet with your group beforehand. Decide who will speak on each issue.
Tell your personal story. Make sure it relates to the talking points!
Make friends with staff of elected officials. Support staff often plays a critical role what the elected official prioritizes.
Be respectful and polite!
Work at building a relationship. Thank your legislator for prior support. If there is no prior support on our issues, maybe there is something else you can be positive about.
Close the meeting with the “ask”. Be firm but courteous in asking for support. If need be say, “I am unclear as to your position. Can we count on you to support X, Y & Z?” If they want to think about it before committing to a position, ask when would be a good time to get back to them.
Follow up. Send a thank you card and make sure you write down all the details of your meeting. Even small notes about demeanor or attitude help when you plan your next step.
Don’t start the meeting without introducing yourself. Make sure as part of your introduction to include where you live and your connection to the policy maker (for example, if you’re visiting an elected official, let them know you live in their district if you do). If you are in a group, you might select one to do introductions.
Don’t do all the talking. Let the legislator express his/her concerns. You may be able to answer them. Listening is a critically important skill in the legislative process.
Don’t rant. Ranting doesn’t get you anywhere.
Don’t use inflammatory or accusatory language. You don’t like it when someone implies or calls you an idiot because you don’t agree with them. Keep it real, but respectful. (You never know. In the 90’s Connie. Norman, a trans/AIDS activist, built a relationship with her very right-wing legislator. She contacted him before big bills and after, critiquing his votes. Always respectful, she let him know the impact of his votes, and about her own struggle for equality and medical care. One day, there was no letter from Connie after a vote. He knew something was wrong, and finally tracked her down in the hospital. On the next AIDS bill to come up, he told this story and dedicated his vote – the deciding vote – to their friendship.)
Don’t stay too long. For elected officials, 15 to 30 minutes is about max. Legislators’ days are unbelievably busy.
Don’t show disappointment if you meet with a staffer. Legislative aides are trusted advisors. They are in the room when the legislator makes decisions on how to vote. Be nice.
Adapted from the Transgender Law Center and Equality California’s Transgender Advocacy Day Materials 2010
American Medical Association. (2008). Removing Barriers to Care for Transgender Patients: AMA Resolution 114, 115, and 122. American Medical Association.
American Medical Association. (2008, June). The AMA House of Delegates Resolutions. Retrieved from http://www.ama-assn.org/ama1/pub/upload/mm/471/114.doc
Bobo/Kendall/Max. (2010). Organizing for Social Change: Midwest Academy Manual for Activists. Santa Ana: Seven Locks Press.
Cooperative for Assistance and Relief Everywhere, Inc. (2001). Advocacy Tools and Guidelines: Promoting Policy Change. Atlanta, USA: Cooperative for Assistance and Relief Everywhere.
Grant, J. M., Mottet, L. A., & Tanis, J. (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington, D.C.: National Center for Transgender Equality; Natinoal Gay and Lesbian Task Force.
Grant, J. M., Mottet, L. A., & Tanis, J. (2010). National Transgender Discrimination Survey Report on Health and Health Care. Washington, D.C.: The National Center for Transgender Equality and the National Gay and Lesbian Task Force.
The San Francisco Human Rights Commission. (2007). San Francisco City and County Transgender Health Benefit. San Francisco: The City and County of San Francisco.
The Women’s Foundation of California. (2008). The Women’s Policy Institute Handbook. San Francisco: The Women’s Foundation of California.
Transgender Law Center. (2008). How To Start A Transgender Clinic. San Francisco: Transgender Law Center.
Transgender Law Center. (2009). The State of Transgender California Report. San Francisco: Transgender Law Center.