Welcome back to the Healing Pain Podcast with lore m. dickey, PhD

It’s a pleasure to be spending this time with you. One of the activities that I do each week is I set aside some time to sit down and brainstorm about all the various topics that are related to chronic pain. The reason why I do that is it helps me find interesting and inspiring people to share with you on this show. If you follow this show for probably for a couple of years I’ve been doing it, you know that I’ve spoken about popular topics such as pain education, pain psychology, exercise, physical therapy and nutrition. One topic that interests me and quite frankly is the topic that doesn’t receive enough attention in the media or receive grant money for research is the topic of health disparities. A health disparity is a difference in the health status of different groups of people.

For example, patients such as racial minorities and women have been identified as not receiving adequate pain care. Another group that faces significant barriers, adequate healthcare are transgender people. Transgender is an umbrella term for a diverse group of people whose gender identity or expression differs from societal expectations of how they should look, act or identify based on the sex they were assigned at birth. There are approximately 1.5 million transgender people living in the United States of America. Although this data is incomplete because many transgender people feel uncomfortable or feel that it’s not safe to share their personal information.

From a healthcare perspective, transgender people experience higher rates of suffering and disabling conditions including a wide range of mental health problems and chronic pain conditions including chronic pelvic pain. Unfortunately, when transgender people seek treatment, they often encounter providers who do not understand their unique needs, face challenges with health insurance and are often neglected or perhaps even mistreated within the healthcare system. Here to speak with us about improving transgender healthcare is Dr. lore m. dickey. lore was raised as a female but never truly felt at home with the female identity. Several years after his transition, he returned to school to become a licensed clinical psychologist. He learned early in life that the best way to make a change is to be part of the solution. lore is the author of two books, 22 journal articles and seventeen book chapters.

He’s an advocate for the trans community and a prolific and engaging speaker. lore is also providing you with two free resources that you can download on the show. The first is the American Psychological Association Task Force on Guidelines for Psychology Practice with Transgender and Gender Nonconforming People. lore developed these guidelines along with the APA. The second is a complete list of all the books and book chapters which lore has contributed to. lore did receive the 2014 Presidential Citation by the American Psychological Association for his dedication to the LGBT community. He’s got great resources. Take a moment now to download them. To download them, all you have to do is text the word, 137DOWNLOAD, to the number 44-222. You can do that right on your smartphone or if you’re on a computer, you can open up a new browser and type in the URL www.IntegrativePainScienceInstitute.com/137download. lore is a leader in transgender healthcare. I want to thank him for joining us on this show and all the work that he’s doing for the transgender community. Let’s begin and let’s meet Dr. lore dickey.

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Transgender Healthcare with lore m. dickey, PhD

lore, welcome to the show. It’s great to have you here.

Joe, thanks for asking me to be here.

This is a new conversation that we’re broaching on the show. I know it’s going to help a lot of practitioners as well as other people that are interested in the topic. You and I obviously are both licensed healthcare practitioners. The topic of LGBTQ and trans health to this day is still new. It hasn’t permeated the greater culture as well as probably most medical healthcare training. A good place to start is could you give us an overview of some of the more common challenges that trans people face in the healthcare system?

There are a couple of studies that had been completed by the National Center for Transgender Equality, the latest being the US Transgender Survey, USTS. It’s important to note that the latest survey had over 27,000 participants. We’re not talking about a convenient sample of 30 people. Over 25% of people indicated things like fear of discrimination from their provider, fear of being mistreated by their provider, not being able to afford care and having to educate their provider. That’s nearly ubiquitous for trans people in terms of the ways that they end up interacting with their providers. Never in a million years if I’m seeing a medical provider they’d expect me to tell them what diabetes is, how to treat it or what the prognosis is. It’s the same thing on the mental health side. Never would I expect a mental health provider to have me educate them on what it means to have depression, what the prognosis is, all of those things.

For transgender people, oftentimes their providers are expecting them to provide even some basic information about what it means to be trans. I can understand wanting to know about that particular individual’s experience as a trans person, but that’s different than having them educate them about when and where their hormones are appropriate, when and whether surgery is appropriate, what it means to have a legal transition. Yet, that happens far too frequently with trans people in any kind of a healthcare setting.

It’s an interesting place to begin. To prepare for this show, I’ve read all about your gray work. I reached out to some of my former professors in physical therapy school. I said, “Is this type of education filtering into physical therapy curriculum at all?” The responses I got were about 30 minutes in a doctoral level PT program, which is over the course of a few years’ worth of training, which is small. My question is as a trans person, you’re going to access medical care, see a physician. Do we have any information on what traditional medical curricula? Are they covering this topic at all? Are physicians receiving information in school about this?

In general, no. It’s laughably barely more than what people are getting in physical therapy training. It could be for 60 minutes. That’s covering lesbian, gay, bisexual and transgender people. I’m not talking a semester hour. I’m talking 60 minutes. You can’t even cover the beginnings of, for example, HIV prevalence and treatment in an hour. That certainly for lesbian, gay, bisexual, and transgender people is important. One of the things that are coming up for me is making sure that people understand the difference between gender identity and sexual orientation. We see the LGB and T lumped together these days. That has been the case for many years that we’ve been doing that. Sexuality and gender identity are separate concepts that inform one another.

If I’m a gay-identified person, you know who I’m attracted to based on my gender identity, expression and the person who I’m in love with gender identity and expression or the person who I’m attracted to. There’s a difference between attraction and behavior. We’re not here to get into a whole bunch of detail about sexual orientation. It’s not as straightforward as it used to be. Even though the LGB and the T are tacked together most often, gender identity is not a sexual orientation. Being transgender is not a sexual orientation. I have a sexual orientation outside of being a transgender person. Even though my gender identity informs what that sexual orientation is, there are two separate concepts but interrelated.

It’s important for us to discuss as we go on. Maybe you want to say a little bit more about this. Is it that in the past we put people more into silos, you’re either going to be male or female? Now there’s more of a gender continuum that’s occurring. It can be confusing for the general public and it can be confusing for healthcare providers as well. I particularly think as a physical therapist, I don’t do pelvic healthcare. There are many physical therapists that are involved in pelvic healthcare that are supporting and interested in this topic. Can you talk about the idea of a gender continuum a little bit for practitioners?

You said it well initially. We have these silos. You’re either male or you’re female. We call that the gender binary. There are two choices. You think of binary code and how computer code is written. There are zeros and ones. I don’t know who the zero is, whether those are men or women. You have two choices. What we see now is that people identify somewhere along a spectrum. I even talk about my own coming out story. I came out many years ago and began taking hormones. I remember having to educate my family about what it meant to be trans and what pronouns they should use. Believe it or not, somebody back then, my sister was asking me, “What pronoun should my kids use?”

I was as confused as she was. At that point, there were only two sets that we had choices for when you’re talking about an individual, he, him, his, she, her, hers. Now we’ve got a broad spectrum of pronouns that people use to identify themselves. Had I come out probably several years later, I might have used non-binary pronouns. I present primarily in masculine identity. Most people read me as being male. I have what’s called passing privilege. Passing is problematic because there are many people who will never be able to do that because of what their bodies were like before they began a transition. I’m very fortunate in that I’m 5’9”. I’ve never had a female figure. All it took was a little bit of testosterone. I’ve got male pattern baldness and hair on my body in places I didn’t know I could grow it.

Other kinds of muscular changes that have happened. If you’re 5’2” assigned female at birth and you start taking testosterone, you’re never going to be 6’2”. You’re probably never going to be 5’2.5”. Likewise, if you are 6’2” with broad shoulders, big hands, big feet, a prominent Adam’s apple, you can take all the estrogen in the world you want, but your shoulders aren’t going to stop being broad. Your feet aren’t going to get smaller. Your hands aren’t going to get smaller. The only way you’re going to be able to change the size of your Adam’s apple is through surgery. That’s a surgery that generally is not covered by any health insurance. It’s considered elective surgery. It’s not considered to be medically necessary.

I’ve had enough in a different direction there. The one thing I want to say though about the gender spectrum is, in my mind, what we’re seeing is that society is going back to what existed in indigenous cultures for years, decades, millennia even. That’s we have gender in different places. If you look at, for instance, the Māhū in Hawaii or Polynesia, the Fa’afafine in Samoa, the Kathoey in Thailand, the Hijra in India and Pakistan, as some examples. These are all ways that trans people identified somewhere besides these two anchored places that can’t move. It seems that we were making a full circle. There’s a lot that happened to indigenous cultures in order for us to make that circle. Fortunately, we’re seeing the trans people in those indigenous cultures rise up again and hold the place of honor in their community that they once had.

It’s quite interesting how in certain cultures there’s this beautiful spectrum of self-expression and self-actualization in the indigenous cultures that we somehow have forgotten or don’t allow to happen in this society.

What happened years ago in those societies is that they were colonized. When these primarily European Christian people made their way into these communities, they said, “No. This doesn’t work for us. You need to be either this or that. You can’t be somewhere in between because we don’t have a script for that.” Colonization was a big piece of how trans people, they weren’t called trans back then, were wiped off community maps in those locations. It’s sad. Unfortunately, we’re beginning to see a resurgence of people with those marginalized identities in those cultures.

I want to come back to the topic of healthcare. With regard to third-party payers and access, are there barriers there for the trans community that exists?

Third-party payers are a complicated topic. For the audience’s benefit in case you’re not aware of this, there are private insurers. Typically, people have access to those private insurers either through their employer or through, for example, a market place policy, assuming that the marketplace still exists. I’m a little bit not quite sure where that is. I’ve been fortunate to have an employer-based policy for quite some time. You have Medicare. It’s something that’s offered by the federal government. It’s for people who are elderly and people who have a disability. That’s a disability that is approved by the Social Security Administration. People get SSI or SSD. They’re eligible for Medicare. That’s the federal government. The third type of insurance that you would have is Medicaid. That’s offered by the states. It’s also public insurance.

It’s for people living in poverty and children. That’s how that one works. For the most part with private insurers, if you have a favorable policy, it’s because your employer has negotiated what benefits you get in that policy based on their value as a company. For example, I work for a place called North Country Healthcare. We’re what’s called a federally qualified health center, which means that we see anybody who walks in our door regardless of their ability to pay. We see lots of people on Medicare and Medicaid. We also see people who have private insurance. I have a policy that ultimately bills through Blue Cross Blue Shield of Arizona.

You could have a policy, Joe, that also bills through Blue Cross Blue Shield of Arizona, but it doesn’t cover any trans care. Mine does not have an exclusion for that care. When you see those exclusions for care, usually it says something like, “We will not cover sex reassignment procedures.” It may stop there or it may continue as it did for me when I lived in Louisiana and say, “Even if those procedures are deemed to be medically necessary.” Medically necessary is like the golden ticket on the Polar Express. It’s the one that gets you into that special party with Santa Claus and all the elves and their toys. If you don’t have that exclusion, your care is probably going to be covered, assuming you’ve got a diagnosis of gender dysphoria, whatever’s being done is considered medically necessary. I could get my hormones covered. I can get surgeries covered. Any type of facial feminization has always been considered to be an elective procedure like breast augmentation for transwomen is often considered to be an elective procedure yet for a trans guy to have a chest masculinization surgery that would be considered medically necessary. Why it’s medically necessary for the trans guys and not for the transwomen when you talk about their chest is a puzzle to me.

I didn’t know they would piece that out and all those different parts, which makes it complicated for everyone.

It does. One of the things that have frustrated me for years is that when people need a trans person, I’m thinking about in a social setting, not in a clinical setting. They all of a sudden think they have a license to ask that trans person all kinds of invasive questions in the same ways that people think that they can touch a pregnant woman’s belly. “You hardly know me and yet you want to touch me? Get away.” I always tell people what’s the way that we ask people about their genitals. We ask them if they’ve had the surgery. The reality is for transwomen, they can do that in a single surgery. A lot of trans women don’t do it in a single surgery because they can’t afford the procedure. For trans guys, it’s almost never a single procedure. I have had a total of six surgeries, four of which have been specific to my genitals. I can tell you that it has been a long and arduous process. When I speak to a group of people, ask them to raise their right hand and have them take this oath about not asking trans people about their genitals unless you have a legitimate reason to do so.

For example, if a physical therapist is doing some pelvic floor work with a transmasculine individual, someone who’s assigned female at birth, they’re going to need to know some information about what’s going on in the genital region. For someone like me who’s had a metoidioplasty, I had a vaginectomy, how are we going to do pelvic floor work with someone who no longer has the vaginal opening? That’s a totally legitimate conversation for a physical therapist, a physical therapist that’s doing pelvic work to have with their patient. If I come in for a post-surgery work for having my hip replaced, that’s not relevant. We seem to think that it’s okay to ask people about that. The way that I usually go about that, I say, “Joe, is it okay for me to ask you about your genitals?” You’re getting this awkward, uncomfortable laugh. I say, “Joe, if it’s not okay for me to ask you about yours, why do you get to ask me about mine?” People get it, “I understand.”

I’m a gay man and some of those topics have existed in the lesbian and gay community for a long time where people ask you questions quite frankly about your either sexual relationship or these open-ended, “How does this work?” I have never asked a straight couple, “What do you do behind your bedroom door?” It’s your bedroom door. You can do whatever you want behind it as far as I’m concerned. The flip side of that is as people are naturally curious as humans, who they are and they’re trying to learn. How do we help practitioners cultivate a desire to learn and potentially the courage to make mistakes, apologize and try again as they’re working with trans people in their practice?

One of the things that are super common for people to make mistakes about is around names and pronouns. It’s amazing how many times, this hadn’t happened as much as it did when I first transitioned. That once people learned that I was transmasculine, all of a sudden they decided that they could use female pronouns because that’s the sex I was assigned at birth. When you make a mistake, not if you make a mistake, when you make a mistake, own it. I’m trying to get used to calling you Joe and using masculine pronouns. I’m sorry that I use the wrong pronouns with you. I’ll do better next time. What that does is it takes the pressure off of you, the patient or client from having to correct me. There’s always a power differential in the healthcare setting. The provider is the one who has the power. It can be very difficult for the patient to be able to say, “This isn’t okay with me what you did. If I as a provider can own my confusion, my mistake, my screw up, the patient knows that I’m making an effort to get it right and not purposely messing things up in a way that’s going to impact our relationship.”

I know you’ve done some work in the ACT community, Acceptance and Commitment Therapy. As we’re talking about this topic, the ACT is a number of exercises around perspective taking. I’m thinking to myself where is this being taught as far as the perspective taking of helping or identifying with someone who’s on this gender continuum, taking a perspective of where they are. I don’t think it exists. My question is we already spoke about does this exist in medical school? Does it exist in PT school? What’s happening with regard to the APA? What’s happening in graduate-level psychology programs? How has much education with regard to trans care filtered in there?

There are probably two or three places where you would see this. The first is going to be in a psychopathology class where people are studying the Diagnostic and Statistical Manual of Mental Disorders: DSM-5, that’s the latest version of that. One of the disorders in there is gender dysphoria. They might explore it there. When they’re exploring it in that context, they’re looking at what’s wrong with the person as opposed to what are the areas of resilience that a person has to be able to deal with the challenges that they face. That’s one area. Regardless of what kind of psychology you’re doing, clinical or counseling, you’re going to have a psychopathology class. The second area would be more likely to be with people who are in counseling psychology and that would be either in a course about gender or a course about multicultural issues.

The course about gender obviously it makes sense that you would cover more than masculinity and femininity. Although when I took that class several years ago, we were given two book lists to read from, one about boys and men and the other about girls and women. I raised my hand and I said, “We’re missing a list.” The professor said, “If you prepare a list of readings similar to what I’ve got on these two lists, I’ll be happy to give it to the students.” She did that, which was awesome. People had a chance to read something that was a little bit different. In a multicultural class, there’s typically always a unit on sexual orientation and gender identity. It would be covered in that area.

Ideally, multiculturalism is covered across the curriculum but that doesn’t always happen. The last place you would possibly see this and it would take a pretty astute professor to cover this is when you’re taking a class on psychological assessment. How do you, for example, score in assessment where you have to indicate what the patient’s sex or gender is? If you were doing a personality assessment on me, you had to choose either male or female in order to get a score, what are you going to choose? How do you make that decision? Little has been written on how to work through that and still come up with valid results.

Does it belong in the DSM-5?

No, that’s the short answer.

At one point, homosexuality was a diagnosis and that has been taken out.

That was in 1973.

How much is this being discussed in the realm of psychology? There may be pros and cons to taking it out because you don’t have a diagnosis, which means potentially you may not be able to get care covered.

The people who were worried about being able to get care covered are those who have public insurance. People who are living in poverty or people who are incarcerated. They need to be able to get a diagnosis. The World Health Organization writes what’s called the International Classification of Diseases. You probably work with that every day in physical therapy or the ICD. The world is on ICD-10, which the US has been on for maybe a few years now even though it came out over a decade ago. The World Health Organization will be coming out with ICD-11. In the ICD-11, gender dysphoria or whatever they ended up deciding to call it will be a medical condition rather than a mental health condition. One of the things that the World Health Organization has demanded is that any other diagnostic reference like the DSM-5 is consistent with the ICD codes. When we see gender dysphoria moved to a medical condition, it’s still diagnosable. It should come out of the DSM at that point.

What types of community-based resources are available for trans people?

The internet is a great resource. You can come up with some good websites. You can come up with some not very helpful websites. One of the issues with not helpful websites is that you can find people who are essentially trolling that website so that they can fetishize or eroticize trans people in ways that are not very useful. In larger cities, you’re going to have health centers where trans people can access hormones, typically using an informed consent approach to providing hormones, which means that the trans person understands what the hormones can and can’t do, what the risks and benefits are and what the costs are associated with hormones. Instead of having to come to a provider like me, establish a relationship and get me to write a letter saying, “This person should be able to start hormones.”

I list all of those things that previous psychiatric history whether or not that’s reasonably well-controlled. I don’t even know what reasonably well-controlled means. It adds an extra layer of somebody getting access to care. For example, in Chicago, the Howard Brown Center is a place where people can get care. Whitman Walker in Washington, DC, the Tom Waddell Clinic in San Francisco, the LA Los Angeles LGBTQ Health Center. There are a couple of places in New York and I don’t remember the names of them. One is the Gender Identity Center. It’s specifically for people who are trans. Oftentimes, we’ll see this work lump together and there’s a valid reason why that happens. The people who are smartest about HIV care have been caring for gay men for many years. Trans women especially are at high risk of HIV transmission especially those who are forced to work in street economies because they can’t get a job. They’ve lost their home and all other issues. It makes sense from that perspective. If a person needs care regarding HIV treatment, that’s one of the best places for them to go.

If you are a practitioner and you go into PubMed and you look up transgender, you’ll see things like higher rates of anxiety and depression, suicide and PTSD. Those were all important topics that need funding and resources. You brought up resiliency, which I find to be interesting and in the trans people that I know that I’ve come in contact with in my life, I find that to be extremely resilient. I’ve learned so many things from them. What can we learn from people that are in transition and have been through this that instead of focusing on, “The dysfunction.” Where is the beauty in this that we should all be paying attention to?

First, I want to back up and say you can also go to PubMed and put in transgender and resiliency. You won’t get as many articles as you would with regard to anxiety, depression, suicide and all of those issues. You will find people who are doing research in that area. We often think of resilience in a couple of different ways. The first is about how you’re resilient as an individual. Second is how the community helps to bully you when you need support. To me being able to manage a transition, be it social, which is typically about the way you dress, the name and pronouns that you use medical. It’s about some combination of hormones and surgery and legal, which is about changing all of your documents so that they are consistent if you choose to do that and can afford it.

No matter which version of the transition you make, the fact that you can get through that is to me a clear measure of resilience, your ability to bounce back from a difficult situation. When I transitioned many years ago, I quickly realized that I could only come out to two people a day. If I saw you at 10:00 in the coffee line and I had already come out to two people, it was not your day to find out about my history. Even though I could tell you are looking at me trying to place me. I start to look familiar, but there was something different about me that didn’t quite fit for you. That wasn’t your day because it was emotionally exhausting for me to come out to someone. I learned that and put that little wall up around myself in a way that protected me and allowed me to come out to who I needed to come out to and keep myself safe. The end result would be that I would be emotionally distressed overall of this that I couldn’t go to work. I have to keep going to work. I’ve got to pay rent, car payment, student loans or whatever it is that’s hanging over your head.

What’s the one message you would like to get across to our audience or anyone who comes across this show?

There are probably two messages. The first is that being transgender is a normal variation of the human experience. Trans people have existed throughout history. As long as humans have been walking this planet, trans people have existed. We see that in the indigenous cultures that we talked about earlier in the show. Second, when you make a mistake, correct yourself and correct yourself in the presence of the trans person so they realize that you get it. Those two things will help you not pathologize the people who you’re working with or interacting with and will help them understand that you’re making your best effort to meet with them on a safe, respected playing level.

lore, thank you for being on the show sharing such great information and on a topic that we need more ears and eyes on this topic. Especially the times we’re in where we have support from people and then we have some other people who have yet to arrive at the table with us, which they will over time. How can people learn more about the great work you’re doing, the books you’ve written, all the information about you? Where can they go?

Don’t go to the Little Scholar if you want to look at articles. I won’t waste time talking about the hitch in their system that doesn’t pull up articles that I’ve published like PubMed and the resource you’ve mentioned before. I have two books out, one is published by the American Psychological Association and the other is published by New Harbinger Press. I have another book coming out. I don’t have a date yet on that one, but that’s going to be more of a case book than the other two have been. My website is Solution-Masters.com. That’s my personal website. You can find out a little bit more about me.

I would be remiss if I didn’t say something about suicide in the trans community and how high those numbers are. It’s critically high compared to any other marginalized group. I know you said you wanted to send people to one place. I have another place that people can go to, which is MyBandanaProject.org, which is a little intervention that I developed to help people who are trans and having thoughts of ending their life. Over 40% of trans people have indicated in multiple surveys that they’ve attempted suicide at least once in their lifetime. That’s far and above any other group. In the general population, it’s less than 2%.

I want to thank lore for being on the show. You can go into the website he mentioned or you can go to his individual website which is Solution-Masters.com. Make sure you download the free gift, which is a free book chapter to a book that lore gave us as a free download so you can sample his work. Once again, take this information, share it out with your friends and family on Facebook, on Twitter, on LinkedIn and a favorite Facebook group that you have so we can help share this great message. I am so happy to have you here with me to share this information. We’ll see you next time.

Important Links:

• Dr. lore m. dickey
• Guidelines for Psychology Practice with Transgender and Gender Nonconforming People
• US Transgender Survey
• North Country Healthcare
• Diagnostic and Statistical Manual of Mental Disorders: DSM-5
• International Classification of Diseases
• American Psychological Association – Affirmative Counseling and Psychological Practice With Transgender and Gender Nonconforming Clients
• New Harbinger Press – A Clinician’s Guide to Gender-Affirming Care
• MyBandanaProject.org
• @loremdickey on Twitter
• https://NorthCountryHealthCare.org/providers/lore-dickey-phd-lp/

About lore m. dickey

lore m. dickey transitioned in 1999. Raised as a female, lore never truly felt at home with a female identity. Several years after his transition he returned to school to become a psychologist. He learned early in life that the best way to make a change is to be a part of the solution.

lore is the author of two books, 22 journal articles, and 17 book chapters. He is a prolific and engaging speaker.