 I'm a licensed marriage and family therapist right here on Oahu, and it delights me to welcome back Dr. Janet Brito. She's a clinical psychologist and a certified sex therapist here in Hawaii, filling a gap that has long existed, and now there's a place to go, welcome Dr. Brito. Thank you. I'll be back. So, today we said we were going to focus on the specialties that come up when you are a therapist or a health provider of some sort, and your patients, clients are lesbian, gay, transgender, bisexual, queer, asexual, and what's the eye? Intersex. Intersex. And tell us what we need to know about that. And, you know, some of the people watching may be therapists or other kinds of health providers, and this is especially for their information, but as a consumer of health services, when you go to the doctor or the therapist, this is good information for you too. Absolutely. Yeah. I think it's extremely important because a lot of patients who identify as lesbian, gay, bisexual, like you said, are not seeking services, are not going to see their providers either for medical or for therapy because there's a fear of being discriminated. They face significant amounts of stigma, and so there's this fear around asking for help even though they may need it, and we know that there are higher risks for HIV, STI, substance use, depression, anxiety, suicide, I mean the whole gamut. So it's very important that we are more knowledgeable about how to work with this population and be there as a person of support. And to let people know that we are supportive and that they won't face that kind of discrimination? Absolutely. So how to be an LGBTQIA friendly therapist, healthcare professional, how to be an ally, how to be there for the individual. So one of the first steps is to step away from that model of disorder, where it's like there's something pathological or wrong about this person that they need to be converted or changed, and I think that used to be the case, and so- But didn't they pass a law that you're not allowed to do those kind of conversions anymore? Exactly, because a lot of the therapy was focused on trying to change this person, and so it's more about shifting from that model to more of focusing on the biopsychosocial aspects of the person. The same as you would with anybody. Exactly. Okay, this person is here, what's going on, or I'm having trouble with my relationship, I'm having trouble feeling motivated, I'm feeling down, okay let's focus on that versus on we need to change your sexual identity or your gender. Right, because most of the time that's not what they're there for. Exactly. Right. So it shouldn't be the focus of therapy unless it's a concern for them. Right, but it's interesting that, I mean so often that the populations most in need of help are reluctant to seek it, right, and especially with this population, yeah it's really hard because there is so much discrimination in the world. It's easy to understand that they would think, oh why should it be any different going to a therapist, there's probably going to be discrimination there too. Right, or some kind of bias that doesn't, and everybody has biases, it's important to be aware of them, but then if you impose them on your client, then that's where it could become a problem. Oh and I suppose, I mean part of our training is you need to become self-aware to know that if there is such a bias, you should refer people out. Exactly. Right, that's a very good point. So yeah. But besides, what else would be different if you have these minority clients? I think another way to work with this population is to let them know, let's say that you have worked on your biases and you're comfortable working with this population, I think it's important to let them know that you are friendly. So this could be something that you could do in your office. So having magazines that are friendly, having some type of little, like a pride flag or a little pink triangle, something to convey inclusiveness. And acceptance. Exactly. It's like okay, I am aware, I have some knowledge about what these letters mean, I am aware of some of the issues that you face, the stigma that you are experiencing, some of the minority stress, and you're welcome here. This is a place that you can come and be yourself. So that's one way of doing it. Another way is with your intake forms. So I would stay away from check boxes and make more of a fill in the blank, so then the person doesn't have to figure a little box for themselves. Exactly. It's like, okay, gender, you know, sexual orientation, relationship status. So they get to decide what that word is for them. I've never thought about that. I mean, I don't think on my intake forms there is a question about that at all. Oh, okay. Should they pick? I mean, I ask them all sorts of questions, you know, from their preferred name. You know, what is your preferred name, what is your preferred pronoun to, what is your relationship status, and what is your sexual orientation. I think it helps me put things into context. So, you know, it's a general intake, like any other question I may ask them about their medical condition. Right. So it's not meant to, yeah, it's within the context. It's different than if you're just trying to be nosy and you're trying to, you know, ask for your own sake and your own curiosity versus like, okay, how am I getting a bigger picture of this person? Yeah. Yeah. So I think that's one of the biggest things is the preferred name and preferred pronoun. I know that I have seen most of my patients get really happy about that. It's like, oh, you're asking me what is my preferred name, let's say for somebody who is transitioning, identifies as either trans or genderqueer. There's all sorts of definitions or labels and you want to ask the patient what their definition is of themselves. Right. And so that's a wise thing, just go with what they prefer. Exactly. Use their terms. Right. Use their wife. Don't say it's their friend. Right. You know, if they use gay, don't use homosexual. Right. So use their language to let them know that you are accepting of them, inclusive, affirmative. So much of it seems to be just an extension of what we do with all of our clients. You know, I always use, try to use the client's words, you know? If a client says, I was really mad, then I say, so I heard you say you were really mad. I don't say angry. I mean, it sounds like a menini thing, but I mean, above, sometimes I think above all what people want is to feel heard. Absolutely. It's very affirming to use the client's language, you know, in that example or with their gender or their sexual orientation or their relationship status. So I think sometimes providers get hung up on what the right thing is. I know it happens with the preferred name thing. I know there's a legal name and they have that with their insurance card. And that's fine. You could use it for billing, but in your intake or your reports, I think it's important to use the client's preferred name. It's not up to you to decide whether trans, being trans is okay or not. That's not your decision, right? Because I have seen this often where the provider is not using the client's preferred pronoun or preferred name because they don't believe in somebody being trans. So, you know, and it's very difficult for the client. They're upset. I laugh because of what the therapist's beliefs are, it's like, what has that got to do with it? Right. Right. And if you make a mistake, which I have, you know, I use the wrong name or the legal name, then you apologize to it. You acknowledge it and you move on. Yeah. You know, and most clients are like, it's okay, thank you for acknowledging it. You know? Yeah. It's not a big deal. Right. I think it just becomes a big deal if it's a big deal in your head and you don't, and you're not present, like, you know? Yeah. I mean, the same is like, you know, if somebody calls me Stevie, I might say to them, no, no. My sister called me Stevie and I'd hated it then and I hate it now. Don't call me Stevie anymore. Right. You correct them. And that's part of the, part of the treatment is to develop that assertiveness, those assertiveness skills to correct people when they use your, the wrong name that you don't like and for you to be able to say to them, I'm not comfortable with that, please use the, this name or this preferred pronoun. Yeah. That's part of the, some of the things that we work on with clients who are transitioning, socially transitioning. So if a therapist is straight and a gay couple comes to him or her, should the fact that the therapist is straight make him feel like he's inappropriate in any way, is it necessary to refer around? Should he ask that of the clients? I don't think, I think the person is asked themselves about their competence around that area. If they have some awareness of this population, I think that's key. Because there are unique issues facing this population. So if they have some general knowledge about this and they're able to be open and non-judgmental, I think it's extremely appropriate. You know, but I do think there has to be some kind of awareness of what it means to be identified as LGBT, et cetera. I don't think it's just like, let me just go- Because there are special issues around that. Exactly. So I think that's important. And then of course, conveying the respect. And if the client is okay with it, I think it's perfectly fine. I think sometimes what happens though, clients feel like they're having to educate their therapist about what it's like to be gay or lesbian or face those issues. And sometimes clients have reported that that's not comfortable for them. Like, I shouldn't have to educate you on HRT or what it means to be in a same sex relationship. So if that's an issue for the client, then I think that's important to address, but other clients don't have a problem with that. And it should be. I remember the first time I was on the client's side of the couch and I was seeing a therapist. I had a whole bunch of, I had like this checklist. I had questions, you know, because I wanted to see if this is a good fit. Yeah. Right? And so like, I'm not a religious person. So I said something like, you know, if you give me anything that feels kind of woo-woo to me, you know, whether it's a religious thing, a spiritual thing, you know, that I don't know if we can go on. If that's a big part of your belief system, you know, if you're going to tell me I need to pray or I need to believe in this guru or anybody, you know, I needed to get, you know, I needed to know a little bit of her beliefs because I thought it could influence the way she looks at me. Yeah, how she kind of, yeah, how she conceptualizes what you're talking about. Right. Yeah. Yeah. So maybe as a minority couple, and in talking about minority, I mean, even if it's a black couple or person, a singular person or Hispanic, whatever, that might be a legitimate question to just put it out there on the table and say, hey, look, obviously I'm a person of color. Right. What are your feelings about that? To ask the therapist? Yeah, I mean, definitely. I think it depends on the client. I haven't had much. I lived in Minnesota and it's predominantly Caucasian. Yeah. Nobody, I mean, I did look different, but nobody harassed me. Yeah, most clients don't, but I think there's a certain amount of intimidation. Going to an expert, a doctor, right? So I always tell as a therapist, I always say, look, you know, my biggest fault as a therapist is I like to talk about myself. And I'm a completely open book. So here's your chance. Anything you want to know about me? What I believe in? Do I have kids? Am I married? Where I'm from? You open it up for them. Ask me. Yeah, I do, because they won't most of the time. But it could be this thing that's always there, you know, so later on down the road, if I say something that upsets them, they'll go, oh, that's because he's from New York. I see. I told you, honey. You see? I see, I see. Or that's because he's a guy. Or that's because he's straight. Or because he's gay or whatever. I see. See, I don't usually open it up for that type of discussion. I usually present my credentials first that this is a training I've had, and I've worked with this population, and you could feel comfortable being here with me because I am aware of issues that you face. That's kind of how I present it. And then as a client, I might say, yeah, but you, you know. Maybe, yeah. You're really pretty. How does that influence it? Yeah, maybe. And then I'd have to assess that, like, well, how is this going to work here? But that's something to think about. I'd have to see whether I want to add that into my, you know. You see, but that's great that you're totally open. You're not dismissing it. You're saying, yeah, I've got to think about that. And on that note, we have to go to a break. Don't go away. Don't touch your mouse. We'll be right back with Dr. Janet Brito. I'm Tim Appachaw, host for Moving Hawaii Forward, a show dedicated to transportation issues and traffic. We identify those areas where we do have problems in the state, but also the show is dedicated to trying to find solutions, not just detail our problems. So join me every other Tuesday on Moving Hawaii Forward. I'm Tim Appachella. Thank you. You can be the greatest. You can be the best. You can be the king, conveyin' all your chest. You can be the world. You can be the war. You could talk to God, don't bangin' on his door. I am still Stephen Phillip Katz. I'm still a licensed and marriage therapist, and I am still with Dr. Janet Brito, a clinical psychologist and certified sex therapist. So what else is the same or different when dealing with a minority population like this? Same or different. Same, everybody is struggling in one way or the other, whether it's with their relationship or with their self-esteem or their body image or heavy motivation or trouble relaxing. People are dealing with similar issues. However, I think this population has experiences significant amounts of discrimination and violence and stigma, and that impacts the, that increases the stress that they're feeling. Right, just one more thing. Exactly, because of that intersectionality. So it's like you're a woman who's gay and ethnic minority. It's like, oh, and you don't have a job and you don't have enough income. But it all kind of goes together. So everything needs to be addressed. I don't believe it can be separated. I think when you're working this population, you're looking at the whole person. You're asking about those kind of those isms, because there is that, you know, either sexism or classism or there's a bias on gender. You should be male or female. You can't be on the, you know, on the spectrum. So those issues really kind of come together. So the person is dealing with multiple things at the same time, and that causes higher levels of stress. Speaking of stress, just a question makes, gives me stress. Do you think the current political climate has an influence? Definitely. I think that it's unsafe right now. I believe that it's causing a lot of, I feel stressed about it, and I have heard clients express fear around this issue and being able to come out or be themselves or receive healthcare, you know. Oh, right. Oh, I was just in Washington for the National Associate in Mental Illness Convention. And they don't like to take a partisan view, but the fact is that the current proposed Senate healthcare bill, the first thing that gets slashed is mental health. Right. Right, so that's troubling. Yeah. So it's an issue that's present. I know in Hawaii, at least with trans care, it seems to be like they're friendly toward that. So if somebody wants to have a medical intervention, let's say, and undergo hormone replacement therapy. Insurance covers. Yeah, insurance. As far as I know, commercial insurance covers that. And also gender confirming surgeries are covered by the insurance. When you say commercial, as opposed to like quest? Yeah. You're not sure about quest? I'm not sure about that. I know in Minnesota, there was a, when I left, they were working toward that and it did pass, so I don't know here that maybe I think it is, I'm not sure. So, but you do need some letters. So if somebody wants to have, let's say, mastectomy, they will need some letters from their providers to affirm that they have gender dysphoria and that. Providers meaning psychologists. Yes. Medical doctor or psychologist to provide this letter that they, whatever the procedure they need is medically necessary. So there's still some hoop jumping that they need that this population needs to go through. It's not something really easy. And so I think that sometimes that's difficult for them to deal with because they're having to go to providers to get these letters to say that they need it. So I, I mean, what's the proof if you feel like you need it? Yeah. And I explained that I'm not trying to be a gatekeeper. I'm just, you know, I'm supporting you with what you need from the insurance and yeah. That's a tough position to be in. Yeah. Yeah. So. And there must be people that, I mean, as you go through the process, if you're going through a transgender process, right? With surgery. I mean, similar to like, I know that if you want to get bariatric surgery, right, to lose weight, one of the requirements is that you seek therapy beforehand. Right. And it seems like, whether it's a requirement or not, a person would be wise to seek therapy because there's a lot of consequences, psychological consequences. Yeah. I would assume anybody can use help navigating that. Yeah. For a person who wants to undergo a medical intervention, I use WPATH criteria, which is the World Professional of Transgender Health. Uh-huh. So they have, they have four criteria. And one of them is you must be over 18, you must be half gender dysphoria, be diagnosed with gender dysphoria. You must have, be able to have informed consent. And the last one is where I fit in is if there's any mental health issues or substance abuse issues that need some stabilization, it's a point that you address that before you undergo this medical intervention. And so I strongly recommend that. It's not required that people be in therapy, but I strongly recommend that they be with a therapist, at least before and during the transition because of the, it means another, if you're going through HRT, it's another puberty. So it's like a very, it could be emotionally challenging. What puberty is hard. So I'm always saying it's really important to have some support. And most people are like, yeah, I'm totally in agreement with this because it's a big change. See now, that's an area that if somebody came to me with, I would probably refer out, because I don't feel I have the experience or knowledge to do that, right? So I would call you. Thank you. Yeah, I really enjoy working with this population. And I think I've had to learn more of the medical terms and the terminology and just ask questions. And I think that people have been kind to me along the way because it wasn't something that I had known all along. So I have way more exposure to it and experience. And it's, I think it's very useful. So besides being a clinical psychologist, you're also a certified sex therapist. So is that, do you need any kind of special training to deal with the minority population as far as the sex therapy goes? There isn't any specific certifications, although there are some new ones that are coming out, but WPATH does have coursework if you want to become like a gender specialist or call yourself a gender affirmative provider or some sort. And my training came from University of Minnesota where I worked in the trans health program for the last two years. So that's kind of where I got the bulk of my training. I think it's, it is important to get some training. I don't think because there's all these medical procedures or how does it... Well, I wasn't even thinking only in terms of trans but just in terms of lesbian or gay. Yeah, there are some new trainings that are available if you want to get, learn more about how to be a more affirmative provider. So you, there's new certificates that are being offered. I think it's useful that's something that you really want to specialize in. It's a good niche to go into. Cause it's, we're not getting that education in graduate school. That's for sure. So it needs to come from somewhere, you know and sex therapy is not happening in graduate school either. I didn't have any classes. Yeah, so I think it's important if you, that's an interest for you to pursue advanced training. Yeah. And it would be totally legitimate for a client to ask if that's a concern of a therapist. Absolutely. Yeah, because it's very, it can get very complicated. So I know that for my certification for sex therapy it was pretty rigorous and intense as far as like the coursework I had to take. This is besides my doctorate classes and then a practicum and then supervision. So it was very involved. And I was pretty committed to that. So yeah. Yeah, it's a shame that it's not part of the regular counseling programs or psychology programs. And medical schools as well. It should just be more available and people should be trained to ask these types of questions because people want to be asked these types of questions. And I mean, whether it's present or not sex is a big part of people's lives. It's a class of lifespan, you know. It's a class of lifespan. So and it's not something like you can just get rid of. Right, and to me it's totally negligent as a therapist not to ask a client about that. Exactly. Whether they're in a relationship or not in a relationship, what are you doing about that? Yeah, I think it's very important to ask those questions and to complete some kind of sex history with your patient and ask about that piece, whether it's about their sexual functioning or about their sexual identity or their gender or how they do relationships. Yeah. I think it's essential and very important to do. Yeah, I mean, it's so connected to your emotional life. Yeah. Yeah. So I've heard many patients say nobody, I haven't been able to talk to anyone about this, you know, because they want to talk to their physician but they're not comfortable or they feel embarrassed or they don't know what questions to ask or what to say. So I think it's important to ask your, what are you working with about their sexual health? Yeah, I mean, so I'm just thinking of a couple that I saw yesterday that they live 5,000 miles apart for many months at a time. How do they deal with that as far as sex goes? Good question. Yeah, yeah. Yeah. Like, you know, then there's all issues about pornography, are they okay with that? They're not okay with that. Some people think it's a sin. Some people think it's not. And it's just normal and whatever, right? So I would ask them, what is their relationship agreement? You know, do they have an exclusive right monogamous relationship agreement and is porn part of the, part of the sex. Right, where does that fit? Right, is it a boundary or not a boundary or what happens if we're away from each other? You know, really having a in-depth conversation about what those limits are. Having so many couples like have a hard time talking about it with each other. Absolutely, it's a taboo, so. Taboo, right. The need to have it. If you want to write that book, totem and taboo. Right. Yeah, it still exists. I mean, we think we're enlightened, but it's so hard for people to talk about sex. Yeah, it's difficult. So at least we're having that conversation to kind of lessen that shame. You see, everybody, it's okay. You can talk about telling them, it's okay. It's okay to talk about sex. All right, so we're just about out of time. Is there anything vital that I missed that just needs to be said? No, thank you, thanks for having me again. I'm really happy to be here with you talking about this. Thank you, Dr. Brita. Thank you. Thanks for joining us again for Shrink Wrap, Hawaii. We'll be back in a couple of Tuesdays. See you then, aloha.