As a caseworker, start your relationship with Ash by thanking them for being so open and honest about their experience. Ask Ash what pronouns they use and ask them their preference for how to use both pronouns—pick one and stick to it, pick one at different times, or use a mix. Ash says they want you to use both pronouns equally with them, but with medical providers, they’d prefer you to use just he/him pronouns. Confirm for Ash that this is a safe space for them to talk, but be transparent about what information can and cannot remain confidential. Acknowledge that the misalignment between Ash’s gender identity and their placement in the juvenile facility might be causing them a lot of discomfort or trauma and affirm that your priority is Ash’s safety. Ask whether they feel threatened by transphobic staff members or other youth. If they do, explore specific ways to ensure Ash’s safety in your facility, including moving Ash to a different unit or having conversations with other staff about inappropriate actions. However, be very careful to not put Ash at further risk: Moving them to solitary confinement can be damaging, and staff members may retaliate. Think intentionally and consciously about the moves you make to protect Ash.
Recognize that the idea of being pregnant may be causing gender dysphoria and other anxieties for Ash. Ask Ash how he would like to talk about the potential pregnancy. Are there non-gendered words or phrases he would like to use? Are there any words or phrases (e.g., vagina, period) he would like to avoid? Ash might also prefer to avoid other terms or phrases due to additional identities he holds; make space for him to share his boundaries. Listen to his preferences without judgement and do your best to use these phrases. If you forget to use the correct phrase, apologize, and move forward.
Let Ash know that it is standard procedure to receive a comprehensive health exam, including gynecological exams, within the first seven days of arriving at a juvenile facility. Find out what your facility’s pregnancy protocols are, and to what degree Medicaid exclusion policies might impact the type of care that is provided at the facility; explain these policies to the best of your ability. Explain some medical care options (e.g., pregnancy tests, prenatal care, abortion services when and where legal, and adoption counseling), what services are available on-site, and what services are only available if Ash is transferred to a medical facility. Also be transparent about where your knowledge is limited. Ask what medical care might interest Ash and note that a health care provider will need to describe options in more detail.
Medical procedures might be uncomfortable or traumatic for Ash as a transmasculine person—especially if he’s experienced any sexual violence or sex trafficking in the past—so be transparent about what the appointment with the health care provider might involve. Invite him to think about what procedures he might like to avoid, ways in which he would not like his body touched, and the pace at which he needs procedures to occur. Help him brainstorm ways to describe these boundaries and what questions he might want to ask so they have a clear sense of their medical options. Affirm his right to have agency over their health care. Talk through how the appointment might make Ash feel. Work with him to identify steps he can take to regulate his emotions during and after the appointment.
Next steps and ongoing care
Write out a care plan and ask Ash to identify some care goals for himself. With Ash’s assent, let them know you can pull together a care team; depending on the number of staff you have available, ask whether Ash prefers specific staff, such as those who have identities that align with his (such as race or religion). Ensure that these team members will use he/him pronouns as Ash has requested, respect Ash’s boundaries around medical procedures, and allow Ash to guide the care he receives.
Check in with Ash after the appointment to debrief, asking what went well and what could be changed for the next time. Reassure them that you’ll be a resource for as long as they’re in your facility. However, if they decide to go forward with the pregnancy, they likely won’t be in the detention facility throughout the entire pregnancy. Help them think through a plan for when he leave the facility and, if possible, create a list of recommended providers. Note that, depending on the state, Ash might need to reapply for Medicaid upon leaving; provide them with resources to support this application, or a referral to another case manager outside of the facility who can support. If Ash isn’t pregnant or chooses to not continue the pregnancy, you may want to discuss possible contraceptive methods that won’t cause or exacerbate gender dysphoria. Set a regular meeting time to continue following up with Ash for as long as they remain your client.