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LGBT Cultural Competency Training

crmallon
May 01, 2019
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LGBT Cultural Competency Training

LGBT Cultural Competency for health care professionals.

crmallon

May 01, 2019
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  1. Objectives Define LGBT-related terms and concepts Describe physical and mental

    health disparities in lesbian, gay, bisexual, and transgender (LGBT) populations Identify one theory that explains some of the health disparities seen in LGBT populations. Describe the application of LGBT cultural competency concepts to caring for LGBT patients and families. By the end of this course, learners will be able to: Identify policies and laws that protect the rights of LGBT individuals.
  2. What Is LGBT Cultural Competency? LGBT cultural competency means having

    a sensitivity to and understanding of the issues that differently or uniquely affect members of sexual and gender minority communities in order to provide appropriate care for these diverse patients. (Boroughs, Andres Bedoya, O’Cleirigh, & Safren, 2015). Most health care professionals receive little, if any, LGBT-specific education or training. Bias against LGBT individuals is common, even among health professionals. Microaggressions and discrimination from healthcare professionals negatively affects LGBT access to care. Resulting care avoidance and treatment delays are frequent contributing factors to poor outcomes for this population. (National LGBT Health Education Center, n.d.) Why Does It Matter?
  3. 3.5 8.2 11 0.3 0 2 4 6 8 10

    12 Adults Who Identify as Lesbian, Gay, or Bisexual Adults Who Report Same Sex Sexual Contact Adults Who Report at Least Some Same Sex Attraction Adults Who Identify as Transgender (National LGBT Health Education Center, n.d.) How Many Americans Experience Same-Sex Attraction? Percent of Adults 3.5% of U.S. adults self-identify as lesbian, gay, or bisexual and only 0.3% identify as transgender. The prevalence of those who self-report same-sex sexual contact or same-sex attraction is significantly higher. This suggests potentially greater numbers of patients with undisclosed risk factors due to the impact of stigma.
  4. Terms to Know Gay • May refer to a man

    or woman who is exclusively attracted to and/or physically intimate with persons of the same sex. Synonym: homosexual. Lesbian • A woman who is exclusively attracted and/or physically intimate with other women. Note: Both of these terms may be used by cis-gender or trans men or women if they are gay or lesbian. Bisexual Man Bisexual Woman
  5. More Terms to Know Bisexual • Someone who is attracted

    to and/or physically intimate with both men and women. Pansexual • Someone who can be attracted to and/or physically intimate with people of any biological sex, gender, and gender identity. Asexual • Someone who has no desire for physical intimacy with anyone, but may or may not experience romantic attraction/affection.
  6. Sexual Orientation and Gender Identity Sexual orientation Physical and emotion

    attraction to others Self identification as gay, lesbian, bisexual, or something else One’s sexual behavior with the gender(s) one is attracted to Gender Identity Internal sense of being a man/male, a woman/female, both, neither, or another gender. A person’s awareness or acceptance of his or her sexual orientation (identity, attraction, and behavior) can change over time and may be influenced by the cultural environment. (National LGBT Health Education Center, n.d.)
  7. Gender Identity: Terminology Cisgender: Cisgender is a term that describes

    people who are not transgender. Transgender man: Someone who was assigned female at birth but whose gender identity is male. Transgender woman: A person who was assigned male at birth but whose gender identity is female is a transgender woman Gender-queer or gender-fluid: People who have a non-binary gender identity. They do not identify as either male or female, or they may see themselves as a combination of the two, or something else. Image: Award-winning actress Jamie Clayton is a transsexual woman, 2017; National LGBT Health Education Center, n.d.)
  8. Gender Affirmation Gender affirmation or transition refers to the process

    by which individuals are affirmed in their gender identity. Changes that transgender people may choose to make to affirm their gender identity include: • Social changes: more masculine or feminine clothing, pronouns, new name • Medical: cross-sex hormones, surgery • Legal: changing their name and sex on birth certificate, driver’s license, etc. Gender expression describes how one expresses their gender socially - through mannerisms, speech patterns, dress, hairstyle, etc. One’s gender expression may be more or less masculine than a person’s stated gender. (National LGBT Health Education Center, n.d.)
  9. LGBT Health Disparities (Gonzales & Henning-Smith, 2017; Razzano et al.,

    2014; Swinson, Berkman, Brown, Gaynes, & Palmieri, 2016; Ye, Shim, & Rust, 2012). All LGBT individuals experience significantly higher rates of mental health conditions and many preventable chronic health problems compared to heterosexual and cis-gender adults.
  10. LGBT Health Disparities 20.5 30.8 39 30 0 5 10

    15 20 25 30 35 40 45 Smoking Prevalence Smoking Prevalence, % Heterosexual Adults Lesbian and Gay Adults Bisexual Adults Transgender Aduls (Gonzales & Henning-Smith, 2017; Hottes, Bogaert, Rhodes, Brennan & Gesink, 2016; Keuroghlian, n.d.) After controlling for sociodemographic characteristics, individuals who identify as LGBT were found to have: • 2 x higher odds of COPD • 1.3 x higher odds of cancer • 1.3 x higher odds of obesity • 3-4 x higher odds of alcohol, marijuana, or cocaine use • 8 x higher odds of any drug use
  11. Cancer Lesbian and Bisexual Women Rates of cervical cancer are

    the same for lesbians and bisexual women as for heterosexual women, however, lesbians have significantly lower cervical cancer screening rates. Also, lesbian and bisexual women over 40 are significantly less likely to get a mammogram than heterosexual women. Educational programs should emphasize the need for women who have sex with women to be screened according to usual guidelines Transgender Men The majority of transgender men do not undergo complete sex reassignment surgery. This means they still have a cervix. Cancers of female reproductive organs are still possible in these individuals. Transgender men with a cervix should follow the same screening guidelines as females. Pap tests can be difficult for transgender men for a number of reasons. Sensitivity to these unique barriers is important while still emphasizing the importance of regular screening. (National LGBT Health Education Center, n.d.) LGBT Health Disparities
  12. HIV/AIDS (National LGBT Health Education Center, n.d.) HIV incidence is

    highest among black men who have sex with men (MSM). This higher prevalence of HIV infection leads to a higher possibility of transmission, even with similar frequency of risk behaviors as other populations. The CDC recommends annual HIV testing for symptomatic LGBT individuals, but more frequent testing is recommended for those with additional risk factors. (Baral, 2013; CDC, 2018) LGBT Health Disparities
  13. 5 3 2.91 2.41 1.93 3.15 Gay and bisexual men,

    odds of panic disorder Lebian and bisexual women, odds of generalized anxiety disorder Gay men, odds of depression Bisexual men, odds of depression Lesbian women, odds of depression Bisexual women, odds of depression Increased Odds Ratio LGBT Mental Health Disparities (Hottes, Bogaert, Rhodes, Brennan, & Gesink, 2016; Keuroghlian, n.d.) Compared to heterosexual men and women, LGBT individuals have higher odds of the following: • The higher the number, the higher the odds of and stronger the association with the outcome. • Odds ratio (OR) = 1 means LGBT status did not affect the odds of the outcome of interest (anxiety or depression). • OR > 1 means LGBT status was associated with higher odds of the outcome (anxiety or depression).
  14. Factors Contributing to LGBT Health Disparities • More frequent experiences

    of childhood abuse, bullying, and sexual victimization compared with heterosexual and cis- gender individuals. • Experiences of trauma and abuse often lead to symptoms of PTSD symptoms in LGBT populations, which are highly correlated with substance use disorder. • Isolation due to fewer social supports and inclusive services. • Experiences of real or perceived prejudice from healthcare providers erodes patient trust, leading to • withholding personal information • omitted screenings • decreased treatment adherence • avoidance of healthcare altogether (Bidell & Whitman, 2013; Burke et al., 2015; McCabe & Rubinson, 2008; Radix & Maingi, 2018).
  15. Institutionalized stigma and discrimination reinforces bias and contributes to major

    life stress. Among a sample of 34,653 LGBT individuals living in U.S. states that banned gay marriage from 2002-2005: • mood disorders increased 30% • generalized anxiety disorder increased 200% Institutionalized Stigma and Discrimination in Public Policy Permits same-sex marriage State performs civil unions Domestic partnerships Recognizes out-of-state marriages Constitutional ban on gay marriage Image: Google Gay Marriage Map, retrieved 12/19/2019
  16. Minority Stress Theory This theory explains how: • external stigma-related

    stressors (discrimination, victimization) and • internal stigma-related stressors (internalized homophobia or transphobia, expecting rejection, feeling the need to conceal one’s identity) can lead to disruptions in coping, emotional regulation, and interpersonal functioning. Minority Stress Theory explains why individuals who identify as LGBT are at significantly increased risk of mental illness. (Keuroghlian, n.d.; Medley et al., 2017; White Hughto, Reisner & Pachankis, 2015) 37.4 13.1 17.1 3.6 Any Mental Illness in the Past Year, Age 18+ Serious Mental Illness in the Past Year, Age 18+ NSDUH - Past Year Mental Illness by Sexual Minority Status, Percent of the Population, 2014-2015 Lesbian, Gay, or Bisexual Heterosexual
  17. How Can You Help? Applying LGBT Cultural Competence Create a

    welcoming and inclusive environment • Use intake forms that reflect the full range of gender identities, sexual orientations, and family arrangements • Post your organization’s nondiscrimination policy in a visible location • Display inclusive posters and reading materials in patient waiting rooms and care areas Image: “Do Ask, Do Tell: Talking to your provider about being LGBT.” Retrieved 19 Dec. 2018
  18. How Can You Help? Applying LGBT Cultural Competence Use inclusive

    and neutral language • Instead of: “Do you have a wife/husband or boy/girlfriend?” • Ask: “Do you have a partner?” or “Are you in a relationship?” or “What do you call your partner?” • Listen to the words people use to describe their own identities and partners--use the same terms, if comfortable. Image: LGBT couple. Creative commons, pixabay.com. Retrieved 12/19/2018 (National LGBT Health Education Center, n.d.)
  19. How Can You Help? Applying LGBT Cultural Competence Avoid making

    assumptions about gender identity or sexual orientation • Don’t assume you know a person’s gender identity or sexual orientation based on how they look or sound • Don’t assume you know how a person wants to describe themselves or their partners • Don’t assume all of your patients are heterosexual or cisgender (not transgender) • Use gender-neutral terms before you know which to use. • For example, avoid using pronouns (e.g. “he” and “she”) or words like “Sir,” “Ma’am,” “Mrs.,” “Miss.,” or “Mr.” when possible. • Instead of: “How may I help you, Sir?” • Say: “How may I help you?” • Instead of: “She is here for her appointment.” • Say: “The patient is here in the waiting room.” • Instead of: “The men’s restroom is over there.” • Say: “The restrooms are down that hall.” And remember: Same-sex partners should always be acknowledged as family members, not as “friends.” (National LGBT Health Education Center, n.d.)
  20. How Can You Help? Applying LGBT Cultural Competence Always use

    patients’ preferred names and pronouns • Occasionally, people may use words or pronouns that are unfamiliar. Gender neutral pronouns such as “they" or even “ze" are sometimes used instead of “he” or “she.” If you are unsure about a patient’s preferred name or pronouns, you should ask: • “I would like be respectful—what name and pronouns would you like me to use?” • If you accidentally use the wrong term or pronoun: • “I’m sorry. I didn’t mean to be disrespectful.” (National LGBT Health Education Center, n.d.) Traditional Masculine He laughed I called him The book is his His book is red He likes himself Traditional Feminine She laughed I called her The book is hers Her book is red She likes herself Gender Neutral (singular They) They laughed I called them The book is theirs Their book is red Their like themself Gender Neutral (singular Ze) Ze laughed (pronounced “zee”) I called hir (pronounced “here”) The book is hir Hir book is red Ze likes hirself
  21. How Can You Help? Applying LGBT Cultural Competence Transgender Affirmation

    Transgender people often change their name to affirm their gender identity. If a patient’s name doesn’t match insurance or medical records, ask: • “Could your chart/insurance be under a different name?” • “What is the name on your insurance?” To avoid confusion, add this information to registration paperwork and in medical records. Don’t be afraid to politely correct your colleagues if they make a mistake or make insensitive comments. • “My understanding is that this patient prefers to be called ‘Jane’, not ‘John’.” • “Those kinds of comments are hurtful to others and do not create a respectful work environment.” (National LGBT Health Education Center, n.d.)
  22. How Can You Help? Applying LGBT Cultural Competence Understanding the

    effect of bias among healthcare professionals Implicit biases are unconscious stereotypes and assumptions about people that arise from associations outside your conscious awareness. Biases can lead you to think or feel negatively about a person based on irrelevant characteristics such as race, gender, of LGBT status. Research shows that healthcare professionals demonstrate the same levels of implicit bias as the general population, and that these biases do influence diagnosis, care, and treatment decisions. (Burke et al., 2015; FitzGerald & Hurst, 2017; National LGBT Health Education Center, n.d.; Sabin, Riskind, & Nosek, 2015)
  23. How Can You Help? Applying LGBT Cultural Competence In a

    sample of 4,441 U.S. medical students across the country, • 81% exhibited implicit (unconscious) bias against LGBT individuals and • 46% exhibited explicit (conscious) bias. In another study of 18,983 health care professionals, male and female RNs exhibited the highest levels of bias against LGBT individuals. This bias is common, but unacceptable in the healing professions. (Burke et al., 2015; FitzGerald & Hurst, 2017; National LGBT Health Education Center, n.d.; Sabin, Riskind, & Nosek, 2015) Explicit Bias • Expressed Directly • Aware of bias (conscious) • Example: Refusing to use the preferred name and pronouns of transgender patients. Implicit Bias • Expressed Indirectly • Unaware of bias (unconscious) • Example: Unconsciously making LGBT patients wait longer in the waiting room than other patients.
  24. How Can You Help? Applying LGBT Cultural Competence Understanding the

    effect of bias among healthcare professionals One result of implicit bias are microaggressions. These are brief, everyday comments or interactions that insult or demean another person. Microaggressions may be conscious or they may be unintentional. In a study of LGBT individuals with mental illness, frequently reported microaggressions (acts of discrimination) included: • ignoring the sexual identify of LGBT patients • questioning the sexual orientation of lesbian patients • assuming that their mental illnesses were in some way related to their sexual orientation • not allowing mild displays of affection that were accepted for heterosexual patients These contributed to: • increased life stress • care avoidance • decreased provider trust • low treatment adherence • poor health outcomes. (Kidd, et al., 2016; National LGBT Health Education Center, n.d)
  25. How Can You Help? Applying LGBT Cultural Competence Ending LGBT

    invisibility in health care Lesbian, gay, bisexual, and transgender people experience significant health disparities and require preventive services and treatment interventions tailored to their unique needs. Yet many health care professionals do not know the sexual orientation or gender identity (SO/GI) of their patients and are too uncomfortable to ask, leading to culturally insensitive remarks, less effective counseling, missed screenings, and other missteps. SO/GI data collection for all patients is recommended by the Institute of Medicine and the Joint Commission. (National LGBT Health Education Center, n.d)
  26. How Can You Help? Applying LGBT Cultural Competence Ending LGBT

    invisibility in health care How to Ask Sexual Orientation/Gender Identity (SO/GI) Questions: • Explain that the information is confidential. • Ask alongside demographic questions on intake paperwork. • Include a question about preferred name and gender pronouns on registration forms. • Ask open-ended questions during patient interviews: “Do you have any concerns or questions about your sexual orientation, sexual desires, or gender identity?” • Explain that you ask these questions of all patients. (National LGBT Health Education Center, n.d)
  27. Where Research and Theory Meets Policy and Regulation LGBT Policies

    and Laws Luckily, there are now a number of laws on the books that protects the rights of lesbian, gay, bisexual, and transgender individuals. In addition, antidiscrimination policies at the federal and local levels seek to protect the health and well-being of this population.
  28. Where Research and Theory Meets Policy and Regulation LGBT Policies

    and Laws Timeline of LGBT Legal Protections in New Hampshire • Discrimination based on sexual orientation prohibited by NH state law in 1998 • Same-sex marriage legalized in NH on January 1, 2010 • Discrimination based on gender identity and gender expression prohibited in public employment, in access to state programs, and in state contracting by executing order by Gov. Hassan in 2016. • Discrimination based on both sexual orientation and gender identity prohibited in public accommodations, housing and/or any private or public employment by state law in July 2018. • A ban on conversion therapy for minors will become effective in the state in January 2019.
  29. Enacted in 2010, Section 1557 is the nondiscrimination provision of

    the Affordable Care Act (ACA) that prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities. This law applied existing protections from discrimination on the basis of sex to include gender identity and sex stereotyping. This offered concrete protections to transgender and gender nonconforming individuals, as well as many lesbian, gay and bisexual people who experience discrimination based on sex stereotyping. Section 1557 applies to individuals participating in: • Any health program or activity funded by HHS • Any health program or activity that HHS itself administers • Health Insurance Marketplaces plans Section 1557 of the Patient Protection and Affordable Care Act
  30. There will be no discrimination in providing services, access to,

    or employment in any programs or activities… because of age, sex, race, creed, color, marital status, familial status, physical or mental disability, religion, national origin, sexual orientation or political affiliation or belief. Riverbend CMHC complies with Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Employment decisions are made without regard to race, color, religion, national origin, veteran’s status, sex, age, physical or mental disability. Concord Hospital complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Concord Hospital does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. NH Nondiscrimination Policies NH-DHHS Riverbend Concord Hospital DHMC Dartmouth-Hitchcock complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Dartmouth- Hitchcock does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
  31. LGBT Policies and Position Statements American Nurses Association (ANA) condemns

    discrimination based on sexual orientation, gender identity, and/or expression in health care. Nurses must deliver culturally congruent, safe care and advocate for LGBT populations. • Provision 1 of the Code of Ethics for Nurses with Interpretive Statements asserts: “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (p. 1).
  32. LGBT Policies and Position Statements “The American Medical Association (AMA)

    reaffirms its long-standing policy that there is no basis for the denial to any human being of equal rights, privileges, and responsibilities commensurate with his or her individual capabilities and ethical character because of an individual’s sex, sexual orientation, gender, gender identity, or transgender status.”
  33. LGBT Policies and Position Statements American Psychological Association has numerous

    statements on the topic, including statements such as: • APA opposes discrimination against people on the basis of sexual orientation or actual or perceived gender identity and expression and will take a leadership role in actively opposing the adoption of discriminatory legislation and initiatives • American Psychological Association opposes portrayals of lesbian, gay, and bisexual youth and adults as mentally ill due to their sexual orientation and supports the dissemination of accurate information about sexual orientation and mental health in order to counteract bias that is based in ignorance about sexual orientation.
  34. LGBT Policies and Position Statements National Association of Social Workers

    The NASW Code of Ethics which calls upon social workers to abide by the core value of social justice, dignity and worth of the person, importance of human relationships, integrity and competence. “NASW recognizes that there is considerable diversity in gender expression and identity among our population and believes that people of diverse gender… should be afforded the same respect and rights as any other person.” National Association of Social Workers, Social Workers Speaks Abstracts: Transgender and Gender Identity Issues (2012).
  35. The Importance of LGBT Cultural Competence Education in Healthcare Research

    demonstrates that LGBT health disparities are linked to the effects of culturally incompetent care and to healthcare professionals’ implicit bias, prejudice, and discomfort working with this population. These issues erode patient trust and lead to treatment avoidance and decreased adherence, omitted screenings, and downstream health disparities. In response to these findings, the Institutes of Medicine, (now the National Academies), has recommended that all healthcare professionals participate in LGBT Cultural Competency training annually. (Bidell & Whitman, 2013; Burke et al., 2015; McCabe & Rubinson, 2008; Radix & Maingi, 2018)
  36. In Review We defined terminology related to sexual orientation and

    gender identity and expression. We discussed health disparities affecting the LGBT population, including increased rates of smoking, substance use, cancer, HIV, and mental health disorders. We discussed contributing factors to these health disparities, including Minority Stress Theory. We discussed the application of LGBT cultural competency concepts to patient care, including creating a welcoming environment, inclusive communication tips, collecting SO/GI data, and recognizing the role of bias. Finally, we explored various laws and policies related to the care of LGBT patients.
  37. References Bidell, M. P., & Whitman, J. S. (2013). A

    review of lesbian, gay, and bisexual affirmative counseling assessments. Counseling Outcome Research and Evaluation, 4(2), 112–126. https://doi.org/10.1177/2150137813496423 Boroughs, M. S., Andres Bedoya, C., O’Cleirigh, C., & Safren, S. A. (2015). Toward Defining, Measuring, and Evaluating LGBT Cultural Competence for Psychologists. Clinical Psychology : A Publication of the Division of Clinical Psychology of the American Psychological Association, 22(2), 151–171. https://doi.org/10.1111/cpsp.12098 Burke, S. E., Dovidio, J. F., Przedworski, J. M., Hardeman, R. R., Perry, S. P., Phelan, S. M., … van Ryn, M. (2015). Do contact and empathy mitigate bias against gay and lesbian people among heterosexual first-year medical students? A report from the medical student CHANGE study. Academic Medicine, 90(5), 645–651. https://doi.org/10.1097/ACM.0000000000000661 CDC. (2018). HIV Testing in Clinical Settings. Retrieved December 17, 2018, from https://www.cdc.gov/hiv/testing/clinical/index.html FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics, 18(1), 19. https://doi.org/10.1186/s12910-017-0179-8 Gonzales, G., & Henning-Smith, C. (2017). Health Disparities by Sexual Orientation: Results and Implications from the Behavioral Risk Factor Surveillance System. Journal of Community Health, 42(6), 1163–1172. https://doi.org/10.1007/s10900- 017-0366-z Google. (2018). Gay Marriage Map. Retrieved December 19, 2018, from