Your LGBTQ Patient Providing Culturally Competent Care Timothy D. Rodden, M.Div., MA, BCC, FACHE Director of Pastoral Services, Christiana Care Health System Co-Chair, Delaware LGBTQ Health Equity Task Force, United Way of Delaware 1
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Objectives/Topics for Discussion Terminology LGBTQ Health Equity/Disparities A few stories Creating a welcoming environment Healthcare Equality Index LGBTQ Cultural Competency, additional resources 3
Terminology Lesbian A woman who is physically and romantically, as well as emotionally, attracted to other women. Gay A man who is physically and romantically, as well as emotionally, attracted to other men. Sometimes, this term is used generally to describe a person (male or female) who is attracted to members of the same sex. Bisexual A person who is physically and romantically, as well as emotionally, attracted to both men and women. Transgender An umbrella term used for people whose gender identity is different from their sex assigned at birth. Terminology (con t) Queer A term that has historically been used in a derogatory way, queer has been reclaimed as an umbrella term by some members of the LGBTQ community. Sex A categorization of a person as male or female. At birth, infants are assigned a sex male or female based on bodily characteristics such as chromosomes, hormones, internal reproductive organs and genitalia. Gender Identity A person s internal sense or identity of being male or female. Gender Expression The external expression of a person s gender identity. This may be expressed through culturally defined understanding of masculine or feminine appearance (haircut and clothing, for example) or behavior. 4
LGBT Experience Lesbian, Gay and Bisexual a. 75% report being verbally abused b. 32% report being target of physical violence c. 34% rejected by family Transgender a. 57% report being rejected by family b. 26% report being fired c. 19% report being refused housing Kaiser Family Foundation, National Center for Transgender Equality (2011) 5
Delayed/Avoided Health Care % adults delaying/not seeking health care Heterosexual 17% LGB 29% % adults receiving emergency health care Heterosexual 18% LGB 24% California Health Interview Survey 2007 Disparities Study, 2010 When Health Care Isn t Caring 6
When Health Care Isn't Caring 2010 Lambda Legal I ll be refused medical service because I m 60 50 40 30 20 10 0 51.9 20 9.1 LGB Transgender Living w/ HIV When Health Care Isn t Caring 2010 Lambda Legal 7
Medical personnel will treat me differently because I m 80 70 60 50 40 73 30 20 35.5 28.5 10 0 LGB Transgender HIV When Health Care Isn t Caring 2010 Lambda Legal What is different treatment 56% of LGB and 70% of Transgender patients reported at least one of these care experiences: a. Being blamed for health condition b. Refusal to touch or excessive precautions c. Harsh language d. Physical roughness (higher for LGBT racial/ethnic minorities and low-income LGBT people) 8
Continued e. Being pointed at or laughed at f. Hearing biased comments g. Waiting unusually long for a response to a request h. Having rules over enforced i. Experiencing deliberate sloppiness or carelessness j. Being walked out on Transgender patient experience Denied/delayed/avoided and different care particularly common for transgender patients Elongated wait times Confidentiality violations Staff coming by to take a look Unnecessary questions and exams Use of wrong gender/name accidentally or deliberately Mocking comments, expressions of disgust, etc. Denied or questioned bathroom use Room assignments by birth gender, not current one 9
Same sex couples We may be treated differently if there is a public display of affection We may not be able to indicate our couple status at admitting/registration Visitation with our loved one may be denied, challenged or limited even with new CMS/Joint Commission visitation requirements LGBT Elders More isolated and distressed with more disabilities and more chronic diseases They may especially delay care and worry May feel like they have to hide who they are, or go back in the closet to lessen fears and anxieties that they won t be treated right 10
A Story from Christiana Care Dear Health and Aging Team [Healthcare Equality Index], It's not often that I get to witness the impact of your work inaction. However, this past Friday, my partner woke up very sick, and we knew that we needed to get them medical attention immediately. The primary source of their illness--their uterus-- made it extremely anxiety-producing for them to decide if they wanted to go to the hospital. Because they identify as transmasculine / gender-queer, they faced a very real choice of whether they wanted to wait in extreme agony while trying to get in-touch with a trans-friendly GYN or have a potentially dysphoria-inducing experience at the hospital. (continued) Luckily, a quick scan of the HEI showed Christiana Hospital-- about 20 minutes away-- was a leader in LGBT Healthcare Equality. That information helped persuade them to let me take them to the hospital. When we arrived at Christiana, the staff was amazing. The doctor used my partner's preferred name and gender pronouns when addressing them, and even said, "people with uteri" when articulating what was wrong. We couldn'tve asked for a better experience (under the circumstances). I really want to thank you for all of the work you do to ensure people--like my partner--have a more affirming, culturally competent experience in their medical care. 11
Another Story I was admitted to Metropolitan Hospital last year because I had pain in my leg, a growing rash on my upper thigh, and a headache and fever. I had scratched that area when I was driving my garden tractor past a sticker bush. Most of the doctors who saw me suspected it was cellulitis, which was the final diagnosis. About a day after I was admitted I saw a new doctor. She arrived while my partner Don was visiting. She looked at the rash on my upper thigh. While completing her examination she asked who Don was, and I told her he is my partner. Her demeanor immediately changed, she stiffened up and she said, This must be an STD. (continued) Then she proceeded to list all of the STDs she was going to test me for. I told her that all of the previous doctors believed this was a bacterial infection, and I (not being a medical professional) was not aware of any STD that would have these symptoms. She said, No, this is an STD, and left rather abruptly. I understand that she would want to cover all bases, but I was alarmed by her change in demeanor, and concerned that she became fixated on STDs, and was ignoring everything that previous doctors had said before. I thought to myself gay people can get bacterial infections too, let s not miss that because we re dwelling on STDs. Not only did I detect prejudice, but I was concerned I wasn t going to get the proper care. 12
(continued) I think I would have felt better if she would have calmly said something like As a precaution I would like to test you for various STDs to rule them out as a cause of your difficulties. Subsequent doctors confirmed that I had cellulitis. Overall my experience with the staff was very positive. I was pleased that antibiotics got me over the cellulitis, and I went home assured I didn t have any STDs. To Treat Me You Have To Know Who I Am Full Length Version (10:18) 5:04 Minute Excerpt 3:41 Minute Excerpt 13
Challenges and Opportunities Field Guide 14
The Healthcare Equality Index provides a road map for healthcare systems in measuring best practices for LGBT (lesbian, gay, bisexual and transgender) patient and- family centered care and for LGBT workforce inclusion. (published by the Human Rights Campaign Foundation) Healthcare Equality Index HEI CORE FOUR LEADER CRITERIA 15
HEI Core Four Requirements ADDITIONAL BEST PRACTICES LGBT Patient Services & Support Transgender Patient Services & Support Patient Self Identification Medical Decision Making Employee Benefits and Policies Community Engagement jointcommission.org/lgbt 16
SAMPLE RESOURCES LGBT Patient Services & Support Create a Welcoming Environment Prominently post Patient Non- Discrimination Policy or Bill of Rights Waiting rooms and common areas should reflect and be inclusive of LGBT patients and families Forms should have inclusive, genderneutral language and allow for patient self-id Provide access to gender-neutral restrooms 17
Christiana Care Visiting Policy: Key elements Visitors shall not be restricted, limited or denied visitation privileges on the basis of race, color, national origin, religion, sex, gender identity or expression, sexual orientation or disability. Visitors shall have equal visitation rights regardless of their legal relationship to the patient consistent with patient preferences. Support of mutually beneficial partnerships among families is integral to planning the delivery of care and services provided. Staff members shall share Visiting Guidelines with patients and visitors. Definitions: Visiting Policy As used throughout this Policy and Visitation Guidelines, the word family means any individual who plays a significant role in an individual s life such as spouses, domestic partners/civil unions, significant others (of both different and same sex), and other individuals not legally related to the patient as per patient preferences. Family includes a minor patient s parents, regardless of the gender of either parent. 18
Patient Rights and Responsibilities You have the right to say who can visit you during your stay. This can be your spouse, domestic partner (including same-sex partner), other family members, friends or anyone else you want to have come visit. Sometimes for a medical reason we may need to limit visitors for your health and safety or the health and safety of other patients. We will let you know this and why. Patient Rights and Responsibilities You have the right to quality care regardless of your race, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity or expression, source of payment or any other status that is an illegal basis for discrimination. 19
LGBTQ Cultural/Clinical Competence National LGBT Health Education Center Webinars and Video Training Learning Modules National LGBT Cancer Network (Cancer Network) To Treat Me You Have to Know Who I Am Vanessa Goes to the Doctor (Trans Primary Care Experience) Healthcare Equality Index, Human Rights Campaign (HEI) Brene Brown on Empathy Resources and Suggested Readings Glossary of Terms National LGBT Health Education Center: Categories of Modules and Webinars Introduction to LGBT Health Transgender Health LGBTQ Youth LGBT Older Adults LGBT People of Color LGBT Families HIV/STI Treatment and Prevention Behavioral Health Collecting Data on Sexual Orientation and Gender Identity Cancer and LGBT People Organizational Change Other Issues in Primary Care 20
Other Resources The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding (Institute of Medicine, 2011) Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender Individuals in the U.S. (Ranji, et al. Kaiser Family Foundation, January 8, 2014) 10 Tips 21
LGBTQ Cultural/Clinical Competence (Slide 39) National LGBT Health Education Center http://www.lgbthealtheducation.org/ Webinars and Video Training http://www.lgbthealtheducation.org/lgbt-education/webinars/ Learning Modules http://www.lgbthealtheducation.org/lgbt-education/learning-modules/ National LGBT Cancer Network http://www.cancer-network.org/ To Treat Me You Have to Know Who I Am https://www.youtube.com/watch?v=nuhvjgxgaac&feature=youtu.be Vanessa Goes to the Doctor (Trans Primary Care Experience) https://www.youtube.com/watch?v=s3edkf3pfro Human Rights Campaign/Healthcare Equality Index http://www.hrc.org/hei Brene Brown on Empathy https://www.youtube.com/watch?v=1evwgu369jw Additional Resources and Suggested Readings http://www.lgbthealtheducation.org/lgbt-education/lgbt-health-resources/ Glossary of Terms http://www.hrc.org/resources/glossary-of-terms 22