LGBTQ+ Cultural Competency in Healthcare

Intersections of LGBTQ+ with Cultural Competency, Humility, and Health Equity/Disparities

• Karla A. Bell, PT, DPT, PhD, FNAP, from Thomas Jefferson University, focuses on sexual and gender diverse populations
• She believes in inherent respect, dignity, and equal treatment of all human beings
• Human connectedness and caring are fundamental in healthcare, from delivery to education

Learning Objectives

• Participants will utilize respectful and culturally appropriate terminology when discussing healthcare with someone who identifies as a sexual or gender minority
• Participants will identify and convey the importance of being culturally sensitive and respectful with patients who identify as a sexual or gender minority
• Participants will integrate LGBTQ+ healthcare needs and disparities knowledge into best physical therapy practices

Brave Space

• Open and brave dialogues should be had
• What is shared may differ from someone's own lived experience when working with others in the community

APTA Core Values and Code of Ethics

• The core values and code of ethics obligate practitioners to treat all patients with respect and provide optimal care
• The Code of Ethics includes Principles 1, 2, 3, 4, and 8
• Core values include accountability, altruism, collaboration, compassion, caring, duty, excellence, integrity, social responsibility, and inclusion

What LGBTQ+ Patients Say

• Patients use physical therapy to improve their lives, movement, and community involvement
• They care about quality healthcare and safety in PT spaces
• They want to be understood as people with complex identities related to histories and societal influences
• Some community members avoid seeking care due to fear of poor treatment or past negative experiences

Advice for PTs

• Be aware that many LGBTQ+ people have a history of trauma
• People who seek care want to be affirmed and have options
• Things should be done in ways that are genuine and authentic
• Training and education in LGBTQ+ health should be increased (everyone from front desk, billing, and volunteers)
• Use consistent inclusive practices and include all-gender restrooms/spaces to change
• Awareness of community resources that may help is needed

Overview: Language and Importance for Healthcare

• Language is the foundation of cultural humility/competency; it builds trust and rapport
• The topic is important due to discrimination, poorer health outcomes, structural/social/political determinants of health, and gaps in education and training

Important Considerations

• People do not need to disclose their identities to work in an inclusive way
• Not all 2SLGBTQ+ people have trauma histories or mental health challenges
• 2SLGBTQ+ folks and communities are resilient
• 2SLGBTQ+ identity is not a result of trauma or pathology
• 2SLGBTQ+ identities are healthy, natural, and positive
• Individual and societal oppression, violence, and neglect cause traumatic stress and mental health disparities

Multiple Communities

• LGBTQ+ is an umbrella term that encompasses sexual and gender diverse populations
• Sexual orientation and gender identity are two completely different identities within the LGBTQ+ umbrella

Sexuality: Key Concepts

• Sexual orientation is someone's internal sense of their own sexual identity, usually defined by the gender of the people they find attractive
• Sexual desire is someone's internal experience of sexual attraction and interest or alack thereof
• Sexual behavior is real-world actions and decision-making about sex (the sexual who, what, when, where, why, how?)
• Terms to describe sexual orientation include lesbian, gay, bisexual, queer, straight, asexual, etc.
• Sexual desire and behavior could change at any time due to social and/or physiological factors

Gender: Key Concepts

• Assigned sex is the sex someone is labeled at birth based on the visual appearance of genitals, cannot be changed
• Gendered physical characteristics are elements of physical anatomy, genetic makeup, and hormonal profile historically associated with "sex", can be changed with medical intervention
• Gender Identity is someone’s own internal sense of their gender
• Gender Expression is the way someone presents their gender to the world
• Terms to describe gender include man, woman, genderqueer/non-binary, etc.

Pronouns: Real Impact of Misgendering

• Using chosen name/correct gender pronoun across multiple contexts is associated with lower depression, suicidal ideation, and suicidal behavior
• Better health outcomes and well-being are linked to inclusive practices with LGBTQ+ communities

Determinants of Health

• Lack of data, poverty, lack of gender recognition, lack of relationship recognition, lack of access to care, and homelessness impact LGBTQ vulnerabilities in social determinants of health
• Stress and coping and discrimination also impact LGBTQ health

Political and Structural Determinants of Health

• Structural determinants of health include income, education, employment, housing, and access to healthcare
• Political determinants involve policies and decisions related to healthcare, social services, and public health

Health and Healthcare Disparities

• Health and healthcare disparities are directly tied to discrimination and stigma that LGBTQ+ individuals face
• Political and structural determinants of health
• Differences in health conditions/diseases are not connected to the identity itself, but how people are treated because of their identity

U.S. Transgender Survey - 2022 Results

• Sample size was 92,329
• 47% considered moving to another state due to consideration or passing of anti-trans laws
• 28% did not see a doctor when needed due to cost
• 24% didn't see a doctor due to fear of mistreatment
• 48% of those who saw a health care provider had a negative experience due to gender minority identity

LGBTQ+ Youth

• 12% of LGBTQ+ young people attempted suicide in the past year
• 45% of transgender and nonbinary young people considered moving to an different state because of LGBTQ+-related politics and laws
• 90% of LGBTQ+ young people said their well-being was negatively impacted due to recent politics.

General Health Disparities Across the Lifespan

• Substance use, mental health, cardiovascular issues, and cancer
• More than two times more likely to have used any illicit drug in the past year (39.1% vs 17.1%)
• 10.4% of SGD individuals misused prescription pain relievers vs 4-5% of heterosexual adults
• ~91% of transgender respondents have had lifetime suicide thoughts after being refused treatment by a healthcare provider
• LGBTQ+ adults are at least 36% less likely to have ideal cardiovascular health

Gender Affirmation - Transition Components

• Social: coming out, living as your affirmed gender, clothing, hair style, pronouns, and name
• Legal: Court ordered name, Driver's license, birth certificate, and Gender marker
• Medical: Puberty Blockers, hormones, surgery (~25-35% of trans and nonbinary people receive gender-affirming surgeries)

Social Transition

• Family acceptance of LGBTQ+ youth is associated with positive mental health
• Usage of chosen name resulted in a 29% decrease in suicidal ideation and a 56% decrease in suicidal behavior

Medical Transition

• Access to gender-affirming care for TNB youth 13-20 was associated with 60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a 12-month f/u
• Gender-affirming hormones (GAHT) decreases both emotional and behavioral problems
• Gender transition improves the overall well-being of transgender people

Hormones

• HRT (Hormone Replacement Therapy) is largely used for cis women taking hormones
• HT or GAH (Hormone Therapy or Gender-Affirming Hormones) are used to take hormones to develop secondary sex characteristics that better align with your gender identity
• Puberty Blockers delay or stop puberty-related changes in your body

Transfeminine Hormones

• Estrogen and an androgen blocker (blocks testosterone or T) help develop secondary sex characteristics like breasts and redistribution of body fat towards the hips and breasts

Transmasculine Hormones

• Testosterone or T help develop secondary sex characteristics like a deeper voice, growth of facial hair and muscle, as well as redistribution of body fat away from hips and breasts

Binding

• 85-98% of transmasculine and gender diverse individuals bind
• Involves using tight-fitting undergarments or other methods to flatten the chest
• 50% report wearing binders 7 days/week and more than 8 hours/day with 89-97% reporting at least one negative health outcome
• Benefits of binding outweigh the risks
• Of those who don't bind, 67% report due to unsupportive parents and 40% felt their life hasn't started because of chest dysphoria

Binding Years Calculation

• Intensity x frequency x number of years spent binding
• Within first month binding: can experience back pain, chest pain, abdominal pain, numbness, headache
• Within first year: shoulder pain, weakness, numbness postural changes, etc.
• More than One binding year: can experience rib fracture, scarring, swelling, skin changes, skin infection, respiratory infection, rib or spine changes, muscle wasting, chest tissue changes

Potential Treatment Options

• Screen for TOS
• Abdominal and diaphragm activation and/or release
• Teach patient to self release pecs, traps, elevators of scap
• Teach patient to activate scap stabilizers
• Review binding habits, binder size/type, symptoms
• Discuss all options - i.e. top surgery

Inclusive Language/Non-gendered Language/Pronouns

• Introducing yourself with your pronouns signals that you are an affirming space
• Does not put pressure on the patient to figure out if you are welcoming
• Practice using gender-neutral pronouns with colleagues, friends, family or app

Correcting Misgendering

• Correct pronouns to describe misgendered individuals
• Apologize for any mistakes and correct it

Creating an Inclusive Space

• Introduce yourself with name and pronouns.
• Do not make assumptions.
• Provide Representation in the Images in clinical spaces
• Maintain Confidentiality.
• Ask how you should refer to them to others including parents.
• Signal inclusion with pride flag

Reducing Gender Dysphoria Triggers and Anxiety

• Ask permission
• Follow your patients' lead
• Explain what you are doing before, and during
• Respect boundaries with regard to disrobing and touch
• Avoid surprises and judgment
• Offer gowns or sheets as appropriate