Caring for LGBTQ Clients 9-28-2017 Presentations/Caring... · Caring for LGBTQ Clients John Parker...

Caring for LGBTQ ClientsJohn Parker – Der Boghossian, MPA

Rainbow Health Initiative


Community-based. Non-profit. Founded in 2001 by a group of community activists, health care providers, and health advocates.Committed to advancing the health and wellness of the lesbian, gay, bisexual, transgender and queer communities through research, education and advocacy.

Learning ObjectivesBy the end of this session, you should be able to:• Explain two frameworks that contribute to LGBTQ health disparities

(Minority Stress Theory and Intersectionality) and how these can be applied in clinical settings.

• Describe how to apply a Trauma-informed approach to healthcare to improve outcomes for LGBTQ clients.

• Describe the Minnesota LGBTQ Standards of Inclusion for Health and Human Services and how they promote culturally responsive care for LGBTQ clients.

Institute of MedicineWhat is causing LGBTQ health disparities?• IOM identified 4 theories in their landmark 2011 reportWe will focus on two today:• Minority Stress Theory• Intersectionality

Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academy of Sciences. Retrieved from http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2011/The-Health-of-Lesbian-Gay-

Bisexual-and-Transgender-People/LGBT%20Health%202011%20Report%20Brief.pdf

What does it do?• Calls attention to chronic stress• Sexual and Gender minorities (may) experience• Resulting from their stigmatization

Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academy of Sciences. Retrieved from http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2011/The-Health-of-Lesbian-Gay-

Bisexual-and-Transgender-People/LGBT%20Health%202011%20Report%20Brief.pdf

Minority Stress Theory

“Minority stress theory (MST) proposes that health disparities can be explained in large part by:

“stressors induced by a hostile, homophobic culture”

Dentato, M. P., Halkitis, P. N., & Orwat, J. (2013). Minority Stress Theory: An Examination of Factors Surrounding Sexual Risk Behavior among Gay & Bisexual Men Who Use Club Drugs. Journal of Gay & Lesbian Social Services, 25(4). Retrieved from http://doi.org/10.1080/10538720.2013.829395


Which (often) results in:• experiences of external prejudice• expectations of rejection• internalized homophobia

Dentato, M. P., Halkitis, P. N., & Orwat, J. (2013). Minority Stress Theory: An Examination of Factors Surrounding Sexual Risk Behavior among Gay & Bisexual Men Who Use Club Drugs. Journal of Gay & Lesbian Social Services, 25(4). Retrieved from http://doi.org/10.1080/10538720.2013.829395


External Prejudice

Internalized Homophobia/ Transphobia

Expectation of Rejection


Minority Stress Theory“[The] need to be constantly ‘on guard’ […] alert, or mindful of the possibility that the other person is prejudiced” (p. 517).

Crocker, J., Major, B., & Steele, C., (1998). Social stigma. In D. Gilbert, S.T. Fiske, & G. Lindzey (Eds.), The handbook of social psychology (4th ed.), (504-553). Boston, MA: McGraw-Hill.

Individual

Vigilance

Coping

Adaptation

Resilience


Clinical Implications

Cannot assume clients/patients trust you (experiences of prejudice; expectations of rejection)• Build rapport and trust• Mirror their language• Shared-Decision makingCannot assume clients/patients have positive self-image (internalized homophobia/transphobia)• Screen for Minority Stress


Assess for Minority Stress• RESOURCE: Association for American Medical Colleges• Clinical Vignette, including 5 minute video demonstrating how-to• https://www.aamc.org/initiatives/diversity/450456/minority-

stress.html

AAMC Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development. (February, 2016). Clinical Vignettes. Washington, DC: Association of American Medical Colleges. Available online

at: https://www.aamc.org/initiatives/diversity/450456/minority-stress.html


Minnesota LGBTQ Standards of Inclusion• Addressing Minority Stress is woven into Standards

Intersectionality• Socially locate individuals in the context of their “real lives”• Through axes of race, class, and gender examine how formal and

informal systems of power are:• Deployed• Maintained• Reinforced

Berger, M.T. & Guidroz, K. (2009). The intersectional approach: Transforming the academy through race, class, & gender.

IntersectionalityCentral tenets:

• Human lives cannot be reduced to a single characteristic• Human experience cannot be understood by prioritizing one single factor• Social categories are dynamic and socially constructed• The promotion of social justice and equity are paramount

Hankivsky, O. et al. (2014). An intersectionality-based policy analysis framework: critical reflections on a methodology for advancing equity. International Journal for Equity in Health, 13, 119.

Clinical ImplicationsMedical/Social/Sexual Histories• Allow patient to name and claim their own experience(s)• The experience of living as a Black, Bisexual, Trans woman with a

household income of $35,000 is different than a cisgender Latina who is Lesbian with a household income of $50,000.

Clinical ImplicationsIndividuation• “Immediate implications would include assessing the extent to which

any identity formation is creating emotional, physical, or social distress for the patient.”

• A client/patient centered approach• Build trust and rapport with client. • Who are they as an individual?

Makadon, H.J., Mayer, K.H., Potter, J., Goldhammer, H. (Eds.). (2015). Fenway guide to lesbian, gay, bisexual, and transgender health. 2nd Ed. Philadelphia, PA: American College of Physicians.

Clinical ImplicationsSocial Isolation• Patients may feel isolated/alienated from their racial/ethnic

community because of their SO/GI identity• May also feel alienated from LGBTQ community because of their

racial/ethnic community• Patients may feel isolated/alienated from the LGBTQ community as

they age. • CHECK FOR: Families of choice; social supports

Clinical ImplicationsHealthcare Access• Barriers to access may not exist based on an individual’s SO/GI

identity, but may exist based on their racial/ethnic identity, social class, ability, immigration status, etc.

• Also, patient may decline to disclose SO/GI identity because of fear of “compounding” discrimination.• If the patient is a person of color, or undocumented, or living with a disability,

their focus may be on navigating racism, nativism, ableism, and they may not have energy to deal with potential discrimination based on SO/GI identity.

Clinical ImplicationsPatient Satisfaction Surveys• Analyze results by multiple axes of identity (at least three)

• Race/Ethnicity, Ability, Social-class• Race/Ethnicity, Gender, Ability• Race/Ethnicity, Sexual Orientation, Social-Class• Race/Ethnicity, Age, Gender Identity

TraumaDefinition(s):

• Emotional wound(s)• Experiencing/witnessing traumatic event• “Traumatic stress occurs when our ability to respond to threat is

overwhelmed”

Traumagenic event: An event that has potential to produce traumatic response

Levine, P. A. (1997). Waking the tiger: Healing trauma. Berkeley, CA: North Atlantic Books.

TraumaTrauma responses:

• Re-experiencing – intrusive thoughts, flashbacks, nightmares• Numbing/Dissociating (mentally detach themselves, “dream state,” “space

out”• Avoidance of people/place/things that remind of event• Memory loss of event(s)• Hyper-arousal/hyper-vigilance• Intense fear



• Intense helplessness• Intense horror• Difficulty managing emotions• Easily triggered, difficulty with self-regulation• Exhaustion• Anxiety• Depression• Chronic stress response: easily overwhelmed; in survival mode (no energy/attention

for long-term)



• Loss of basic trust in organizations/systems• Difficulty reversing senses of helplessness/humiliation• Altered behaviors (coping mechanisms) transmitted to next generation• Persistent feelings of hurt, powerlessness, shame, and/or humiliation• Us vs. Them deeply engrained• Unhealed trauma used to justify acts of aggression


TraumaTypes of Trauma:

• Individual – Acute Stress Disorder, PTSD from traumagenic event• Complex/Cumulative – prolonged exposure to external stressful forces• Historical – cumulative wounding across generations; massive group trauma • Cultural – effects of genocide; massive group trauma• Structural – trauma created from legal, economic, political systems• Participation-Induced Traumatic Stress – Traumatic responses in perpetrators • Secondary Trauma – Compassion fatigue, burnout, vicarious trauma


Clinical ImplicationsTrauma-Informed Care1. Understanding of health issue is placed within context of the whole

individual and their life context.2. Emphasis on patient skill-building, autonomy.3. Collaborative relationship; trust and safety built over time.

Sciolla, A.F. (2017). “An overview of trauma-informed care” in Trauma, resilience, and health promotion in LGBT patients: What every healthcare provider should know. K.L. Eckstrand & J. Potter (Eds). Cham, Switzerland: Springer International

Publishing.

Clinical ImplicationsScreen for TraumaConsider use of Primary Care Post Traumatic Stress Disorder Screen• 4 questions• Can be used in taking a medical/social history

Poteat. T.C. & Singh, A.A. (2017). “Conceptualizing trauma in clinical settings: Iatrogenic harm and bias” in Trauma, resilience, and health promotion in LGBT patients: What every healthcare provider should know. K.L. Eckstrand & J. Potter (Eds). Cham,

Switzerland: Springer International Publishing.

Clinical ImplicationsPhysical Exam Guiding Principles1. Ensure locus of control remains with patient2. Engage in shared decision making3. Explain procedure using patient’s preferred terminology4. Discuss modifications to exam to promote patient comfort5. Acknowledge patient’s trauma history

Petzmeier, S.M. & Potter, J. (2017). “Patients and their bodies: The physical exam” in Trauma, resilience, and health promotion in LGBT patients: What every healthcare provider should know. K.L. Eckstrand & J. Potter (Eds). Cham, Switzerland: Springer

International Publishing.

What are the Minnesota LGBTQ Standards of

Inclusion?

Process• Data gathering on LGBTQ health inequities in Minnesota (2012 –

Present)• Bush Foundation Community Innovation Grant (2015)• Convened advisory board (2015)• Advisory board and staff research best practices and developed

standards (2015-2016)• Published in 2016

LGBTQ Standards of Inclusion

Advisory Board• Khalid Adam, Hennepin County Center for Innovation and Excellence• Mauricio Cifuentes, Comunidades Latinas Unidas En Servicio• Eli Coleman, University of Minnesota• Nathalie Crowley, Duluth Trans+• Peek Ehlinger, Minnesota Transgender Health Coalition• Angela Goepferd, Children’s Hospital and Clinics of Minnesota• Dionne Hart, Care from the Hart• John Knudsen, Mayo Clinic• Sandra Laski, ADC-MN• Eric Meininger, Gilette Children’s Speciality Healthcare• Alex Nelson, Reclaim!• Barbara Satin, GLBT Generations• Erin Wilkins, Family Tree Clinic


Create and sustain an inclusive physical environment for LGBTQ communities


Recruit and retain LGBTQ employees


Require LGBTQ culturally responsive education for all care providers and support staff


Develop policies, procedures and care provisions that are Intersectional


Implement an equitable and inclusive LGBTQ patient experience from in-take through completion of care


Assessment• RHI can provide assessment based on Standards of Inclusion• RHI highlights strengths of your clinic• Based on assessment, RHI makes strategic recommendations

specific to your clinic and lived experiences


Contact [email protected]

612-206-3180


LGBTQ Provider Directoryhttp://www.mnlgbtqdirectory.org/

LGBTQ Patient Toolkithttp://www.rainbowhealth.org/resources-for-

you/patient-toolkit/


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