Make Your Facility More Inclusive

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Tips to help you navigate the landscape of sexual orientation and gender identification.


Ciscentric. Femme. Polysexual. Ze. If the words and the discussion surrounding sexual orientation and gender identity make your head spin, you're not alone. I'm a member of the community that researches and teaches about gender and human sexuality, and I'm always needing to learn more. The way we talk about gender and sexuality changes constantly — it's hard even for those of us who study it to keep up. The good news is it's not necessary to be an expert in order to do a good job for patients and to be an excellent colleague to providers in the LGBTQIA2S+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, two-spirit, and more) community. All it really takes is good old-fashioned common decency. Show respect. Avoid assumptions. Listen, learn and empathize. If you do, the outcomes will be positive, both in professional satisfaction and in facility economics.

A life and death matter

If you entered your profession to help people (which I hope at least part of you did!), great satisfaction awaits you in caring for this community. Few populations need healthcare help more than LGBTQIA2S+ patients.

Studies show that 30% of LGBTQIA2S+ people lack a healthcare provider (only 10% of age-matched heterosexuals do). The reasons are well-known. First, members of this population are more likely to be unemployed or underemployed due to discrimination. Despite often having higher levels of education, they often have lower incomes and may not have health insurance. If they do have insurance, their domestic partners may not be covered. If they're trans or non-binary, insurance may not cover some services they need.

Perhaps most importantly, they fear the healthcare system because they have been stigmatized or traumatized previously.1 In one study, 73% of transgender respondents and 29% of lesbian, gay and bisexual respondents reported that they believed they would be treated differently by medical personnel because of their status. When asked why, more than half reported that they had experienced outright refusal of care, that a provider refused to touch them or used excessive precautions when touching them, or were abused verbally or even physically.2

In a study I did of Colorado transgender patients, 40% reported delaying medical care due to cost, inadequate insurance, and/or fear of discrimination. Many were depressed, had suicidal thoughts and had even attempted suicide within the past year. Having a transgender-inclusive provider resulted in much better care, significantly less depression and one-half the number of suicide attempts.3

Because so many LGBTQIA2S+ people are disengaged from the healthcare system, many are misinformed. For instance, studies show that a significant number of lesbian women may not realize that they are at risk for sexually transmitted infections like chlamydia or herpes, and fail to seek Pap smears as a result. That results in a higher cervical cancer rate for both lesbian and bisexual women. Many gay men do not know that vaccinations for human papillovirus can reduce their elevated risk for anal cancer. Lesbian women are also at elevated risk for breast cancer, and yet anecdotal evidence suggests that they seek breast exams less frequently than heterosexual women do.

Being inclusive is not just the right thing from an ethical standpoint. It's also good for provider economics. Estimates vary widely, but in a recent Gallup poll, 4.5% of Americans identified as LGBTQIA2S+. Among millennials, the percentage was 8.1%, suggesting either that the population will grow or perhaps that it is actually larger than the survey shows.

This represents a significant opportunity, because inclusive providers tend to be scarce in many areas. Here in Ann Arbor, Mich., such providers are usually available, but in the state's upper peninsula, some LGBTQIA2S+ people travel 6 to 7 hours just to see inclusive therapists, and trans and non-binary people living in other rural areas in the state travel 3 hours to get their hormone injections. I can tell you that if my partner or I discover an inclusive provider and post about it in one of our LGBTQIA2S+ Facebook groups, the provider often becomes so busy that we can no longer get an appointment ourselves. That's how economically powerful inclusivity can be.

INCLUSIVE IDEAS
All Patients Should Feel Welcome

If you believe it's time to make your facility more inclusive to patients of all sexual orientations and gender identities, here are 17 tips on how to reach that goal.

1. In your marketing materials, make it clear that you welcome LGBTQIA2S+ patients. Display a rainbow flag on your materials and your website. If at all possible, the photos on your website and in your collateral should show gay/lesbian/bisexual couples, and trans people in addition to straight couples and cisgender people.

Semantics matter. If the name of your facility is gender-exclusive — for example, "The Women's Surgery Center" — you are basically telling trans men and nonbinary individuals that they're not welcome.

2. Particularly if your bathrooms are one-person, why not post gender-inclusive restroom signs? Nonbinary and trans patients should not be stressed about which room to use.

3. In every way possible — and I really can't stress this enough — accept and respect your patients' identities as they know them to be — not necessarily as the government or an insurer sees them. On your intake form, in person or both, ask every patient, "How would you like for me to refer to you?" This includes both their name and their pronouns. To show you're inclusive, consider listing your own pronouns on your badge.

If you have trouble wrapping your mind around the importance of this, imagine that your physician insists on calling you Peter even though your name is Paula. How likely would you be to return to that provider? Addressing patients by the name and gender with which they live authentically affirms them and helps build the provider-patient relationship.

4. Speaking of intake forms, most I've seen need some revisions. First, in addition to "married," "single," "divorced" and "widowed," the form should include "partnered/living with partner" as well as "multiple partners" or "dating." If your form asks about "gender" or "sex," remember that the terms are not the same. Sex essentially refers to a few components (gonads, external genitalia, hormones, etc.) and is assigned by a medical provider at birth as male, female, or sometimes, as intersex. Gender refers to how we identify ourselves, and here there are so many options that it might be best to offer man, woman, nonbinary, and "another gender" with a blank space. A final note: If your form asks about orientation — lesbian, gay, straight, bisexual, queer and asexual — remember that transsexual does not belong here. Trans is related to gender, not sexual orientation.

5. When another person accompanies the patient, assume nothing. Do not say things like "This must be your husband." That could ruin your rapport. Just ask, "Who is this in the room with you?" The same goes when you are asking about transportation. Ask, "Who will be driving you home?" instead of, "Will your wife be driving you home?"

6. Make sure the information on the intake form makes its way to the whiteboards in the OR and PACU bays. The name the patient goes by and the pronouns should both be written on the boards.

7. It may be tempting to gossip about LGBTQIA2S+ patients when they're out of the room or under anesthesia: "He, she, it, I don't know what to call them." Avoid this at all costs. Remember, the colleague with whom you're gossiping may be LGBTQIA2S+ themselves, or have a sibling or child who is.

8. If you're really intent on becoming inclusive, immerse yourself. Exposure therapy works. I recommend watching Trans, a documentary available on Prime. It centers on Christine McGinn, MD, a plastic surgeon who does transgender surgery and is transgender herself. If you live near a university or work at a university facility, make a point of attending some of the LGBTQIA2S+ events on campus. Follow LGBTQIA2S+ people on social media.

Practice introducing yourself with your pronouns to your colleagues, friends and patients. "Hi, I'm Dr. Shanna Kattari, I use the pronouns 'she' and 'her.'"

There are lots of books on the subject; UCLA's Williams Institute has a wonderful compendium of titles. The Fenway Institute, which is associated with Boston's Fenway Health, offers a number of helpful webinars and presentations on LGBTQIA2S+ health, and so does the University of California at San Francisco.

9. Practice using gender-inclusive personal pronouns— "they," "their" and "them—"in place of gendered pronouns. When you think about it, it's not that hard. If you find a cell phone in a restaurant, for example, you'd tell the waiter, "Someone left their phone." Cute dog; you ask "What's their name?" Practice describing patients this way to colleagues. "The patient came in, they're 34 years old, I spoke to them, they signed off on the lap chole, so-and-so will pick them up after the procedure."

10. If you mess up, apologize and move on. "Nurse, can you please bring those forms for him? Sorry, I mean, can you please bring those forms for them?"

11. Don't be afraid to ask relevant anatomical questions, but explain why you're asking. If the patient has a broken arm, whether they have had gender affirmation surgery or not is irrelevant. If they are about to undergo abdominal surgery on the other hand, and they will need to be catheterized, it's appropriate.

12. Treat bodies, not identities. Every person with a cervix requires a Pap smear and everyone with a prostate is susceptible to prostate cancer, no matter their gender.

13. Always be on the lookout for ways to make LGBTQIA2S+ patients more comfortable. For instance, some hospitals do hysterectomies in maternity ORs. For trans men or nonbinary individuals, they should consider doing them in the main OR, so that the patient is not the only man or nonbinary person in the PACU.

14. Avoid asking LGBTQIA2S+ patients about their identities. You wouldn't ask your cisgender heterosexual patients about what it's like to be cisgender and heterosexual. When I went in for knee surgery, my partner accompanied me. After he left, the provider said "Oh my god, I never would have guessed he was trans. How long has he been on testosterone?" He likely meant no harm, but it was completely inappropriate.

15. Avoid tokenizing your LGBTQIA2S+ colleagues. They are there to do their jobs. They are not there to help you with your own LGBTQIA2S+ patients. They are not there to help you process what you did wrong in your last encounter with a trans patient.

16. If you are cisgender, recognize the fact of cisgender privilege and acknowledge its unfairness. No one stares at you when you go to a public bathroom or a gym locker room. You can flirt with someone without worrying that your sex assigned at birth might cause rejection later. If you get married to a person of the opposite sex, you can legally change your entire name for free whereas it costs trans people $200 to $300. If you are a cisgender woman who wants breast implants, you can simply schedule an appointment with a plastic surgeon, whereas a trans woman needs a letter from a licensed mental health professional documenting gender dysphoria. (They need 2 letters for bottom surgery.) There's lots more, but you get the idea.

17. Establish non-discrimination policies in your workplace that explicitly include gender identity/expression and sexual orientation, and post them prominently. If unfriendly or discriminatory practices occur in your facility, address them promptly.

— Shanna ?K. ?Kattari, PhD, MEd, CSE, ACS

Hope for the future

Overcoming long-held beliefs, habits and practice patterns is hard, but it can be done. The Human Rights Campaign Foundation's Healthcare Equality Index shows improvement in LGBTQIA2S+ patient-centered care every year. In 2019, about 10% of the nation's hospitals asked to be rated. Two-thirds of that group (including iconic facilities like Yale New Haven, Mass General and Barnes-Jewish) earned the "Leader in LGBTQ Healthcare Equality" designation for meeting stringent criteria for LGBTQ patient-centered care, patient services and support, employee benefits and patient and community engagement.

I hope all facilities someday meet those criteria. Until then, those of us in the LGBTQIA2S+ community need your help. Please answer the challenge to become an inclusive provider. OSM

Footnotes to this article can be found here.

Hope for the future

Overcoming long-held beliefs, habits and practice patterns is hard, but it can be done. The Human Rights Campaign Foundation's Healthcare Equality Index shows improvement in LGBTQIA2S+ patient-centered care every year. In 2019, about 10% of the nation's hospitals asked to be rated. Two-thirds of that group (including iconic facilities like Yale New Haven, Mass General and Barnes-Jewish) earned the "Leader in LGBTQ Healthcare Equality" designation for meeting stringent criteria for LGBTQ patient-centered care, patient services and support, employee benefits and patient and community engagement.

I hope all facilities someday meet those criteria. Until then, those of us in the LGBTQIA2S+ community need your help. Please answer the challenge to become an inclusive provider. OSM

ACCURACY & RESPECT
Know These Common Identity Terms

It can be challenging to stay current on definitions of sexual orientation and gender identifications. Here's a rundown of the terms you should understand.

  • Asexual ?A person who doesn't feel sexual attraction to others.
  • Bisexual ?A person who is sexually and/or romantically attracted to people of more than one gender.
  • Cisgender ?Someone who lives and identifies as the gender in line with the sex they were assigned at birth. "Trans" means "across" or "on the opposite side of," whereas "cis" means "on the same side of."
  • Gay ?A term used mostly for men who are sexually and/or romantically attracted to men and only men.
  • Gender ?The social meanings and expectations historically ascribed to sex assigned at birth. The term "gender binary" refers to a society that only recognizes men and women.
  • Gender ?Identity The gender with which an individual identifies. It may or may not align with society's assumptions.
  • Gender Expression ?How someone presents their gender to the world. Can involve clothes, jewelry, hair, etc., and also how someone moves, sits, acts, etc.
  • Heterosexual ?A term coined in 1892 to describe men who have relationships only with women and women who only have relationships with men.
  • Intersex Person/Person with Intersex Condition ?An individual whose combination of chromosomes, hormones, internal sex organs and genitals differs from one of the 2 most common patterns. As many as 1 in 100 babies fall into this category.
  • Lesbian ?A term describing women who are sexually and/or romantically attracted to women only.
  • LGBTQIA2S+ ?An acronym for Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersexed, Allies and Two Spirits.
  • Pansexual ?A person who is attracted to individuals regardless of their sex or gender.
  • Polysexual ?A person who is oriented toward sexual encounters and relationships involving more than 2 people.
  • Queer ?Once a slur, this often serves as an umbrella word to describe everyone who diverges from hetero- and homonormative genders and sexualities. Individuals may also hold this as an individual identity, and often ascribe some political beliefs to it.
  • Questioning ?A person who feels they don't fit into any one classification system.
  • Sex assigned at birth Usually male or female (sometimes intersex), noted by a medical professional on the birth certificate.
  • Transgender or Trans ?A person whose gender identity differs from social expectations connected to the sex they were assigned at birth.
  • Transsexual ?An outdated word still used occasionally by some individuals. Use transgender as an umbrella term and only use this term if someone uses it for themselves.
  • Two-Spirit An indigenous North American who embodies a gender(s) outside of cisgender, and/or sexual orientation outside of heterosexuality. Traditionally, some tribes view these individuals as healers or leaders.

— Shanna ?K. ?Kattari, PhD, MEd, CSE, ACS

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