Caring for LGBTQI Pa"ents and Families

Caring for LGBTQI Pa1ents and Families LGBTQI = Lesbian, Gay, Bisexual, Transgender, Queer/Ques8oning, and Intersex Student Commi;ee Members Laura Bri(on Ethan Cicero Mar2na Le Maor Miron Leonora Tisdale Eric Westbrook Faculty Advisors Dr. Beverly Foster Kathy Moore Director, Undergraduate Program Assistant Dean, Student Affairs What We Ask of You   An aHtude of curiosity and kindness   Your full a(en2on – cell phones and computers put away   An open mind   Ques2ons – feel free to ask them! We will make our slides and resources available, plus a video of our presenta1on will be posted online! Objec1ves   Describe terminology and concepts related to lesbian, gay, bisexual, transgender, queer/ques2oning, and intersex (LGBTQI) popula2ons.   Explain what it means to give cross-­‐cultural care and how to overcome barriers to providing be(er care to LGBTQI people.   Describe approaches to taking a comprehensive history with LGBTQI pa2ents.   List strategies for crea2ng a safe and welcoming environment for LGBTQI pa2ents and staff. Nursing Code of Ethics “An individual’s lifestyle, value system and religious beliefs should be considered in planning healthcare with and for each pa8ent. Such considera8on does not suggest that the nurse necessarily agrees with or condones certain individual choices, but that the nurse respects the pa8ent as a person.” We do not need to agree with our pa1ents to respecNully and compassionately care for them. First Step….Assessment   Federal Government Assessment: Healthy People 2020   Completed every 10 years by Federal Government   1st 2me objec2ves were included for LGBT people   Priori2zed health needs for LGBT popula2on with goals   Goal: Improving the health, safety, and well-­‐being To treat me, you have to know who I am Folks who iden-fy as LGBTQI experience: Lower access to   Housing   Employment   Health insurance   Marriage   Adop2on   Re2rement benefits   Knowledgeable and competent providers Higher rates of   Violence   Vic2miza2on   Hate crimes   Bullying in school   Family rejec2on   Sexual assault   Homelessness   Poverty LGBTQI Health Concerns   Depression, anxiety, suicide   Hate crimes, domes2c violence, sexual assault   Cigare(e smoking   Alcohol and recrea2onal drug use and abuse   Sexually transmi(ed infec2ons and HIV, viral hepa22s   Excess weight and obesity (lesbians and bisexual woman), ea2ng disorders (gay men)   Cardiovascular disease   Cancers: anal, HIV-­‐related; risk factors for breast and reproduc2ve cancers Health dispari-es linked to societal s-gma, discrimina-on, and denial of civil and human rights. What Do These Le;ers Mean? LGBTQI encompasses Sexuality and Gender Iden1ty Lesbian Gay Bisexual Either/Or Queer Ques2oning Transgender Intersex What Do These Le;ers Mean? Sexuality or Sexual Orienta1on Sexual Orienta1on An enduring pa(ern of or disposi2on to experience sexual or roman2c desires for, and rela2onships with, people of one’s same sex, the other sex, or both sexes Lesbian Women oriented towards women Gay Men oriented towards men Bisexual People oriented towards people of either gender Queer an inclusive unifying sociopoli2cal, self affirming umbrella term for people who are LGBTQI or any other nonheterosexual sexuality, sexual anatomy, gender iden2ty What Do These Le;ers Mean? Gender Iden1ty Gender Iden1ty a person’s basic sense of being a man or boy, a woman or girl, or another gender Cisgender individuals who have a match between the gender they were assigned at birth, their bodies, and personal iden2ty Transgender an umbrella term that describes a wide variety of cross-­‐gender behaviors and iden22es. Intersex used for a variety of condi2ons in which a person is born with a reproduc2ve or sexual anatomy that doesn’t seem to fit the typical defini2ons of female or male (old term = hermaphrodite) FTM and MTF Female-­‐to-­‐Male and Male-­‐to-­‐Female [transgender] -­‐ describes the trajectory of a person who is changing or has changed their body and lived gender role from a birth-­‐assigned female/male to an affirmed male/female Genderqueer one who defies or does not accept stereotypical gender roles and may choose to live outside expected gender norms Iden11es….we all have them. Health Needs   The acronym LGBTQI: an umbrella term   Health needs are ogen grouped together   Each le(er represents a dis2nct popula2on with its own health concerns and health dispari2es   Past experiences with provider insensi2vity and hos2lity can produce intense fears of disclosure of sexuality or gender iden2ty, causing many to avoid health care altogether Nurses must look at the en1re picture and understand the context of the pa1ent’s life in order to provide comprehensive compassionate care. Ini1a1ng a Therapeu1c Rela1onship   Get to know your pa2ent as a person   Validates LGBTQI lives as normal and not focused on sexual behavior   Helps assess social adjustment and community support   Be respechul and empathe2c   Do not make assump2ons   Address sensi2ve topics carefully, yet treat as rou2ne.   You may learn a lot of what you need to know to guide the rest of the history Incorrect assump-ons can interfere with the establishment of a trus-ng therapeu-c rela-onship. GeXng to Know Your Pa1ent Let pa1ents use their own terminology   Ask them to explain what their terms mean to them   Discuss choice of language, especially for their anatomy   Listen and echo back the language heard Transgender individuals may be very uncomfortable with physical exams that involve their genitalia – be extra sensi1ve “What can I do to make you more comfortable?” “Would you like someone else in the room?” Chief complaint may not be the main reason for the visit “Do you have any other problems or ques8ons” or “Want anything else checked out while you are here?” Physical Presenta1on   Avoid assump2ons about sexual orienta2on and gender iden2ty by the pa2ent’s appearance   Do not rely on external appearances to iden2fy a pa2ent   Informa2on regarding sexual orienta2on and/or gender iden2ty should only come from the pa2ent   Gender iden2ty is dis2nct from sexual orienta2on (don’t assume transgender people are all homosexual) Physical Presenta1on: Transgender Pa1ents Transgender people present themselves in a variety of ways   Some medically or surgically alter their body   Some change hairstyle and dress while others make NO changes to their appearance   Most, but not all, will change their given name What does it mean to Transi1on?   A range that can vary from person to person   Does not necessarily include surgery or hormones   Minimal – clothing, name, or pronoun choice   Complete – hormones, anatomical reconstruc2on Cul1va1ng a Suppor1ve Environment   It is not always possible to know someone’s gender by their name or how they look or sound   If you are unsure about a person’s gender iden2ty, or how they wish to be addressed, ask politely for clarifica2on   It can be uncomfortable to be confused about someone’s gender   It can also feel awkward to ask someone what their gender is “I’d like to be respecGul – how would you like to be addressed?” “What name would you like me to use?” Cul1va1ng a Suppor1ve Environment   You will slip-­‐up. Expect it.   Slip-­‐ups with transgender pa2ents’ names and pronouns happen.   Apologize and ask the pa2ent what they prefer. Pa2ents will appreciate your sincerity and good inten2ons. “I apologize for using the wrong pronoun/name. I did not mean to disrespect you.” “How would you like to be addressed?” “What name would you like me to use?” Recovering from an error or an assump1on Pa1ent Confiden1ality LGBTQI pa1ents may be par1cularly worried about confiden1ality   Explain that you only ask if informa2on is clinically relevant   Provide affirma2on ager they disclose informa2on “This informa8on helps me to provide you with beQer care.” “I’m glad you told me this.” “I know this wasn’t easy for you to tell me, and I appreciate your honesty.” Reiterate confiden1ality under HIPAA   Explain who has access to medical records under HIPAA   If they are on an insurance plan with family, their family may be able access info that may be revealing (lab tests, medica2ons) Gender-­‐Neutral Communica1on Use neutral and inclusive language in interviews and when talking with all pa2ents. Ask ques2ons that do not assume heterosexuality. Instead of this… Try this… “Are you married?” “Are you involved in a rela2onship?” “Do you have a girlfriend or “Do you have a partner(s)?” a boyfriend?” “How do you refer to that person?” Mom and Dad Parent, Parental Unit Son, Daughter Child, Offspring What other examples come to mind? Pa1ent Assessment Ask open-­‐ended ques1ons vs yes/no ques1ons   “Tell me about yourself.”   “Who lives in your home with you?” Use non-­‐judgmental communica1on   Listen to how your pa2ent describes themselves and their family, then follow their lead   Example: If a female pa2ent refers to her wife, the clinician should also say wife, even if the couple is not legally married If you are not sure what terminology to use, ask your pa-ent. Assessment: Sexual History   Sexual behavior, desire, and iden2ty do not always align   Sexual behavior and iden2ty can change over 2me   Commi(ed rela2onships may be with more than one person Example: Do not assume a male pa2ent iden2fies as gay if he has sex with men. Do not assume a male pa2ent who iden2fies as gay only has sex with men. “Sex” has different meanings to different people. Find out what it means to your pa-ent. Assessment: Sexual History Reiterate: sexual history is rou2ne and confiden2al. Explain why you are inquiring about their sexual behaviors.   “I am going to ask you some ques8ons that I ask all of my pa8ents.”   “Have you been sexually involved with anyone during the past year, including oral, vaginal, or anal sex, or other kinds of sexual prac8ces?”   “Have you ever been sexually involved with men, women, or both?”   “Are you currently involved with women, men, or both?”   “What term (if any) do you prefer that I use to best describe your sexual orienta8on? For example, do you consider yourself gay, lesbian, bisexual, heterosexual, or are you not sure?”
Assessment: Mental Health Assess coping styles   “How do you deal with your problems?”   “Do you talk about your problems?”   “Are you able to do something to distract yourself during 2mes of stress?”   “Are you able to confront factors that cause you stress?”   “Who do you turn to when you are down, lonely, or need someone to talk to?”   “Have you ever thought about seeing a counselor or therapist? Do you think that might be helpful?” Know local resources for community referrals and pa1ent support. Assessment: Mental Health Suicide idea1on screening and support   “Over the past few weeks, have you ever felt down or depressed?”   “Have you had less interest in doing things that you normally enjoy?”   “Have you ever thought about hur2ng yourself?”   “Have you ever actually tried to hurt yourself? What did you do and tell me what happened?” You may be the only person the pa1ent feels comfortable talking to about these concerns! Assessment: Substance Use Do you currently smoke cigare;es?   “How much and for how long? Have you ever tried quiHng? Do you need or want help quiHng?” Do you drink alcohol? How o`en?   “How many drinks do you typically have? Do you ever get drunk?” Have you ever used any drugs such as marijuana, cocaine, ecstasy, GHB, crystal meth, etc?   “Which drugs do you currently use? How ogen?” Do you ever have sex while drunk or high?   “Have you ever done something sexually while high or drunk that you regre(ed or didn’t really want to?” Assessment: Safety and Violence   “How are things going at home, school or work?”   “Do you feel safe when you are at home?”   “Do you feel safe in your neighborhood and school/work?”   “Has anyone ever picked on you? Can you tell me about it? Was this because you are LGBTQI?”   “Who can you turn to for advice, support or protec2on?”   “Has anyone ever forced him or herself on you sexually, or touched you in a sexual way that was unwanted?” Pa1ent Educa1on Topics  
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Smoking cessa2on Alcohol and drug use, harm reduc2on Safer sex Proper nutri2on and exercise Mental health: coping skills, triggers, referrals Local resources Medica2on administra2on “Am I welcome here?” “Am I welcome here?” Visual Cues   Gender neutral bathrooms   Safe Zone or rainbow s2ckers   LGBTQI reading material in wai2ng areas   Photos of LGBTQI couples and families   LGBTQI pa2ent educa2on materials “Am I welcome here?” The Perilous Recep1on Desk Remember: The en8re wai8ng room can see a pa8ent check-­‐in. Verbal Cues of Inclusivity   Ask preferred name and pronoun   Avoid “Sir” and “Ma’am”   If issues with insurance/ID, discuss with pa2ent in a private room, not in front of the wai2ng room Wri;en Cues of Inclusivity   Forms include transgender op2ons   “Partner” instead of “husband/wife” or “married” Develop and display non-­‐discrimina1on policies! Microaggressions in the workplace   Harassment and/or ostracism   Ques2oned/denied bathroom use   Being addressed as the wrong sex or by the wrong name   Inappropriate and intrusive ques2ons   Nega2ve comments: stereotyping, jokes, ridicule, judgments, mockery, taunts, and abuse   Distribu2on and pos2ng of material hos2le to LGBTQI people   Inappropriate nursing handoff communica2ons regarding pa2ent’s sexuality or gender iden2ty Harmless?   No. Very hurhul to pa2ents and staff   Can be overheard and hurt others Bo(om line   Don’t do it   Don’t tolerate it from coworkers Handoff Role Play Websites for Further Educa1on   Center for Disease Control and Preven2on: cdc.gov/lgbthealth   Center of Excellence for Transgender Health University of California, San Francisco: transhealth.ucsf.edu   Gay and Lesbian Medical Associa2on: glma.org   Fenway Health Ins2tute: lgbthealtheduca2on.org   Joint Commission -­‐ Advancing effec2ve communica2on, cultural competence, and pa2ent-­‐and family-­‐centered care: A roadmap for hospitals jointcommission.org/assets/1/18/LGBTFieldGuide_WEB_LINKED_VER.pdf   Human Rights Campaign: hrc.org   Na2onal Gay and Lesbian Task Force: thetaskforce.org   UCSF: University of California, San Francisco: lgbt.ucsf.edu Based on Your Request www.lgbthealtheduca2on.org   Educa2onal programs   On-­‐demand webinars   Learning modules   Online courses Compassionately Caring for LGBT Persons in Your Faith Community Journal of Chris8an Nursing October/December 2012 References  
American Nurses Associa2on. (2001). Code of ethics for nurses with interpre8ve statements. Retrieved from: Nursesbooks.org.  
Center of Excellence for Transgender Health, University of California, San Francisco. h(p://transhealth.ucsf.edu  
Ins2tute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a founda2on for be(er understanding. Retrieved from: h(p://www.iom.edu/Reports/2011/The-­‐Health-­‐of-­‐Lesbian-­‐Gay-­‐Bisexual-­‐and-­‐Transgender-­‐
People.aspx  
Joint Commission. (2011). Advancing effec8ve communica8on, cultural competence, and pa8ent-­‐and family-­‐centered care: A roadmap for hospitals. Joint Commission. Retrieved from: www.jointcommission.org/assets/1/18/LGBTFieldGuide_WEB_LINKED_VER.pdf  
Joint Commission. (2011). R3 Report. Requirement, ra2onale, reference. Joint Commission. Issue 1, February 9, 2011.  
Killerman, S. (2013). The Social Jus2ce Advocate's Handbook: A Guide to Gender. Aus2n, TX: Impetus Books.  
New York City Health and Hospitals. (2011). To Treat Me, You Have to Know Who I Am. Retrieved from: h(ps://www.youtube.com/watch?v=NUhvJgxgAac  
U.S. Department of Health and Human Services. Office of Disease Preven2on and Health Promo2on. (2010). Healthy people 2020. Retrieved from: h(p://healthypeople.gov/2020/topicsobjec2ves2020/overview.aspx?topicid=25 Ques1ons? Laura Bri;on lbri([email protected] Maor Miron [email protected] Ethan Cicero [email protected] Leonora Tisdale [email protected] Mar1na Le [email protected] Eric Westbrook [email protected] “All people, regardless of sexual orienta1on or iden1ty, deserve a safe and suppor1ve environment in which to achieve their full poten1al.” – Harvey Milk