Introduction to LGBTQ Health Care Issues

1. An educational resource from LavenderHealth.org, 2010 www.lavenderhealth.org Introduction to LGBTQ Health Care Issues

2. Authors • Michele J. Eliason, PhD, • Associate Professor, San Francisco State University • Suzanne L. Dibble, DNSc, RN, • Professor, University of California, San Francisco • Jeanne DeJoseph, CNM, PhD, • Emeritus Professor, University of California, San Francisco • Peggy Chinn, RN, PhD, • Emeritus Professor, University of Connecticut • Carla Randall, RN, PhD • Associate Professor, University of Southern Maine

3. Presenter Information

4. A Lawsuit was filed April, 2009 Janice Langbehn and Lisa Pond, together 18 years, were about to depart on a cruise with their 3 children, when Lisa collapsed. The hospital refused to accept information from Janice regarding Lisa's medical history, informing her that she was in an antigay city & state and that she would receive no information or acknowledgment as family. A doctor finally told Janice that there was no chance of recovery. Despite the acknowledgment that no medical reason existed to prevent visitation -- and the fact that Janice held a durable healthcare power of attorney for Lisa -- no hospital employee would allow Janice or the couple’s children to see Lisa until nearly eight hours after their arrival, only in time to witness the last rites.

5. The need for LGBTQ content in health care education • As the opening case example indicates, LGBTQ people and communities have too often experienced discrimination and poor care. • This section addresses basic terminology used in this program.

6. L,G,B,T, and Q? • The initials LGBTQ are used in this presentation to stand for: • Lesbian • Gay • Bisexual • Transgender • Queer and questioning • These are not the only terms used for sexual identity: there are many terms that vary by geographical region, age group, racial/ethnic group, and so on.

7. Why include the “Q” • Many people, especially youth, do not use LGBT, but define themselves as “queer” a broader term. • Some use it to reclaim a word flung at them in hatred, because to use it oneself takes the power out of it. • Q can also stand for questioning, a necessary step in developing identities, and a potentially stressful time for many who later adopt an LGBTQ identity.

8. Why the need for LGBTQ education? • There is little accurate information in our culture about LGBTQ people. Families, schools, religious organizations, the media, etc., still contain many myths and stereotypes. • Health care professional education currently contains little or no information to counteract the stereotypes.

9. Why the need for education? • LGBTQ people and families make up a significant portion of the health care consumer population. • Everyone has LGBTQ friends, relatives, coworkers, and everyone has a sexual and gender identity, so understanding these issues helps everyone.

10. Case Example Discussion: • Could what happened to Janice and Lisa occur in the health care setting where you work? • Why or why not?

11. Concepts related to sex, gender, and sexuality What’s in a Word?

12. Sex • What a confusing term! Sex has two meaning, neither one very clear cut. • Sex = biological characteristics that distinguish men from women, such as chromosomes, genitals, internal organs of reproduction, hormones. • Sex = a set of behaviors associated with sexual arousal, pleasure, reproduction, and other human experiences.

13. Gender • The social and cultural characteristics that are associated with being a man or a woman in a particular culture. • Includes dress, hairstyles, adornments, communication styles, postures, etc. • Assumes that there are two and only two sexes (male and female), thus only two gender types (masculine and feminine).

14. Sexual Orientation • The term that refers to whether we are attracted to men, women, or both, and in western cultures, includes: • Lesbians • Gay men • Bisexual people • Heterosexual people • Many other terms are used by specific subsets of the population, and some people do not use labels at all.

15. Other terms related to sexuality • Sexual orientation implies a fixed and permanent sexuality. Alternatives include: • Sexual preference refers to a sexual choice or style that is modifiable • Sexual identity refers to the part of the self-concept that is related to sexuality, like other personal identities based on race, gender, age, etc • We recommend using sexual identity—it is the most neutral term.

16. Other terms related to sexuality • Identity Terms (what people call themselves): • Queer, gender queer • Homosexual, same gender loving, two spirit • Behavior Terms (what people do): • MSM (men who have sex with men) • MSMW (men who have sex with men and women) • WSW (women who have sex with women) • WSWM (women who have sex with women and men)

17. Sexual Expression • How people act out their sexual desires • Differs widely among people, regardless of their sexual and gender identities • Heavily influenced by culture, especially religion • Sexual expression is not directly tied to sexual identity (i.e., there is no such thing as “gay sex”)

18. Gender Identity • Self-concept related to gender: • how well do I fit into male/female, and feminine/masculine expectations for my culture? • Gender identity is established early in life, as children identify their own gender around age 3, and the gender of others around 6.

19. Transgender • An umbrella term that describes people whose gender identity is not congruent with their physical bodies or sex assigned at birth. • Includes transsexuals, cross-dressers, androgynous people, drag queens and kings, and gender queer identifications, among others.

20. Gender Terms • Male-to-female (MTF, MtF, M2F) • Female-to-male (FTM, FtM, F2M) • Transition: the process of altering the body and behavior to pass as one’s psychological gender. • Can include hormone treatments, surgeries, speech therapy, psychological therapy, electrolysis, and other things. • Not all transgender people do all or any of these things.

21. Intersex • Intersex is an umbrella term for a number of biological conditions or variations that affect reproductive organs or genitals, so that the person does not clearly fit into the categories of male or female. • Some of these are apparent at birth (as ambiguous genitalia); others manifest later • Examples: congenital adrenal hyperplasia, androgen insufficiency syndrome, hypospadias

22. Intersex Advocacy and Information • The Intersex Society of North America recently closed, but continues to have information posted on a web site. (www.isna.org) • A new organization, Accord Alliance, will continue the work ISNA started to improve health care for people with intersex bodies.

23. Gender Expression • How people choose to present themselves on a continuum of feminine and/or masculine: • Clothing • Hairstyles • Communication styles • Aggression/Assertion • Passive/Dominant personality

24. Discussion Question • How did you express your gender today? How much variation is there day to day in your gender expression?

25. Sources of Diversity in Sex/Gender • Most of the definitions used here are the western, middle-class academic terms; there are variations by: • Sociocultural group: ethnicity, geographic region, religion, non-western cultures, socioeconomic class differences, age group, sex/gender.

26. Is LGBTQ a “Culture?” • LGBTQ people organize around a common identity and express a sense of community with shared beliefs • There is a long and extensive LGBTQ history with a unique language (coming out, transition, passing, stealth, gender queer, femme, etc) • There are LGBTQ social and political organizations, many concerned with health care

27. Is LGBTQ a Culture? • There are rituals and rites of passage in LGBTQ communities and personal development. • There are cultural productions from an LGBTQ sensibility: music, art, theater, literature, etc, that reflects the communities experiences in the world. • Having a culture does not mean agreement on all issues.

28. Coming Out and Disclosure • Sexual and gender identities are not always visible differences, so LGBTQ people have to first identify their own sexuality or gender and then make decisions about who/where to reveal them to others. • Coming out: the process of understanding one’s own sexuality and gender • Disclosure: the process of telling others

29. Coming Out • Can occur at any age or stage in life • Can be a very stressful time, with concern about how family, children, peers, coworkers religious leaders, neighbors, and others will respond. • Is a process that continues throughout the lifespan

30. Disclosure to health care professionals • Health care settings are often a “Don’t ask, don’t tell” situation. Health care providers typically do not ask, and written forms have no option for patients to identify themselves. • Disclosure is potentially dangerous if health care professionals have negative attitudes about LGBTQ people.

31. Some Disclosure Stories • Miguel, who was usually very careful about sexual behavior, had an unsafe sexual encounter with a man while on vacation, and decided to ask his primary care provider at the HMO for an HIV test. The PCP seemed ok about his disclosure, but every time after that, every symptom he had was interpreted in the framework of HIV/AIDS. • How would you feel if every symptom you had was evaluated this way?

32. Disclosure Stories • When Gloria divorced her husband and started a new relationship with a woman, she told her nurse practitioner that she was bisexual. The NP’s response was that she had not received much information in school about bisexual health issues, and hoped that Gloria would feel comfortable telling her what she needed. • What do you think of this NP’s response?

33. Disclosure Stories • Mae came out as a lesbian to her gynecologist at a yearly exam, and thought it went well, but her doctor started to ask her very personal questions about her sex life that did not seem relevant to her routine care. She started to feel very uncomfortable with this health care provider. • What assumptions do you think this physician had about Mae?

34. Disclosure Stories • Rachel told the nursing staff where she had just started working that she was a transgender woman and had been born male. The charge nurse insisted that Rachel reveal her birth name and that other staff members call her by her “legal” name, since Rachel had not yet officially changed her name. • What effect might this insistence on the “legal” name have on Rachel and the staff of this nursing unit?

35. Disclosure to health care professionals • Patients may disclose to: • Get better care, be able to include a partner in health care decision-making, to be honest • Patients may not disclose to: • Prevent discrimination or poor quality care, avoid loss of job, custody of children, insurance benefits, avoid losing family or community support, avoid gossip, protect their privacy

36. In your health care work setting: • How are LGBTQ patients/clients currently treated? • Do written forms include sexual and gender diversity? • Do health care providers ask patients about sexuality and gender? • Are there openly LGBTQ workers? Are they accepted? • Is there talk about LGBTQ patients at the nurses’ station? What kind of talk?

37. THE DEADLY EFFECTS OF STIGMA

38. Stigma • Being perceived as belonging to a group about which society has negative attitudes, or considers “deviant.” • Stigmatization: the process of creating stigma, also called “othering.” • Sets up “us versus them” mentality.

39. Terms Related to the Stigma of LGBTQ Identities

40. Discussion Questions • Can you remember the first time you learned about the existence of LGBTQ people? • What did you learn? • What was the context (who told you, where, how old were you)? • Did you learn something positive, negative, or neutral about LGBTQ people?

41. Homophobia • Negative attitudes about lesbian and gay people • More common in: • Men than women • Youth and older adults than young or midlife adults • Evangelical/fundamentalist religions than other religions or no religious affiliation • Less educated people than more educated • People with unacknowledged/unaccepted same-sex desires • People who are also racist and sexist

42. Biphobia • Negative attitudes about people who are bisexual • Comes from stereotypes about bisexual people • Same correlates as homophobia, but can also be found among lesbian and gay people

43. Transphobia • Negative attitudes about people who are transgender or challenge gender stereotypes • Gender is one of the most deep-seated set of stereotypes in western culture—strong beliefs that there are only two sexes and they are fixed at birth or even before birth.

44. Stereotypes at the Root • Stereotyping lies at the root of homo-, bi-, and trans-phobia. As a youth, what stereotypes did you learn about: • Gay men • Lesbians • Bisexual men • Bisexual women • Transgender people

45. HIV-Related Stigma • Negative attitudes about people with HIV/AIDS. • Related to a combination of racism, homophobia/biphobia, fears of contagion, and stigma of potentially terminal illnesses. • Some people still think of HIV/AIDS as only a “gay” disease.

46. Heterosexism • The institutional level of stigma • Biases found in the dominant institutions of society, such as medicine/science, education, the media, law, government, and religion. • Another concept, “heteronormativity,” refers to the fact that the majority of society is based on a heterosexual model that makes LGBTQ people invisible.

47. Gender Normativity • An institutionalized belief system that: • There are only two sexes • You stay the sex you are born all your life • Gender comes from sex: femininity comes from being in a female body and masculinity comes with a male body Gender variation is harshly punished in our society

48. Think of the taunts on the playground when you were growing up: • Which of those insults were gender-based? • Which ones were based on perceived sexuality?

49. Internalized Oppression • The stigma that stems from homophobia, biphobia, and transphobia can be internalized by people who adopt LGBTQ identities and manifest as: • Shame and guilt (can lead to depression) • Self-hatred (can lead to suicide attempts) • Self-destructive behaviors (substance abuse, unsafe sexual behaviors)

50. Example of Internalized Oppression • Casey grew up in a fundamentalist Christian religion that permeated the family and community. Casey was taught that all LGBTQ people are sinners who will go to hell, and when Casey felt different from others, became severely depressed and ran away from home, consumed with shame and guilt that the family would find out.