Tackling Barriers in Accessing Healthcare for LGBTQ Individuals

1. Tackling Barriers in Accessing Healthcare for LGBTQ Individuals Albina Veltman, MD, FRCPC Assistant Professor of Psychiatry, McMaster University Department of Psychiatry & Behavioural Neurosciences aveltman@stjoes.ca

2. Objectives • Understand the terminology related to LGBTQ communities • Gain knowledge regarding some of the specific health care needs of LGBTQ individuals • Understand the barriers that LGBTQ individuals face in accessing healthcare • Gain knowledge regarding how to reduce healthcare access barriers

3. The ABCs of LGBTTTIQQ communities • Lesbian • Gay • Bisexual • Transgender • Transsexual • Two-spirit • Intersex • Queer • Questioning

4. Other Important Terminology • Sexual orientation: how one identifies their sexual attraction and affection, both physical and emotional • Gender identity: a person’s deep sense of being male, female, neither or both • Heterosexism: assumption that everyone is or should be heterosexual • Ally: a person who is not a member of a specific group, but who supports that group, challenges discrimination and oppression of that group, and explores their own biases

5. “When I went to an addiction treatment clinic, the nurse asked me, ‘What’s the name of your husband?’ I said, ‘I don’t have a husband’. ‘Okay’, she then asked, ‘is it your boyfriend?’ I said, ‘I have a partner’. She said, ‘What’s his name?’ When it comes to these questions, it’s so uncomfortable. I don’t make it a big deal myself. I just said, ‘Her name is Sharon’. But then you can see their faces changing. Then you feel uncomfortable for the rest of the questions.”

6. Kinsey Scale

7. Holistic Approach • LGBTQ people have the same health concerns as anyone else, as well as some additional risk factors • Important to engage the whole person, do not treat patients like a collection of risk factors • Important to understand that life issues for people who are LGBTQ are similar to everyone else: • Work stressors • Financial issues • Long Term Relationships • Parenting • Aging 7

8. Special Considerations in LGBTQ Patients • Increased vulnerability due to: • Burden of maintaining a secret/double identity • Loss of supports/isolation • Bullying/violence • Discrimination/Heterosexism/Genderism • Coming out process • Internalized homophobia • Pathologization by the medical/psychiatric community

9. Special Considerations in Transgender Patients • Trans individuals report that health care professionals: • Have serious misconceptions about trans people • Confuse transgender and gay/lesbian identities • Appear uncomfortable providing services and treated them differently once they became aware of their trans identity or history • Trans individuals also felt vulnerable around the fact that their hormones and overall care could be ended abruptly; this in turn affected what they felt comfortable telling their health providers. • http://www.transpulse.ca/documents/Trans_PULSE_Phase_I_Report.pdf

10. Specific Health Care Needs of Gay and Bisexual Men Ten Things Health Care Providers should Discuss with their Gay or Bisexual Male Patients 1. HIV/AIDS, Safe sex 6. Prostate/Testicular/Colon cancer 2. Substance Use 7. Alcohol 3. Depression/Anxiety 8. Tobacco 4. Hepatitis Immunization 9. Fitness (Diet and Exercise) 5. STDs 10. Anal Papilloma All men who have sex with men (MSM) should be vaccinated for Hepatitis A and Hepatitis B. http://www.glma.org/news/releases/n02071710gaythings.html

11. Specific health care needs of Lesbian and Bisexual Women Ten Things Health Care Providers should Discuss with their Lesbian and Bisexual Female Patients 1. Breast Cancer 6. Tobacco 2. Depression/ Anxiety 7. Alcohol 3. Gynecological Cancer 8. Domestic Violence 4. Fitness (Diet and Exercise) 9. Osteoporosis 5. Substance Use 10. Heart Health http://www.glma.org/news/releases/n02071710lesbianthings.html

12. Specific Health Care Needs of Transgender Individuals Ten Things Health Care Providers should Discuss with their Transgender Patients 1. Access to Health Care 6. STDs and Safe Sex 2. Health History 7. Alcohol and Tobacco 3. Hormones 8. Depression/Anxiety 4. Cardiovascular Health 9. Injectable Silicone 5. Cancer 10. Fitness (diet & exercise) http://www.glma.org/_data/n_0001/resources/live/Top%20Ten%20Trans.pdf

13. Specific Health Care Needs of Intersex Individuals • Intersex Society of North America’s Recommendations for Treatment • http://www.isna.org/node/138 • The American Academy of Pediatrics recommends when deciding the sex of rearing of a baby with ambiguous genitalia, one should consider fertility potential, capacity for normal sexual function, endocrine function, potential for malignant change, testosterone imprinting, and timing of surgery. • http://aappolicy.aappublications.org/cgi/reprint/pediatrics;118/2/e488.pdf

14. LGBTTTIQQ Youth statistics • Nine out of 10 LGBT students experience harassment at school (vs. 62% of non-LGBT students) • 60% of LGB students feel unsafe at school because of their sexual orientation. • Lesbian, gay, and bisexual adolescents are almost twice as likely to use drugs and alcohol than are heterosexual teens. • It is estimated that between 20 and 40 percent of all street-involved youth identify as lesbian, gay, bisexual, and/or transgender.

15. LGBTTTIQQ Youth suicide • Lesbian, gay, and bisexual youth are up to four times more likely to attempt suicide than their heterosexual peers. • More than 1/3 of LGB youth report having made a suicide attempt. • LGB youth who come from highly rejecting families are more than 8 times as likely to have attempted suicide than LGB peers who reported no or low levels of family rejection. • Of all completed youth suicides, approximately 30% self-identified as lesbian, gay or transgender.

16. Barriers to Accessing Health Services for LGBTQ Individuals • Discomfort/fear of disclosing LGBTQ status due to real or perceived Homophobia/Biphobia/Transphobia • Patient’s own internalized homophobia/biphobia/transphobia • Provider ambivalence/discomfort related to inadequate education re: LGBTQ issues • Heterosexist assumptions on forms/interviews

17. Barriers to Accessing Health Services for LGBTQ Individuals • Pathologization of LGBTQ status (consideration of sexuality/gender status as part of illness, history of homosexuality and gender identity disorder in the DSM) • Previous experiences or stories of “corrective/reparative” therapies • No opportunity for disclosure – providers not asking the right questions • “Dual alienation”

18. Dual Alienation • ‘I’m not really all that accepted in the mental health patient community because I’m a lesbian and I’m not accepted in the lesbian community because I’m a mental health patient. I don’t feel like I belong anywhere.’’

19. Dual Alienation “The LGBTTTIQ community is already marginalized. The mental health community is already marginalized. When you belong to two marginalized groups, you become that much further marginalized.”

20. Pathologization of LGBTTTIQQ communities • History of homosexuality in the DSM • Consideration of sexuality/gender status as part of illness • Expectation of increased rates of psychiatric diagnoses • Inclusion of Gender Identity Disorder in the DSM • Requiring diagnosis for hormone/surgical treatments

21. Pathologization “I’ve had several doctors and nurses tell me that I must be depressed because I’m a lesbian and I haven’t dealt with that. That’s bullshit. I was a happy, out, and proud-in-a-relationship lesbian before I got depressed for the first time. I don’t think it has anything to do with my being gay.”

22. Gender Identity Disorder in the DSM: The Controversy Continues • Many Transgender activists/individuals want GID to be removed from the DSM • WPATH and CPATH (World/Canadian Professional Associations for Transgender Health) support the removal of Gender Identity Disorder from the DSM • If not under psychiatry’s umbrella, who will diagnose/treat? How will individuals received the treatment they need and want without a diagnosis?

23. Dismissiveness/“Neutrality” • Dismisses the potential importance of sexuality as a part of the client’s identity • Doesn’t take into account the experience of the individual

24. Positive Experiences with Providers • Can facilitate recovery in general • Can facilitate process of coming out • Greatly increases sense of connection and self-worth • Can be extremely helpful when provider is queer, but not a necessity • Importance of linkages with community “When a nurse shared that she was a lesbian: It made me feel less ashamed. It was because she is a nurse and she is gay and there is nothing wrong with that. I didn’t have to be ashamed for being gay.”

25. Negative Experiences with Providers • Negative impacts of stigma and lack of understanding on clinical work: • Overemphasis on LGBT identity • Lack of understanding > irrelevant lines of inquiry and focus • Regarding LGBT as a result of mental illness • Complicates/hinders recovery process “There was one doctor who asked me ‘If you have children, how can you be a lesbian?’” • Bottom line: Lack of client-centred care

26. Client-Centred Care “When I go see my family doctor, or my psychiatrist, or a nurse, especially about something very important, I don’t want them to treat me clinically as if I was just a walking disease in front of them. I want them to treat me like a real person. A whole person. I’m more than a walking disease or disorder. I have feelings. I have a family. I have friends. I have goals and dreams. I want them to make me feel like I matter, that all of that stuff means something to them. That they really care. If all health care folks treated their patients that way, there would be no issues about feeling discriminated against, stigmatized, or ignored.”

27. LGBTQ Persons’ suggestions for improvements in service delivery • Services that are LGBT only • Specific groups for LGBT consumers • Having an LGBT-specific provider • Better referrals/linkages with community resources • Environment in which providers are out and dialogue is open • Environment of client-centred care and professionalism

28. Defining Care LGBT Affirmative • LGBT-tolerant Aware that LGBT people exist and use their services • LGBT-sensitive Aware of, knowledgeable about, and accepting of LGBT people • LGBT-affirmative Actively promote self-acceptance of an LGBT identity as a key part of health and recovery

29. Allies • If you’re not LGBTQ yourself, become an ally.

30. What constitutes a positive space? • Inclusive language • Lack of assumptions • LGBT posters/pamphlets/signs • Respect • Acceptance and celebration of diversity

31. How do you use inclusive language? • Asking the Right Questions – CAMH • Use gender neutral language – no assumptions! • Reflecting back language used by client • Normalizing the questions

32. Think! • What can you do to improve health care access and servicesfor LGBTQ individuals in your community?

33. What can you do to improve the situation? • Reflect on your own reactions and feelings • Examine your own language use • Educate yourself – take action to be an ally • Speak up when you see discrimination, insensitivity, gaps in knowledge and action • Advocate for policy changes that are LGBTQ-affirmative • Include gender identity and sexual orientation in a zero-tolerance discrimination policy at your facility/organization

34. Think! • Do your beliefs about sexuality and gender identity negatively affect the health care you provide for your patients? • Do you feel that you know the health care needs of LGBTQ patients?

35. Biases in Health Care Forms/Interviews • Do the forms in your medical clinics have boxes that only offer the choices: single/ married/ widowed/ divorced? • When a female patient says that she is sexually active, is the next question automatically “What are you using for birth control?” • Are the only choices on your forms under gender, male or female?

36. LGBTQ-Affirmative Care • Instead of boxes for gender, have a blank line where patients can identify themselves as they choose, not in the rigid categories that you choose for them. • When asking about sexual behaviour, ask “are you sexually active with men, women, or both?” And then, only if appropriate, ask about birth control. • Ask all your patients about domestic violence using the terms “partner, family member, or caretaker” instead of “boyfriend or husband”.

37. LGBTQ-Affirmative Care • When treating a transgender individual, use the pronoun appropriate to their preferred gender. If unsure, always ask your patients what pronoun they prefer. • Don’t make assumptions about your patients based on their stated gender or sexual identity. • Use gender-neutral language(e.g. partner, significant other). • Encourage your patients to include their family of choice in their health care.

38. TREATMENT DO'S AND DON'TS DO’S • Use the proper pronouns based on client’s self-identity when talking to/about transgender individuals. • Allow transgender clients to continue the use of hormones when they are prescribed. Advocate that the transgender client using “street” hormones get immediate medical care and legally prescribed hormones. • Allow transgender clients to use bathrooms and showers based on their gender self-identities.

39. TREATMENT DO'S AND DON'TS DO’S • Ask all clients about their sexual orientation and gender identity. • Be guided by your LGBTQ clients. Listen to what they say is comfortable for them. • Acknowledge clients’ significant others and encourage their participation in treatment. • Require all clients and staff members to create and maintain a safe environment for all LGBTQ clients. • Post a non-discrimination policy in the waiting room that explicitly includes sexual orientation and gender identity.

40. TREATMENT DO'S AND DON'TS DON’TS • Don’t call someone by pronouns that they do not identify with. • Never make a transgender patient choose between hormones and treatment and recovery. • Don’t make atransgender patient be responsible for educating staff. • Don’t assume that individuals who are transgender are gay. • Don’t make transgender individuals use bathroom facilities that are incongruent with their preferred and presenting gender. • Never allow staff members or clients to make transphobiccomments.

41. TREATMENT DO'S AND DON'TS DON’TS • Don’t label your clients. • Don’t pressure clients to come out. Respect their sense of where they are in this process and their need to feel safe. • Don’t ignore significant others and family members. • Don’t interpret on behalf of the client, e.g., “It must be hard being a lesbian,” or “You must be angry because your parents don’t accept your being a person of transgender experience.” Instead, follow your client’s lead.

42. Resource for Transgender Individuals and Clinicians: “True Selves” by Mildred Brown

43. LGBTQ Resources for Clinicians

44. Web Resources • www.thewellhamilton.ca – The LGBTQ Community Wellness Centre of Hamilton website contains information regarding local resources and events • www.rainbowhealthontario.ca – Ontario-wide resource for LGBTQ health • http://www.camh.net/Publications/Resources_for_Professionals/ARQ2/arq2.pdf - Asking the Right Questions Manual from CAMH – helpful resource for knowing how to ask questions regarding sexuality and gender identity • www.pflag.org – Parents and Friends of Lesbians and Gays – Organization that supports families and friends of LGBTQ individuals. • www.thetrevorproject.org– The Trevor Project – Suicide Prevention for the LGBTQ community

45. Web Resources • www.fenwayhealth.org - The Fenway Institute works to make life healthier for those who identify as LGBTQ, people living with HIV/AIDS, and the larger community. • http://www.glma.org - The Gay and Lesbian Medical Association exists to maximize health care for LGBTI individuals. • www.transpulse.ca - The Transpulse Project website contains information regarding a recent study of health care disparities within the transgender community. • http://www.transgendercare.com/default.asp -TransgenderCare is a website designed to help those looking for a better understanding of male to female transitioning.

46. Web Resources • http://www.gender.org - Gender Education and Advocacy is a U.S. National organization focused on the needs, issues, and concerns of gender variant people in human society. • http://www.wpath.org - The World Professional Association for Transgender Health is a professional organization devoted to the understanding and treatment of gender identity disorders. • http://www.isna.org - The Intersex Society of North America is devoted to systemic change to end shame, secrecy, and unwanted genital surgeries for people born with an anatomy that someone decided is not standard for male or female.

47. Questions? He who asks a question is a fool for five minutes He who fails to ask a question is a fool for life Old Chinese Proverb