Comments on CMS RFI on Essential health Benefits

2: Change Organizations as Well As People

a. We highlight two examples from The National LGBT Cancer Network Best and Promising Practices

1: Promote LGBTQI professional safety and leadership in public health. The first resource for LGBTQI expertise is an institution’s own staff. Are LGBTQI staff valued? Have the institution formed an internal advisory group to assist with agency engagement? 

2: Include LGBTQI community members in policy planning steps. The second resource for LGBTQI expertise is local community leadership. Does the organizations routinely make sure LGBTQI are represented on advisory bodies and review groups? Does the organization ask the same of grantees?

Guidance for how institutions and individuals can be allies and champions of safe and welcoming care for LGBTQI people can be found in Recognition Criteria of the National LGBT Cancer Network. For institutions, the focus is on policies, trainings, and facilities. For the individual, the focus is on experience, commitment, and accountability. 

Prominently display a patient bill of rights that explicitly includes the rights of transgender people.  An example is excerpted below and available in full here:

3: Prepare for Your Audience

Part of what the trainer’s job when setting up the training is to assess the needs and find out some basics for where the learners are.  Institutions can survey the trainees ahead of time about what they want to learn.  Visiting the site of the organization and meeting with leadership and staff can be helpful in a pre-assessment.  The trainer can ask department leadership “What do you see as the most important thing for me to convey to your staff?”  Answers will vary, but the process gives people the opportunity to identify what is not known, lets the leadership define what their goals are, and can identify an LGBTQI champion to carry the torch on establishing an institutional commitment to LGBTQI cultural competency.

If possible, do an online survey that collects data from learners ahead of time. This gives the trainer something to bring it into the room and talk about. It lets people realize that they are not only person with questions and is another way for folks to learn from each other. For some people, seeing a filtered version of what they said may help them be more willing to talk about their journey.

4. Curriculum Fundamentals

a. Nothing in this subsection.

b. Examples which focus solely on the health inequities of LGBTQI patients may reinforce negative perceptions of LGBTQI people.  It is important to include examples that provide information about the resilience of the LGBTQI communities.

What Goes Unsaid, the video and accompanying resource guide from the National LGBT Cancer Network, provides three examples of members of the trans community that focus on strengths. 

Patients prefer for providers to mirror the language the patient uses to describe themselves.  It helps for the patient to feel seen and understood by their provider.

Making assumptions about your LGBTQI patients can potentially result in missing important clinical indicators. Avoiding stereotypes includes removing heterosexist assumptions from their speech.  This takes practice.  For example, when entering an examination room, instead of asking, “Is this your husband?” or “Is this your wife?”, ask “Who have you brought with you today?”  Another way to remove assumptions from speech is instead of asking “Who’s kid is that?” or “Do you have children?” the provider could ask, depending on the clinical relevance, “Are you parenting?,” “Have you parented?,” or “Have you given birth?”

It is important that providers do not ask questions in a way that allows the provider to avoid subjects which may be uncomfortable to the provider. For example, some providers are uncomfortable asking questions about sexual behaviors. This discomfort can be reduced by training and education. Learning to take a sexual history is available as a free CME at the Fenway Institute’s National LGBTQIA+ Health Education Center.

Another stereotype is that older adults are not sexually active.  Unfortunately, some providers stop asking about sexual behavior with older queer adults.  Providers make assumptions about the patients sexual behaviors, and fail to take the opportunity to ask questions or provide sexual health care that many seniors need.

Even highly skilled and knowledgeable providers can make assumptions about a patient’s needs.  For example, a provider with a speciality in gender transition-related care may assume that a transgender patient is seeking hormone therapy or surgical intervention.  Instead, a provider can ask questions about the transition goals of a transgender patient.  Many transgender patients have non-medical transition related goals, and each has specific goals that align with their particular needs.  In alignment with the goal of  informed consent, the provider can help the patient consider the variety of gender affirming treatments to determine which is best for their individual circumstances.

An example from a clinical resident:  A provider in training at a local medical school was told to “be thorough and don’t overlook any questions, even if you think you don’t need to ask them.” The trainee had a cisgender gay-identifying man in the clinic.  When talking through all the questions about the patient’s sexual encounters, the trainee collected information about the patient’s sexual encounters with other cisgender gay men.  But the trainee didn’t ask the patient about their sexual encounters with anyone else.  The trainee had almost left the room, but the teacher asked the patient about sex with anyone else.  When asked, the patient revealed that he also had sex with women. This extra question pulled the trainee back into the room to ask the patient all the necessary questions related to sex with women.  Here the trainee narrowly avoided allowing a stereotype to reduce the quality of the care the patient received.

Another example: During a routine visit to her established primary care provider, a cisgender lesbian-identifying woman patient is asked by her provider about her methods of preventing pregnancy.  Instead of asking, “How are you preventing pregnancy?” which is a question that may seem bizarre to the patient who does not routinely have reproductive sex, the provider can ask “Can you tell me the genders of your sexual partners?“ and “Do you have any interest in reproduction? or “Do you have any plans to become pregnant?” or, “I know you identify as a lesbian, and I wanted to ask if you have any questions or concerns about pregnancy or reproduction?”  Framing the question thoughtfully reduces the patient’s discomfort; using inclusive language signals that the provider is skilled and knowledgeable.

Another example: A woman is visiting her gynecologist, accompanied by her partner, a man.  The patient is requesting help from her provider to manage irregular periods.  The partner accompanies the patient into the exam room.  The provider asks her what type of contraception she is using, to query the potential sources of the irregular bleeding.  The patient discloses that she is not using contraception because her partner is a transgender man.  Afterward, the provider refuses to make-eye contact with the patient or their partner, and, embarrassed, fumbles, forgetting to ask important questions.  The provider quickly ends the visit by recommending a specialist.  The patient leaves the visit with a sense of confusion and embarrassment.  What could the provider have asked to avoid assumptions?  How could they have reacted to reduce the awkwardness?

Another example:  Alan, a cisgender gay man, has been admitted to the emergency room with pain in his chest.  He is hooked up to a monitor and has undergone a full battery of cardiac screening tests, and now is waiting for the results from the attending physician. Robert, Alan’s gay male husband, is sitting by the bedside, holding Alan’s hand and is clearly very worried. The doctor comes in with another clinician who he introduces as a resident. The doctor glances at Alan’s chart and says “I see you checked off your sexual orientation as gay. Have you taken an HIV test recently?” Alan quickly answers “I know I am negative. This is my husband Robert. We are married”. The doctor says to Alan without looking at Robert, “I would strongly recommend that you take another HIV test while you are here today.”  Robert interrupts and appears very upset. “Excuse me, Doctor, but my husband may be having a heart attack. Can you please tell us right now what is going on with the cardiac tests results?”  Why are Robert and Alan upset?  What are the biases and microaggressions here?

Another example: A woman is visiting her gynecologist. The provider asks the patient about her periods. The patient replies that she does not get periods.  The provider reacts with alarm and skepticism, which embarrasses and distresses the patient.  This negative reaction reinforces the patient’s sense that the health care environment does not understand her or views her, a intersex woman, as abnormal.  The provider could have initially inquired in a neutral, non-judgmental way about the reason for a lack of periods.  

c.

i. The basic concepts and essential terminology are routinely the presented in introductory presentations. These resources were produced experts at the National LGBT Cancer Network:

• Definitions are available here.  The appropriate language in LGBTQI communities change frequently so trainers should update their trainings regularly to ensure accurate and respectful definitions are being shared. 
• A helpful resource for teaching the distinction between gender identity, gender expression, and sexual orientation is the Gender Unicorn.  
• Here is a simple, text-based, slide that distinguishes between gender identity and sexual orientation.    
• Some learners find it helpful to understand that LGBT is an umbrella term that encompasses many communities. 
• An example of a slide with definitions of some common sexual orientations.  
• An example of a visual, this slide helps distinguish between sexual orientation, gender identity, and gender expression.

ii. Thanks to the efforts of researchers and advocates, every year more information is available on health disparities in LGBTQI communities.  Some information on transgender health disparities can be found at U.S. Trans Survey, conducted by the National Center for Transgender Equality. National level data from the federal government exists on particular issues like tobacco use, substance abuse, and HIV.  General information on health disparities is often effective in communicating the need for LGBTQI organizational and cultural competency.  Resources for data on LGBTQI discrimination on national and state levels is available at the Williams Institute and the Movement Advancement Project (MAP).

The National LGBTQIA+ Health Education Center and the National LGBT Cancer Network have excellent collections of resources for particular populations.  For training pediatricians and geriatricians, the special needs of LGBTQI youth and elders should be considered.  Lesbian and bisexual women are particularly understudied, making cultural competency for queer women particularly important to consider.  

For information on the long-term effects of discrimination and research on the health needs of LGBTQI people, search the National Library of Medicine.  PubMed.gov has publicly available, peer-reviewed, up-to-date research relevant to particular medical specialties.  Note, some of these research results are from studies conducted with fewer participants than are available from national surveys.

Depending on the practices of each jurisdiction, state and city level data on LGBTQI community health disparities may be available. This information may be collected by the state, county, or city public health departments.

Click here for more on organizational factors that contribute to creating a culturally competent and welcoming clinical environment as a whole with both administrative and provider orientated examples and suggestions. 

iii.  Federal nondiscrimination standards in healthcare arise from Section 1557 of the Affordable Care Act.  An overview of state level non-discrimination provisions can be found at the Movement Advancement Project (MAP).  Many cities have their own non-discrimination protections, which can be found through the local LGBTQI community center or the local government.  Additionally, many medical professions have ethical practice standards, which can be located through the state medical boards.  Finally, the institutional policies and organizational mission and purpose can be relevant sources of non-discrimination requirements, depending on the audience.

When traveling to other states, look up the laws in their state and provide an overview of what protections or lack of protections are in place for LGBTQI people. For example, New York City has specific protections for LGBTQ patients in their LGBTQ Health Care Bill of Rights, outlines legal protections for LGBTQ+ individuals in health care settings. 

If there are no protections, some trainers spin it in a positive way by saying, “Even though there are no specific legal protections in your area, it’s great that you have made the effort to go above and beyond the call of duty to provide high-quality services to these patients.” 

iv. Trainers can use their own experiences as a training tool to teach about intersectionality.  Using the “body” or experiences of the trainer and their own intersecting identities can be helpful, especially for trainers who are part of multiple minority communities, for example, trainers who are Black lesbian women.  Personal stories are often the most powerful.  However, sharing personal stories also carries risk, and trainers should be careful about what information they disclose.

Appropriate, safe and helpful disclosures depend on the training context and circumstances. Expert trainers may recount their own experiences of learning to challenge their biases or relevant experiences of discrimination.  Some reviewers expressed that trainers using personal experiences can be alienating and can be perceived as unprofessional.  While trainers can use their own vulnerability as a model for learners, they also need to be careful to protect themselves and to ensure learners are prepared to understand the relevance and impact of the account.  For example, sharing personal experiences of discrimination can be potentially retraumatizing to trainers and some learners if the dominant group members are not equipped to reflect on its application to their practice.

Using celebrities or fictional characters as examples of intersectionality can provide distance for the trainer and might increase the familiarity and comfort of some learners.  Celebrities can be useful cultural bridges for some learners.  One common example is the famous statement from Audre Lorde:  “I am a Black, lesbian, mother, warrior, poet.” This can be an excellent introduction into the way that intersectional identities show up in people’s lives.

Videos such as “What Goes Unsaid,” from the National LGBT Cancer Network, can help introduce the importance of treating the whole patient.  

The disparate impact of the COVID-19 pandemic on the Black and Latinx communities has highlighted the inequities in our healthcare system.  Trainers may find it useful to examine the racial and ethnic disparities in mortality from COVID-19 to help learners see the persistent effects of marginalization on health.

v. Whole trainings can be devoted to discussing microaggressions.  This video is a humorous illustration on what it feels like to be on the receiving end of microaggressions: Microaggression Mosquito video.

The American Psychological Association has collected tools to encourage self-reflection on socioeconomic status in students.  Our experts recommend the “My Multicultural Self" exercise 

My Multicultural Self example 1

My Multicultural Self example 2

These activities provide space to talk about hidden and public identities and to identify and describe flaws in stereotypes.  This activity is also an experience in understanding that the salience of our identities depends on the context.

Depending on the training environment, the trainer’s own lived experience can be a teaching tool in intersectional privilege and oppression.  For example, one expert trainer, who is an elder white-passing Latina introduces herself speaking in Spanish.  Using Spanish lets the learners know that she is “an old Mexican lady, not an old white lady.”  This subverts the expectations of learners.  In this case, the trainer is equipped with an acute awareness of their privilege as a light-skinned, light-eyed Mexican, and works to undermine stereotypes and challenge assumptions of whiteness and of Hispanic culture.

For another example, the same expert trainer from the previous example can talk about when she was younger and had typically racist beliefs about people that were darker than her.  She can talk about a lifelong process of learning awareness and self-reflection.  The trainer can use their journey, going all the way back to talk about where the racist beliefs were learned, and how to trace them from events in their life.  In this example, self-disclosure is a tool for learning.  This lets the learners know that the trainer has learned and is working through their own biases and emphasizes that cultural competency is a continuous learning process aided by curiosity, thoughtfulness, and humility.  

vi. The skills to create an inclusive workplace take practice.  Learners and trainers benefit from receiving concrete tools, often in form of helpful mnemonics, that can be deployed strategically in their work or training environment and from humanizing examples which provide the emotional grounding to allow them to respond to negative attitudes and behaviors with empathy and understanding.

The video “Ouch, that stereotype hurts” while a bit dated, provides accessible examples of soft skills for how to interrupt inappropriate comments, jokes, or remarks in the workplace.

A training video on microaggressions: Vanessa Goes to the Doctor.  

The CLARA method is a widely used de-escalation and communication technique for navigating difficult cross-cultural communication. Find a helpful worksheet here and an alternative one here. 

Center yourself or Calm yourself
Listen
Affirm
Reflect
Ask for elaboration or Add more information.

The National LGBT Cancer Network Curriculum has collected a diverse set of strategies for addressing negative attitudes in their toolkit: “BEAFARRUP” Strategies:

Be Direct –“That sounds pretty judgmental and I don’t think we as practitioners can do our job well by projecting those views.”
Educate – “Actually if you look at various literature, trans, GNC, intersex people have always existed throughout history…they just used different words.”
Assume Good Intention –“I know you don’t mean to offend anyone on purpose, but when I hear you say Y, it makes me more closed off from you because X.”
Fall Back on Policy/Rules –“Saying (or doing) that actually violates our non-discrimination policy here at X.”
Asking questions – “What do you mean by X, can you elaborate?”
Relocate/Postpone (consider the time + place) – “Do you have a minute? Can we chat over in the next room?”
Re-direct (If there a safety concern with the other strategies) – “Maybe we should focus on X since we only have an hour to do Y.”
Use Humor – “Well, my closet is pangender with a sprinkle of genderqueerness.”
Personalize– “My brother just came out to me as trans so when I hear people say Z, it personally offends me and makes me feel X.”

Click for a paper with more on organizational factors that contribute to creating a culturally competent and welcoming clinical environment as a whole with both administrative and provider orientated examples and suggestions.

Consistently, the best advice for making mistakes is to simply acknowledge the mistake, apologize, correct the mistake, and move on.  It is important not to make a big dramatic moment about the mistake.  Making a “big deal” about the mistake can compound the embarrassment and inappropriately focus more on protecting the feelings of the person in the dominant culture.  Instead, it is better to respectfully apologize, quickly correct the mistake, and move forward.  This strategy, particularly in a work environment, prioritizes the mutual goal of creating a respectful environment and minimizes the overall impact of the error.  Note, it is essential to correct the error.  Environmental improvements require practicing behavior change.  

In their 2-hour training on Gender Appropriate Language, Howard Brown trainers spend time explaining to people how to apologize and then give them time to practice.  “Stop and look someone in the eye, acknowledge the mistake and then move forward.  If you want to have a meltdown, you can do that with a friend, away from the person you misgendered.  If you still need more training, then it is available to you.”  Training is very helpful because people are really concerned about making mistakes and training gives them the language to make mistakes and move forward.  In the healthcare setting, everyone shares a common goal of making a safe space for the patients by getting rid of errors in the environment, so they will correct one another.  In this context, it is a “call in,” not a “call out.”  A “call-in” is a correction done in a compassionate way.  Making the reminder keeps everyone on track.  It is possible to call-in or remind people in a variety of ways, depending on the context.  For example, speak face-to-face in meetings, communicate by handwritten notes, or send it in an email.  

vii. Part of being culturally competent involves recognizing that LGBTQI people have to come out at every stage of the process.  They have to come out to the front desk, to the nurse, and to the provider.  Health care providers can make answering questions about sexual orientation and gender identity routine for patients by including these questions on intake forms.  Best practices include making it a standardized part of demographic data collection.  When patients see that it is part of the intake process for everyone, it sends the message that this place can be culturally competent and friendly to LGBTQI people.  Including information on medical records can help by reducing the burden on the patient so they are able to focus on the decision-making they do in the visit.

In some settings LGBTQI patients may feel unsafe disclosing their status as a sexual or gender minority.  For example, asking verbally for sexual orientation and gender identity in a crowded emergency room or in the waiting room is not appropriate.  The patient should be given reasonable privacy protections and opportunities for privacy when asked to disclose potentially stigmatizing information.  

Providers may need to navigate LGBTQ care differently for a pediatric population.  For example, an LGBTQ patient may disclose their sexual orientation and/or gender identity to the provider, but not to their parent/caregiver. Then the provider must document this information appropriately so as not to inadvertently out the patient to their parent/caregiver if the patient does not want that information disclosed. These changes require thoughtful institutional policies and may present challenges in the record keeping and billing process.

Institutional change can be challenging, especially when it comes to changing routine behaviors.  In particular, it is challenging to train providers to introduce themselves with their pronouns.  To normalize questions about an individual’s pronouns and otherwise signal that the provider/health care institution views all gender identities as normal, the provider might introduce themselves with their own pronouns, for example: “Hi, I am Dr. Smith and I use she/her pronouns.” Occasionally some patients are confused by the pronoun question, but this is an opportunity for the provider to demonstrate the cultural competence of the institution in creating a welcoming environment that includes everyone.

When taking a sexual history and/or asking about sexual orientation and gender identity, it is helpful to phrase the question in an open-ended manner. For example, rather than asking “Do you have sex with men, women, or both?,” which implies a binary way of viewing and thinking about gender and people’s sexual partners; ask “What are the genders of people you are attracted to?” Or “What are the genders of people you have sex with?” This simple change of phrasing is inclusive of non-binary people. Learning to take a sexual history is available as free CME at the National LGBTQIA+ Health Education Center.

Learners may benefit from pre-writing short scripts to learn how to introduce themselves with their pronouns and to ask for others.  This exercise is helpful for frontline staff as well. If someone gave a front-desk person a name different than on their paperwork, they can develop scripts to ask in respectful, general ways to find the information they need.  Each person’s specific needs will depend on their different job description.

Queer family structures are diverse and part of cultural competency is avoiding language that signals an assumption that the individual is in a different-gender relationship, is in a heterosexual relationship, or is cisgender.  Rather than asking, when a person arrives with another person, “Is this your spouse/partner/family member?” ask “Who have you brought with you today?”

viii. Before a member of the organization asks a question related to gender, sex, sexual or affectional orientation, sexual development, family structure, employment, or immigration status, they should ask themselves:  “Why do I need to know?”  They should have a clear and appropriate reason for asking. If you are doing it to provide better care, it is probably appropriate.  If the question is not related to care, it is probably not appropriate.  For example, a patient with a sprained ankle does not need to be subjected to questions about their sexual development.  When a client is asking for the bathroom, tell them where the restrooms are, do not ask which restroom they are looking for.

Intersex people experience inappropriate curiosity as a barrier to healthcare. Intersex (people with differences of sexual development, or DSD) is a blanket term that applies to relatively large minority of people: 1.7%, or 1 out of every 58 people are intersex.  Practitioners in many fields are likely to have intersex patients and should be prepared to provide excellent care, including the knowledge that many in the intersex community experienced nonconsensual interventions in infancy or childhood that may have caused extreme distress.  It is important to avoid expressing surprise or irrelevant curiosity if an individual discloses an intersex condition; assure individuals that there is a wide range of normal sexual development and that the person’s information will be completely confidential.

Trainers can compare good curiosity vs. inappropriate curiosity through examples and case studies. 

For all patients, only ask for information that the patient needs you to have, not the information that you think you need to satisfy your curiosity.  Only ask questions that are related to the patient’s chief complaint that day.  For example, a story: “A trans individual was experiencing shortness of breath and she went to a hospital emergency room because she was scared.  In the hour that she was there, no fewer than 40 people came by the ER to just look at her.  After that hour, she called a friend and traveled 2+ hours to a hospital that was familiar with her. The staff at the second hospital were able to check out her lungs and treat the pneumonia that caused the shortness of breath.”   If someone comes in with shortness of breath, and they are trans, you shouldn’t start asking them questions about past surgeries, unless they are immediately post-operative and you are concerned with follow-up.  Unless it is specific to their chief complaint, you don’t need to ask them.

Overall, general questions are safer to ask.  For example, if someone has been on hormones for a long time, you can ask “I see that you’ve been on [hormone] for a long time. How is that working for you? Are you happy with your care?”  General questions can let patients know you are knowledgeable and caring but allow the patient to remain in control of how much detail to share and where to focus the provider’s attention.

ix. As described in the chart below, stigma impacts access to high-quality health care because both providers and patients come into the clinical environment with complex identities and social ties.  Clear communication and mutual understanding must be built for successful shared decision making to take place.   Mutual understanding is a challenge within the context of these complex identities.  Cultural competency provides the tools to communicate an attitude of respect and appreciation for the patient’s closely-held identity and self-perception.

What Goes Unsaid, the video and accompanying resource guide from the National LGBT Cancer Network provides examples that demonstrate how stigmatizing events create barriers to healthcare for three members of the transgender community.

The Association of American Medical Colleges has a searchable library of educational resources available online at MedEdPortal with case studies of LGBT patients interactions.  

Introductory trainings on LGBTQI cultural competence usually covers stigma’s impact on health.  Trainings should talk about how experiencing stigma throughout a lifetime can result in development of  coping skills that are not necessarily healthy.  For example, a lifetime of using cigarette smoking to socialize as stress relief can lead to elevated risks of lung cancer.

Stigma across the life course is a barrier to finishing education, a barrier to employment, and a barrier to health insurance.  For example, family rejection of an LGBTQI child, like an adverse childhood event, negatively affects the life course of the individual.  Family rejection impairs a person’s ability to access housing, nutrition, and clothes.  Without the necessities that many people take for granted, it is difficult to benefit from or access education.  Lack of education impedes access to employment, which, due to the predominance of employer-sponsored health insurance, impedes access to healthcare.  Through each of these difficulties, LGBTQI people are learning to navigate the wider social structures to find safety and security.  Historically, sexual and gender minorities have learned to survive by hiding their identities from the dominant culture.  LGBTQI culture creates alternative norms and structures that allow us to survive and find happiness.   However, a lifetime of surviving stigma can lead to fear of going to the doctor for fear of experiencing further stigmatization from providers.

Another example: A provider described the story of how an older, heterosexual Black woman came to be living with HIV.  The patient was recently widowed.  Her children were encouraging her to date romantically.  She begins to date the deacon in her local church. After a few weeks of dating, they begin to be sexually intimate with each other.  Around this time the patient begins to feel ill and goes to her doctor.  Her doctor does not ask about sexual history for a long time.  When finally she is asked about potential HIV exposure, the patient says “No! I could not have been exposed.”  Thankfully, based on the HIV screening guidelines, she does get an HIV screen. The patient finds out that she is positive and, after contact tracing is completed, her sexual partner also tests positive for HIV.  After having conversations with her partner about their HIV status the patient begins to experience HIV stigma from her church community.  The patient was strong in her faith and a long-standing member of her church, yet she lost many friends over the diagnosis.  She experienced internal stigma from her own shame and embarrassment and self-blaming for contracting HIV, compounded by external stigma from her community, due their blaming assumptions and negative stereotypes of people who have HIV.

x. The most straightforward way to communicate respect for a patient’s sexual orientation, gender identity, and gender expression, and variation in sex characteristics/intersex status is to mirror the language the patient uses to describe themselves.  It helps for the patient to feel seen and understood by their provider.  It is important to use the patient’s language to describe their body and its parts.  For transgender and intersex persons in particular, providers should be sensitive of the potential for trauma when using the medicalized language describing sexual organs and secondary sexual characteristics.  Transgender and intersex individuals may have developed alternative vocabularies for describing themselves and navigating the difference between their gender identity and their biological anatomy.  Providers can access this vocabulary by asking their patients for their preferences.

Providers can also communicate respect for their patients by mirroring the language they use to describe their behaviors and identity.  In particular, it may be important to distinguish between sexual orientation and sexual behavior. For example, some men who have sex with men do not describe themselves as gay or bisexual, and may even describe themselves as heterosexual or straight.  A provider can be prepared for and catch these important differences by asking open-ended questions and listening closely to the answers.

Providers may not be aware of how impactful their responses are on their patient’s health and well-being.  Providers should refrain from expressing shock or surprise towards patients.  This includes maintaining neutral facial expressions, body language, and language.  For example, a Latina woman, who identifies as “transexual” is telling a new provider of her experiences doing survival sex work.  She tells her provider that she is HIV negative.  During previous medical encounters, she has experienced shocked reactions from providers.  This reaction upsets her and it depresses her motivation to continue treatment because it feels to her that providers are assuming that transgender women of color are HIV positive.  However, in this care encounter, her provider expresses praise, gratitude, and congratulations on her status in a way that emphasizes the patient’s strength.  This positive reaction worked to counter previous negative feelings and helps to retain the patient in care and builds a foundation of respect for mutual decision making.

To emphasize resilience, do not tell people that they are brave or resilient. Rather, acknowledge that the hardships and tests which LGBTQI people are subjected to require them to build coping mechanisms and alternatives to the dominant culture.  LGBTQI people, like all people, develop coping mechanisms for surviving the trauma in their lives, perhaps through self-medication with alcohol or illicit substance use, or with nicotine or food.  The disproportionate experiences of trauma in LGBTQI communities contribute to the disproportionate rates of substance use disorder, tobacco use, and obesity among LGBTQ people.

Unfortunately, some healthcare systems exclude the support systems for LGBTQI people, for example, hospital policies that exclude non-traditional or chosen families from visiting patients.  LGBTQI people have created systems and families in their lives that support happiness.  Refusing to allow LGBTQI people to choose their own families or allow families to be with them during medical care is traumatizing and harmful to LGBTQI people.  Welcoming LGBTQI chosen families supports the patient’s recovery.

Some trainers use, as simulations, quotes from gay families relating their negative experiences in healthcare encounters.  The trainer shows quotes from these experiences and lets the healthcare provider learner think about how to disrupt these negative interactions.

d. It is important that the general clinical environment looks like an LGBTQI affirming and culturally competent place.  Patients are looking for clues that this will be a friendly and affirming space and these are the first things they see.  The pictures, art and educational materials on display should be inclusive of people with different sexual orientations, gender expressions, and different races and ethnicities.  Successfully changing organizational cultural requires buy-in from the whole institution.

This article on primary care affirming spaces describes organizational and structural factors that contribute to a welcoming environment.  LGBTQI cultural competency must be built into the deeper structural elements of a healthcare institution.  It should be a consideration when constructing the electronic medical records system, the architecture of the building, and in the evaluation and diagnosis of medical needs.  Here are some slides with two case studies excerpted from a Mount Sinai Health System cultural competency training that demonstrate some of the ways that patients can benefit from cultural competency.

Institutional policies to change the environment to be more LGBTQI-affirming  include using LGBTQI images (e.g., rainbow lanyards for ID badges, posters, Safe Zone stickers); ensuring that all public-facing staff ask about individuals’ pronouns and uses those pronouns; provide all-gender restrooms throughout the facility; include magazines in the lobby that reflect various family types and identities across race/ethnicity; staff and providers wearing pronoun pins and providers introducing themselves by including their own pronouns; and using inclusive intake forms that collect data on sexual orientation and gender identity and expression.

Vulnerable patients are looking for signals that they are safe during the medical encounter.  Pronoun badges and other visible signs of structural cultural competency are important indicators that an organization is a trans-affirming environment. Pronouns pins, rainbow pins for lanyards and lab coats are an invitation for people to share with you about the queer people in their life.

An example in a story: “An attending physician, a cisgender heterosexual woman, at a local hospital called for regular cultural competency trainings with third- and fourth-year medical residents.  She was given a pin and suddenly out of the woodwork, patients started telling her about their children and friends who are LGBTQI.  She asked a patient she had for years, who is living with HIV, “Do you have anyone at home who can take care of you?” The patient responded, “Yes, my husband.” The provider was stunned at the patient’s declaration, as he had never disclosed his sexual orientation or partnership status during any of their previous encounters. 

One way to help providers be more aware of how to create a welcoming environment is for them to be familiar with the cultures of the communities they serve.  LGBTQI culture is accessible in the mainstream media through television and movies, for example, the show Pose or the documentary Disclosure, both available on Netflix. 

Organizations should also strive to be visible in their communities through a presence at their local LGBTQI community center.  Health care institutions can be visible by setting up posters or pamphlets and by participating in community events.  It is important to be careful when reaching out to a new community! Even within the same city, the markers of LGBTQI cultural competency can differ from neighborhood to neighborhood.  Rather than trying to translate culture, it is recommended that trainers learn what the culture is and then try to clearly communicate your understanding and the remaining questions.  Being visible and being present are the first steps toward becoming a welcoming and affirming environment.  However, even if an organization can identify their LGBTQI patients, if they are not aware of how to treat them with respect and to care for them with dignity then your institution may be contributing to the historical malpractice and continuing the harm that LGBTQI people have experienced from the general medical community.

Helping young LGBTQI patients engage in shared decision making is also important.  Sometimes LGBTQ children cannot come out to their parents, and intersex children may not have developed the vocabulary and resilience to verbally disagree with their parents.  Providers can provide a safe space for children by incorporating practices that teach children autonomy over their own body.  For example, asking children about their health, and waiting for and listening to their answers.  Giving the children options and control over their care environment, and children having responsibility to communicate with their providers without parental interruption, demonstrates at an early age that children are responsible for their health.

Ongoing training is important, as standards of care for LGBTQI people change regularly. In the event of an incident where a patient has a negative experience with your organization, it is better to proactively reach out to experts in the local LGBTQI community to support your institution in addressing the issue.  Restorative justice processes are helpful in identifying the sources of harm and finding opportunities for healing, and can be accomplished in a way that affirms the dignity of each person.

As noted, these guidelines and considerations apply with equal or greater relevance to the Black and brown communities.  Communities of immigrants, Native peoples, and English-language-learners experience barriers to accessing healthcare and all incorporate LGBTQI people within them. 

e. Federal nondiscrimination standards in healthcare arise from Section 1557 of the Affordable Care Act.  An overview of state level non-discrimination provisions can be found at the Movement Advancement Project (MAP).  Many cities have their own non-discrimination protections, which can be found through the local LGBT community center or the local government.  Additionally, many medical professions have ethical practice standards, which can be located through the state medical boards.  Finally, the institutional policies and organizational mission and purpose can be relevant sources of non-discrimination requirements, depending on the audience.

Patient-centered care is at the core of providing culturally competent care. To help illustrate this point, it may be helpful to remind providers that in almost all situations, medical providers are required to obtain informed consent from their patients before administering care.  At a minimum, this includes discussing the variety of treatment options available to patients.

Some federally funded medical providers may have additional compliance concerns that arise from requirements for meaningful use of electronic medical records. In particular, trainers could help institutions determine if institutional policies fulfill requirements related to collecting data on sexual orientation and gender identity.

Receiving a high score on the Human Rights Campaign’s Healthcare Equality Index can be a motivator for some institutions seeking a positive reputational boost.  Sometimes organizations are motivated to avoid reputational damage from negative publicity for discrimination experienced by an LGBTQI community member.

Organizations may be increasingly motivated by the consequences of failing to comply with legal non-discrimination requirements.  Lawsuits can be brought against health organizations for failing comply with federal, state, or local non-discrimination requirements.  Other institutions, fearing lawsuits, may proactively set up training sessions for their staff.  Trainers may find that examining public allegations of incidents that can lead to the lawsuits are effective training tools for some providers.  Trainers may find it effective to emphasize how litigation can be avoided by well-trained and culturally competent providers and staff.

Some trainers can use the text of the organizational mission or vision, usually found on their website.  These are statements of values that staff and providers usually commit to when they agree to work with the institution.  Organizational mission statements are a potentially useful starting point for building consensus on community norms and values.

f. Role play in different clinical scenarios is the most common method of practicing skills building.  Here are a few materials from our expert trainers that should be modified and updated to fit the needs of the individual trainers.

• Facilitator instructions for role-play activities.
• A guide for discussion and debrief after role-play activities. 
• A resource sheet supporting shared-decision making role-play activities.
• A role-play for a behavioral health provider in a clinical practice, concerning interpersonal violence. 
• A role-play for a social worker in a clinical practice, concerning older adults. 
• A role-play for a nurse practitioner in an FQHC, concerning a PrEP candidate.
• A role-play for a primary care practitioner in a large health center, concerning a transgender patient.

The Association of American Medical Colleges has a searchable library of educational resources available online at MedEdPortal with case studies of LGBT patients interactions for different clinical specialties.  

Scenarios that are specific to clinical or practice areas help learners understand the importance of LGBTQI cultural competency for their patients and clients.  For example, in a training for a pain clinic at a pediatric institution, some participants did not understand how LGBTQI issues were relevant to their clinical practice.  The trainer was able to describe that many LGBTQI youth came to the clinic with stomach pain that was eventually assessed as a physiological result of minority stress. In other words, the young person had a tremendous amount of anxiety about their experiences.

Dentists also should be trained in LGBTQI cultural competency.  Everyone has teeth and dental care is (or should be) standard medical care.  LGBTQI cultural competency training for dental professionals should include sources of stigma for LGBTQI people.  LGBTQI people are at increased risk of eating disorders stemming from social pressure and not wanting their body to develop in certain ways or not wanting to sexualize their body.  Substance abuse and anorexia are both issues that show up in your teeth. Cisgender bisexual and lesbian women are more likely to be overweight, and cisgender gay and bisexual men are more likely to be underweight.  Queer youth are more likely to be victims of assault and fear coming out.  Sitting in that dentist chair, where the patient cannot leave and the lack of bodily autonomy and control are visceral, can be very fearful and traumatizing.  Dentists need to be aware of these issues, be able to see the signs, and talk to their patients.  The dental professionals need to know how to talk to them and let patients and clients know that the provider is there to help them.  The dentists and other professionals need to be culturally competent to speak to their patients so they can feel comfortable in the chair and receive the whole benefit of health care. 

One expert trainer described that in trainings for nurses conducted through HEALE, learners are taught to screen and treat the body parts that people have. Providers were trained to be able to talk to patients about the body parts that everyone has.  This trainer used the example that every patient has an anus.  This is particularly important for transgender patients.  For example, some learners may need to be reminded to provide a prostate exam for an elder transgender woman.  In another example, even if a trans man has had chest-reconstruction surgery, they will still need some kind of chest examination, potentially a mammography.  Because providers are members of society and their practice is influenced by that culture and society, they need LGBTQI cultural competency trainings to help them break out of the dominant cultural frame and its assumptions to consider the perspectives and experiences of their patients. 

One reviewer developed a resource for role play called “RESIST Racism” an app that works on mobile phones and discusses 3-4 different situations encountered by 3 different gay men. Users explore the situations over 7 days; and may only view one day at a time.  This extends the learning experience over more time, and may take no more than about 5 minutes each day.

g. Each patient or client brings their own unique circumstances into the clinical setting.  Some learners may create a false sense of mastery after navigating the clinical role-play.  The trainer can help learners develop humility by emphasizing the limitations of different patient profiles used in the training.  One method of doing so is by stating the lack of diversity of experience in the training participants or profiles. Ultimately, the goal is to help providers practice cultural competency by approaching each interaction with humility.  The recommended standard includes the “cultural humility” framework, which emphasizes the importance of maintaining an open attitude and curiosity about each individual and their circumstances, provider and staff self-awareness of their own biases, and a commitment to engage in ongoing self-reflection.

h. Providers may struggle with dedicating the time required to learn soft skills.  There appears to be a preference for hard knowledge over soft skills, which is reflective of their practice.  A preference for hard knowledge might present as prioritizing clinical and diagnostic tools over interpersonal skills like active listening.  Trainers can emphasize that medical care requires both sets of skills.  In addition, providers may underestimate the time commitment for trainings, so it may be necessary for trainers and organizational champions to push for more time for trainings.  Generally speaking, our experts recommend that, “if you think you need an hour, you probably need two hours.”  Trainings can be condensed, but the content reflects the commitment, therefore shorter sessions may be more appropriately framed as introductions or discussions on the topics, as they are less likely to be able to impart skills.

Because trainers are unable to cover every topic, they should provide written materials, web sites and other resources for learners to go further.  We recommend providing additional materials even for topics that the presenter is able to cover during the in-person session, as this enables the learner to learn at their own pace.

It is important to provide tips for providers and front-line staff for how to manage stress and a busy workload while giving each patient the appropriate attention.  Some grounding exercises are helpful: a simple practice of taking a moment, and a few breaths, before meeting a patient; offering a smile and a handshake or other culturally appropriate greeting; starting with open-ended questions rather than pronouncements.

Cultural competency trainings are primarily about the soft skills.  Learners can be prepared for this in the description of the class, or a description that is part of the larger course that makes it clear what the learner should expect.  It can be helpful to include role-play opportunities in which the provider can experience an encounter from the patient’s point of view.

i. Different audiences of learners will naturally require different content in each training.  Trainings should differ for different members of each healthcare organization depending on their role.

Trainers can suggest ways in which learners can learn more about the experiences of LGBTQI people who may not be represented in the training, for example, through attending local events in different communities, reading stories or articles authored by or discussing different communities, watching films or videos by LGBTQI writers with performances by LGBTQI actors.

One method to keep track of what is not being covered is to create a “parking lot” or holding space for issues and questions that arise in a training that call for additional information or attention.  A parking lot helps learners to know their questions are heard and remembered, even if the issue they bring up is unable to be addressed in full at the time it is raised.

Intersex issues are particularly likely to be unfamiliar to most learners and to many institutions. The existence of individuals with intersex traits, and the mistreatment that they may have encountered in the health care system, should be expressly named in most trainings, and resources provided to learners for more information. Many intersex individuals report having to educate their own providers and more must be done to encourage thorough full-life care. Some intersex people explain that medical professionals suggest interventions that are no longer medically indicated and/or rooted in stereotypes around sex and gender, such as a woman with an intersex variation who has healthy internal testes being told she should remove them when there is no medical need but the physician was trained at a time when individuals assigned female were routinely subjected to medically unnecessary gonadectomies.

Our recommendations are likely limited to the United States.  This is particularly important to understand when talking about intersecting identities because the history of racial oppression in the United States is different than in other places.  The history of the United States, its cultural norms, and how the dynamics of oppression manifest may not directly apply to other cultures or contexts.  These guidelines can still allow for a global conversation so long as we acknowledge that the dominant culture and historical oppressions shift in other countries.

j. LGBTQI people are present in all areas of a health care institution’s operations.  They are patients, clients,  providers, executives, security personal, environmental services staff, and front-desk staff.  Ideally, this diversity would be present throughout clinical trainings as well.  For example, if the institution has a simulation lab, the simulations should include LGBTQI patients.  Including LGBTQI people in non-LGBTQI specific trainings helps to develop the skills necessary to treat LGBTQI patients and clients with dignity and care.

5. Delivering Effective Trainings

a. Adult Learning

It is key that learners are self-motivated.  As stated, self-motivated adult learning builds on the learners existing skills and meets their immediate needs.

Pre-assessment

The learning objectives for the training should be about 60% based on the individualized assessment before the training.  This makes it more relevant to the learner’s practice.  Usually the needs assessment is made by phone call with the person organizing the training, in particular to find out if there has been an incident that needs to be addressed.

If unable to do an in-depth needs assessment, the trainer can pass out index cards at the beginning of the class and ask learners to write down questions about the topic.  The trainer can go through the questions and make sure they are answered before the session is over.  This method allows the questions to be anonymous and compensates for not having the capacity to do a needs assessment.

Another alternative to a pre-assessment is to do a quick assessment of the room at the very beginning of the training by asking: “What do you want to get out of this workshop?”  The trainer can list each answer and check them off as the training goes on.  In any case, the trainer should try to get a sense of who is in the room and give people some time to tell what they want to get out of the training.  Another interactive, learner-generated group exercise is to give learners a minute to jot down their thoughts and questions, and in groups decide on one or two priorities for the larger group.

If the learning objectives are created outside of the classroom, the trainer can contribute to an environment of self-motivated learning by circulating the learning objectives and reviewing them at the beginning.  This is an opportunity to provide a reminder of the objectives that were agreed upon before the training was started and of the things that need to be accomplished in the room.

Facilitating learning environments

One trainer recommends a ground rule: “We are all teachers and learners.”  This sets up the expectation from the beginning that the group recognizes that everyone has something to offer and something to learn, and that the trainer is there to facilitate that learning.  One trainer phrases it this way, “I am much more interested in what you have to say than in what I have to say, because I present this material a lot.  I want to know what you think of it and what your questions are.”  These phrases remind learners that “we are all on the journey together” and helps to break down the barrier between the trainer and the learner.  In adult learning environments, folks have expertise in their area far beyond what the trainer brings. 

The language of “the journey” while potentially cliché, is a reminder that trainings are just the beginning of a process.  One training is never enough, but it can be part of a life-long journey.  Learners can hear, both implicitly and explicitly that mistakes and setbacks are normal, and that learning is part of the process, so please keep going forward.  The trainer is giving them space and tools to get to a new place.

Virtual trainings

In the recent months of the COVID-19 pandemic, the in-person LGBTQI cultural competency programs are now conducted almost exclusively in online, virtual meeting spaces.  

Trainers have had to change the way they train, in the time of COVID, to account for the necessity of remote learning.  Some trainings are done in a way that people can access as recorded, self-directed training.  Self-directed learning refers to the automated presentations conducted online, which are self-paced.   Even when the learner is alone during the training, going through the talk by themselves, the training is still more effective if it is interactive.  Some interactive offline methods translate well to online, self-directed trainings.  For example, quizzes that allow the learner to measure or assess themselves against the right answer and interactive case studies where the learner engages in a simulated visit or clinical encounter and afterwards compares notes to the experts. 

Often self-directed trainings are considered “knowledge-based” trainings that are likely an efficient option for complying with different licensing requirements.  The Fenway Institute’s National LGBTQI Health Education Center has a number of online, self-guided modules that contain case studies on a variety topics related to LGBTQI health.  However, attitudes and behaviors-based trainings require different learning objectives and different methods.

Online trainings can blend technology tools together to maximize learner interactions, so picking the platform is very important.  One expert finds the Zoom platform is very accessible.  The trainer described that the Zoom platform has low bandwidth requirements and therefore increased accessibility in rural and technology-challenged places.

The technology and participation requirements vary based on the training: 

The more critical and skill practice the training is, the more important it is that they are on camera.  With skills like motivational interviewing, the participants cannot participate if they are not on camera.  The visual information from the video is helpful, even if it is limited to the torso or head.  For knowledge-based learning, there is less need to be on camera.  Virtual, or online attitudes and behavior trainings are difficult.  Trainings on cultural competency require people to reflect on the importance of their work on marginalized communities, which needs empathy and reflection.  You can make the most inroads with people when they are able to talk and have guided dialogues, skills training, role plays, and case studies.

Online trainings should be kept smaller, as small groups are better for practicing skills and learning from each other to develop skills.  The smaller groups create safer spaces for sensitive topics.  It allows room for people that are less likely to be verbal to find their way into the conversation.

Online platforms create novel opportunities.  An example from a trainer, “When we had 80 people show up, we were able to divide them into 40 rooms, and practice with each other in pairs. We could make it work in the large context.”  Large groups can be made smaller on some platforms by using breakout rooms.  Trainers can divide the room in half for any reason, or construct groups of 4-6 people when appropriate, or do skill practice in groups of 2-3.

Live virtual trainings can benefit from recorded demonstrations on some of the challenging topics, like addiction in the brain or microaggressions.  Recorded experts give the trainer a tool that allows them to insert the expertise, while still having the support of the skilled trainer for handling the questions and concerns.  Even longer recordings can be trimmed down to accommodate the needs of the specific group.

Trainers find that polling questions are an interactive tool helpful for engaging learners.  This gives learners another opportunity besides speaking on camera.  Chat functions in virtual environments can be used for people who do not want to be on camera or speak out loud.  The chat function is an excellent place for limited discussion and answers to straightforward questions.

There is sophisticated polling software available for purchase that allows for more interactive opportunities. Poll Everywhere is a polling software that is relatively accessible and relatively cheap.  It allows different kinds of responses, and can display graphs, word clouds, and updates the visualization as data is collected. The different polling options allows the trainer to introduce group influence effects, or keep responses hidden until after the poll closes.  These interactive, user generated activities help to build buy-in and keep attention. Interactive, learner generated activities also break the barriers that keep people from speaking to each other.

In the virtual training there are hard barriers to bringing people into discussion so the trainers have to make ways of breaking them into conversation. In one LGBT cultural competency training a trainer used a poll to ask people about the general feeling in their community toward the LGBT community, “Was it generally more positive or negative?”  By asking about the community’s level of experience, comfort and knowledge, the learner’s feelings are stirred up, and propels them to be present in the learning experience, and gets them into thinking about their feelings.

Learner-generated Activities.

Many trainers try to always start the training with a learner generated activity, like creating group norms.  Here are other examples:

From a training on the impact of drugs on the brain:  The trainer pulls up a white board and asks someone to draw an image of the brain and have learners write where in the brain the drugs have an impact.  Afterwards, the trainer goes to a slide with a brain and the impacts and talk about them.  Then they can compare the answers and get the contributions from the learners.  They are primed and ready to think about what they already know and so they are more likely to bring it in and contribute to the discussion.

An example from a training on LGBTQI cultural competency to social workers: The trainer, again at a white board, asks learners to name different identities.  The trainer takes the list down or has learners come up and write the identities on the board.  Afterwards, the trainer goes to a slide and discusses that everyone has a sexual orientation, sex, and gender identity.  This list can be used throughout the training to discuss difference.  Gender is frequently an issue where learners do not easily understand that the gender binary does not exist.  When you add in that sex is also non-binary, and that sexual orientation is unrelated to these other non-binaries, is can be very confusing for people.  Starting with vocabulary can help to work through the issue of creating affirming environments and poke at some biases early so learners can grow aware of their knowledge gaps.  As you work through the content, their preconceived ideas and unconscious biases become more apparent as people play with the interaction between the communities and concepts.

b. Information and research on the sources of LGBTQI health inequities are important in cultural competency trainings because they help health care service professionals understand their role in ameliorating those inequities. 

Discrimination in education, housing, and employment is a structural source of inequality for LGBTQ people.  Discrimination in health care is the reason this toolkit exists. Resources for data on LGBTQI discrimination on national and state levels is available at the Williams Institute and the Movement Advancement Project (MAP).  State and local health departments may also collect information specific to LGBTQI communities.

Information about the effects of family support and religious institutions on LGBTQ people can be found at the Family Acceptance Project, including publications and research, and short documentaries featuring the parents of LGBTQ children. 

The Minority Stress Model connects the chronic physical and mental health impacts of stress on minority populations.  A brief primer on the minority stress model can be found here.

c. Public board affirmations and executive-level affirmations of commitments to LGBTQI equality can be helpful in establishing and communicating an institutional commitment to LGBTQI health.  Public statements combined with resources and other affirmative actions are more effective.  Providing resources, like LGBTQI cultural competency trainings for staff and board members and supporting organizational champions are the minimum.  Other affirmative actions include providing visible markers of LGBTQI acceptance and safety, like gender-neutral bathrooms, pronoun stickers, and the prominent presence of LGBTQI media and images in public spaces.

A widely used method of indicating and evaluating organizational commitment to addressing structural and individual determinants of health for LGBTQI people is participation and standing in the Healthcare Equality Index (HEI), a national benchmark survey. Healthcare institutions find that the criteria in the HEI can be used as a helpful guide for organizational change. The HEI is a well-reputed measure which evolves over time to keep up with changing standards.  The Human Rights Campaign also publishes a Corporate Equality Index, which may have additional helpful measures. 

It can be challenging to get institutional buy-in for making LGBTQI cultural competency a priority for an organization.  It is usually a process of developing internal champions and expertise to establish the value of the investment.  Potentially persuasive information and arguments depend on the perspective of the recipient. 

• For operational leadership: 
  • Data on the patient population or broader service area of an institution 
  • Legal requirements for LGBTQI non-discrimination policies and practices
• Medical Providers: 
  • Data on the health disparities of the patients they serve
  • Professional ethical practice requirements
• Security Staff: 
  • The need for safe environments for LGBTQI patients
• Front desk staff: 
  • The role of LGBTQI Cultural Competency in patient comfort and interactions

d. Successful trainings create an inclusive environment that affirms and supports each learner through their process.  Learners are then trained to create inclusive environments to support and affirm the patients and clients of the organization.  Here is research from Gallup on the benefits of a diverse and inclusive workplace.

The video “Ouch, that stereotype hurts” while a bit dated, provides accessible examples of soft skills for how to interrupt inappropriate comments, jokes, or remarks in the workplace.  A more timely production, Vanessa Goes to the Doctor is an enlightening training video on microaggressions from the National LGBT Cancer Network.

The CLARA method is a widely used de-escalation and communication technique for navigating difficult cross-cultural communication. Find a helpful worksheet here and an alternative one here. 

Center yourself or Calm yourself
Listen
Affirm
Reflect
Ask for elaboration or Add more information. 

The National LGBT Cancer Network Curriculum has collected a diverse set of strategies for addressing negative attitudes in their toolkit: “BEAFARRUP” Strategies:

Be Direct –“That sounds pretty judgmental and I don’t think we as practitioners can do our job well by projecting those views.”
Educate – “Actually if you look at various literature, trans, GNC, intersex people have always existed throughout history…they just used different words.”
Assume Good Intention –“I know you don’t mean to offend anyone on purpose, but when I hear you say Y, it makes me more closed off from you because X.”
Fall Back on Policy/Rules –“Saying (or doing) that actually violates our non-discrimination policy here at X.”
Asking questions – “What do you mean by X, can you elaborate?”
Relocate/Postpone (consider the time + place) – “Do you have a minute? Can we chat over in the next room?”
Re-direct (If there is a safety concern with the other strategies) – “Maybe we should focus on X since we only have an hour to do Y.”
Use Humor – “Well, my closet is pangender with a sprinkle of genderqueerness.”
Personalize– “My brother just came out to me as trans so when I hear people say Z, it personally offends me and makes me feel X.”

Click for a paper with more on organizational factors that contribute to creating a culturally competent and welcoming clinical environment as a whole with both administrative and provider orientated examples and suggestions. 

4. Curriculum Fundamentals

b. Examples which focus solely on the health inequities of LGBTQI patients may reinforce negative perceptions of LGBTQI people.  It is important to include examples that provide information about the resilience of the LGBTQI communities.

What Goes Unsaid, the video and accompanying resource guide from the National LGBT Cancer Network, provides three examples of members of the trans community that focus on strengths. 

Patients prefer for providers to mirror the language the patient uses to describe themselves.  It helps for the patient to feel seen and understood by their provider.

Making assumptions about your LGBTQI patients can potentially result in missing important clinical indicators. Avoiding stereotypes includes removing heterosexist assumptions from their speech.  This takes practice.  For example, when entering an examination room, instead of asking, “Is this your husband?” or “Is this your wife?”, ask “Who have you brought with you today?”  Another way to remove assumptions from speech is instead of asking “Who’s kid is that?” or “Do you have children?” the provider could ask, depending on the clinical relevance, “Are you parenting?,” “Have you parented?,” or “Have you given birth?”

It is important that providers do not ask questions in a way that allows the provider to avoid subjects which may be uncomfortable to the provider. For example, some providers are uncomfortable asking questions about sexual behaviors. This discomfort can be reduced by training and education. Learning to take a sexual history is available as a free CME at the Fenway Institute’s National LGBTQIA+ Health Education Center.

Another stereotype is that older adults are not sexually active.  Unfortunately, some providers stop asking about sexual behavior with older queer adults.  Providers make assumptions about the patients sexual behaviors, and fail to take the opportunity to ask questions or provide sexual health care that many seniors need.

Even highly skilled and knowledgeable providers can make assumptions about a patient’s needs.  For example, a provider with a speciality in gender transition-related care may assume that a transgender patient is seeking hormone therapy or surgical intervention.  Instead, a provider can ask questions about the transition goals of a transgender patient.  Many transgender patients have non-medical transition related goals, and each has specific goals that align with their particular needs.  In alignment with the goal of  informed consent, the provider can help the patient consider the variety of gender affirming treatments to determine which is best for their individual circumstances.

An example from a clinical resident:  A provider in training at a local medical school was told to “be thorough and don’t overlook any questions, even if you think you don’t need to ask them.” The trainee had a cisgender gay-identifying man in the clinic.  When talking through all the questions about the patient’s sexual encounters, the trainee collected information about the patient’s sexual encounters with other cisgender gay men.  But the trainee didn’t ask the patient about their sexual encounters with anyone else.  The trainee had almost left the room, but the teacher asked the patient about sex with anyone else.  When asked, the patient revealed that he also had sex with women. This extra question pulled the trainee back into the room to ask the patient all the necessary questions related to sex with women.  Here the trainee narrowly avoided allowing a stereotype to reduce the quality of the care the patient received.

Another example: During a routine visit to her established primary care provider, a cisgender lesbian-identifying woman patient is asked by her provider about her methods of preventing pregnancy.  Instead of asking, “How are you preventing pregnancy?” which is a question that may seem bizarre to the patient who does not routinely have reproductive sex, the provider can ask “Can you tell me the genders of your sexual partners?“ and “Do you have any interest in reproduction? or “Do you have any plans to become pregnant?” or, “I know you identify as a lesbian, and I wanted to ask if you have any questions or concerns about pregnancy or reproduction?”  Framing the question thoughtfully reduces the patient’s discomfort; using inclusive language signals that the provider is skilled and knowledgeable.

Another example: A woman is visiting her gynecologist, accompanied by her partner, a man.  The patient is requesting help from her provider to manage irregular periods.  The partner accompanies the patient into the exam room.  The provider asks her what type of contraception she is using, to query the potential sources of the irregular bleeding.  The patient discloses that she is not using contraception because her partner is a transgender man.  Afterward, the provider refuses to make-eye contact with the patient or their partner, and, embarrassed, fumbles, forgetting to ask important questions.  The provider quickly ends the visit by recommending a specialist.  The patient leaves the visit with a sense of confusion and embarrassment.  What could the provider have asked to avoid assumptions?  How could they have reacted to reduce the awkwardness?

Another example:  Alan, a cisgender gay man, has been admitted to the emergency room with pain in his chest.  He is hooked up to a monitor and has undergone a full battery of cardiac screening tests, and now is waiting for the results from the attending physician. Robert, Alan’s gay male husband, is sitting by the bedside, holding Alan’s hand and is clearly very worried. The doctor comes in with another clinician who he introduces as a resident. The doctor glances at Alan’s chart and says “I see you checked off your sexual orientation as gay. Have you taken an HIV test recently?” Alan quickly answers “I know I am negative. This is my husband Robert. We are married”. The doctor says to Alan without looking at Robert, “I would strongly recommend that you take another HIV test while you are here today.”  Robert interrupts and appears very upset. “Excuse me, Doctor, but my husband may be having a heart attack. Can you please tell us right now what is going on with the cardiac tests results?”  Why are Robert and Alan upset?  What are the biases and microaggressions here?

Another example: A woman is visiting her gynecologist. The provider asks the patient about her periods. The patient replies that she does not get periods.  The provider reacts with alarm and skepticism, which embarrasses and distresses the patient.  This negative reaction reinforces the patient’s sense that the health care environment does not understand her or views her, a intersex woman, as abnormal.  The provider could have initially inquired in a neutral, non-judgmental way about the reason for a lack of periods. 

4. Curriculum Fundamentals

d. It is important that the general clinical environment looks like an LGBTQI affirming and culturally competent place.  Patients are looking for clues that this will be a friendly and affirming space and these are the first things they see.  The pictures, art and educational materials on display should be inclusive of people with different sexual orientations, gender expressions, and different races and ethnicities.  Successfully changing organizational cultural requires buy-in from the whole institution.

This article on primary care affirming spaces describes organizational and structural factors that contribute to a welcoming environment.  LGBTQI cultural competency must be built into the deeper structural elements of a healthcare institution.  It should be a consideration when constructing the electronic medical records system, the architecture of the building, and in the evaluation and diagnosis of medical needs.  Here are some slides with two case studies excerpted from a Mount Sinai Health System cultural competency training that demonstrate some of the ways that patients can benefit from cultural competency.

Institutional policies to change the environment to be more LGBTQI-affirming  include using LGBTQI images (e.g., rainbow lanyards for ID badges, posters, Safe Zone stickers); ensuring that all public-facing staff ask about individuals’ pronouns and uses those pronouns; provide all-gender restrooms throughout the facility; include magazines in the lobby that reflect various family types and identities across race/ethnicity; staff and providers wearing pronoun pins and providers introducing themselves by including their own pronouns; and using inclusive intake forms that collect data on sexual orientation and gender identity and expression.

Vulnerable patients are looking for signals that they are safe during the medical encounter.  Pronoun badges and other visible signs of structural cultural competency are important indicators that an organization is a trans-affirming environment. Pronouns pins, rainbow pins for lanyards and lab coats are an invitation for people to share with you about the queer people in their life.

An example in a story: “An attending physician, a cisgender heterosexual woman, at a local hospital called for regular cultural competency trainings with third- and fourth-year medical residents.  She was given a pin and suddenly out of the woodwork, patients started telling her about their children and friends who are LGBTQI.  She asked a patient she had for years, who is living with HIV, “Do you have anyone at home who can take care of you?” The patient responded, “Yes, my husband.” The provider was stunned at the patient’s declaration, as he had never disclosed his sexual orientation or partnership status during any of their previous encounters. 

One way to help providers be more aware of how to create a welcoming environment is for them to be familiar with the cultures of the communities they serve.  LGBTQI culture is accessible in the mainstream media through television and movies, for example, the show Pose or the documentary Disclosure, both available on Netflix. 

Organizations should also strive to be visible in their communities through a presence at their local LGBTQI community center.  Health care institutions can be visible by setting up posters or pamphlets and by participating in community events.  It is important to be careful when reaching out to a new community! Even within the same city, the markers of LGBTQI cultural competency can differ from neighborhood to neighborhood.  Rather than trying to translate culture, it is recommended that trainers learn what the culture is and then try to clearly communicate your understanding and the remaining questions.  Being visible and being present are the first steps toward becoming a welcoming and affirming environment.  However, even if an organization can identify their LGBTQI patients, if they are not aware of how to treat them with respect and to care for them with dignity then your institution may be contributing to the historical malpractice and continuing the harm that LGBTQI people have experienced from the general medical community.

Helping young LGBTQI patients engage in shared decision making is also important.  Sometimes LGBTQ children cannot come out to their parents, and intersex children may not have developed the vocabulary and resilience to verbally disagree with their parents.  Providers can provide a safe space for children by incorporating practices that teach children autonomy over their own body.  For example, asking children about their health, and waiting for and listening to their answers.  Giving the children options and control over their care environment, and children having responsibility to communicate with their providers without parental interruption, demonstrates at an early age that children are responsible for their health.

Ongoing training is important, as standards of care for LGBTQI people change regularly. In the event of an incident where a patient has a negative experience with your organization, it is better to proactively reach out to experts in the local LGBTQI community to support your institution in addressing the issue.  Restorative justice processes are helpful in identifying the sources of harm and finding opportunities for healing, and can be accomplished in a way that affirms the dignity of each person.

As noted, these guidelines and considerations apply with equal or greater relevance to the Black and brown communities.  Communities of immigrants, Native peoples, and English-language-learners experience barriers to accessing healthcare and all incorporate LGBTQI people within them. 

4. Curriculum Fundamentals

e. Federal nondiscrimination standards in healthcare arise from Section 1557 of the Affordable Care Act.  An overview of state level non-discrimination provisions can be found at the Movement Advancement Project (MAP).  Many cities have their own non-discrimination protections, which can be found through the local LGBT community center or the local government.  Additionally, many medical professions have ethical practice standards, which can be located through the state medical boards.  Finally, the institutional policies and organizational mission and purpose can be relevant sources of non-discrimination requirements, depending on the audience.

Patient-centered care is at the core of providing culturally competent care. To help illustrate this point, it may be helpful to remind providers that in almost all situations, medical providers are required to obtain informed consent from their patients before administering care.  At a minimum, this includes discussing the variety of treatment options available to patients.

Some federally funded medical providers may have additional compliance concerns that arise from requirements for meaningful use of electronic medical records. In particular, trainers could help institutions determine if institutional policies fulfill requirements related to collecting data on sexual orientation and gender identity.

Receiving a high score on the Human Rights Campaign’s Healthcare Equality Index can be a motivator for some institutions seeking a positive reputational boost.  Sometimes organizations are motivated to avoid reputational damage from negative publicity for discrimination experienced by an LGBTQI community member.

Organizations may be increasingly motivated by the consequences of failing to comply with legal non-discrimination requirements.  Lawsuits can be brought against health organizations for failing comply with federal, state, or local non-discrimination requirements.  Other institutions, fearing lawsuits, may proactively set up training sessions for their staff.  Trainers may find that examining public allegations of incidents that can lead to the lawsuits are effective training tools for some providers.  Trainers may find it effective to emphasize how litigation can be avoided by well-trained and culturally competent providers and staff.

Some trainers can use the text of the organizational mission or vision, usually found on their website.  These are statements of values that staff and providers usually commit to when they agree to work with the institution.  Organizational mission statements are a potentially useful starting point for building consensus on community norms and values.

4. Curriculum Fundamentals

f. Role play in different clinical scenarios is the most common method of practicing skills building.  Here are a few materials from our expert trainers that should be modified and updated to fit the needs of the individual trainers.

• Facilitator instructions for role-play activities.
• A guide for discussion and debrief after role-play activities. 
• A resource sheet supporting shared-decision making role-play activities.
• A role-play for a behavioral health provider in a clinical practice, concerning interpersonal violence. 
• A role-play for a social worker in a clinical practice, concerning older adults. 
• A role-play for a nurse practitioner in an FQHC, concerning a PrEP candidate.
• A role-play for a primary care practitioner in a large health center, concerning a transgender patient.

The Association of American Medical Colleges has a searchable library of educational resources available online at MedEdPortal with case studies of LGBT patients interactions for different clinical specialties.  

Scenarios that are specific to clinical or practice areas help learners understand the importance of LGBTQI cultural competency for their patients and clients.  For example, in a training for a pain clinic at a pediatric institution, some participants did not understand how LGBTQI issues were relevant to their clinical practice.  The trainer was able to describe that many LGBTQI youth came to the clinic with stomach pain that was eventually assessed as a physiological result of minority stress. In other words, the young person had a tremendous amount of anxiety about their experiences.

Dentists also should be trained in LGBTQI cultural competency.  Everyone has teeth and dental care is (or should be) standard medical care.  LGBTQI cultural competency training for dental professionals should include sources of stigma for LGBTQI people.  LGBTQI people are at increased risk of eating disorders stemming from social pressure and not wanting their body to develop in certain ways or not wanting to sexualize their body.  Substance abuse and anorexia are both issues that show up in your teeth. Cisgender bisexual and lesbian women are more likely to be overweight, and cisgender gay and bisexual men are more likely to be underweight.  Queer youth are more likely to be victims of assault and fear coming out.  Sitting in that dentist chair, where the patient cannot leave and the lack of bodily autonomy and control are visceral, can be very fearful and traumatizing.  Dentists need to be aware of these issues, be able to see the signs, and talk to their patients.  The dental professionals need to know how to talk to them and let patients and clients know that the provider is there to help them.  The dentists and other professionals need to be culturally competent to speak to their patients so they can feel comfortable in the chair and receive the whole benefit of health care. 

One expert trainer described that in trainings for nurses conducted through HEALE, learners are taught to screen and treat the body parts that people have. Providers were trained to be able to talk to patients about the body parts that everyone has.  This trainer used the example that every patient has an anus.  This is particularly important for transgender patients.  For example, some learners may need to be reminded to provide a prostate exam for an elder transgender woman.  In another example, even if a trans man has had chest-reconstruction surgery, they will still need some kind of chest examination, potentially a mammography.  Because providers are members of society and their practice is influenced by that culture and society, they need LGBTQI cultural competency trainings to help them break out of the dominant cultural frame and its assumptions to consider the perspectives and experiences of their patients. 

4. Curriculum Fundamentals

c.

i. The basic concepts and essential terminology are routinely the presented in introductory presentations. These resources were produced experts at the National LGBT Cancer Network:

• Definitions are available here.  The appropriate language in LGBTQI communities change frequently so trainers should update their trainings regularly to ensure accurate and respectful definitions are being shared. 
• A helpful resource for teaching the distinction between gender identity, gender expression, and sexual orientation is the Gender Unicorn.  
• Here is a simple, text-based, slide that distinguishes between gender identity and sexual orientation.    
• Some learners find it helpful to understand that LGBT is an umbrella term that encompasses many communities. 
• An example of a slide with definitions of some common sexual orientations.  
• An example of a visual, this slide helps distinguish between sexual orientation, gender identity, and gender expression.

ii. Thanks to the efforts of researchers and advocates, every year more information is available on health disparities in LGBTQI communities.  Some information on transgender health disparities can be found at U.S. Trans Survey, conducted by the National Center for Transgender Equality. National level data from the federal government exists on particular issues like tobacco use, substance abuse, and HIV.  General information on health disparities is often effective in communicating the need for LGBTQI organizational and cultural competency.  Resources for data on LGBTQI discrimination on national and state levels is available at the Williams Institute and the Movement Advancement Project (MAP).

The National LGBTQIA+ Health Education Center and the National LGBT Cancer Network have excellent collections of resources for particular populations.  For training pediatricians and geriatricians, the special needs of LGBTQI youth and elders should be considered.  Lesbian and bisexual women are particularly understudied, making cultural competency for queer women particularly important to consider.  

For information on the long-term effects of discrimination and research on the health needs of LGBTQI people, search the National Library of Medicine.  PubMed.gov has publicly available, peer-reviewed, up-to-date research relevant to particular medical specialties.  Note, some of these research results are from studies conducted with fewer participants than are available from national surveys.

Depending on the practices of each jurisdiction, state and city level data on LGBTQI community health disparities may be available. This information may be collected by the state, county, or city public health departments.

Click here for more on organizational factors that contribute to creating a culturally competent and welcoming clinical environment as a whole with both administrative and provider orientated examples and suggestions. 

iii.  Federal nondiscrimination standards in healthcare arise from Section 1557 of the Affordable Care Act.  An overview of state level non-discrimination provisions can be found at the Movement Advancement Project (MAP).  Many cities have their own non-discrimination protections, which can be found through the local LGBTQI community center or the local government.  Additionally, many medical professions have ethical practice standards, which can be located through the state medical boards.  Finally, the institutional policies and organizational mission and purpose can be relevant sources of non-discrimination requirements, depending on the audience.

When traveling to other states, look up the laws in their state and provide an overview of what protections or lack of protections are in place for LGBTQI people. For example, New York City has specific protections for LGBTQ patients in their LGBTQ Health Care Bill of Rights, outlines legal protections for LGBTQ+ individuals in health care settings. 

If there are no protections, some trainers spin it in a positive way by saying, “Even though there are no specific legal protections in your area, it’s great that you have made the effort to go above and beyond the call of duty to provide high-quality services to these patients.” 

iv. Trainers can use their own experiences as a training tool to teach about intersectionality.  Using the “body” or experiences of the trainer and their own intersecting identities can be helpful, especially for trainers who are part of multiple minority communities, for example, trainers who are Black lesbian women.  Personal stories are often the most powerful.  However, sharing personal stories also carries risk, and trainers should be careful about what information they disclose.

Appropriate, safe and helpful disclosures depend on the training context and circumstances. Expert trainers may recount their own experiences of learning to challenge their biases or relevant experiences of discrimination.  Some reviewers expressed that trainers using personal experiences can be alienating and can be perceived as unprofessional.  While trainers can use their own vulnerability as a model for learners, they also need to be careful to protect themselves and to ensure learners are prepared to understand the relevance and impact of the account.  For example, sharing personal experiences of discrimination can be potentially retraumatizing to trainers and some learners if the dominant group members are not equipped to reflect on its application to their practice.

Using celebrities or fictional characters as examples of intersectionality can provide distance for the trainer and might increase the familiarity and comfort of some learners.  Celebrities can be useful cultural bridges for some learners.  One common example is the famous statement from Audre Lorde:  “I am a Black, lesbian, mother, warrior, poet.” This can be an excellent introduction into the way that intersectional identities show up in people’s lives.

Videos such as “What Goes Unsaid,” from the National LGBT Cancer Network, can help introduce the importance of treating the whole patient.  

The disparate impact of the COVID-19 pandemic on the Black and Latinx communities has highlighted the inequities in our healthcare system.  Trainers may find it useful to examine the racial and ethnic disparities in mortality from COVID-19 to help learners see the persistent effects of marginalization on health.

v. Whole trainings can be devoted to discussing microaggressions.  This video is a humorous illustration on what it feels like to be on the receiving end of microaggressions: Microaggression Mosquito video.

The American Psychological Association has collected tools to encourage self-reflection on socioeconomic status in students.  Our experts recommend the “My Multicultural Self" exercise 

My Multicultural Self example 1

My Multicultural Self example 2

These activities provide space to talk about hidden and public identities and to identify and describe flaws in stereotypes.  This activity is also an experience in understanding that the salience of our identities depends on the context.

Depending on the training environment, the trainer’s own lived experience can be a teaching tool in intersectional privilege and oppression.  For example, one expert trainer, who is an elder white-passing Latina introduces herself speaking in Spanish.  Using Spanish lets the learners know that she is “an old Mexican lady, not an old white lady.”  This subverts the expectations of learners.  In this case, the trainer is equipped with an acute awareness of their privilege as a light-skinned, light-eyed Mexican, and works to undermine stereotypes and challenge assumptions of whiteness and of Hispanic culture.

For another example, the same expert trainer from the previous example can talk about when she was younger and had typically racist beliefs about people that were darker than her.  She can talk about a lifelong process of learning awareness and self-reflection.  The trainer can use their journey, going all the way back to talk about where the racist beliefs were learned, and how to trace them from events in their life.  In this example, self-disclosure is a tool for learning.  This lets the learners know that the trainer has learned and is working through their own biases and emphasizes that cultural competency is a continuous learning process aided by curiosity, thoughtfulness, and humility.  

vi. The skills to create an inclusive workplace take practice.  Learners and trainers benefit from receiving concrete tools, often in form of helpful mnemonics, that can be deployed strategically in their work or training environment and from humanizing examples which provide the emotional grounding to allow them to respond to negative attitudes and behaviors with empathy and understanding.

The video “Ouch, that stereotype hurts” while a bit dated, provides accessible examples of soft skills for how to interrupt inappropriate comments, jokes, or remarks in the workplace.

A training video on microaggressions: Vanessa Goes to the Doctor.  

The CLARA method is a widely used de-escalation and communication technique for navigating difficult cross-cultural communication. Find a helpful worksheet here and an alternative one here. 

Center yourself or Calm yourself
Listen
Affirm
Reflect
Ask for elaboration or Add more information.

The National LGBT Cancer Network Curriculum has collected a diverse set of strategies for addressing negative attitudes in their toolkit: “BEAFARRUP” Strategies:

Be Direct –“That sounds pretty judgmental and I don’t think we as practitioners can do our job well by projecting those views.”
Educate – “Actually if you look at various literature, trans, GNC, intersex people have always existed throughout history…they just used different words.”
Assume Good Intention –“I know you don’t mean to offend anyone on purpose, but when I hear you say Y, it makes me more closed off from you because X.”
Fall Back on Policy/Rules –“Saying (or doing) that actually violates our non-discrimination policy here at X.”
Asking questions – “What do you mean by X, can you elaborate?”
Relocate/Postpone (consider the time + place) – “Do you have a minute? Can we chat over in the next room?”
Re-direct (If there a safety concern with the other strategies) – “Maybe we should focus on X since we only have an hour to do Y.”
Use Humor – “Well, my closet is pangender with a sprinkle of genderqueerness.”
Personalize– “My brother just came out to me as trans so when I hear people say Z, it personally offends me and makes me feel X.”

Click for a paper with more on organizational factors that contribute to creating a culturally competent and welcoming clinical environment as a whole with both administrative and provider orientated examples and suggestions.

Consistently, the best advice for making mistakes is to simply acknowledge the mistake, apologize, correct the mistake, and move on.  It is important not to make a big dramatic moment about the mistake.  Making a “big deal” about the mistake can compound the embarrassment and inappropriately focus more on protecting the feelings of the person in the dominant culture.  Instead, it is better to respectfully apologize, quickly correct the mistake, and move forward.  This strategy, particularly in a work environment, prioritizes the mutual goal of creating a respectful environment and minimizes the overall impact of the error.  Note, it is essential to correct the error.  Environmental improvements require practicing behavior change.  

In their 2-hour training on Gender Appropriate Language, Howard Brown trainers spend time explaining to people how to apologize and then give them time to practice.  “Stop and look someone in the eye, acknowledge the mistake and then move forward.  If you want to have a meltdown, you can do that with a friend, away from the person you misgendered.  If you still need more training, then it is available to you.”  Training is very helpful because people are really concerned about making mistakes and training gives them the language to make mistakes and move forward.  In the healthcare setting, everyone shares a common goal of making a safe space for the patients by getting rid of errors in the environment, so they will correct one another.  In this context, it is a “call in,” not a “call out.”  A “call-in” is a correction done in a compassionate way.  Making the reminder keeps everyone on track.  It is possible to call-in or remind people in a variety of ways, depending on the context.  For example, speak face-to-face in meetings, communicate by handwritten notes, or send it in an email.  

vii. Part of being culturally competent involves recognizing that LGBTQI people have to come out at every stage of the process.  They have to come out to the front desk, to the nurse, and to the provider.  Health care providers can make answering questions about sexual orientation and gender identity routine for patients by including these questions on intake forms.  Best practices include making it a standardized part of demographic data collection.  When patients see that it is part of the intake process for everyone, it sends the message that this place can be culturally competent and friendly to LGBTQI people.  Including information on medical records can help by reducing the burden on the patient so they are able to focus on the decision-making they do in the visit.

In some settings LGBTQI patients may feel unsafe disclosing their status as a sexual or gender minority.  For example, asking verbally for sexual orientation and gender identity in a crowded emergency room or in the waiting room is not appropriate.  The patient should be given reasonable privacy protections and opportunities for privacy when asked to disclose potentially stigmatizing information.  

Providers may need to navigate LGBTQ care differently for a pediatric population.  For example, an LGBTQ patient may disclose their sexual orientation and/or gender identity to the provider, but not to their parent/caregiver. Then the provider must document this information appropriately so as not to inadvertently out the patient to their parent/caregiver if the patient does not want that information disclosed. These changes require thoughtful institutional policies and may present challenges in the record keeping and billing process.

Institutional change can be challenging, especially when it comes to changing routine behaviors.  In particular, it is challenging to train providers to introduce themselves with their pronouns.  To normalize questions about an individual’s pronouns and otherwise signal that the provider/health care institution views all gender identities as normal, the provider might introduce themselves with their own pronouns, for example: “Hi, I am Dr. Smith and I use she/her pronouns.” Occasionally some patients are confused by the pronoun question, but this is an opportunity for the provider to demonstrate the cultural competence of the institution in creating a welcoming environment that includes everyone.

When taking a sexual history and/or asking about sexual orientation and gender identity, it is helpful to phrase the question in an open-ended manner. For example, rather than asking “Do you have sex with men, women, or both?,” which implies a binary way of viewing and thinking about gender and people’s sexual partners; ask “What are the genders of people you are attracted to?” Or “What are the genders of people you have sex with?” This simple change of phrasing is inclusive of non-binary people. Learning to take a sexual history is available as free CME at the National LGBTQIA+ Health Education Center.

Learners may benefit from pre-writing short scripts to learn how to introduce themselves with their pronouns and to ask for others.  This exercise is helpful for frontline staff as well. If someone gave a front-desk person a name different than on their paperwork, they can develop scripts to ask in respectful, general ways to find the information they need.  Each person’s specific needs will depend on their different job description.

Queer family structures are diverse and part of cultural competency is avoiding language that signals an assumption that the individual is in a different-gender relationship, is in a heterosexual relationship, or is cisgender.  Rather than asking, when a person arrives with another person, “Is this your spouse/partner/family member?” ask “Who have you brought with you today?”

viii. Before a member of the organization asks a question related to gender, sex, sexual or affectional orientation, sexual development, family structure, employment, or immigration status, they should ask themselves:  “Why do I need to know?”  They should have a clear and appropriate reason for asking. If you are doing it to provide better care, it is probably appropriate.  If the question is not related to care, it is probably not appropriate.  For example, a patient with a sprained ankle does not need to be subjected to questions about their sexual development.  When a client is asking for the bathroom, tell them where the restrooms are, do not ask which restroom they are looking for.

Intersex people experience inappropriate curiosity as a barrier to healthcare. Intersex (people with differences of sexual development, or DSD) is a blanket term that applies to relatively large minority of people: 1.7%, or 1 out of every 58 people are intersex.  Practitioners in many fields are likely to have intersex patients and should be prepared to provide excellent care, including the knowledge that many in the intersex community experienced nonconsensual interventions in infancy or childhood that may have caused extreme distress.  It is important to avoid expressing surprise or irrelevant curiosity if an individual discloses an intersex condition; assure individuals that there is a wide range of normal sexual development and that the person’s information will be completely confidential.

Trainers can compare good curiosity vs. inappropriate curiosity through examples and case studies. 

For all patients, only ask for information that the patient needs you to have, not the information that you think you need to satisfy your curiosity.  Only ask questions that are related to the patient’s chief complaint that day.  For example, a story: “A trans individual was experiencing shortness of breath and she went to a hospital emergency room because she was scared.  In the hour that she was there, no fewer than 40 people came by the ER to just look at her.  After that hour, she called a friend and traveled 2+ hours to a hospital that was familiar with her. The staff at the second hospital were able to check out her lungs and treat the pneumonia that caused the shortness of breath.”   If someone comes in with shortness of breath, and they are trans, you shouldn’t start asking them questions about past surgeries, unless they are immediately post-operative and you are concerned with follow-up.  Unless it is specific to their chief complaint, you don’t need to ask them.

Overall, general questions are safer to ask.  For example, if someone has been on hormones for a long time, you can ask “I see that you’ve been on [hormone] for a long time. How is that working for you? Are you happy with your care?”  General questions can let patients know you are knowledgeable and caring but allow the patient to remain in control of how much detail to share and where to focus the provider’s attention.

ix. As described in the chart below, stigma impacts access to high-quality health care because both providers and patients come into the clinical environment with complex identities and social ties.  Clear communication and mutual understanding must be built for successful shared decision making to take place.   Mutual understanding is a challenge within the context of these complex identities.  Cultural competency provides the tools to communicate an attitude of respect and appreciation for the patient’s closely-held identity and self-perception.

What Goes Unsaid, the video and accompanying resource guide from the National LGBT Cancer Network provides examples that demonstrate how stigmatizing events create barriers to healthcare for three members of the transgender community.

The Association of American Medical Colleges has a searchable library of educational resources available online at MedEdPortal with case studies of LGBT patients interactions.  

Introductory trainings on LGBTQI cultural competence usually covers stigma’s impact on health.  Trainings should talk about how experiencing stigma throughout a lifetime can result in development of  coping skills that are not necessarily healthy.  For example, a lifetime of using cigarette smoking to socialize as stress relief can lead to elevated risks of lung cancer.

Stigma across the life course is a barrier to finishing education, a barrier to employment, and a barrier to health insurance.  For example, family rejection of an LGBTQI child, like an adverse childhood event, negatively affects the life course of the individual.  Family rejection impairs a person’s ability to access housing, nutrition, and clothes.  Without the necessities that many people take for granted, it is difficult to benefit from or access education.  Lack of education impedes access to employment, which, due to the predominance of employer-sponsored health insurance, impedes access to healthcare.  Through each of these difficulties, LGBTQI people are learning to navigate the wider social structures to find safety and security.  Historically, sexual and gender minorities have learned to survive by hiding their identities from the dominant culture.  LGBTQI culture creates alternative norms and structures that allow us to survive and find happiness.   However, a lifetime of surviving stigma can lead to fear of going to the doctor for fear of experiencing further stigmatization from providers.

Another example: A provider described the story of how an older, heterosexual Black woman came to be living with HIV.  The patient was recently widowed.  Her children were encouraging her to date romantically.  She begins to date the deacon in her local church. After a few weeks of dating, they begin to be sexually intimate with each other.  Around this time the patient begins to feel ill and goes to her doctor.  Her doctor does not ask about sexual history for a long time.  When finally she is asked about potential HIV exposure, the patient says “No! I could not have been exposed.”  Thankfully, based on the HIV screening guidelines, she does get an HIV screen. The patient finds out that she is positive and, after contact tracing is completed, her sexual partner also tests positive for HIV.  After having conversations with her partner about their HIV status the patient begins to experience HIV stigma from her church community.  The patient was strong in her faith and a long-standing member of her church, yet she lost many friends over the diagnosis.  She experienced internal stigma from her own shame and embarrassment and self-blaming for contracting HIV, compounded by external stigma from her community, due their blaming assumptions and negative stereotypes of people who have HIV.

x. The most straightforward way to communicate respect for a patient’s sexual orientation, gender identity, and gender expression, and variation in sex characteristics/intersex status is to mirror the language the patient uses to describe themselves.  It helps for the patient to feel seen and understood by their provider.  It is important to use the patient’s language to describe their body and its parts.  For transgender and intersex persons in particular, providers should be sensitive of the potential for trauma when using the medicalized language describing sexual organs and secondary sexual characteristics.  Transgender and intersex individuals may have developed alternative vocabularies for describing themselves and navigating the difference between their gender identity and their biological anatomy.  Providers can access this vocabulary by asking their patients for their preferences.

Providers can also communicate respect for their patients by mirroring the language they use to describe their behaviors and identity.  In particular, it may be important to distinguish between sexual orientation and sexual behavior. For example, some men who have sex with men do not describe themselves as gay or bisexual, and may even describe themselves as heterosexual or straight.  A provider can be prepared for and catch these important differences by asking open-ended questions and listening closely to the answers.

Providers may not be aware of how impactful their responses are on their patient’s health and well-being.  Providers should refrain from expressing shock or surprise towards patients.  This includes maintaining neutral facial expressions, body language, and language.  For example, a Latina woman, who identifies as “transexual” is telling a new provider of her experiences doing survival sex work.  She tells her provider that she is HIV negative.  During previous medical encounters, she has experienced shocked reactions from providers.  This reaction upsets her and it depresses her motivation to continue treatment because it feels to her that providers are assuming that transgender women of color are HIV positive.  However, in this care encounter, her provider expresses praise, gratitude, and congratulations on her status in a way that emphasizes the patient’s strength.  This positive reaction worked to counter previous negative feelings and helps to retain the patient in care and builds a foundation of respect for mutual decision making.

To emphasize resilience, do not tell people that they are brave or resilient. Rather, acknowledge that the hardships and tests which LGBTQI people are subjected to require them to build coping mechanisms and alternatives to the dominant culture.  LGBTQI people, like all people, develop coping mechanisms for surviving the trauma in their lives, perhaps through self-medication with alcohol or illicit substance use, or with nicotine or food.  The disproportionate experiences of trauma in LGBTQI communities contribute to the disproportionate rates of substance use disorder, tobacco use, and obesity among LGBTQ people.

Unfortunately, some healthcare systems exclude the support systems for LGBTQI people, for example, hospital policies that exclude non-traditional or chosen families from visiting patients.  LGBTQI people have created systems and families in their lives that support happiness.  Refusing to allow LGBTQI people to choose their own families or allow families to be with them during medical care is traumatizing and harmful to LGBTQI people.  Welcoming LGBTQI chosen families supports the patient’s recovery.

Some trainers use, as simulations, quotes from gay families relating their negative experiences in healthcare encounters.  The trainer shows quotes from these experiences and lets the healthcare provider learner think about how to disrupt these negative interactions.

4. Curriculum Fundamentals

h. Providers may struggle with dedicating the time required to learn soft skills.  There appears to be a preference for hard knowledge over soft skills, which is reflective of their practice.  A preference for hard knowledge might present as prioritizing clinical and diagnostic tools over interpersonal skills like active listening.  Trainers can emphasize that medical care requires both sets of skills.  In addition, providers may underestimate the time commitment for trainings, so it may be necessary for trainers and organizational champions to push for more time for trainings.  Generally speaking, our experts recommend that, “if you think you need an hour, you probably need two hours.”  Trainings can be condensed, but the content reflects the commitment, therefore shorter sessions may be more appropriately framed as introductions or discussions on the topics, as they are less likely to be able to impart skills.

Because trainers are unable to cover every topic, they should provide written materials, web sites and other resources for learners to go further.  We recommend providing additional materials even for topics that the presenter is able to cover during the in-person session, as this enables the learner to learn at their own pace.

It is important to provide tips for providers and front-line staff for how to manage stress and a busy workload while giving each patient the appropriate attention.  Some grounding exercises are helpful: a simple practice of taking a moment, and a few breaths, before meeting a patient; offering a smile and a handshake or other culturally appropriate greeting; starting with open-ended questions rather than pronouncements.

Cultural competency trainings are primarily about the soft skills.  Learners can be prepared for this in the description of the class, or a description that is part of the larger course that makes it clear what the learner should expect.  It can be helpful to include role-play opportunities in which the provider can experience an encounter from the patient’s point of view.

4. Curriculum Fundamentals

i. Different audiences of learners will naturally require different content in each training.  Trainings should differ for different members of each healthcare organization depending on their role.

Trainers can suggest ways in which learners can learn more about the experiences of LGBTQI people who may not be represented in the training, for example, through attending local events in different communities, reading stories or articles authored by or discussing different communities, watching films or videos by LGBTQI writers with performances by LGBTQI actors.

One method to keep track of what is not being covered is to create a “parking lot” or holding space for issues and questions that arise in a training that call for additional information or attention.  A parking lot helps learners to know their questions are heard and remembered, even if the issue they bring up is unable to be addressed in full at the time it is raised.

Intersex issues are particularly likely to be unfamiliar to most learners and to many institutions. The existence of individuals with intersex traits, and the mistreatment that they may have encountered in the health care system, should be expressly named in most trainings, and resources provided to learners for more information. Many intersex individuals report having to educate their own providers and more must be done to encourage thorough full-life care. Some intersex people explain that medical professionals suggest interventions that are no longer medically indicated and/or rooted in stereotypes around sex and gender, such as a woman with an intersex variation who has healthy internal testes being told she should remove them when there is no medical need but the physician was trained at a time when individuals assigned female were routinely subjected to medically unnecessary gonadectomies.

Our recommendations are likely limited to the United States.  This is particularly important to understand when talking about intersecting identities because the history of racial oppression in the United States is different than in other places.  The history of the United States, its cultural norms, and how the dynamics of oppression manifest may not directly apply to other cultures or contexts.  These guidelines can still allow for a global conversation so long as we acknowledge that the dominant culture and historical oppressions shift in other countries.

4. Curriculum Fundamentals

j. LGBTQI people are present in all areas of a health care institution’s operations.  They are patients, clients,  providers, executives, security personal, environmental services staff, and front-desk staff.  Ideally, this diversity would be present throughout clinical trainings as well.  For example, if the institution has a simulation lab, the simulations should include LGBTQI patients.  Including LGBTQI people in non-LGBTQI specific trainings helps to develop the skills necessary to treat LGBTQI patients and clients with dignity and care.

4. Curriculum Fundamentals

g. Each patient or client brings their own unique circumstances into the clinical setting.  Some learners may create a false sense of mastery after navigating the clinical role-play.  The trainer can help learners develop humility by emphasizing the limitations of different patient profiles used in the training.  One method of doing so is by stating the lack of diversity of experience in the training participants or profiles. Ultimately, the goal is to help providers practice cultural competency by approaching each interaction with humility.  The recommended standard includes the “cultural humility” framework, which emphasizes the importance of maintaining an open attitude and curiosity about each individual and their circumstances, provider and staff self-awareness of their own biases, and a commitment to engage in ongoing self-reflection.

4. Curriculum Fundamentals

c. ii. Thanks to the efforts of researchers and advocates, every year more information is available on health disparities in LGBTQI communities.  Some information on transgender health disparities can be found at U.S. Trans Survey, conducted by the National Center for Transgender Equality. National level data from the federal government exists on particular issues like tobacco use, substance abuse, and HIV.  General information on health disparities is often effective in communicating the need for LGBTQI organizational and cultural competency.  Resources for data on LGBTQI discrimination on national and state levels is available at the Williams Institute and the Movement Advancement Project (MAP).

The National LGBTQIA+ Health Education Center and the National LGBT Cancer Network have excellent collections of resources for particular populations.  For training pediatricians and geriatricians, the special needs of LGBTQI youth and elders should be considered.  Lesbian and bisexual women are particularly understudied, making cultural competency for queer women particularly important to consider.  

For information on the long-term effects of discrimination and research on the health needs of LGBTQI people, search the National Library of Medicine.  PubMed.gov has publicly available, peer-reviewed, up-to-date research relevant to particular medical specialties.  Note, some of these research results are from studies conducted with fewer participants than are available from national surveys.

Depending on the practices of each jurisdiction, state and city level data on LGBTQI community health disparities may be available. This information may be collected by the state, county, or city public health departments.

Click here for more on organizational factors that contribute to creating a culturally competent and welcoming clinical environment as a whole with both administrative and provider orientated examples and suggestions. 

4. Curriculum Fundamentals

c. iii.  Federal nondiscrimination standards in healthcare arise from Section 1557 of the Affordable Care Act.  An overview of state level non-discrimination provisions can be found at the Movement Advancement Project (MAP).  Many cities have their own non-discrimination protections, which can be found through the local LGBTQI community center or the local government.  Additionally, many medical professions have ethical practice standards, which can be located through the state medical boards.  Finally, the institutional policies and organizational mission and purpose can be relevant sources of non-discrimination requirements, depending on the audience.

When traveling to other states, look up the laws in their state and provide an overview of what protections or lack of protections are in place for LGBTQI people. For example, New York City has specific protections for LGBTQ patients in their LGBTQ Health Care Bill of Rights, outlines legal protections for LGBTQ+ individuals in health care settings. 

If there are no protections, some trainers spin it in a positive way by saying, “Even though there are no specific legal protections in your area, it’s great that you have made the effort to go above and beyond the call of duty to provide high-quality services to these patients.”

4. Curriculum Fundamentals

c. iv. Trainers can use their own experiences as a training tool to teach about intersectionality.  Using the “body” or experiences of the trainer and their own intersecting identities can be helpful, especially for trainers who are part of multiple minority communities, for example, trainers who are Black lesbian women.  Personal stories are often the most powerful.  However, sharing personal stories also carries risk, and trainers should be careful about what information they disclose.

Appropriate, safe and helpful disclosures depend on the training context and circumstances. Expert trainers may recount their own experiences of learning to challenge their biases or relevant experiences of discrimination.  Some reviewers expressed that trainers using personal experiences can be alienating and can be perceived as unprofessional.  While trainers can use their own vulnerability as a model for learners, they also need to be careful to protect themselves and to ensure learners are prepared to understand the relevance and impact of the account.  For example, sharing personal experiences of discrimination can be potentially retraumatizing to trainers and some learners if the dominant group members are not equipped to reflect on its application to their practice.

Using celebrities or fictional characters as examples of intersectionality can provide distance for the trainer and might increase the familiarity and comfort of some learners.  Celebrities can be useful cultural bridges for some learners.  One common example is the famous statement from Audre Lorde:  “I am a Black, lesbian, mother, warrior, poet.” This can be an excellent introduction into the way that intersectional identities show up in people’s lives.

Videos such as “What Goes Unsaid,” from the National LGBT Cancer Network, can help introduce the importance of treating the whole patient.  

The disparate impact of the COVID-19 pandemic on the Black and Latinx communities has highlighted the inequities in our healthcare system.  Trainers may find it useful to examine the racial and ethnic disparities in mortality from COVID-19 to help learners see the persistent effects of marginalization on health.

4. Curriculum Fundamentals

c. v. Whole trainings can be devoted to discussing microaggressions.  This video is a humorous illustration on what it feels like to be on the receiving end of microaggressions: Microaggression Mosquito video.

The American Psychological Association has collected tools to encourage self-reflection on socioeconomic status in students.  Our experts recommend the “My Multicultural Self" exercise 

My Multicultural Self example 1

My Multicultural Self example 2

These activities provide space to talk about hidden and public identities and to identify and describe flaws in stereotypes.  This activity is also an experience in understanding that the salience of our identities depends on the context.

Depending on the training environment, the trainer’s own lived experience can be a teaching tool in intersectional privilege and oppression.  For example, one expert trainer, who is an elder white-passing Latina introduces herself speaking in Spanish.  Using Spanish lets the learners know that she is “an old Mexican lady, not an old white lady.”  This subverts the expectations of learners.  In this case, the trainer is equipped with an acute awareness of their privilege as a light-skinned, light-eyed Mexican, and works to undermine stereotypes and challenge assumptions of whiteness and of Hispanic culture.

For another example, the same expert trainer from the previous example can talk about when she was younger and had typically racist beliefs about people that were darker than her.  She can talk about a lifelong process of learning awareness and self-reflection.  The trainer can use their journey, going all the way back to talk about where the racist beliefs were learned, and how to trace them from events in their life.  In this example, self-disclosure is a tool for learning.  This lets the learners know that the trainer has learned and is working through their own biases and emphasizes that cultural competency is a continuous learning process aided by curiosity, thoughtfulness, and humility.  

4. Curriculum Fundamentals

c. vi. The skills to create an inclusive workplace take practice.  Learners and trainers benefit from receiving concrete tools, often in form of helpful mnemonics, that can be deployed strategically in their work or training environment and from humanizing examples which provide the emotional grounding to allow them to respond to negative attitudes and behaviors with empathy and understanding.

The video “Ouch, that stereotype hurts” while a bit dated, provides accessible examples of soft skills for how to interrupt inappropriate comments, jokes, or remarks in the workplace.

A training video on microaggressions: Vanessa Goes to the Doctor.  

The CLARA method is a widely used de-escalation and communication technique for navigating difficult cross-cultural communication. Find a helpful worksheet here and an alternative one here. 

Center yourself or Calm yourself
Listen
Affirm
Reflect
Ask for elaboration or Add more information.

The National LGBT Cancer Network Curriculum has collected a diverse set of strategies for addressing negative attitudes in their toolkit: “BEAFARRUP” Strategies:

Be Direct –“That sounds pretty judgmental and I don’t think we as practitioners can do our job well by projecting those views.”
Educate – “Actually if you look at various literature, trans, GNC, intersex people have always existed throughout history…they just used different words.”
Assume Good Intention –“I know you don’t mean to offend anyone on purpose, but when I hear you say Y, it makes me more closed off from you because X.”
Fall Back on Policy/Rules –“Saying (or doing) that actually violates our non-discrimination policy here at X.”
Asking questions – “What do you mean by X, can you elaborate?”
Relocate/Postpone (consider the time + place) – “Do you have a minute? Can we chat over in the next room?”
Re-direct (If there a safety concern with the other strategies) – “Maybe we should focus on X since we only have an hour to do Y.”
Use Humor – “Well, my closet is pangender with a sprinkle of genderqueerness.”
Personalize– “My brother just came out to me as trans so when I hear people say Z, it personally offends me and makes me feel X.”

Click for a paper with more on organizational factors that contribute to creating a culturally competent and welcoming clinical environment as a whole with both administrative and provider orientated examples and suggestions.

Consistently, the best advice for making mistakes is to simply acknowledge the mistake, apologize, correct the mistake, and move on.  It is important not to make a big dramatic moment about the mistake.  Making a “big deal” about the mistake can compound the embarrassment and inappropriately focus more on protecting the feelings of the person in the dominant culture.  Instead, it is better to respectfully apologize, quickly correct the mistake, and move forward.  This strategy, particularly in a work environment, prioritizes the mutual goal of creating a respectful environment and minimizes the overall impact of the error.  Note, it is essential to correct the error.  Environmental improvements require practicing behavior change.  

In their 2-hour training on Gender Appropriate Language, Howard Brown trainers spend time explaining to people how to apologize and then give them time to practice.  “Stop and look someone in the eye, acknowledge the mistake and then move forward.  If you want to have a meltdown, you can do that with a friend, away from the person you misgendered.  If you still need more training, then it is available to you.”  Training is very helpful because people are really concerned about making mistakes and training gives them the language to make mistakes and move forward.  In the healthcare setting, everyone shares a common goal of making a safe space for the patients by getting rid of errors in the environment, so they will correct one another.  In this context, it is a “call in,” not a “call out.”  A “call-in” is a correction done in a compassionate way.  Making the reminder keeps everyone on track.  It is possible to call-in or remind people in a variety of ways, depending on the context.  For example, speak face-to-face in meetings, communicate by handwritten notes, or send it in an email. 

4. Curriculum Fundamentals

c. vii. Part of being culturally competent involves recognizing that LGBTQI people have to come out at every stage of the process.  They have to come out to the front desk, to the nurse, and to the provider.  Health care providers can make answering questions about sexual orientation and gender identity routine for patients by including these questions on intake forms.  Best practices include making it a standardized part of demographic data collection.  When patients see that it is part of the intake process for everyone, it sends the message that this place can be culturally competent and friendly to LGBTQI people.  Including information on medical records can help by reducing the burden on the patient so they are able to focus on the decision-making they do in the visit.

In some settings LGBTQI patients may feel unsafe disclosing their status as a sexual or gender minority.  For example, asking verbally for sexual orientation and gender identity in a crowded emergency room or in the waiting room is not appropriate.  The patient should be given reasonable privacy protections and opportunities for privacy when asked to disclose potentially stigmatizing information.  

Providers may need to navigate LGBTQ care differently for a pediatric population.  For example, an LGBTQ patient may disclose their sexual orientation and/or gender identity to the provider, but not to their parent/caregiver. Then the provider must document this information appropriately so as not to inadvertently out the patient to their parent/caregiver if the patient does not want that information disclosed. These changes require thoughtful institutional policies and may present challenges in the record keeping and billing process.

Institutional change can be challenging, especially when it comes to changing routine behaviors.  In particular, it is challenging to train providers to introduce themselves with their pronouns.  To normalize questions about an individual’s pronouns and otherwise signal that the provider/health care institution views all gender identities as normal, the provider might introduce themselves with their own pronouns, for example: “Hi, I am Dr. Smith and I use she/her pronouns.” Occasionally some patients are confused by the pronoun question, but this is an opportunity for the provider to demonstrate the cultural competence of the institution in creating a welcoming environment that includes everyone.

When taking a sexual history and/or asking about sexual orientation and gender identity, it is helpful to phrase the question in an open-ended manner. For example, rather than asking “Do you have sex with men, women, or both?,” which implies a binary way of viewing and thinking about gender and people’s sexual partners; ask “What are the genders of people you are attracted to?” Or “What are the genders of people you have sex with?” This simple change of phrasing is inclusive of non-binary people. Learning to take a sexual history is available as free CME at the National LGBTQIA+ Health Education Center.

Learners may benefit from pre-writing short scripts to learn how to introduce themselves with their pronouns and to ask for others.  This exercise is helpful for frontline staff as well. If someone gave a front-desk person a name different than on their paperwork, they can develop scripts to ask in respectful, general ways to find the information they need.  Each person’s specific needs will depend on their different job description.

Queer family structures are diverse and part of cultural competency is avoiding language that signals an assumption that the individual is in a different-gender relationship, is in a heterosexual relationship, or is cisgender.  Rather than asking, when a person arrives with another person, “Is this your spouse/partner/family member?” ask “Who have you brought with you today?”

4. Curriculum Fundamentals

c. viii. Before a member of the organization asks a question related to gender, sex, sexual or affectional orientation, sexual development, family structure, employment, or immigration status, they should ask themselves:  “Why do I need to know?”  They should have a clear and appropriate reason for asking. If you are doing it to provide better care, it is probably appropriate.  If the question is not related to care, it is probably not appropriate.  For example, a patient with a sprained ankle does not need to be subjected to questions about their sexual development.  When a client is asking for the bathroom, tell them where the restrooms are, do not ask which restroom they are looking for.

Intersex people experience inappropriate curiosity as a barrier to healthcare. Intersex (people with differences of sexual development, or DSD) is a blanket term that applies to relatively large minority of people: 1.7%, or 1 out of every 58 people are intersex.  Practitioners in many fields are likely to have intersex patients and should be prepared to provide excellent care, including the knowledge that many in the intersex community experienced nonconsensual interventions in infancy or childhood that may have caused extreme distress.  It is important to avoid expressing surprise or irrelevant curiosity if an individual discloses an intersex condition; assure individuals that there is a wide range of normal sexual development and that the person’s information will be completely confidential.

Trainers can compare good curiosity vs. inappropriate curiosity through examples and case studies. 

For all patients, only ask for information that the patient needs you to have, not the information that you think you need to satisfy your curiosity.  Only ask questions that are related to the patient’s chief complaint that day.  For example, a story: “A trans individual was experiencing shortness of breath and she went to a hospital emergency room because she was scared.  In the hour that she was there, no fewer than 40 people came by the ER to just look at her.  After that hour, she called a friend and traveled 2+ hours to a hospital that was familiar with her. The staff at the second hospital were able to check out her lungs and treat the pneumonia that caused the shortness of breath.”   If someone comes in with shortness of breath, and they are trans, you shouldn’t start asking them questions about past surgeries, unless they are immediately post-operative and you are concerned with follow-up.  Unless it is specific to their chief complaint, you don’t need to ask them.

Overall, general questions are safer to ask.  For example, if someone has been on hormones for a long time, you can ask “I see that you’ve been on [hormone] for a long time. How is that working for you? Are you happy with your care?”  General questions can let patients know you are knowledgeable and caring but allow the patient to remain in control of how much detail to share and where to focus the provider’s attention.

Cultural competency and humility are critical for addressing the inequities in HIV-related risks and health outcomes in sexual and gender minority communities, particularly among Black and Latino same-gender loving men and Black women. Cultural Humility training resources specific to HIV providers are available from Gilead Science. For more information regarding this resource or training, reach out to Anthony Gutierrez, Community Liaison for Gilead Science, by email at anthony.gutierrez5@gilead.com. Anthony can put you in contact with your local liaison.

4. Curriculum Fundamentals

c. ix. As described in the chart below, stigma impacts access to high-quality health care because both providers and patients come into the clinical environment with complex identities and social ties.  Clear communication and mutual understanding must be built for successful shared decision making to take place.   Mutual understanding is a challenge within the context of these complex identities.  Cultural competency provides the tools to communicate an attitude of respect and appreciation for the patient’s closely-held identity and self-perception.

What Goes Unsaid, the video and accompanying resource guide from the National LGBT Cancer Network provides examples that demonstrate how stigmatizing events create barriers to healthcare for three members of the transgender community.

The Association of American Medical Colleges has a searchable library of educational resources available online at MedEdPortal with case studies of LGBT patients interactions.  

Introductory trainings on LGBTQI cultural competence usually covers stigma’s impact on health.  Trainings should talk about how experiencing stigma throughout a lifetime can result in development of  coping skills that are not necessarily healthy.  For example, a lifetime of using cigarette smoking to socialize as stress relief can lead to elevated risks of lung cancer.

Stigma across the life course is a barrier to finishing education, a barrier to employment, and a barrier to health insurance.  For example, family rejection of an LGBTQI child, like an adverse childhood event, negatively affects the life course of the individual.  Family rejection impairs a person’s ability to access housing, nutrition, and clothes.  Without the necessities that many people take for granted, it is difficult to benefit from or access education.  Lack of education impedes access to employment, which, due to the predominance of employer-sponsored health insurance, impedes access to healthcare.  Through each of these difficulties, LGBTQI people are learning to navigate the wider social structures to find safety and security.  Historically, sexual and gender minorities have learned to survive by hiding their identities from the dominant culture.  LGBTQI culture creates alternative norms and structures that allow us to survive and find happiness.   However, a lifetime of surviving stigma can lead to fear of going to the doctor for fear of experiencing further stigmatization from providers.

Another example: A provider described the story of how an older, heterosexual Black woman came to be living with HIV.  The patient was recently widowed.  Her children were encouraging her to date romantically.  She begins to date the deacon in her local church. After a few weeks of dating, they begin to be sexually intimate with each other.  Around this time the patient begins to feel ill and goes to her doctor.  Her doctor does not ask about sexual history for a long time.  When finally she is asked about potential HIV exposure, the patient says “No! I could not have been exposed.”  Thankfully, based on the HIV screening guidelines, she does get an HIV screen. The patient finds out that she is positive and, after contact tracing is completed, her sexual partner also tests positive for HIV.  After having conversations with her partner about their HIV status the patient begins to experience HIV stigma from her church community.  The patient was strong in her faith and a long-standing member of her church, yet she lost many friends over the diagnosis.  She experienced internal stigma from her own shame and embarrassment and self-blaming for contracting HIV, compounded by external stigma from her community, due their blaming assumptions and negative stereotypes of people who have HIV.

4. Curriculum Fundamentals

c. x. The most straightforward way to communicate respect for a patient’s sexual orientation, gender identity, and gender expression, and variation in sex characteristics/intersex status is to mirror the language the patient uses to describe themselves.  It helps for the patient to feel seen and understood by their provider.  It is important to use the patient’s language to describe their body and its parts.  For transgender and intersex persons in particular, providers should be sensitive of the potential for trauma when using the medicalized language describing sexual organs and secondary sexual characteristics.  Transgender and intersex individuals may have developed alternative vocabularies for describing themselves and navigating the difference between their gender identity and their biological anatomy.  Providers can access this vocabulary by asking their patients for their preferences.

Providers can also communicate respect for their patients by mirroring the language they use to describe their behaviors and identity.  In particular, it may be important to distinguish between sexual orientation and sexual behavior. For example, some men who have sex with men do not describe themselves as gay or bisexual, and may even describe themselves as heterosexual or straight.  A provider can be prepared for and catch these important differences by asking open-ended questions and listening closely to the answers.

Providers may not be aware of how impactful their responses are on their patient’s health and well-being.  Providers should refrain from expressing shock or surprise towards patients.  This includes maintaining neutral facial expressions, body language, and language.  For example, a Latina woman, who identifies as “transexual” is telling a new provider of her experiences doing survival sex work.  She tells her provider that she is HIV negative.  During previous medical encounters, she has experienced shocked reactions from providers.  This reaction upsets her and it depresses her motivation to continue treatment because it feels to her that providers are assuming that transgender women of color are HIV positive.  However, in this care encounter, her provider expresses praise, gratitude, and congratulations on her status in a way that emphasizes the patient’s strength.  This positive reaction worked to counter previous negative feelings and helps to retain the patient in care and builds a foundation of respect for mutual decision making.

To emphasize resilience, do not tell people that they are brave or resilient. Rather, acknowledge that the hardships and tests which LGBTQI people are subjected to require them to build coping mechanisms and alternatives to the dominant culture.  LGBTQI people, like all people, develop coping mechanisms for surviving the trauma in their lives, perhaps through self-medication with alcohol or illicit substance use, or with nicotine or food.  The disproportionate experiences of trauma in LGBTQI communities contribute to the disproportionate rates of substance use disorder, tobacco use, and obesity among LGBTQ people.

Unfortunately, some healthcare systems exclude the support systems for LGBTQI people, for example, hospital policies that exclude non-traditional or chosen families from visiting patients.  LGBTQI people have created systems and families in their lives that support happiness.  Refusing to allow LGBTQI people to choose their own families or allow families to be with them during medical care is traumatizing and harmful to LGBTQI people.  Welcoming LGBTQI chosen families supports the patient’s recovery.

Some trainers use, as simulations, quotes from gay families relating their negative experiences in healthcare encounters.  The trainer shows quotes from these experiences and lets the healthcare provider learner think about how to disrupt these negative interactions.

4. Curriculum Fundamentals

c. i. The basic concepts and essential terminology are routinely the presented in introductory presentations. These resources were produced experts at the National LGBT Cancer Network:

• Definitions are available here.  The appropriate language in LGBTQI communities change frequently so trainers should update their trainings regularly to ensure accurate and respectful definitions are being shared. 
• A helpful resource for teaching the distinction between gender identity, gender expression, and sexual orientation is the Gender Unicorn.  
• Here is a simple, text-based, slide that distinguishes between gender identity and sexual orientation.    
• Some learners find it helpful to understand that LGBT is an umbrella term that encompasses many communities. 
• An example of a slide with definitions of some common sexual orientations.  
• An example of a visual, this slide helps distinguish between sexual orientation, gender identity, and gender expression.