Sexual and Gender Minority Health: Considerations for Nursing Practice Hillary J. Dutton, MPH, MS, RN, CNE (she/her/hers) NURSE-UN 1248 Contemporary Issues in Healthcare Class Objectives 1. Define SGM terminology 2. Discuss health inequities among SGM persons 3. Describe role of stigma and marginalization in SGM health disparities 4. Explore literature on nurses’ attitudes towards SGM persons 5. Discuss how to support our patients and colleagues Acknowledgements Thank you to the following individuals for generously sharing their slides and expertise: • Gabby Bolaños, BSN, RN, MEDSURG-BC, GERO-BC • Kelseanne Breder, PhD, PMHNP, RN • Caroline Dorsen, PhD, RN Framing the Discussion • What are the moral concerns and ethical dilemmas involved in the care of SGM individuals and communities? • What are the applicable provisions from the code of ethics that guide nursing care for SGM communities? • How can the nursing process for clinical-ethical situations guide nursing care for SGM communities? What is the role of nursing in addressing SGM health disparities? Case 1 You hear some colleagues speaking in the lunchroom about a patient on the floor, laughing and whispering about “what parts he, or she, or it might have” and pretending to play “rock, paper, scissors” to decide “who is going to go find out.” Your discomfort is made worse because you know that one of the other nurses sitting in the room is transgender himself. What do you do? Case 2 You work in GYN oncology and get report that a new patient will be coming to the floor who is having some adverse reactions to his chemo regimen. He is a transgender man being treated for ovarian cancer. As you are readying his room, the other patient politely expresses that she “doesn’t want to be rude, but she just doesn’t feel comfortable having a male roommate.” How do you handle this? Case 3 A colleague announces at a team meeting that he will no longer care for LGBTQ+ patients due a “religious exemption.” What is your colleague talking about? Is this legal? How do you handle this? Case 4 The new policy at your hospital is to ask everyone their sexual orientation and gender identity. Your first patient is an older AfricanAmerican veteran. You believe in the new policy but are worried about offending your patient. What do you do? Overview of Sexual and Gender Minority Health Sexual and Gender Diversity LA County Department of Mental Health Characterizing the SGM Community • LGBTQIA2S+ • Sexual and Gender Diverse • Sexual and Gender Minority • Diversity of identity throughout a spectrum, not across a binary Establishing Relevant Terminology • Sex assigned at birth – AFAB/AMAB • These elements may not always align • Concepts are fluid and evolving A Brief History of SGM Rights and Health For a more detailed timeline, see this article from CNN The Stonewall Riots How the Stonewall Riots Sparked a Movement The AIDS Epidemic • Originally called Gay-Related Immune Deficiency (GRID) • Concentrated in homosexual men in major cities • Stigma and marginalization limited interventions to prevent and treat HIV/AIDS • Ethical concerns for medication development A Brief History of SGM Rights and Health Marriage Equality Federal Protection from Discrimination SGM Health Disparities SGM persons have disparities in most of the leading US health indicators (Healthy People 2020 and 2030): • • • • • • • • Access to healthcare Clinical preventive services Injury and violence Mental health Nutrition, physical activity and obesity Reproductive and sexual health Substance abuse Tobacco Our SGM Patients: Sobering Statistics • Lesbian women have at least twice the risk of being overweight or obese than heterosexual women • Suicide attempts among SGM adolescents are at least 5 times that of the general adolescent population • Close to 50% of MTF transgender persons of color in NYC are HIV+ • SGM persons have among the highest rates of alcohol, tobacco and drug use in the US Causes of SGM Health Disparities • Combination of: • Individual risk behaviors • Social and economic realities • Stigma • Health care provider/institution factors Conceptualizing SGM Health Disparities Stigma and Marginalization Stigma Marginalization • Social process • Stereotyping, discrimination, rejection of human difference • Peripheralization based on identities, associations, experiences, and environment (Hall et al., 1994) • Occurs across multiple levels of influence • Both a process and an experience • Produces health vulnerabilities Intersectionality • Multiple marginalized identities • Intersecting experiences of oppression • Recognition of inherent power dynamics Minority Stress Theory (Meyer, 2003) • SGM adults are subject to ongoing psychological stress due to their social experiences as sexual and/or gender minorities • Multiple chronic stressors over the life course increase risk of adverse health outcomes Patient-Provider Relationship • Lack of knowledge among healthcare providers • Fear of mistreatment or discrimination • Fear of refusal of treatment or services An opportunity for providers to develop strong relationships with SGM patients – how? Barriers to Access and Utilization SGM Equality by State: October 2022 SGM Equality by State: October 2023 SGM Equality by State: Sexual Orientation SGM Equality by State: Gender Identity (10/22) SGM Equality by State: Gender Identity (10/23) SGM Equality by State: Bans on Medical Care for Transgender Youth (10/22) Movement Advancement Project. "Equality Maps: Healthcare Laws and Policies." https://www.lgbtmap.org/equalitymaps/healthcare_laws_and_policies. Accessed 10/05/2022. SGM Equality by State: Bans on Medical Care for Transgender Youth (10/23) SGM Equality by State: Transgender Healthcare “Shield” Laws (10/23) Considering the Role of Public Policy Public Policy in New York What does this mean for nursing practice? Codes of Ethics for Nurses “Inherent in nursing is a respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful of and unrestricted by considerations of age, colour, culture, disability or illness, gender, sexual orientation, nationality, politics, race, religious or spiritual beliefs, legal, economic or social status.” ICN Code of Ethics, 2021 “The nurse practices with compassion and respect for the inherent dignity, worth and unique attributes of every person… The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.” ANA Code of Ethics, 2015 ANA Position Statement – 2018 “ANA condemns discrimination based on sexual orientation, gender identity, and/or expression in healthcare and recognizes that it continues to be an issue despite the increasing recognition and acceptance of SGM populations. Many SGM individuals have reported experiencing some form of discrimination or bias when accessing healthcare services. Persistent societal stigma, ongoing discrimination, and denial of civil and human rights impede individuals’ selfdetermination and access to needed healthcare services, leading to negative health outcomes including increased morbidity and mortality. Nurses must deliver culturally congruent, safe care and advocate for SGM populations.” ANA Position Statement: Nursing Advocacy for SGM Populations Research: Nursing’s Silence on SGM Health Nursing Students Attitudes Clinical Practice: Nursing Literature SGM Patient Experiences With Providers SGM Content in Health Professions Education Nursing • Median of 2 hours devoted to teaching SGM health Physicians • Median of 5 hours of SGM focused content • Implications for practice setting Nursing Practice – What can you do? Theory of Cultural “Compentimility” Campinha-Bacote, J. (December, 2018). Cultural competemility: A paradigm shift in the cultural competence versus cultural humility debate – part I. OJIN: The Online Journal of Issues in Nursing, 24(1). Knowledge • Learn about SGM culture and experience • Find out about your workplace’s policies that may (or may not) support your SGM patients and colleagues • Find out about state and national policies that may or may not protect your SGM patients and colleagues Gender Identity Research & Education Society Human Rights Campaign Foundation Movement Advancement Project National Center for LGBTQIA+ Health Education Center Attitudes • Be conscious of potential explicit and implicit biases • Practice compassion and empathy • Don’t be afraid to admit what you don’t know (but don’t expect your patients to be the ones to teach you) • If you make a mistake, acknowledge it, apologize*, and move on Skills • Practice what to say when patients or other colleagues say something potentially hurtful about SGM persons • Remember the cumulative effect of that “microaggressions” • Practice asking questions about sexual orientation and gender identity (SOGI) in a thoughtful, straightforward, non-judgmental way and think about WHAT information you need to know and WHY Skills • Share your preferred pronouns when introducing yourself to patients and coworkers and ask others theirs • Work on moving to an identity-based healthcare model • Avoid assuming binary anatomy • Utilize non-gendered language as much as possible • Always ask open ended questions What does culturally competent, humble, and affirming care for SGM communities look like? Saf et y Trust w ort hiness and Transp arency List en op enly and ow n m ist akes. Creat e op p ort unit ies for client s t o share ab out t heir id ent it y and aut hent ically affirm t heir exp eriences. Dem onst rat e a p roact ive affirm ing st ance t o honor and celeb rat e sexual and g end er d iversit y t hroug h affirm ing form s, lang uag e, visual sig nals, and LGBTQ+ com p et ent st aff. LGBTQ+ Traum a-Inf orm ed Care Peer Sup p ort LGBTQ+ p eer g roup s nat urally enab le m ut ual aid , as p rocessing sim ilar exp eriences allow s for ext ernal valid at ion and help s challeng e neg at ive self-b eliefs. Collab orat ion and Mut ualit y SA MHSA ’s p rincip les of t raum a-inform ed care g uid e p ract it ioners t o creat e safet y, t rust , t ransp arency, collab orat ion, and em p ow erm ent in help ing relat ionship s, and t o ensure t hat services have cult ural and g end er relevance. Ind ivid ualized g oal p lanning resp ect s t he ind ivid ual w hile coaching t he client t o exp lore alt ernat ives, op t ions, and d ecision-m aking st rat eg ies on t he p at h t o self-accep t ance. Researchers Jill S. Levenson, PhD, LCSW , Shelley Craig PhD, RSW , LCSW , and A shley A ust in, PhD, LCSW , have sug g est ed st rat eg ies for t ranslat ing t hese p rincip les int o affirm at ive p ract ice for LGBTQ+ client s. Em p ow erm ent , Voice, and Choice Creat e op p ort unit ies for LGBTQ+ client s t o t ake t he lead in fram ing t heir ow n life st ory & t reat m ent -relat ed need s Levenson, J. S., Craig, S. L., & Austin, A. ( 20 21) . Traum a-inform ed and affirm at ive m ent al healt h pract icesw it h LGBTQ+ client s. Psychological Services. Cult ural, Hist orical, and Gend er Issues Make services cult urally relevant and resp onsive t o t he uniq ue feeling s and t reat m ent need s of t ransg end er and g end er-d iverse client s. Gender-Affirming Care A Potential Clinical Model for Meeting the Health Needs of SGM Clients Goldhammer, H., Krinsky, L., & Keuroghlian, A.S. (2019). Meeting the behavioral health needs of LGBT older adults. Journal of the American Geriatric Society, 67, 15651570. https://doi.org/10.1111/jgs.15974 Advocacy and Allyship – What can you do? • Make your allyship visible! • Tell your patients and colleagues that you support and respect them • Be the one who tells other people that a joke or comment is not appropriate • Make sure there is a safe place for your colleague to use the restroom • Ask your employer about whether guidelines exist for transitioning employees Back to our guiding question… what is the role of nursing in addressing SGM health disparities? National Nursing LGBTQ Health Summit • Meeting of nursing leaders to discuss role of nursing in addressing SGM health disparities • Tripartite focus: education, practice, research • Recommendations for nursing profession Hughes, T. 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