Lecture part 1
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So this lecture will be on the care of the LGBTQ eye.
0:04
A plus community. What are all these letters mean?
0:08
L is for lesbian. G is for gay and bisexual.
0:12
T is for transgender. Q is for queer.
0:17
Eye is for intersex. Is for ally.
0:20
And Plus stands for everything that we're not encompassing with this label.
0:24
Now I want to remind everyone to love your neighbor as yourself.
0:31
There are seven passages that are used over and over and over again to justify a bias against the LGBTQ people.
0:35
But there are over 100 Bible verses about love.
0:44
So let's all be safe and focus on love.
0:48
Scripture has been used to justify slavery, to exclude divorced people from participating
in sacraments,
0:51
to exclude women from ministry, to persecute left handed people.
0:58
And if the church has been wrong in its treatment of LGBTQ issues, then this would not be unprecedented, is all I'm saying.
1:04
So I want you to keep these verses in mind.
1:11
First of all, the verse for you created my inmost being unit me together in my mother's womb.
1:14
I praise you because I am fearfully and wonderfully made. Your works are wonderful.
1:21
I know that full well.
1:25
Sexual identity and gender identity are components of a person's personality, and as such are part of who God made each of us to be.
1:28
God did not make a mistake in creating LGBTQ people.
1:36
God also welcomes people of all genders and all sexual identities.
1:40
And we see that in Matthew.
1:45
There is neither Jew nor Gentile, neither slave nor free, nor is there male and female, for
you are all one in Christ Jesus.
1:48
That's Galatians and Acts. God has shown me that I should not call anyone impure or unclean,
1:56
and Jesus gladly socialized with people that the religious establishment disapproved of.
2:04
And above all, as I started this slide,
2:10
love the word God with all your heart and with all your soul and with all your mind and with all your strength.
2:14
The second is this Love thy neighbor as yourself. There is no commandment greater than this.
2:20
So. Cultural competency, however, goes far beyond LGBTQ.
2:27
It can bridge gender differences, ethnicity differences, worldview differences, financial differences, right?
2:35
Cultural competency goes beyond that. So we know that socio cultural differences between patient and provider influence,
2:43
the communication between them, the understanding between them, as well as the clinical decision making.
2:51
This is shown in the literature, unfortunately. So cross-cultural care is in essence the care of every single patient.
2:56
As I said, not just those of the child care communities, not straight or heterosexual communities, but for all patients.
3:03
And at the end of the day, we need to just come back to focusing on communicating effectively and providing high quality care above all else.
3:11
So take a patient based approach, right? So first you assess, you know, core cross cultural issues, right?
3:20
And you need to explore those. And we did talk about those on the previous slide.
3:27
Communication was one, decision making was one, but also trust, family and loved one,
dynamics, traditions, spirituality.
3:32
And then, you know, in this talk, sexual and gender issues, it's important to explore the patient's understanding of illness.
3:40
Right. The explanatory model represents how the patient understands their illness cause meaning and consequence and understanding.
3:48
A patient's explanatory model allows you to adapt your communication and kind of
3:55
tailor your treatment recommendations to their concerns and their perspectives.
4:01
Right. So it's important to use that explanatory model to represent how the patient understands their disease.
4:05
And then with the social context,
4:11
this is basically seeing the manifestations of a person's illness are linked to that individual's social environment.
4:14
And three specific aspects of the patient's social context have particular relevance to the cross-cultural clinical exchange,
4:21
and that's changing environment, right? Like migration, perhaps literacy and language.
4:29
Can they read? Do they speak English?
4:34
Do they need a translator? Do they have family translating for them?
4:37
And then life control, right? Like the social stressors that we all have as well is on the flip side of that, our support system.
4:41
And then you want to negotiate a mutually acceptable approach to care.
4:49
And you know, even when you have the same socio cultural backgrounds as your patients,
4:53
substantial differences may still exist and expectations or agendas or values between you and your patients.
5:00
So the process, process of cross-cultural negotiation will be helpful as long as you acknowledge different explanatory models and,
5:07
you know, develop strategies to kind of manage those.
5:15
So what does that look like here? Well, we're going to look at a slide that might help us put this into perspective a little bit better later on.
5:19
But I just want to remind you that gender is defined and enforced very differently in different parts of the world.
5:29
Right. And sometimes these are strictly defined.
5:36
For example, the male role may commonly be seen as that of a protector, maybe a spokesperson for the family.
5:40
And it can be a hot button issue talking about gender roles and norms and deviation from that.
5:48
But this needs to be negotiated with tact and respect, and you'll be able to maintain a therapeutic relationship if you keep that above all else.
5:55
So oftentimes, you know,
6:03
difficult situations may arise due to the patient and the provider being maybe different or same
6:07
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sex or gender discomfort with examinations of the general area or the rectum or the breasts.
6:15
And then sometimes people just have plain old shame when discussing sexual issues.
6:22
Right? So health care providers should just keep this in mind.
6:26
Keeping sexual issues, gender issues. Pay attention to body language and particular cues a patient is giving you.
6:31
And then make sure you're not misgendering. And what misgendering means is that you're you'd be making incorrect assumptions about a patient's gender.
6:41
So if you thought you walked into the room and you saw a very masculine appearing, female was a male, and you, you know,
6:48
refer to them as such, even though they actually identify as female, it can just cause difficulties in trust and communication.
6:58
Right. So we haven't always been good at this in health care,
7:05
but this is where asking for people's pronouns like when when it's becoming more normalized for sure not everyone does it,
7:10
even though that's where we'd ideally like to be,
7:19
but that that helps open the door and kind of can engage trust in even just asking that question rather than assuming.
7:21
And there are some techniques I want to give you guys some actual quotes that might be helpful to get out of situations
7:28
where there may be maybe just an incongruence in understanding with sexual and gender stuff going on in in the clinic.
7:38
So be aware of how the patients and their loved ones do view gender roles in a comedy.
7:47
Right? And this is sometimes not only culturally sexually driven, but also culturally driven as well.
7:53
So you may want to see something like, unfortunately, we have no female providers in clinic today,
7:58
but if you're willing to risk your appointment, I can make sure that your wife will see a female doctor next week.
8:04
Right. So clearly in this context, there is some discomfort with, you know,
8:09
with maybe the husband or wife or both with her seeing a male provider and if she's more comfortable or her husband is more comfortable.
8:17
And so some cultures with her seeing a female provider, this would be a good way to to do this.
8:27
And then you want to just always ask for permission. And we talk about this in the breast and pelvic lab.
8:33
Right. But you want to ask for the patient and in some cases the loved ones permission, if you will,
8:38
or what's acceptable to them, rather than just assuming that you can truck on in there and do some sort of intimate exam.
8:43
So one thing you can say is I perform breast examinations to look for signs of breast cancer.
8:50
Is this okay with you? Asking their permission and putting the onus on them will help them feel autonomy and like they're in control.
8:56
And this is also very helpful for victims of sexual assault or abuse or just patients who are uncomfortable with,
9:04
you know, showing their most vulnerable selves to someone they don't know or they've just met.
9:14
You want to be sensitive to patient's views on sexual issues openly.
9:19
And I urge you, I included it in this document as well as on canvas.
9:24
But the Kdka's Guide to Taking a Sexual History.
9:30
It's fantastic,
9:34
but one thing that you may feel comfortable saying is I generally ask all patients about some very personal matters at this point in the visit.
9:35
These are important for nurse practitioners to know about.
9:44
Are you comfortable talking about these things with me that can open the door and just make them maybe not feel singled out?
9:47
Like why? Why is he asking me this? Why is she asking me this?
9:55
We'll ask everyone this, right? And then ask about the sex and gender of the sexual partners rather than how the patient identifies.
9:59
Right. Instead of saying, Are you gay?
10:08
Are you by right? You want to say, are your sexual partners, men, women?
10:12
Both or persons who are nonbinary or another gender.
10:18
When I went to school, the latter part was not in there because we were not as sensitive
to this.
10:23
And at that time, you know, there was a school of thought that gender was fluid, but it hasn't it was still very polarized in man or woman.
10:27
But, you know, now we do have nonbinary individuals really, you know, are it's becoming more common to come across clinically.
10:37
So I think it is worth including in this question. Now, this is the slide that I was referencing earlier in the deck.
10:47
And I love this slide and this is the gender bred person.
10:56
And it kind of really helps you visually wrap your mind about these these concepts.
10:59
If you could all just.
11:08
Remember that there's no such thing as an LGBTQ person, right?
11:14
These are all like different labels representing different identities.
11:17
And sometimes patients or individuals will have like numerous of these identities themselves.
11:22
Right. They can be perhaps gay and transgender, right? Or even lesbian, gay, queer and
transgender.
11:29
But we're getting ahead of ourselves. So let's just start with the basics.
11:36
Right. So again, LGB.
11:39
Represents all sexual identities and the T represents a gender identity as well as an umbrella term for many gender identities.
11:43
So queer, on the other hand, means different things to different people.
11:52
And for some it describes sexuality, for others, their gender, for others, both.
11:56
When we say sexual identities or sexual orientations,
12:00
what we're actually talking about are the ways we categorize and define who we are attracted to romantically or sexually or even otherwise.
12:04
Right? When we have the gender identities, we're talking about the ways we categorize and define our genders.
12:12
And as I kind of alluded to earlier, we used to put those into more of a box rather than thinking of it as a continuum.
12:20
And so I think it's important to note that while we may hear mention of the LGBTQ community often, right, I've even referenced it in this talk.
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12:27
There are many times that we are not referring to gender identity or trans issues specifically, but are referring to sexuality.
12:37
And it's important to note that nuanced difference. So that's what I draw your attention to the gender, Brad.
12:43
Person so we can kind of focus on the distinctions between gender sex and attraction.
12:52
Right. So traditionally the word gender used to mean like man or woman.
12:58
And we describe this as the gender binary.
13:04
Right? It's more of a continuum. It's a binary. And so the phrase you probably heard is like two options, right?
13:07
The binary rather than the continuum. But in reality, the way folks experience gender is far more complex than that.
13:16
And so that's why we call it non-binary.
13:23
And it's kind of this is like if you've grown up your whole life, just only thinking like man and woman exist.
13:25
And in that sense, like, I guess in most simple terms, the idea of a man and what that means.
13:30
And then you have the idea of the woman and what that means. It's kind of helpful if you think of a line between the two.
13:39
If you could plot a line from man to woman and then put non-binary in the scale, like somewhere along the line, perhaps in the middle.
13:45
Right. Or if they are in the middle, they identify as genderqueer by gender.
13:58
And another one of the non-binary age and gender identity labels.
14:04
It's just different than man or woman. So it doesn't necessarily mean it's in the middle.
14:10
It's just kind of like it doesn't fall into one extreme or the other.
14:15
If you think of a man and woman on opposite ends of the continuum.
14:20
Okay, so it's just a helpful kind of an understanding, like a more diverse way that people
just experience and make sense of gender.
14:24
Okay. And so our gut reaction is that like.
14:34
Well, when you dissect gender into its most important component parts like you, you may think, Oh, well, how can this be true?
14:40
But gender is best understood when you break it up into three parts.
14:48
One is gender identity,
14:52
and that's how you in your head define and understand your gender based on the options for gender that you know to exist, right?
14:53
If you only know man or woman to exist, like you're going to pick a man or woman, right?
15:01
With gender expression, the way you demonstrate gender through your dress, your actions or your demeanor.
15:07
And then there's also biological sex, right? And that's the physical parts of your body that we think of as either male or female.
15:15
But we're going to talk about these things one by one. Gender identity can be thought of as aspects of man or woman.
15:22
This right. And either you do or you don't align with them. In this case, we're talking about the norms and the social expectations, right?
15:29
Versus the roles and ways we fulfill or act out those expectations.
15:36
And that's what we place upon men and women. A few typical norms of man.
15:40
This might be like they're strong willed, they're logical, they're sensible, athletic, right.
15:46
And they carry the roles of leader and builder and protector.
15:51
And for woman ness, we might think of norms like empathetic, sensitive, caring, soft, and roles of, like, teacher, caretaker, supporter.
15:55
Right. So some folks identify with neither man illness or woman.
16:06
This in this sense, but a third gender entirely. Right.
16:09
Some folks identify with aspects of both and might use the label genderqueer to describe their identity.
16:13
Okay, so gender expression.
16:18
The second thing that can be thought of as the aspects of masculinity and femininity you display in your way you dress or the way you do your hair,
16:21
the way you speak, the actions, your demeanor.
16:31
So as examples, masculine dress might be considered like my husband uses the term functional as his wardrobe descriptor, right?
16:34
Or maybe like guys like their clothes baggy or you know, I'm unbridled, let's say.
16:43
Whereas feminine dress, you know, could stereotypically be more form fitting, colorful, frivolous, right?
16:50
So then we have the term androgynous and that is used to describe gender expression.
16:56
That is neither. I'm sorry. I'm sorry. That is both masculine and feminine.
17:01
And then biological sex is the third thing.
17:05
And that can be thought of as aspects of maleness and femaleness and like how you embody your physical self, right?
17:09
So with maleness, there's penis testicles as well as secondary traits developed during puberty like, you know, beards and white shoulders.
17:16
And then you have examples of femaleness, which are primary traits like vagina and ovaries and like breasts and wide hips, right?
17:26
Some folks are predominantly male or female, while others are biologically intersex.
17:34
And there are multiple reasons and ways that our bodies look the way they do or are the way they are.
17:41
And, you know, sometimes that's cancer, right? If we have a mastectomy.
17:47
Hormone imbalances, right. Like females can start to have body hair where they otherwise wouldn't if they didn't have a certain hormone imbalance.
17:51
And, you know, if anyone's transitioning transitioning genders, that can all play a factor in the type of sexed body that we have.
18:01
And regardless of what we have going on, we may identify a particular biological sex regardless.
18:08
Right. And. All of this we have been talking about, remember, is related to gender, which is distinct from sexuality and with sexuality.
18:15
Once again, we often somehow reinforce a different binary right, gay or straight.
18:25
But there are far more ways that people identify and experience sexuality.
18:31
So helpful way to think about that is to distinguish between our romantic and sexual attracted attraction.
18:36
Some folks experience both, some experience one more than the other, and some folks experience little to none of either, right?
18:43
So many of us experience sexual attraction and romantic attraction at about the same levels to the same genders.
18:51
And therefore, it's hard for us to feel that a big difference between the two.
18:56
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But I think recognizing that other people, they may not feel that right.
19:04
There may be an incongruence there or like asexual.
19:10
Right. They're not a romantic, but they may experience romantic attraction, wanting to go on dates, having deep conversations.
19:15
But they don't experience sexual attraction. So I think of it like this.
19:23
There are some celebrities that I find very sexually attracted,
19:27
but I don't experience a desire to like wine and dine them or, you know, have a dinner conversation with them.
19:30
Whereas there are others who I'm like, I want to go on a date with that person when I really don't tell my husband about or like,
19:38
you know, I want to go like take a road trip in the back of a convertible and like eat chili mac and like smash beer cans on our heads.
19:45
There are those people that you just kind of, like, hang out with. Right. And so but are those the same people who want to have sex with.
19:52
Probably not. And if you find both of those great in the same person, that's a person.
20:00
But I want you to reflect within yourself.
20:05
Like, are you one of those people that, you know,
20:09
can not feel a big difference between sexual attraction and romantic attraction, or is there more of a chasm there?
20:12
So consider this, you know, in yourself. And even if you don't feel it, recognize that others do.
20:18
And I hope that's helpful. I know this can be all very confusing.
20:24
There's a lot of stuff at play here, so please let me know if you have any questions.
20:28
But knowing what you know now, armed with your mental image of the gender Brad person,
20:32
I want you to be committed to making care accessible for everyone.
20:39
And these policies have been implemented by the Joint Commission, and I want you to support those.
20:44
And that's patient choice visitors prohibiting discrimination based on sexual orientation, gender identity, gender expression,
20:50
and then just, you know, have subtle signs that make it a welcoming place in your op, like your office environment.
20:58
How photos of LGBTQ families in educational materials and waiting areas just like you'd,
you know,
21:03
show diverse ethnic backgrounds in educational materials in your waiting areas, maybe have a rainbow flag somewhere.
21:10
Doesn't even have to be huge.
21:17
Sometimes putting just a little decal on the door is enough to make people feel comfortable in making sure they feel safe in your clinic.
21:19
And then if you notice, I have a rainbow lanyard, and that's the way I show my support.
21:27
But you could do pens or a pen or other things,
21:33
just as subtle cues as to you being inclusive and caring about making care accessible for the LGBTQ community.
21:37
And then maybe you want to think about editing your intake materials in the clinic once you're, you know, up and running.
21:46
So the language is more inclusive, right? Strictly heteronormative language.
21:53
And heteronormative means that we assume that everyone's heterosexual.
21:58
We assume that there's a mom and a dad and two kids and a white picket fence.
22:02
Right. That's heteronormative language. And that can be super off putting to sexual minorities.
22:06
So just making sure that maybe your your intake materials and other educational
22:12
materials and stuff around the office is just a little more mindful of that.
22:17
And then, you know, offer guidance that's accessible to all on marriage and adoption and parenting and foster parents or surrogate pregnancy,
22:23
and then also be mindful of issues like registration, right?
22:32
So like if if you are in a pediatric clinic and a child is to be registered and your intake form says Mom's name.
22:36
Dad's name. Right. That's super heteronormative language.
22:45
So maybe a better idea would be parent one parent too.
22:48
Right? So that could be a way to edit your intake materials.
22:52
And then I put this, I really encourage you to look at this culture vision document.
22:57
It's very good. So when you have a second, I would appreciate it if you did that.
23:03
And then next, we're going to talk about the appropriate terminology.
23:08
And this is where a lot of people get hung up. So I made it kind of fill in the blank.
23:15
I know you guys like that. It helps you learn. So we're going to go over those right now.
23:19
It's and it's really important to actually use patient's preferred descriptors.
23:25
Right. I want you to directly ask the patients how they prefer to be identified.
23:30
Just like you know what you would say. Do you want to be called Michael or Mike?
23:36
Right. You do that with a name, so please do that with their gender identity, pronouns, sexual partners, etc.
23:42
And also recognize that like language and terminology is continuously evolving
23:48
and there are numerous terms in use and they may not be terms and tenures.
23:52
They may be offensive in ten years, but we need to be fluid and we need to kind of accept the change in that over time.
23:56
And so it's important to, like, keep having this conversation with yourself and with your patients because these things can change.
24:02
So gender. Remember that gender is a concept that can vary by society and it can change over time.
24:11
And gender refers to the socially constructed characteristics of men and women,
24:21
such as roles, norms, behaviors that are labeled by a society as male and female.
24:27
Okay, now gender identity.
24:33
An individual's gender identity can be the same or different from their sex assigned at birth.
24:37
And gender identity is truly and this is the definition here one's innermost concept of self from the perspective of one's gender, right?
24:43
So it can be described as an internal self label. It can identify as either male or female.
24:53
But recognizing that gender is an umbrella term and many identify outside of the construct,
25:00
including no gender, then gender identity encompasses transgender identities too, right?
25:06
Non-binary, gender, queer, intersex, etc. So gender is created by society.
25:13
Gender identity is what somebody feels. Gender expression.
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25:19
That is how gender identity is lived out in the real world.
25:25
Right? The outward manner in which an individual expresses or displays their gender.
25:30
Okay. So let me talk to you real quick about Caitlyn Jenner.
25:36
Right. So Caitlyn Jenner, Caitlyn, for many, many years when Caitlyn Jenner was Bruce Jenner.
25:40
Right. That gender expression was male. Whereas Caitlyn.
25:49
Obviously felt her gender identity and the inside was female and now her gender expression matches the gender identity.
25:55
But that's what's always important, right, is because sometimes people have a different gender identity than gender expression.
26:02
And that's that's really important to to realize.
26:09
And then this is kind of where people's specific pronouns come in.
26:16
She her hers. He him his, they them.
26:19
There's sometimes I've seen people personally choose a combination of these things like they will use like she her hers and they them.
26:23
There's like collectively like either is fine, but just ask.
26:33
And then we have transgender. So that's the umbrella term.
26:39
But transgender is sometimes shortened to trans or trans woman, trans man, transmasculine, trans feminine.
26:43
And that refers to a person whose gender identity differs from their sex assigned at birth.
26:51
So transgender individuals may be referred to as trans woman or transgender woman, and that is a genetic male who self-identifies as a woman.
26:57
Or, for example, trans men or transgender man.
27:08
That is a genetic female who self-identifies as a man.
27:11
Transgender individuals may choose to receive hormone therapy.
27:15
They may or may not undergo various gender affirmation surgeries, which we'll talk about.
27:19
But that is a gender identity. And that is not like the same thing as a sexual orientation.
27:24
And that is very important. I want you to remember that.
27:31
And then there's this gender, and that is a term used to describe a person whose gender identity corresponds to their sex assigned at birth.
27:35
Right. So, for example, I was assigned a female sex at birth and I identify as a woman.
27:43
Therefore, I am cisgender. Okay. That's that's statistically speaking, more typical in society.
27:50
Okay. Now non-binary.
27:58
That's when gender identity and gender expression do not align with the categories of male or female.
28:02
Okay.
28:09
So if they don't feel they're not their, you know, neither man or woman, then the term non-binary is used and includes identities such as gender,
28:10
queer, age, gender, androgynous, etc., etc. And we have natal sex that just refers to the
sex, to the biology, like when they're born.
28:20
And that's genetic, hormonal, anatomic, physical characteristics.
28:33
You could also say biological sex, sex assigned at birth, birth sex.
28:38
And and then we have sexual orientation and that is self-defined.
28:42
And that refers to one's inherent emotional, romantic and sexual attractions to other people.
28:47
Thus, like one single sexual event or desire does not define one sexual orientation.
28:53
Historically, sexual orientation has been thought of as like one of several categories, including heterosexual, lesbian or gay and bisexual.
28:59
However, many perceive their attractions as much more fluid, more readily shaped than
this, and they don't identify within those categories.
29:08
And like, you know, you can kind of like, I don't know if you've ever read Kinsey's work, but it's basically the concept of the Kinsey scale.
29:17
And then we have the term of queer, right? And once that was like a derogatory label,
29:26
but it's been like re adopted and reclaimed as a positive self label in this
29:31
community and that is kind of recognized to be more fluid and less limiting.
29:34
So a lot of people will choose the term queer rather than choosing from one of the other
categories.
29:39
Although you have to be careful because some individuals still find the term offensive.
29:46
So you just once again just ask your patient and then other categories of sexual orientation that have emerged are pansexual, asexual, homosexual.
29:50
Pansexual is sexual, romantic or emotional attraction towards people regardless of their
sex or gender identity.
30:01
So pansexual people may refer to themselves as gender blind,
30:09
asserting that gender and sex are not determining factors in their romantic or sexual attraction to each others.
30:13
Whereas like asexuality is the lack of sexual attraction to others, or low or absent interest or desire for sexual activity.
30:19
It might be considered a sexual or an orientation or even a lack thereof,
30:29
but it may also be categorized more widely to include a broad spectrum of like asexual some identities.
30:34
But we're not going to get into that in this lecture.
30:39
And then lastly, on the sex people, they are attracted to those of all gender identities and sexual orientations.
30:42
And a lot of people use this term kind of interchangeably with pansexual and omni sexual.
30:49
And while they're closely related, there are many differences between the two.
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So those who identify as pansexual feel attraction to people without noticing their gender,
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while many sexual people recognize the gender of potential partners.
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So let's put it this way pansexual people are gender blind, while omni sexual people are not.
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Even though many sexual individuals recognize the gender of those who may feel a romantic attraction,
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it doesn't play a huge factor in their choice of partner.
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So again, just remember, it boils down to sexual orientation is one's inner most emotional, romantic and sexual attractions to other people.
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Sexual behavior embraces a complex spectrum. Patterns of romantic and or sexual activities not clearly categorized.
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We want it to be right. We want to put it in the gay, lesbian, bisexual boxes.
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But sometimes it's just not the case. Interactions are fluid, and we know this.
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31:48
Those people often identify as queer, pansexual, etc. So please let me know if you have any questions.
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I need a glass of water. I'm like coughing up a storm over here.
Gender can be a very confusing concept when you've really only thought about sex and gender as male or female your entire life.
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But I this is graduate school and we are opening up your brain to see the world a different way.
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And so if this is like confusing to you, that's okay.
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I'm happy to be part of your journey to kind of help you figure it out, so please don't hesitate to reach out.