LGBT Health, Cultural Competency, and Chaplaincy- as presented at APC Conference June 2012

1. Rev. Tanya J. Denley, BCC
Association of Professional Chaplains
June 24, 2012

2. “Of all the forms of inequality,
injustice in health is the most
shocking and most
inhumane.”

3.  Board Certified Chaplain
 Ordained as a Minister of the Word and
Sacrament in the Presbyterian Church (USA)
 Have a MA in Bioethics from Loyola
University Chicago

4.  Awareness of disparity in care for GLBT
patients
 Understanding the reasons for disparity
 Skills to address disparity-
 Cultural competency/ culturally appropriate care
 Narrative/listening skills
 Easy tips to make changes to achieve better service
for GLBT patients
 Sharing of participants knowledge and
resources to further the goals of culturally
appropriate care

5.  Human beings have intrinsic dignity and
value (Genesis 1)
 From that comes basic moral rights
 These moral rights allow for humans to live
into their intrinsic dignity and value
 All deserve equal access to health care,
without undue burden
 Equal access to health care means everyone
has a right to access appropriate care

6.  Appropriate care is being respectful and
culturally aware while providing medical care
that is responsive and medically indicated
 Culturally competent care: medical care that is
respectful of the patient, aware of differences
due to culture, and also aware of biases and
assumptions made both by the medical
personnel and the patient.
 Culturally competent care is also responsive to
the specific needs, desires, issues, and fears of
the patients

7.  Gay: Men who self identify as such and have
sexual relations with members of the same sex.
 Lesbian: Women who self identify as such and
have sexual relations with members of the
same sex
 Bisexual: those who self identify as such and
have sexual relations with members of both
sexes
 No assumption is made about past sexual
history

8.  Transgender: those who self identify as such
and who feel that the sexual organs they were
born with do not correspond to their gender
identity.
 No assumption is made to what degree the
transgender person has „transitioned‟ or begun
to live as a member of the opposite sex
 Note: Intersex – those born with genitals of
both sexes will not be addressed in this
presentation

9.  The last twenty years in the United States has witnessed the
rise of HIV/AIDS, increased gay and lesbian activism, and
heightened mainstream awareness of GLBT movements,
 The issue of gay, lesbian, bisexual and transgender (GLBT)
health is a growing topic in medical literature
 A number of relevant, related topics have been examined in
previous literature:
 health concerns specific to GLBT patients;
 statistical reports on those patients who have disclosed their sexual
orientation to health providers;
 arguments for and against such disclosure;
 GLBT patients‟ relative ability to access care;
 definitions of culturally competent care;
 the need for education of health providers vis-à-vis appropriate
treatment of GLBT patients.

10.  Religious mandate
 All are created equal in the sight of God
 Golden rule
 Matthew 25
 APC standards
 PAS 3 Provide pastoral care that respects diversity
and differences, including but not limited to culture,
gender, sexuality orientation and spiritual/religious
practices
 PAS 2Provide effective pastoral support that
contributes to the well being of patients, family staff

11. • Professional obligation to provide care patients
• The AMA, CDC and American Society of Public Health
have issued recommendations regarding care for GLBT
patients. The Joint Commission is focusing on cultural
diversity
• Patients who are discriminated against tend to be
sicker and have higher rates of cancer and heart
disease and tend to die more often from such
diseases
• More and more people are coming out as GLBT and
seeking care, especially at a younger age

12.  1975- “Homosexuality and Public Health”
“homophobia … adversely affects the health of the
people in it 1) interferes with the proper delivery of
health care to the homosexual minority”
 1998- called for more research into GLBT communities
and the prevalence and incidence of disease as well as
specific health concerns for the community
 1999- Statement 9933 “The Need for Acknowledging
Transgendered Individuals within Research and
Clinical Practice,” –“transgendered individuals are not
receiving adequate health care, [or] information,”

13.  1999 Statement 9993 - warned about confusing
transgendered patients with gay and lesbians,
subsuming them into the larger minority and
not being aware of the variations in needs of
health that exists among transgender patients

14.  Physicians who ”offer their services to the public may
not decline to accept patients because of race, color,
religion, national origin, sexual orientation, gender
identity, or any other basis that would constitute
invidious discrimination.”
 “AMA continues (1) to support the dignity of the
individual, human rights and the sanctity of human life
and (2) to oppose any discrimination based on an
individual‟s sex, sexual orientation, gender identity,
race, religion, disability, ethnic origin, national origin,
or age and any other such reprehensible policies.”

15.  “The patient has the right to courtesy respect, dignity,
responsiveness, and timely attention to his or her
needs.”
 H-160.991 states that for a physician to be able to
“render optimal patient care in health as well as in
illness,” the physician needs to be non-judgmental in
regards to a patient‟s sexual orientation and behavior
 Acknowledgement that the physician‟s ignorance of a
patient‟s sexuality and behavior can lead “to failure to
screen, diagnose, or treat important medical problems

16.  2009- issued requirements to focus on effective
communication, cultural competency, and patient
centered care
 Hospitals are being examined on whether they
address the specific patient needs and concerns of
the patient population being served by that
hospital.
 Various requirements are noted- including
documentation required of the hospital‟s
orientation to staff about issues of cultural
diversity

17.  Code of Ethics
 110.1 The individual person posses dignity and
worth
 110.14 Inclusivity and diversity are foundational
values in pastoral services offered to persons
and are valued throughout the structures of the
Association
 120.1 The Association shall promote integrity,
competence, respect for the dignity of all
persons, and collegiality among its members.

18.  120.11 The Association shall admit to
membership, employ and serve all qualified
persons without discrimination regardless of
race, ethnicity, sexual orientation, gender, age,
disability, religion, or faith group.
 130.1 Members shall treat all persons with
dignity and respect.
 130.11 Members shall serve all persons without
discrimination regardless of religion, faith
group, race, ethnicity, sexual orientation, gender,
age, or disability.

19.  130.13 Members shall affirm the religious and
spiritual freedom of all persons and refrain
from imposing doctrinal positions or
spiritual practices on persons whom they
encounter in their professional role as
chaplain.

20.  Gynecological visits focused mostly on birth control
and prevention of or preparation for becoming
pregnant
 Refusal of treatment
 Laughter/ Joking/ Dismissal/ Embarrassment of
providers/detachment and shock
 Lectures on morality and the non-natural behavior
of being GLBT
 Inflection of pain, unconcern, neglect
 Exams that are “rough” “brutal” or “violent”

21.  GLBT patients are more likely to be scolded, treated
hostilely, patronized, categorized as “difficult”, and
provided fewer explanations
 91% of physicians and medical student members of
American Association of Physicians for Human Rights
reported knowledge of anti-gay bias directed toward
patients
 67% reported knowing of GLB patients who have
received substandard care or been denied care due to
their sexuality
 Studies have shown GLBT patients are at higher risk
for depression, and substance abuse.

22.  Less access to insurance and health care
services, including preventive care
 Lower overall health status
 Higher rates of smoking, alcohol, and
substance abuse
 Higher risk for mental health illnesses, such as
anxiety and depression
 Higher rates of sexually transmitted disease,
including HIV infection
 Increased incidence of some cancers

23.  Refusal of care
 Delayed or substandard care
 Mistreatment
 Inequitable policies and practices
 Little or no inclusion in health outreach or
education
 Inappropriate restrictions or limits on visitation

24.  Refusal to allow partners to visit
 Preference for biological families despite valid
DPOA‟s
 Stronger requirements to provide legitimacy of
families
 Birth certificates/adoption papers
 DPOA‟s, living wills, marriage certificates

25.  Ignorance
 Uncomfortable with unknown
 Religious/cultural bias
 Homophobia
 Sexism
 Upholding of the status quo

26.  Clergy
 Civil Union
 Confidentiality
 Job discrimination
 Esp. transgender
 Sexism
 Insurance
 Discrimination
 Coverage
 Access to GLBT friendly providers
 Where to house in hospital

27.  Military Personal
 HIV Status
 Transgender not allowed to enlist
 Health Insurance concerns
 Domestic Partner Benefits
 Inability to access
 Tax burden
 Extra burden to provide documentation
 AMA Recent Statements

28. Awareness Sensitivity Competency
Inclusion Recognize the presence of LGBT Demonstrate understanding of Provide services that are inclusive
people in every community and the importance of designing and of LGBT people
culture encountered in both delivering health services
profession and personal lives inclusive of LGBT people
Sex and gender Differentiate between sexual and Demonstrate sensitivity toward Deliver services that are
gender orientation and identity the diversity of sexual and gender appropriate to people‟s self-
orientation and identities identification of gender and
sexual orientation
Terminology Define key terminology and Demonstrate understanding of Use LGBT terminology
concepts use by LGBT individuals the importance of terminology to appropriately in practice
and communities LGBT identity and community
Roles and Family structure Indentify partnership and family Respect individual roles and Provide services that respect
structures and individuals roles partnership and family structures individual roles and
within them appropriately include LGBT
people‟s partners and families
Diversity Recognize the diversity within Appreciate the diversity with Design and provide services that
the LGBT communities LGBT communities meet LGBT people‟s diverse
health needs
Stigma Describe heterosexism, Accept responsibility for Institute policies and practice
homophobia, and transphobia, addressing stigma at the norms that create a safe and
their institutionalization in the individual and organization level welcoming environment for
public health systems, and impact LGBT practitioners and clients
of LGBT people‟s health within public health
organizations and services

29.  L- Listen to the patient‟s perspective
 E-Explaining and sharing one‟s own
perspective
 A-Acknowledging differences and similarities
between these two perspectives
 R- Recommending a treatment plan
 N- Negotiating a mutually agreed upon plan

30.  From Joint Commission
 Non- discrimination policies relating to sex
orientation, gender identity and expression are
mandatory- right to be free from
discrimination
 Recognize same sex parents, even if one does
not have legal custody
 Recognize same sex marriages the same as
opposite sex marriages even if same sex
marriage is not legal in the state

31.  Parents cannot bar same sex child's partner
 Importance of support person (even if not
DPOA)
 Look at surrounding community- service needs
or lack of opportunities
 A Field Guide, Advancing Effective
Communication, Cultural Competence, and
Patient- and Family-Centered Care for the
Lesbian, Gay, Bisexual and Transgender
Community

32.  Lesbian Health: Current assessment and directions
for the future 1999
 The Health of Lesbian, Gay, Bisexual , and
Transgender People: Building a Foundation for
Better Understanding 2011
 Compilation of information about health issues
and specific concerns for GLBT patients
 Includes information focusing on differing ages
and specific concerns in those stages of life
 A good general foundation of the issues and
concerns facing GLBT patients and families

33.  Religious mandate
 APC standards
 Idea of holistic care
 Support
 Advocacy

34.  Be aware of concerns, fears about treatments
 Provide support for patient and 'family of
choice' as well as biological family
 Be aware of stereotypes, jokes, dergortory
statements
 Be aware of non traditional families
 Be willing to educate staff, call out for not
appropriate statements
 Use of chosen/preferred name/gender
 Support without judgement: meet where the
patient is

35.  For DPOA‟s
 Information/ education for staff
 Wider definition of family
 Adocate for non-discrim statements
 For use of preferred name/gender
 Confidentiality

36.  DO NOT ASSUME
 Ask patient‟s to specify their own gender- do not
limit to male or female
 Refer to patient by name requested by the patient-
not by Mr. or Ms, ma‟am or sir
 On the intake form add a category to the standard
Male/Female choice –e.g. Transgender/Transsexual
 Be aware of the standards of care
 Let the patient talk and listen to what they say
 Ask open ended questions
 Display a non-discrimination policy

37.  Train and evaluate staff to respect the patient
and to maintain levels of respect
 Make intake forms more welcoming
 Relationship Status rather than Marital Status
 Partner‟s name rather than spouse‟s name
 When interviewing patient ask them to define
any terms or behavior you are unfamiliar with
 Make yourself aware of GLBT health issues
and concerns

38.  Let the patient talk and listen to what they say
 Ask for clarification about unfamiliar terms or
behaviors
 Display brochures, LGBT specific media, posters or
pictures that reflect diversity
 Add cultural competence and specific training in GLBT
issues to CPE curriculum
 Use gender neutral language when discussing
relationships or sexual partners
 Use language such as significant other or partner
rather than spouse

39.  Be willing to educate providers
 Be patient
 Silence = death
 Be willing to challenge providers

40.  Mandate cultural competency training
 Cultural competence training includes:
 Gender identity
 Sexual orientation
 Non-traditional families
 DPOA‟s and honoring a patient‟s wishes
 HIPPA
Having this documentation tied with Joint
Commission would see that all hospitals who seek
accreditation would be required to comply
(currently does not affect accreditation)

41.  Henry Benjamin International Gender Dysphoria
Association- now known as World Professional Association
for Transgender Health which produces standards of care for
transgender patients (WPATH.org)
 MyRightSelf.org- Transgender considerations: A Clinical
Primer for the Generalist Working with Trans and LGB
Patients
 Gay and Lesbian Medical Association and their Guidelines
for Care of Lesbian, Gay, Bisexual and Transgender Patients
(GLMA.org)
 Removing the Barriers and the Mautner Project
 www.mautnerproject.org

42.  Gay friendly providers:
 www.glma.org
 Human Rights Campaign
 Straight for Equality in Health Care: Parents and
Friends of Lesbians and Gays
 Boston VA Health Care System policy "Management
of Transsexual Veteran Patients“
 Peterkin, Allan, and Cathy Risdon. 2003. Caring for
lesbian and gay people: a clinical guide. Toronto:
University of Toronto Press

43.  Advancing Effective Communication , Cultural
Competence … Joint Commission
 “The Health of Lesbian, Gay, Bisexual, and
Transgender People: Building a Foundation for
Better Understanding” Institute on Medicine
2011
 “Ending LGBT invisibility in health care: The
First step in ensuring equitable care” Cleveland
Clinic Journal of Medicine 78:4 (April 2011) 220-
224.

44.  Association of Professional Chaplains
 Reading room
 Common standards For Health Care Chaplains
 Code of Ethics
 Health Care Chaplaincy- Cultural and Spiritual
Competency
 Healthcarechaplaincy.org
 Williams, Arthur Robinsons. 2009. Transgender
considerations: a clinical primer for the generalist working
with Trans and LGB Patients. GHP Media, Inc.

45.  Questions
 Input