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LGBTQIA+ Health Equity and Foundational Concepts �

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Our Roots

Fenway Health

Independent 501(c)(3) FQHC
Founded 1971
Mission: To enhance the wellbeing of the LGBTQIA+ community as well as people in our neighborhoods and beyond through access to the highest quality health care, education, research, and advocacy
Integrated primary care model, including HIV and transgender health services

The Fenway Institute

Research, Education, Policy

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The National LGBTQIA+ �Health Education Center��

Training and Technical Assistance
Grand Rounds
Online Learning

CE and HEI Credit

Environmental Influences On Child Health Outcomes (ECHO) Programs
Publications and Resources

www.lgbtqiahealtheducation.org

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Why Programs for LGBTQIA+ People Matter

Links:

https://pubmed.ncbi.nlm.nih.gov/33104312/

https://health.gov/healthypeople/about/workgroups/lesbian-gay-bisexual-and-transgender-health-workgroup

Talking Points:

Fenway Health advocates for and delivers innovative, equitable, accessible health care, supportive services, and transformative research and education. We center LGBTQIA+ people, BIPOC individuals, and other underserved communities to enable our local, national, and global neighbors to flourish.
Health centers are an important source of care for lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender minorities (LGBTQIA+) across the United States.
Many LGBTQIA+ people have experienced discrimination in health care settings. For these reasons, LGBTQIA+ people may approach health care with the expectation of a negative encounter, or they may avoid accessing care altogether.
Creating welcoming, inclusive, and affirming health care environments is critical for increasing access to care for LGBTQIA+ people throughout their lifespan.

Transition:

(Next: Today’s Learning Objectives)

Background Information:

Understanding the Well-Being of LGBTQI+ Populations (2020)

The increase in prevalence and visibility of sexually gender diverse (SGD) populations illuminates the need for greater understanding of the ways in which current laws, systems, and programs affect their well-being. Individuals who identify as lesbian, gay, bisexual, asexual, transgender, non-binary, queer, or intersex, as well as those who express same-sex or -gender attractions or behaviors, will have experiences across their life course that differ from those of cisgender and heterosexual individuals. Characteristics such as age, race and ethnicity, and geographic location intersect to play a distinct role in the challenges and opportunities SGD people face.
Understanding the Well-Being of LGBTQI+ Populations reviews the available evidence and identifies future research needs related to the well-being of SDG populations across the life course. This report focuses on eight domains of well-being; the effects of various laws and the legal system on SGD populations; the effects of various public policies and structural stigma; community and civic engagement; families and social relationships; education, including school climate and level of attainment; economic experiences (e.g., employment, compensation, and housing); physical and mental health; and health care access and gender-affirming interventions.

Healthy People 2030

Healthy People 2030 focuses on collecting data on LGBT health issues and improving the health of LGBT adolescents in particular.
Lesbian, gay, bisexual, and transgender (LGBT) people experience many specific health-related challenges and disparities.
Collecting population-level data is key to meeting the needs of LGBT people, but not all state and national surveys include questions about sexual orientation and gender identity. Adding these types of questions to surveys can help inform effective health promotion strategies for LGBT people.
LGBT adolescents are especially at risk for being bullied, thinking about and dying from suicide, and using illegal drugs. School- and family-based interventions can help reduce these behaviors and improve health in LGBT adolescents.

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Explain foundational concepts and terminology related to sexual orientation and gender identity.
Describe how stigma and discrimination lead to health disparities for LGBTQIA+ people.

Learning Objectives

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Foundational Concepts

Respect

Empathy

Compassion

Mirroring Language

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LGBTQIA+ Concepts and Terminology

Talking Points:

In this module, we use the acronym LGBTQIA+, which stands for lesbian, gay, bisexual, transgender, and queer, intersex, and asexual.
+ Plus There are many identities not explicitly named in the LGBTQIA acronym that represent important parts of communities.
I have given you a handout titled Fenway Glossary. As we go through our training today you may hear terms with which you are unfamiliar, please reference this handout and let us know if you have any questions.
Does anyone have questions about vocabulary before we move to the next slide?
presented by the “+” :Pansexual, Omnisexual, Gender Fluid, Nonbinary, Two Spirit, and many more as people create language that affirms them!
I have given you a handout titled Fenway Glossary. As we go through our training today you may hear terms with which you are unfamiliar, please reference this handout and let us know if you have any questions.
Does anyone have questions about vocabulary before we move to the next slide?

Note to Facilitator: The background information below has a glossary of definitions and recommended talking points that you may choose to use depending upon your audience that you are training.

Background Information:

Lesbian is a term used to describe women who are predominately attracted to women.
Gay is a term that is typically used to describe men who are predominately attracted to men. However, gay has historically also been used as an umbrella term for all same-gender attraction.
It’s helpful to remember that these terms make no assumptions about the bodies, relationships, genitals, or types of sex people may in engage in. For instance, someone who uses the term lesbian to describe themselves, may be attracted to trans women, as well as cisgender women, or nonbinary people.
Bisexual or Bi+ is an umbrella term typically used to describe people who are predominately attracted to people of their same gender and of other genders, or towards people regardless of their gender. Bisexual is sometimes written or referred to as “Bi+” and used as an umbrella term which can include similar terms such as pansexual or pan, omnisexual, sexually fluid, and many others.
It’s important to note that bisexual can and does include attraction to transgender, nonbinary, and gender diverse people.
Transgender is an umbrella term for people whose gender identity does not align with society’s expectations based on the sex they were assigned at birth.
Many identities and terms can fall under the trans umbrella: transgender woman, trans woman, transgender man, trans man, nonbinary (sometimes shortened to “enby”), genderqueer person, genderfluid person, trans feminine, trans masculine.
Queer is a term used to describe someone whose gender identity and/or sexual orientation is unique to them, and outside of social expectations of cis-heteronormativity. It is okay to use the term queer if someone gives you consent to use that term for them.
This term queer has a complex history. It historically and presently, has been used as a hateful term for people in the LGBTQIA+ community who don’t conform to strict societal gender and sexual norms.
In the past few decades, the term queer has been reclaimed and is used by many as an identity descriptor and a means of defining ways of being that are outside of narrow binaries and societal norms. In general, it is best to only use the word queer when someone uses it to describe themselves.
Intersex is an umbrella term that refers to people with a wide range of natural variation in sex characteristics and development that falls outside traditional conceptions of female or male.
Although biological sex has traditionally been seen as binary (female or male) in many cultures, the reality is more complex. Variations may occur in the chromosomes, external genitalia, gonads (testes or ovaries), hormone production, hormone responsiveness, internal reproductive organs, or any combination of these, among others.
The percentage of people who are intersex depends on how intersex is defined. If all variations of reproductive or sex characteristics are included in the definition, experts say that approximately 1 in 58 people, or 1.7% of the population, is intersex.
Language related to intersex health is complex. Currently, the medical field uses the terms differences of sex development (DSD) as well as intersex. The term diverse sex development has also been cited in the literature.
Asexual (Ace) is a term used to describe someone who has no or conditional sexual attraction to others.
Aromantic (Aro) is a term typically used to describe someone who has no or conditional romantic attraction to others.
NOTE: The “A” in LGBTQIA+ does not stand for Ally.
+ Plus There are many identities not explicitly named in the LGBTQIA acronym that represent important parts of the community.
Some terms that might be represented by the “+” :Pansexual, Omnisexual, Gender Fluid, Nonbinary, Two Spirit, and many more as people create language that affirms them!

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Sex Development

The process by which physical sex characteristics emerge at different points across the lifespan; these exist along a continuum, including variations in sex development that do not fit traditional notions of female or male bodies/intersex variations.

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Most people have a sexual orientation and a gender identity

Identities can change

Terminology can vary

Mirror the language people use about their identities

Sexual Orientation and Gender Identity (SOGI)

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Sexual Orientation and Gender Identity�(SOGI) Are Not the Same

Sexual Orientation

Gender

Identity

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Sex Assigned at Birth

Female

Male

Intersex

Talking Points:

Sex Assigned At Birth:

To understand gender identity, we must first understand sex, or sex assigned at birth.
We must break out of binary assumptions about human experiences and bodies.
This term is used to describe the categorization of a person as female, male or intersex, based on factors such as anatomy, hormones, chromosomes, or other factors that leads to an assignment at birth.
It is very important, from the beginning that we break down binaries in our assumptions. Sex assigned at birth is sometimes presumed to be split into a binary, or only two options: male or female. In reality sex is not binary, and there are many people who do not fit into those two boxes.

Intersex

Intersex is an umbrella term for differences in sex traits or reproductive anatomy. Intersex people are born with these differences or develop them at a young age. There are many possible differences in genitalia, hormones, internal anatomy, or chromosomes, amongst people.
Some intersex traits are noticed at birth. Others don’t show up until puberty or later in life. Intersex people often face shame—or are forced or coerced into changing their bodies, usually at a very young age. Most surgeries to change intersex traits happen in infancy.
For more information, follow InterACT Advocates for innovative legal and other strategies to advocate for the human rights of children born with variations in their genitals, chromosomes, hormones, and reproductive anatomy.

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Gender Identity and Gender Expression

Gender Identity

A person's inner sense of being a girl/woman, boy/man, beyond, or having no gender

Gender Expression

How one presents gender to other people, for example through gait, mannerisms, voice, dress, and hairstyle

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Gender Perception

Gender Expression

Gender Identity

Sex Assigned at Birth

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Gender Identity Terminology

Cisgender

A person whose gender identity aligns with societal expectations based on the sex they were assigned at birth.

Transgender or Gender Diverse

A person whose gender identity does not align with societal expectations based on the sex they were assigned at birth.

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Transgender and Gender Diverse Identities

Trans Woman

Trans Feminine

Trans Man

Trans Masculine

Pangender

Gender Fluid

Gender Queer

Gender Expansive

Gender Creative

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Gender Affirmation: The process of undergoing changes to live in greater alignment with one’s own gender identity and/or expression, rather than with society’s expectations based on the sex assigned at birth. �

Psychological affirmation

Social affirmation

Legal affirmation

Medical affirmation

Surgical affirmation

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Sexual Orientation

How a person experiences their physical, emotional, and romantic attachments to others.

Identity

Behavior

Attraction

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What Does the ‘Q’ Stand for in LGBTQIA+?

Q

‘Q’ stands for Queer, which is a term used to describe someone whose gender identity and/or sexual orientation is unique to them, and outside of social expectations.

Queer is a term used to describe someone whose gender identity and/or sexual orientation is unique to them, and outside of social expectations of cis-heteronormativity. It is okay to use the term queer if someone gives you consent to use that term for them.
This term queer has a complex history. It historically and presently, has been used as a hateful term for people in the LGBTQIA+ community who don’t conform to strict societal gender and sexual norms.
In the past few decades, the term queer has been reclaimed and is used by many as an identity descriptor and a means of defining ways of being that are outside of narrow binaries and societal norms. In general, it is best to only use the word queer when someone uses it to describe themselves.

‘Q’ may reflect someone who is ‘questioning’ their gender identity or sexual orientation.

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What Does the ‘A’ Stand for in LGBTQIA+?

A

Asexual (Ace) is a term used to describe someone who has no or conditional sexual attraction to others.

Aromantic (Aro) is a term typically used to describe someone who has no or conditional romantic attraction to others.

NOTE: The “A” in LGBTQIA+ does not stand for Ally.

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What Does the ‘+’ Stand for in LGBTQIA+?

+

+ Plus There are many identities not explicitly named in the LGBTQIA acronym that represent important parts of communities.

Some terms that might be represented by the “+” : Pansexual, Omnisexual, Gender Fluid, Nonbinary, Two Spirit, and many more as people create language that affirms them!

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Minority Stress Framework

Fig. 1: Adapted from Introduction to the special issue on structural stigma and health³

Citation(s):

Adapted from: Hatzenbuehler ML, Nolen-Hoeksema S, Dovidio J. How does stigma "get under the skin"?: the mediating role of emotion regulation. Psychol Sci. 2009;20(10):1282-1289. doi:10.1111/j.1467-9280.2009.02441.

Background Information:

Fig. 1. Diagram adapted from “How does sexual minority stigma get “under the skin?” (Hatzenbuehler, 2009)
Gender minorities are at increased risk for multiple mental health burdens compared to the cisgender population.
The field has identified two distinct determinants of this risk, including group-specific minority stressors and general psychological processes that are common across all genders.
The Gender Minority Stress framework postulates that

(a) gender minorities confront increased stress exposure resulting from stigma;
(b) this stigma-related stress creates elevations in general emotion dysregulation, social/interpersonal problems, and cognitive processes conferring risk for psychopathology; and
(c) these processes in turn mediate the relationship between stigma-related stress and psychopathology.
It is argued that this framework can, theoretically, illuminate how stigma adversely affects mental health and, practically, inform clinical interventions. Evidence for the predictive validity of this framework is reviewed, with particular attention paid to illustrative examples from research on depression, anxiety, and alcohol use disorders.

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Intersectionality

This concept was developed by legal scholar Kimberlé Crenshaw over 30 years ago to describe the unique experiences of Black women who face the compounding factors of both racial and gender discrimination.

Talking Points:

A person’s many identities which overlap with one another in relation to stigma and oppression.
Intersectionality is the idea that a person’s different identities, particularly marginalized identities, overlap and synergize one another and cannot be understood in isolation.
It is important to note that intersectionality isn’t a theory of difference. It’s a theory of systems of oppression. When we treat it as being just about our differences, we are not acknowledging that some differences are privileged and others are marginalized.
This concept was developed by legal scholar Kimberlé Crenshaw over 30 years ago to describe the unique experiences of Black women who face the compounding factors of both racial and gender discrimination, which are different from the experiences of Black men and white women.
Intersectionality is like a kaleidoscope– every time you move your view, there are many, many bits and pieces and colors that create a new image.
Intersectionality is the idea that a person’s many identities overlap with one another, particularly as these relate to stigma and oppression.
Multiple studies show that people living at the intersections of oppression have significant healthcare disparities. For instance, a Black transgender woman will face many layers of oppression in her life, not only racism, but sexism, and transphobia as well. Her experiences with city services can be impacted by this stigma in varying ways.

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“There is no such thing as a single-issue struggle because we do not live single-issue lives.”

~Audre Lorde

Complexities

Age

Education

Sexual Orientation

Multilingualism

Gender Expression

Gender Identity

Disability

Race

Ethnicity

Spirituality

Housing Stability

Food Security

Immigration Status

Family Structure

Socio-Economic Status

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Heterosexism

The assumption that all people are heterosexual

Cissexism

The assumption that all people are cisgender

Homophobia

The fear or hatred of people who are not heterosexual

Transphobia

The fear or hatred of people who are not cisgender

Systems of Oppression

Racism

Sexism

Colorism

Homophobia

Transphobia

Ableism

Classism

Xenophobia

Cissexism

Misogyny

Femmephobia

Religious Persecution

Classism

Fat Phobia

Sizeism

Nativism

Colonialism

White Supremacy

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Learning To Address Implicit Bias Toward LGBTQIA+ Patients

Link: https://www.lgbtqiahealtheducation.org/publication/learning-to-address-implicit-bias-towards-lgbtq-patients-case-scenarios/

https://pubmed.ncbi.nlm.nih.gov/32641233/

Talking Points:

A primary objective for health care professionals is to establish solid, trusting relationships with patients in order to promote healthier behaviors. As with other minority groups, when working with LGBTQIA+ patients, it is especially important to build rapport as a way to counteract the exclusion, discrimination, and stigma that many have experienced previously in health care. Despite our best intentions, however, internal --or implicit--biases may affect the way we talk to and behave with patients. For health care professionals, biases can lead to inequitable care, either through biased clinical decisions, or through communicating bias in conversation with patients.

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ADDRESSING IMPLICIT BIAS

Notice Stereotypes

Replace Stereotypes With Affirming Images

See People As Unique Individuals

Be Curious And Show Empathy

Get to Know People Who Are Different From You

Talking Points:

As previously discussed, stigma or bias can be conscious and intended, but is often implicit or unintended. All people are susceptible to implicit biases.
Implicit bias is the association of negative attributes to a particular group without conscious awareness.
All people are susceptible to implicit bias.
By understanding and building awareness about our implicit biases, we can provide better, more affirming care for all community members.
Some ways that we can reduce our implicit bias include:

Notice stereotypic thoughts or responses and reimagine them with compassion
Imagine a person who represents the opposite of stereotypes for that group of people
Obtain specific information about group members to encourage evaluation based on individual, rather than group-based, attributes
Use your empathy skills to increase your perspectives of people beyond stereotypes in society and the media, this can lead to compassionate action and the capacity to interrupt reacting from bias
Seek opportunities to engage in positive interactions with people from marginalized communities
Follow people who are different from you on social media to listen and learn

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Types of Stigma

Structural or Institutional

Interpersonal

Internalized

Talking Points:

Stigma, or the negative attitudes or discrimination against someone based on characteristics, can be experienced in three major ways.
Structural or institutional stigma occurs when the policies of private or government institutions intentionally or unintentionally restrict the opportunities of certain people. For instance, the lengthy, confusing, and sometimes expensive process of changing a name or gender marker on government identity documents is a form of structural discrimination that transgender and gender diverse people face.
Interpersonal stigma is caused when conscious or implicit bias influences the actions or words of one person towards another. For instance, when someone says to another “if you’re bisexual, that just means your greedy or confused. You need to pick a side.” that is interpersonal stigma.
Internalized or intrapersonal stigma is the bias someone holds against themselves, after exposure to structural and/or interpersonal stigma. For instance, someone feeling like something is wrong with them for being genderqueer is a result of internalized stigma.

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Inclusivity Scale

Actively Discriminatory

Overtly Prejudiced

Aware

Active

Friendly

Fully Inclusive and Affirming

Green ER, Maurer LM. The teaching transgender toolkit: A facilitator’s guide to increasing knowledge, reducing prejudice & building skills. Morristown, NJ: Center for Sexuality Education. 2015.

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Six Principles of Trauma-informed Care

TIC in Organizations: Six Key Principles. TIC Training Center. Published January 21, 2021. https://traumainformedcaretraining.com/tic-in-organizations-six-key-principles/

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Ally is a Verb!

30

bystander

action

ALLY

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Ally Is A Verb!

Allyship is a process, a verb, and a journey
Understand your privilege
Listen and learn
Speak up, not over
You will make mistakes, apologize when you do
Own your intent versus impact

Talking Points:

We can all work together to be better allies to LGBTQIA+ communities. But remember that it’s a journey we’re all on together. That means we can always learn and grow more in our awareness for LGBTQIA+ inclusion and equity.
Allyship is a process, a verb, and a journey
Understand your privilege
Listen and learn
Speak up, not over
You will make mistakes, apologize when you do
Own your intent versus impact
There are many ways we can continue our learning, such as:

If you’re on social media, consider following LGBTQIA+ organizations, celebrities, or advocates. This will bring more LGBTQIA+ content into your world!
Participate in LGBTQIA+ events in your community.
Think about LGBTQIA+ representation in the media you engage with: there are opportunities to find movies, television shows, books, even podcasts with LGBTQIA+ content.
You may hear new terms related to sexual orientation or gender identity. When you do, take the opportunity to learn more. Try searching online for more information, before asking an LGBTQIA+ person.

Learning so many new things can feel overwhelming at times. Just remember you’re not alone in this journey. Reach out for support to others who are also learning to be allies or bring new people along to share!

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Let’s Review Our Learning Objectives

Learn foundational concepts and terminology related to sexual orientation and gender identity.
Describe how stigma and discrimination lead to health disparities for LGBTQIA+ people.

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What Questions Do You Have?

?

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www.lgbtqiahealtheducation.org

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Thank you!