1. WELCOME! Please sit in the following groups: PGY1 Front right PGY2 Front left PGY3 Back left

2. Agenda Introduction (5 min) Small group case discussion (20 min) Pretest (5 min) Didactic presentation (10 min) Group reporting and summary (10 min) Post test AND evaluations (5 min) TOTAL: 55 min

3. Cultural Sensitivity and Patient Communication Case Study: Maria Lauren Oshman MD MPH February 5, 2014

4. Objectives Recognize appropriate terminology when taking a sexual history List 3 health care disparities that may affect lesbian or bisexual patients List 3 strategies for creating a safe and welcoming environment for LGBT patient

5. Let’s review our case: Maria Maria is a 54-year-old Hispanic female Needs routine preventive / chronic care -hypertension -alcohol use -smoking -obesity She has not disclosed her sexual orientation.

6. Model of Sexuality Biological Sex Gender Identity/ Expression Sexual Orientation MaleFemale MasculineFeminine WomenMen Intersexed XYXX Androgynous BothOtherNeither Adapted from: Rob Winn MD, Mazzoni Center, Philadelphia PA

7. Sexuality is not static Married man, “heterosexual” identifying, attracted to men, sexual relationships with wife and with other men Single woman, “lesbian” identifying, attracted to women, sexual relationship with female partner, history of sexual relationships with men in the past Remain nonjudgmental and open-minded to flexible and non-binary models of gender and sexuality with all patients. Fenway Guide to Health, p. 15 & 69

8. Sexuality is not static What percent of women who have sex with women have had sex with men? a. < 10% b. 25% c. > 50% Fenway Guide. P. 15; Fenway Guide p. 69

9. Asking about Sexuality “I am going to ask you some questions about your sexual health that I ask all my patients. The answers to these questions are important for me to know to help keep you healthy. Like the rest of this visit, this information is strictly confidential.” Normalize sexual history. Make it routine. Reinforce confidentiality. Sexually is not just orientation, also behaviors.

10. Asking about Sexuality DON’T “So, are you married?” “Do you use condoms 100% of the time?” How many men have you had sex with recently?” Since you identify as lesbian, we don’t need to talk about condoms. Since you are married, let’s move on to the next question. DO Are you in a relationship? How do you protect yourself from HIV and other STIs? How many sexual partners have you had in the last 6mos? Are you sexually involved with men, women, or both? Do you use condoms or latex dams? Are you sexually active outside of your committed relationship?

11. Asking about Sexuality Mirror patients’ language – How do they identify their sexual orientation? – How do they identify their partners? “Partner” “Wife” “Girlfriend” – How do they identify their gender? Use gender neutral terms unless you are sure – Do you have a partner or spouse? – Are you currently in a relationship? – What do you call your partner? It is ok to ask if you are unsure!

12. The Cross Cultural Interview Respect Curiosity Empathy Adapted from Betancourt and Green, via Makadon

13. The Cross Cultural Interview All clinicians should be able to provide non- judgmental, respectful care to all patients. Use respect, curiosity, and empathy to bridge cross-cultural differences. Be curious about your patients’ beliefs, practices, fears, customs. Direct your questions to pertinent health care issues, not just sheer curiosity.

14. LGBT Health Disparities Tobacco use Alcohol and recreation drug use and abuse STIs, HIV, and hepatitis Overweight and obesity Depression, anxiety, suicide Cardiovascular disease Risk factors for breast and gyn cancer Violence and trauma – Domestic violence – Hate crimes – Sexual assault GLMA Top 10 Things Lesbians Should Discuss with their Healthcare Provider. Accessed 9.23.13. http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageID=691http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageID=691

15. LGBT Health Disparities Tobacco - 2X likely to smoke as heterosexuals -Coping with stress? Social acceptance? -Bars and clubs as social outlets Overweight / obesity -2X odds compared to heterosexuals -Less healthy eating habits? More stress? -Less risk eating disorders Both lead to increased CV risk.

16. LGBT Health Disparities Cervical cancer screening -less likely to get pap tests (74% v 61%) -77% have had sex with men -Female-to-female HPV transmission Breast cancer screening -4X less likely to get a mammogram -Risks: low parity, obesity, smoking, alcohol

17. LGBT Health Disparities Violence -2-3X likelihood sexual assault -Same risk DV as hetero couples Routine inquiry about current and past domestic violence Hate crimes

18. Unique LGBT life issues Coming out as LGB or T Relationships, long-term partnership, and marriage Children: reproduction decisions and adoption Parenting and family issues Dealing with adolescence Legal rights as parents and partners Aging GLMA Top 10 Things Lesbians Should Discuss with their Healthcare Provider. Accessed 9.23.13. http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageID=691http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageID=691

19. Patient Friendly Environment Office cues Staff training Nondiscrimination policy Posters, leaflets and forms Safe zone stickers, lapel pins Office LGBT inclusion audit

20. CONCLUSIONS Recognize appropriate terminology when taking a sexual history List 3 health care disparities that may affect lesbian patients. List 3 strategies for creating a safe and welcoming environment for LGBT patients

21. Thank you! “One of the essential qualities of the clinican is interest in humanity, for the secret of the care of the patient is in caring for the patient.” Frances Weld Peabody The Care of the Patient. JAMA. 1927.

22. Further Resources 1.Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. www.thefenwayinstitute.org www.thefenwayinstitute.org 2.GLMA Guidelines for Care of Lesbian, Gay, Bisexual and Transgender Patients. http://www.glma.org/_data/n_0001/resources/live/GLMA%20guidelines%202006%20FINAL.pdf 3.Howard Brown Center http://www.howardbrown.org Questions or comments: loshman@northshore.orgloshman@northshore.org Graphics and pictures were removed from this presentation for copyright purposes.