1. Addressing Social Determinants of Health for LGBTQ People (Part 2)
JESSICA FLAHERTY

2. Our Roots Fenway Health Independent 501(c)(3) FQHC Founded 1971
Mission: To enhance the wellbeing of the LGBT 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 services
The Fenway Institute
Research, Education, Policy

3.  lgbthealtheducation@fenwayhealth.org  www.lgbthealtheducation.org  

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9. Today’s Faculty
JESSICA FLAHERTY

10. Disclosure I have no financial conflicts of interest.

11. LEARNING OBJECTIVES
Because case managers, peer navigators, community health workers and other enabling services staff help patients create and follow through on plans for food, shelter, income, health care, transportation, and other social determinants, it is important that they understand the issues LGBTQ people face when trying to access these services in the community.
Today we will;
Present a framework for understanding LGBTQ competent care
Introduce practical approaches to improving systems and providing customized care for diverse LGBTQ populations
Explore established evidence-based and promising practices for increasing healthy outcomes among LGBTQ patients

12. SOCIAL DETERMINANTS OF HEALTH
The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities.
SDOH
Neighborhood & Built Environment
Health & Health Care
Social and Community Context
Education
Economic Stability
REFERENCE/CITATION: Healthy People Understanding Social Determinants of Health 2013

13. REVIEW Examples of Social Determinants of Health for LGBTQ people
Access to care
Enormous challenges remain for LGBTQ communities and those living with HIV in accessing quality, non-discriminatory health care services.
Insurance coverage
LGBTQ Americans were more likely to report being uninsured than non-LGBTQ Americans
Employment
23 states have not specifically listed sexual orientation in their law prohibiting discrimination against public employees, and 35 states do not prohibit gender identity discrimination against public employees
Education
Schools nationwide are hostile environments for a distressing number of LGBTQ students, the overwhelming majority of whom routinely hear anti-LGBT language and experience victimization and discrimination at school. As a result, many LGBTQ students avoid school activities or miss school entirely.

14. REVIEW Social Determinants of Health for LGBTQ people Housing
Between 20 percent and 40 percent of all homeless youth identify as lesbian, gay, bisexual or transgender
Transportation
65% of transgender residents of Massachusetts reported experiencing discrimination in public accommodations settings, including public transportation
sources:
When Health Care Isn’t Caring: Survey of Discrimination against LGBT People and People with HIV. New York: Lambda Legal. 2010
In U.S., LGBT More Likely Than Non-LGBT to be Uninsured. Gallup 2014
National School Climate Survey, GLSEN 2015
An Epidemic of Homelessness, National Gay and Lesbian Task Force Policy Institute & National Coalition for the Homeless 2006
Discrimination and Health in Massachusetts: A Statewide Survey of Transgender and Gender Nonconforming Adults, The Fenway Institute, 2014

15. HEALTH DISPARITIES
Social determinants of health are shaped by the distribution of money, power, and resources.
Health disparity is defined as a type of difference in health that is closely linked with social or economic disadvantage.
Health disparities negatively affect groups of people who have systematically experienced greater social or economic obstacles to health.
These obstacles stem from characteristics historically linked to discrimination or exclusion such as race or ethnicity, religion, socioeconomic status, gender, mental health, physical ability, sexual orientation, or geographic location.
REFERENCE/CITATION: U.S. Department of Health and Human Services, Healthy People 2020 Draft. 2009, U.S. Government Printing Office.

16. REVIEW
Lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients have unique health needs and experience numerous health disparities
Mental Health
Rates of depression and anxiety; suicidality
Sexual Health
Risk of HIV/STIs, especially among communities of color; unplanned pregnancy
Violence
Rates of violence and victimization
Child Abuse
Conversion Therapy, Family Rejection, and physical/emotional violence
Substance Use
Rates of tobacco, alcohol, and other drug use

17. LGBTQ Competent Care
Case Managers, Peer Navigators, Community Health Workers and other enabling services staff need training and technical assistance to increase their cultural competency and communication skills, as well as help in finding and creating working relationships with organizations and services that are welcoming and culturally-appropriate for LGBT people.

18. Anti-Oppression Skills
LGBTQ Competent Care
Anti-Oppression Skills

19. REVIEW Anti-Oppression Skills Look for Functional ways of Helping
Resist doing things for LGBTQ patients that they can do for themselves
Provide clear and constructive feedback that notes positive behaviors as well as areas for improvement
Engage LGBTQ patients as partners in formulating plans to improve their lives or behaviors
Take Responsibility
Take responsibility for determining your own group’s standards
Define how your own thoughts and behaviors contribute to a situation
Do not degrade the concerns or issues of LGBTQ patients
Do not assess LGBTQ patients by using the standards of your own group

20. REVIEW Anti-Oppression Skills Make Contact
Make an effort to learn about the lives and concerns of LGBTQ people
Make an effort to get to know and interact personally with LGBTQ people
Be willing to change your perceptions to fit your new experiences
Recognize and Appreciate Differences
Grant equal respect to all people, but learn to distinguish among cultural differences in worldviews, communication patterns, issues of concern, etc.
Develop an awareness of your own assumptions and verbal and nonverbal communication patterns that may be inappropriate for use with LGBTQ patients
Do not assume you understand LGBTQ patients; do not assume LGBTQ patients are just like you

21. REVIEW Anti-Oppression Skills Recognize and Understand Oppression
Seek knowledge about the political, societal and economic realities of LGBTQ people
Avoid depending on a sole (or merely a few) source(s) of information
Develop critical thinking skills
Recognize that the personal experiences of LGBTQ people constitute a valid source of knowledge

22. LGBTQ Competent Care
Communication Skills

23. Communication Skills
Case Managers, Peer Navigators, and Community Health workers can help encourage open conversations with LGBTQ patients by;
Creating an environment where LGBTQ people feel welcome by posting inclusive and affirming language, and using social marketing showing affirming images of LGBTQ people
Developing LGBTQ specific health promotion materials and events
Sharing referrals to LGBTQ competent providers and institutions.

24. Communication Skills
Asking whether patients are transgender or have gender- related concerns
Consistently using the patient’s preferred names and pronouns.
Gently asking, “What pronoun do you prefer?”
If a patient uses different names or gender pronouns when interacting with different people or systems, asking how they want to be identified with which system.
Avoiding intrusive questions about surgical status, legal gender if these are not relevant to client concerns.

25. Communication Skills
Asking yourself, “Do I need to know this, or am I just curious?”
Being sensitive to the fact that some LGBTQ patients may fear the police due to past negative experiences
Using inclusive or neutral language, such as “Do you have a partner or partners?” instead of asking “Are you married?”
Asking permission to include information about the patient’s sexual orientation and gender identity in the medical record, and explaining its importance to quality health care
Making assurances that the patient’s information will be kept confidential.

26. Communication Skills
Providing and explaining the process for reporting and addressing anti-LGBTQ and other forms of discrimination if it occurs in your health center.
Reporting unfriendly and discriminatory practices you may observe at your health enter or partner organizations.
Share stories of health care discrimination with organizations like Lambda Legal, as well as with policy-makers, friends, relatives and trusted co-workers.

27. LGBTQ Competent Care
Understanding Stigma

28. Understanding Stigma
Personal beliefs and perceptions about whether one can access quality health care can impact whether and how individuals seek medical care and interact with medical professionals.
Past experiences of bias, humiliation, harsh treatment and isolation as well as perceived bias by health care providers can cause LGBT people to become alienated from the health care system and reluctant to seek care.
Resulting in poorer health outcomes because of delays in diagnosis, treatment or preventive measures.

29. Collecting Sexual Orientation and Gender Identity (SOGI) Data
LGBTQ Competent Care
Collecting Sexual Orientation and Gender Identity (SOGI) Data

30. Collecting SOGI Data
Gathering SOGI data in clinical settings is recommended by Healthy People 2020, the Institute of Medicine, and the Joint Commission in order to understand, target, and reduce LGBTQ health disparities.
Asking about sexual orientation and gender identity is important because there are wide gaps in research on LGBT health.
Gathering these data in a standardized way can help track health outcomes in the LGBT population, and help to inform interventions to reduce LGBT health disparities.

31. Collecting SOGI Data
Research has shown that patients are willing to answer these questions and understand the importance of their health care providers knowing their sexual orientation and gender identity.
Questions should be included in the demographic part of the form, alongside questions about race, sex, and date of birth.
Patients should also be assured that this information will be kept confidential, and allows health care providers to provide them with the most appropriate care

32. Collecting SOGI Data
Patients should be asked about how they self-identify as to their sexual orientation and gender identity on intake forms
The UCSF Center of Excellence for Transgender Health recommends Gender Identity Data collection should include chosen name, chosen pronouns, current gender identity, and sex listed on original birth certificate (Example 1).
Fenway Health utilizes a patient registration for to collect sexual identity data at all health center locations and throughout its departments (Example 2).

33. Collecting SOGI Data Example 1:
What is your gender identity? ☐ Male ☐ Female ☐ Transgender man / Transman ☐ Transgender woman / Transwoman ☐ Genderqueer / Gender nonconforming ☐ Additional identity (fill in) ________________ ☐ Decline to state 
What sex were you assigned at birth? ☐ Male ☐ Female ☐ Decline to state
Example 2:
Do you think of yourself as ☐ Lesbian, Gay or Homosexual ☐ Straight or Heterosexual ☐ Bisexual ☐ Something else ☐ Don’t Know

34. Collecting SOGI Data (barriers)
LGBT patients may be hesitant to disclose information about their sexual orientation or gender identity due to fears about confidentiality and privacy.
These fears may have to do with the fact that one hands a filled out intake/registration form to a medical office staff person.
Patients may be reluctant to provide such personal information to office staff in a waiting room, because it feels less private than answering the question of a provider in an examination room.

35. Collecting SOGI Data (barriers)
Providers may not be comfortable asking these questions, or lack knowledge on how to elicit this information. Some worry LGBT people will be reluctant to disclose due to anti-LGBT stigma and prejudice.
Providers may worry that they don’t have the time for these discussions. High patient volume may be a barrier to comprehensive, quality data capture.15 However, given the connection between open disclosure of same-sex behavior and health, asking about these issues is integral to providers’ ability to care for their LGBT patients.

36. Understanding ACA Nondiscrimination Provisions and Medicaid Expansion
LGBTQ Competent Care
Understanding ACA Nondiscrimination Provisions
and Medicaid Expansion

37. Section 1557
For discrimination on the basis of sexual orientation and gender identity in qualified health insurance plans
For discrimination on the basis of gender identity in health care facilities and programs receiving federal funding
For discrimination by insurance policies offered on the federal or state insurance marketplaces.
For insurance companies that impose blanket exclusions on gender affirmation treatments (but doesn’t grant a patient an explicit right to insurance coverage of gender affirmation treatments)

38. Section 1557
For denial of treatment to a transgender individual that is offered to a non-transgender individual. (Example, if cisgender men are offered prostate screening, transgender women should be offered the screening and have it covered by insurance as well.)
For insurance companies to provide insurance to everyone who applies at comparable rates, regardless of preexisting conditions such as HIV infection.

39. Medicaid Expansion
The ACA also expanded coverage of LGBT people and PLWH by expanding eligibility criteria for Medicaid, which is a health insurance program for low-income children, pregnant women, parents, seniors, and people with disabilities.
States currently have the option to expand Medicaid eligibility so that individuals earning up to 138% of the federal poverty level (FPL) qualify for Medicaid health insurance based on income alone.
In states expanding Medicaid, 386,500 uninsured low-income LGBT people would be able to qualify for coverage.

40. Developing Effective Community Partnerships
LGBTQ Competent Care
Developing Effective Community Partnerships

41. Community Partnerships
Conduct an inventory of your health center’s partnerships. What individual and/or organizational assets do these partners bring to the table?
Do your partners represent the LGBTQ community?
Do they have the capacity to provide competent health or other direct services?
Do they have relationships to policy makers, health care administrators, or the media?
Do they have connections to other important resources, such as social services, education, jobs, or housing?
Do they provide social support for LGBTQ communities?

42. Training and Workforce Development
LGBTQ Competent Care
Training and Workforce Development

43. Training and Workforce Development
Cultural competency training helps reduce health disparities by developing proficiency in understanding the unique issues LGBTQ people face and supports Case Managers, Peer Navigators, Community Health Workers and other enabling services staff in advocating for their patients.
Trainings should be intersectional, and include the specific ways in which LGBTQ people who are also living with HIV, people of color, low-income, seniors, or are members of other underserved populations experience additional health disparities.

44. LGBTQ Competent Care
Final Thoughts

45. REVIEW Examples of Social Determinants of Health for LGBTQ people
Access to care
Enormous challenges remain for LGBTQ communities and those living with HIV in accessing quality, non-discriminatory health care services.
Insurance coverage
LGBTQ Americans were more likely to report being uninsured than non-LGBTQ Americans
Employment
23 states have not specifically listed sexual orientation in their law prohibiting discrimination against public employees, and 35 states do not prohibit gender identity discrimination against public employees
Education
Schools nationwide are hostile environments for a distressing number of LGBTQ students, the overwhelming majority of whom routinely hear anti-LGBT language and experience victimization and discrimination at school. As a result, many LGBTQ students avoid school activities or miss school entirely.

46. REVIEW Social Determinants of Health for LGBTQ people Housing
Between 20 percent and 40 percent of all homeless youth identify as lesbian, gay, bisexual or transgender
Transportation
65% of transgender residents of Massachusetts reported experiencing discrimination in public accommodations settings, including public transportation
sources:
When Health Care Isn’t Caring: Survey of Discrimination against LGBT People and People with HIV. New York: Lambda Legal. 2010
In U.S., LGBT More Likely Than Non-LGBT to be Uninsured. Gallup 2014
National School Climate Survey, GLSEN 2015
An Epidemic of Homelessness, National Gay and Lesbian Task Force Policy Institute & National Coalition for the Homeless 2006
Discrimination and Health in Massachusetts: A Statewide Survey of Transgender and Gender Nonconforming Adults, The Fenway Institute, 2014

47. Questions?

48. Thank you!
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U30CS22742, Training and Technical Assistance National Cooperative Agreements (NCAs) for $449, with 0% of the total NCA project financed with non-federal sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government