1. Sexual Orientation / Gender Identity
SO/GI

2. Laws/requirements

3. Section 1557
In 2016, Section 1557 built on existing nondiscrimination laws and provided new civil rights protections by prohibiting discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs and activities.
Section 1557 was the FIRST Federal civil rights law to broadly prohibit sex discrimination in health programs and activities.
Sex discrimination includes, but is not limited to, discrimination based on an individual’s sex, including pregnancy, related medical conditions, termination of pregnancy, gender identity and sex stereotypes, including with respect to access to facilities, such as bathrooms and patient rooms.
MU3 requires the ability to collect sexual orientation and gender identity.
Health resources and services require health centers to report outcomes that include information about each patient’s SO/GI.

4. Epic upgrade
The new EPIC upgrade in February 2019 will include the capability to collect precise information about a patient’s sexual orientation / gender identity (SO/GI).
The SO/GI smart form will be utilized by clinical staff in one clinic to begin with. Training and scripting will be provided to the staff in this clinic first and then rolled out to additional clinics.
But first, understanding what SO/GI is and why this capability is being implemented is extremely important.

5. Lgbtq definitions

6. LGBT L = Lesbian G = Gay B = Bisexual
T = Transgender (Gender identity not congruent with the assigned sex at birth)
Alternate terminology
Transgender woman, trans woman, male to female (MTF)
Transgender man, trans man, female to male (FTM)
Non-binary, genderqueer
Genderqueer person (does not fit male/female binary)
Transmasculine, Transfeminine
Gender identity is increasingly described as being on a spectrum

7. What Does ‘Q’ Stand For?
‘Q’ may reflect someone who is ‘questioning’ their sexual orientation, attraction to men, women, both, or neither.
‘Q’ may stand for ‘queer,’ a way some people identify to state they are not straight but also don’t identify with gay, lesbian or bisexual identities. The term queer is particularly commonly used among younger people, and also used by people of all ages. However, this term could be offensive to some people.

8. Health disparities

9. Lgbtq statistics
LGBTQ populations have the highest rates of tobacco, alcohol, and other drug use.
The 2015 National Transgender Discrimination Survey found that:
26% used drugs/alcohol to cope with discrimination.
30% smoked cigarettes daily or occasionally (compared to 20% of US adults).
33% had at least one negative experience with a health care provider such as being verbally harassed or refused treatment because of gender identity.
23% of transgender people report not seeking needed health care in the past year due to fear of gender- related mistreatment.
33% did not go to a health care provider when needed because they could not afford it.

10. Lgbtq statistics Youth
Are 2 to 3 times more likely to attempt suicide
Are more likely to be homeless (20-40% are LGBTQ)
Are at higher risk to contract HIV, STDs
Highest rate of tobacco, alcohol and drug use
Lesbian women and bisexual women are less likely to get preventive services for cancer.
Despite an overall decrease in HIV incidence from (reported for the first time in 2017), incidence remains high and stable among black MSM, and is now increasing among gay and bisexual Latino men (20%) and those ages (35%).

11. Disparities impact
Lesbian, gay, bisexual, transgender, and queer (LGBTQ) people are often “invisible” to their providers. Most clinicians do not discuss sexual orientation or gender identity (SO/GI) with patients routinely, and most health centers have not developed systems to collect structured SO/GI data.
This invisibility masks disparities and impedes the provision of important health care services for LGBTQ individuals, such as appropriate preventive screenings, assessments of risk for sexually transmitted infections and HIV, and effective intervention for behavioral health concerns that may be related to experiences of anti-LGBTQ stigma.

12. Why SO/GI is so important
Like all patients, LGBT people have behavioral as well as medical concerns, and want to discuss issues related to coming out, school, work, relationships, children, aging, and other issues that occur in different stages of life.
An opportunity to share information about their sexual orientation and gender identity in a welcoming environment will facilitate important conversations with clinicians who are in a position to be extremely helpful.

13. So/gi definitions

14. Gender Identity ≠ sexual orientation
Gender Expression
How one presents themselves through their behavior, mannerisms, speech patterns, dress, and hairstyles.
May be on a spectrum.
Gender Identity
A person's internal sense of their gender (do I consider myself male, female, both, neither?).
All people have a gender identity.
A complete glossary of terms is available at

15. Sexual Orientation
Sexual orientation: how a person identifies their physical and emotional attraction to others.
Desire
Gender(s) a person is attracted to physically & emotionally
Behavior:
Men who have sex with men- MSM (MSMW)
Women who have sex with women-WSW (WSWM)
Identity:
Straight, gay, lesbian, bisexual, queer—other

16. Collecting so/gi data in epic

17. Preparation for collecting data in clinical settings
Clinicians: Need to learn about LGBTQ health and the range of expressions related to identity, behavior, and desire. Staff need to understand the concepts.
Non-clinical staff: Front desk and patient registration staff must also receive training on LGBTQ health, communicating with LGBTQ patients, and achieving quality care with diverse patient populations.
Patients: Need to learn about why it is important to communicate this information, and feel comfortable that it will be used appropriately.

18. Collecting demographic data on gender identity
What is your current gender identity?
Male
Female
Transgender Male/Trans Man/FTM
Transgender Female/Trans
Woman/MTF
Gender Queer
Additional Category (please specify)
What sex were you assigned at birth?
What is the name you use?
What are the pronouns you use (he/him; she/her, etc.)?

19. Epic-released smartform
Contains:
•Sexual Orientation
•Gender Identity
•Sex Assigned at Birth
•Pronouns (will not drive pronouns in SmartText or Letters)
•Steps Taken to Transition
•Future Plans
•Organ Inventory: Current Organs, Organs Present at Birth, Organs Hormonally Enhanced or Developed, Organs Surgically Constructed

20. In clinical workflows

21. Editing name fields

22. Decisions, decisions OSU recommendation for February 2019:
The SOGI smart form will be utilized by clinical staff in one clinic. Training and scripting will be provided to the staff in this clinic.
Registration staff will not be instructed to collect this information, however upon patient request, registration will complete the fields in their normal workflows
Clinical staff can get to SOGI SmartForm from the clinical header hyperlink. Preferred pronouns are only in the SmartForm and not referenced elsewhere.
Using patient’s preferred name is the recommended method of referring to the patient
Communication plan for clinicians coming soon!
Titles vs preferred name vs phonetic spelling – watch for training documentation coming soon! Preferred name will show up on wristband so appropriate use of this field is imperative

23. Approach / Interacting with patients

24. Directly asking so/gi questions
Generally as part of social history or filling in blanks left at registration, you might simply say, “We have begun asking patients about their sexual orientation and gender identity so we can provide affirmative care.”
Another example might be, “I see you left these questions blank at registration, and I was wondering if you had questions, and whether we might talk about how you think about yourself in this regard?”

25. Anticipating and managing expectations
LGBTQ people have a history of experiencing stigma and discrimination in diverse settings.
Don’t be surprised if a mistake, even an honest one, results in an emotional reaction.
Don’t personalize the reaction.
Apologizing when patients have uncomfortable reactions, even if what was said was well-intentioned, can help defuse a difficult situation and re-establish a constructive dialogue.

26. Avoiding assumptions
You cannot assume someone’s gender or sexual orientation based on how they look or sound.
To avoid assuming gender or sexual orientation with new patients:
Instead of: “How may I help you, sir?”
Say: “How may I help you?”
Instead of: “He is here for his appointment.”
Say: “The next person is waiting in the reception area.”
Instead of: “Do you have a wife?”
Say: “Are you in a relationship?”
Instead of: ”What are your mother’s and father’s names?”
Say: “What are your parents’ or guardians’ names?”

27. Don’t! Obvious “don’ts” include: Use of any disrespectful language.
Gossiping about a patient’s appearance or behavior.
Saying things about someone not necessary for their care:
“You look great, you look like a real woman/ real man.”
“You are so pretty I cannot believe you are a lesbian.”

28. Putting what you learn in to practice
If you are unsure about a patient’s name or pronouns:
“I would like be respectful—what name and pronoun would you like me to use?”
If a patient’s name doesn’t match insurance or medical records:
“Could your chart/insurance be under a different name?”
“What is the name on your insurance?”
If you accidentally use the wrong term or pronoun:
“I’m sorry. I didn’t mean to be disrespectful.”