Lecture part 1

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West Coast Ultrasound Institute *

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Apr 3, 2024

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 So this lecture will be on the care of the LGBTQ eye. 0:04  A plus community. What are all these letters mean? 0:08  L is for lesbian. G is for gay and bisexual. 0:12  T is for transgender. Q is for queer. 0:17  Eye is for intersex. Is for ally. 0:20  And Plus stands for everything that we're not encompassing with this label. 0:24  Now I want to remind everyone to love your neighbor as yourself. 0:31  There are seven passages that are used over and over and over again to justify a bias against the LGBTQ people. 0:35  But there are over 100 Bible verses about love. 0:44  So let's all be safe and focus on love. 0:48  Scripture has been used to justify slavery, to exclude divorced people from participating in sacraments, 0:51  to exclude women from ministry, to persecute left handed people. 0:58  And if the church has been wrong in its treatment of LGBTQ issues, then this would not be unprecedented, is all I'm saying. 1:04  So I want you to keep these verses in mind. 1:11  First of all, the verse for you created my inmost being unit me together in my mother's womb. 1:14  I praise you because I am fearfully and wonderfully made. Your works are wonderful. 1:21  I know that full well. 1:25  Sexual identity and gender identity are components of a person's personality, and as such are part of who God made each of us to be. 1:28  God did not make a mistake in creating LGBTQ people. 1:36  God also welcomes people of all genders and all sexual identities. 1:40  And we see that in Matthew. 1:45  There is neither Jew nor Gentile, neither slave nor free, nor is there male and female, for you are all one in Christ Jesus. 1:48  That's Galatians and Acts. God has shown me that I should not call anyone impure or unclean,

1:56  and Jesus gladly socialized with people that the religious establishment disapproved of. 2:04  And above all, as I started this slide, 2:10  love the word God with all your heart and with all your soul and with all your mind and with all your strength. 2:14  The second is this Love thy neighbor as yourself. There is no commandment greater than this. 2:20  So. Cultural competency, however, goes far beyond LGBTQ. 2:27  It can bridge gender differences, ethnicity differences, worldview differences, financial differences, right? 2:35  Cultural competency goes beyond that. So we know that socio cultural differences between patient and provider influence, 2:43  the communication between them, the understanding between them, as well as the clinical decision making. 2:51  This is shown in the literature, unfortunately. So cross-cultural care is in essence the care of every single patient. 2:56  As I said, not just those of the child care communities, not straight or heterosexual communities, but for all patients. 3:03  And at the end of the day, we need to just come back to focusing on communicating effectively and providing high quality care above all else. 3:11  So take a patient based approach, right? So first you assess, you know, core cross cultural issues, right? 3:20  And you need to explore those. And we did talk about those on the previous slide. 3:27  Communication was one, decision making was one, but also trust, family and loved one, dynamics, traditions, spirituality. 3:32  And then, you know, in this talk, sexual and gender issues, it's important to explore the patient's understanding of illness. 3:40  Right. The explanatory model represents how the patient understands their illness cause meaning and consequence and understanding. 3:48  A patient's explanatory model allows you to adapt your communication and kind of 3:55  tailor your treatment recommendations to their concerns and their perspectives. 4:01  Right. So it's important to use that explanatory model to represent how the patient understands their disease. 4:05

 And then with the social context, 4:11  this is basically seeing the manifestations of a person's illness are linked to that individual's social environment. 4:14  And three specific aspects of the patient's social context have particular relevance to the cross-cultural clinical exchange, 4:21  and that's changing environment, right? Like migration, perhaps literacy and language. 4:29  Can they read? Do they speak English? 4:34  Do they need a translator? Do they have family translating for them? 4:37  And then life control, right? Like the social stressors that we all have as well is on the flip side of that, our support system. 4:41  And then you want to negotiate a mutually acceptable approach to care. 4:49  And you know, even when you have the same socio cultural backgrounds as your patients, 4:53  substantial differences may still exist and expectations or agendas or values between you and your patients. 5:00  So the process, process of cross-cultural negotiation will be helpful as long as you acknowledge different explanatory models and, 5:07  you know, develop strategies to kind of manage those. 5:15  So what does that look like here? Well, we're going to look at a slide that might help us put this into perspective a little bit better later on. 5:19  But I just want to remind you that gender is defined and enforced very differently in different parts of the world. 5:29  Right. And sometimes these are strictly defined. 5:36  For example, the male role may commonly be seen as that of a protector, maybe a spokesperson for the family. 5:40  And it can be a hot button issue talking about gender roles and norms and deviation from that. 5:48  But this needs to be negotiated with tact and respect, and you'll be able to maintain a therapeutic relationship if you keep that above all else. 5:55  So oftentimes, you know, 6:03  difficult situations may arise due to the patient and the provider being maybe different or same 6:07

 sex or gender discomfort with examinations of the general area or the rectum or the breasts. 6:15  And then sometimes people just have plain old shame when discussing sexual issues. 6:22  Right? So health care providers should just keep this in mind. 6:26  Keeping sexual issues, gender issues. Pay attention to body language and particular cues a patient is giving you. 6:31  And then make sure you're not misgendering. And what misgendering means is that you're you'd be making incorrect assumptions about a patient's gender. 6:41  So if you thought you walked into the room and you saw a very masculine appearing, female was a male, and you, you know, 6:48  refer to them as such, even though they actually identify as female, it can just cause difficulties in trust and communication. 6:58  Right. So we haven't always been good at this in health care, 7:05  but this is where asking for people's pronouns like when when it's becoming more normalized for sure not everyone does it, 7:10  even though that's where we'd ideally like to be, 7:19  but that that helps open the door and kind of can engage trust in even just asking that question rather than assuming. 7:21  And there are some techniques I want to give you guys some actual quotes that might be helpful to get out of situations 7:28  where there may be maybe just an incongruence in understanding with sexual and gender stuff going on in in the clinic. 7:38  So be aware of how the patients and their loved ones do view gender roles in a comedy. 7:47  Right? And this is sometimes not only culturally sexually driven, but also culturally driven as well. 7:53  So you may want to see something like, unfortunately, we have no female providers in clinic today, 7:58  but if you're willing to risk your appointment, I can make sure that your wife will see a female doctor next week. 8:04  Right. So clearly in this context, there is some discomfort with, you know, 8:09  with maybe the husband or wife or both with her seeing a male provider and if she's more comfortable or her husband is more comfortable. 8:17

 And so some cultures with her seeing a female provider, this would be a good way to to do this. 8:27  And then you want to just always ask for permission. And we talk about this in the breast and pelvic lab. 8:33  Right. But you want to ask for the patient and in some cases the loved ones permission, if you will, 8:38  or what's acceptable to them, rather than just assuming that you can truck on in there and do some sort of intimate exam. 8:43  So one thing you can say is I perform breast examinations to look for signs of breast cancer. 8:50  Is this okay with you? Asking their permission and putting the onus on them will help them feel autonomy and like they're in control. 8:56  And this is also very helpful for victims of sexual assault or abuse or just patients who are uncomfortable with, 9:04  you know, showing their most vulnerable selves to someone they don't know or they've just met. 9:14  You want to be sensitive to patient's views on sexual issues openly. 9:19  And I urge you, I included it in this document as well as on canvas. 9:24  But the Kdka's Guide to Taking a Sexual History. 9:30  It's fantastic, 9:34  but one thing that you may feel comfortable saying is I generally ask all patients about some very personal matters at this point in the visit. 9:35  These are important for nurse practitioners to know about. 9:44  Are you comfortable talking about these things with me that can open the door and just make them maybe not feel singled out? 9:47  Like why? Why is he asking me this? Why is she asking me this? 9:55  We'll ask everyone this, right? And then ask about the sex and gender of the sexual partners rather than how the patient identifies. 9:59  Right. Instead of saying, Are you gay? 10:08  Are you by right? You want to say, are your sexual partners, men, women? 10:12  Both or persons who are nonbinary or another gender. 10:18

 When I went to school, the latter part was not in there because we were not as sensitive to this. 10:23  And at that time, you know, there was a school of thought that gender was fluid, but it hasn't it was still very polarized in man or woman. 10:27  But, you know, now we do have nonbinary individuals really, you know, are it's becoming more common to come across clinically. 10:37  So I think it is worth including in this question. Now, this is the slide that I was referencing earlier in the deck. 10:47  And I love this slide and this is the gender bred person. 10:56  And it kind of really helps you visually wrap your mind about these these concepts. 10:59  If you could all just. 11:08  Remember that there's no such thing as an LGBTQ person, right? 11:14  These are all like different labels representing different identities. 11:17  And sometimes patients or individuals will have like numerous of these identities themselves. 11:22  Right. They can be perhaps gay and transgender, right? Or even lesbian, gay, queer and transgender. 11:29  But we're getting ahead of ourselves. So let's just start with the basics. 11:36  Right. So again, LGB. 11:39  Represents all sexual identities and the T represents a gender identity as well as an umbrella term for many gender identities. 11:43  So queer, on the other hand, means different things to different people. 11:52  And for some it describes sexuality, for others, their gender, for others, both. 11:56  When we say sexual identities or sexual orientations, 12:00  what we're actually talking about are the ways we categorize and define who we are attracted to romantically or sexually or even otherwise. 12:04  Right? When we have the gender identities, we're talking about the ways we categorize and define our genders. 12:12  And as I kind of alluded to earlier, we used to put those into more of a box rather than thinking of it as a continuum. 12:20  And so I think it's important to note that while we may hear mention of the LGBTQ community often, right, I've even referenced it in this talk.

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