Webinar: LGBT+ Inclusive Care Basics for Healthcare Professionals

by Meris Shuwarger BSN, RN, CEN, TCRN October 10, 2021 Updated: June 16, 2022 37 min read 1 Comment

Our LGBT+ Inclusive Care Webinar was on Wednesday, October 20, 2021 at 3pm PT

What's the difference between sex, gender, and orientation?

My patient says they use "he/him" pronouns...what does that mean?

I was looking in my patient's chart and saw that they're nonbinary, and I have no idea what to do with that information.

I asked my patient if she was sexually active, and she said yes, but said there's no chance of pregnancy...how can I better ask these questions?

What is the + in LGBT+ for anyway?

In this free webinar, Meris Shuwarger, BSN, RN (she/they) gave an introduction on to how to provide competent and inclusive care to the LGBT+ community.

Meris provided some sobering statistics about the healthcare members of the LGBT+ community traditionally receive, and what fears a patient may have about seeking medical care as a member of this community.

She answered all of the above questions and more, and showed some simple steps to changing your vocabulary, your ideas around sex, gender, and orientation, and some subtle ways to signal that you are a safe person for your LGBT+ patients.

Go ahead and get started. I'm so excited to bring you this presentation. I hope that we're able to learn together through this and share some experiences. So let's get started. This is going to be a presentation-- just to make sure we're all in the right place.

This is about LGBT Plus inclusive care basics for the healthcare professional. You do not have to be a nurse or a nursing student to be here. Anyone is welcome here, and this is specifically geared towards healthcare. However, this information is going to be applicable to any realm where you may work, any aspect of your life as well, and just your day to day experience. So a little bit about me.

So my name is Meris. I use she, they pronouns. I graduated from Chamberlain University College of Nursing here in Columbus, Ohio, and I now work as an emergency trauma nurse locally, and I also serve as the nurse team lead for Level Up RN. You might have seen me on some of our YouTube videos, or maybe you've seen me posting from our Instagram account every now and then.

So I am part of the LGBT community, and so I'm really passionate about the care of all marginalized communities because I think that there's so much room to improve as healthcare professionals in the care that we provide to people who are vulnerable because of their marginalized identities. And I'm very passionate about the care of the LGBT community because I think that there's a lot of ways in which healthcare intersects with the LGBT community in ways that we just could do so much better, specifically, when it comes to reproductive healthcare.

On a personal note, I am married and have two small children who you may hear during this presentation because they are running around downstairs right now, and I have 55 houseplants - you can see one of them up there - and three cats. So I don't have a ton of free time. But when I do, I love to listen to podcasts. I read a lot of books, and I play with my kids whenever I get the chance. So that's about me and who I am.

So I want to share with you kind of what the objectives are for tonight's presentation. What do I hope that you're going to get out of this?

So the first objective is that I want to be able to define what the LGBT Plus community is and the unique ways in which this community faces oppression and specifically healthcare discrimination. That's the point, after all, as this is for the healthcare professional.

Secondly, I want you to be able to differentiate the basics between identifiers such as sex, gender, and orientation, sexual orientation, and the correct language to use around each area. That's going to be one of our biggest focuses today.

And then, the third objective is going to be to identify ways in which the healthcare professional can use inclusive language and other strategies to provide high quality, non-discriminatory healthcare to this vulnerable population.

As we go along, if you have comments, questions, feedback, anything along those lines, I would invite you to put it into the chat. Cathy, Ellis, and Lacy are here with us today as well, and they will be moderating, so I may not respond to you during the presentation itself. However, at the end, we will have a lot of time for Q&A and to circle back to those things. I do want to make sure that you know that this is being recorded. So if there is anything that you would not want to share publicly, I would caution you not to share during this presentation, but just a few things to get out of the way housekeeping wise.

Okay, so this is the meat and potatoes right here. This is what we're going to be talking about the most is the terminology that I need to get across to you about the differences between a bunch of similar but different things.

So first, we're going to talk about sex. So a patient's sex is used to refer to the sex that they were assigned at birth. So typically, this is done when a doctor looks at a newborn's genitals and assigns them a sex, and they say, "This baby is female. This baby is male." But I want to ask you - tell me in the chat - what are some challenges about using genitals to assign a patient's sex to them? What are some challenges when we just observe externally and make a determination about the sex of this infant? And I'm going to tell you-- oh, Keegan, yes. I'm so excited you said that. There are intersex people. That's one huge challenge.

Intersex people are those who may have one type of genitalia that is different than the average, right? So this could be someone who has ambiguous genitalia, meaning we look at the external parts and can't quite make a determination about what these parts are. Then we also have people who may have both sets of genitalia or genitalia that looks different from the norm. When we have someone who is intersex, we can't say with specificity that this person has male or female genitalia, and you will see that I put that in quotation marks, right? Because when we talk about genitals, do genitals have a gender? I would argue no. They are body parts, right? My nose is not male or female. My nose is my nose, and it may look different from somebody else's nose, even if we have the same characteristics, right? So that's going to be one thing there.

Now, tell me as well, anybody else have any other considerations for why looking at the external genitals can be a challenge when it comes to assigning a patient a sex? And as we talk, I want to mention that intersex people, you may think of this as being something that occurs almost never. But that's not the case. That truly is not the case. Intersex individuals occur in the population at a rate similar to or greater than the amount of redheads that there are in a population. So we're not talking about just a few people here and there. We're talking about a big chunk of people.

So one of the other things that I want to mention is that what somebody's genitals look like do not tell us anything about their DNA. And so, we could talk about this for hours. But there are lots of ways that our sex chromosomes can be arranged. So I can have an X and no other chromosome. I could have an XXXY, XXY, XXX, right? There are a lot of different ways that those chromosomes can be arranged, and we can end up not knowing what's going on with a patient's internal DNA structure based on what we see on the outside.

Another thing that I just want to mention is that this is an infant child who cannot tell us anything, who has no concept of gender, who has no concept of anything in our society and can't tell us whether they feel that your assessment of who they are matches with their assessment of who they are. We cannot get that from that patient for many years, right? Because we have to learn about the constructs of gender and sex in our society to have that framework. We have to learn the language to communicate so we can make a determination based on what our best guess is. But then, let's transition to talking about gender.

So gender and sex are often confused for one another. They are often used interchangeably when we talk about the two things, but gender is distinctly different from a patient's sex. Gender refers to how a person feels internally or identifies, and this is typically considered to be a spectrum. So if you think about gender on a binary, you're probably used to thinking about male and female. Those are the two options. They are the only two options, and those are the ones you get to pick from; male and female. But I would propose to you that gender is not a binary. Gender exists beyond the binary and is in fact a spectrum where we might have male on one side and female on the other, although I would argue that that is still too divisive, and lots of things in between.

So tell me, what are some other genders that a person may identify with? What genders have you heard of aside from male and female? Non-binary. Yes. Love it.

So non-binary meaning not binary, so existing outside of the binary. Keep in mind that when I am talking and giving definitions and things that these are generalizations. How a person identifies or how they may feel could be vastly different than the description that I give. So that's all going to be completely valid, however, for some of the identities. If you identify as non-binary, this person might be saying, "I do not feel that I am male or female. I exist beyond the binary. Perhaps I have a gender that I feel is something else entirely."

Oh, yes, gender neutral or gender fluid. I love both of these. So gender neutral, you might hear someone refer to themselves as agender, without gender. So this literally means, "I don't feel that I have a gender," right? This is, "I think that my perception of myself is not constrained by the constraints of a gender spectrum. I feel that I am agender, without gender.

And then, gender fluid, I love gender fluid as a concept. This idea that my gender is fluid. It is constantly changing. Just like my mood is fluid, or how I experience the world around me changes from day to day, sometimes I feel that I am more female. Sometimes, I feel male. Sometimes, I feel that I don't identify with any gender. Gender fluid is again going to be unique to the individual in terms of how they understand their own sense of self and how they would like for you to interact with them and understand them as well. But this is a really awesome one that I think kind of speaks to me on a level of like, "Nothing about me is static," right? "I am ever changing. Every day, I am a slightly different version of myself, so why not my gender also?"

So we have a bunch of other genders. As many people as there are is how many genders there are. It's how I feel. So we have people who identify as demi-something. So a demi-girl, for instance, would be like, "Sometimes, I feel female," right? "But sometimes, not." It's close, but not quite there.

So there's a lot of different ways that a patient may experience their gender, and this may be something that they share publicly with you. And it also may not be. So just remember that the sex on the chart might say male or female, but the patient's gender may not match with the sex that they were assigned at birth. So very important that if you are trying to provide culturally competent care and understanding the community of the LGBT community through this lens that we understand these two terms and how they are different.

Moving on to something that is similar but still different is sexual orientation. So sexual orientation refers to how a person experiences romantic or sexual attraction. So does the person experience romantic or sexual attraction, first of all? That's the first question. And if so, to which genders? So again, we're thinking of this as a spectrum, right?

I can experience no sexual attraction, but I want to have a romantic, intimate relationship with somebody. I may call myself asexual, but hetero romantic or homo romantic, meaning I don't experience sexual attraction. However, I do experience romantic attraction to someone of the same or opposite genders, that kind of an idea.

We may have people who are aromantic and asexual. I don't experience any form of attraction or desire for romantic relationships. However, I want to have close friendships with people. I want to have intimate friendships with others. That is awesome, too. Then, you may be more versed in some other sexual orientations.

So tell me in the comments, what are some other sexual orientations you may have heard of aside from the two that I just gave you, asexual and romantic? What else may you have heard of before?

Bisexual. Absolutely. So I myself identify as bisexual. Bisexual is an interesting term in that bi means two. So this is sometimes thought of as being, "I am attracted to two genders," or, "I'm attracted to genders similar to mine and the opposite to mine." But remember gender being a spectrum. There is no true opposite to my gender. There are just different genders. So I define my own bisexuality as I am attracted to genders like and unlike my own.

You may have also heard Keegan says pansexual. Absolutely, right? Pansexuality, pan meaning all. So this is a term that is sometimes used. You will hear people say hearts, not parts, and this is the idea that I am attracted to people, not genders.

So I am going to be attracted to whoever I am attracted to. There is kind of an overlap of ven diagram, if you will, of bisexuality and pansexuality. How people identify matters to that person. So it matters to me that I identify as bisexual. It matters to somebody else that they identify as pansexual, and our job is to just respect whatever term a person uses to refer to their own sexuality.

Some others that you may or are probably familiar with, someone who is gay. This term, you can hear-- there's a little bit of confusion. Gay used to mean men who are attracted to other men exclusively. It now is kind of used as this umbrella term for anybody in the LGBT community.

Lesbian is a woman who is attracted exclusively to other women. Then, there are so many others, which, again, I could just talk to you for an hour about the different types of sexual orientations that exist in the world.

Queer, yes, I love that you mentioned the term queer because queer is what we call reclaiming a slur. So queer is a term that not everyone is going to be comfortable using. It is a term that is very commonly, historically and in the present, used in a derogatory manner. This is a word that is used to hurt somebody. And when you exist in a marginalized community, you have the right to reclaim those hurtful words and say, "No, you don't get to use that word against me. I get to use that word, and I'm going to use it to refer to myself." This is very personal. This is a decision for the individual. I like this word. I use it to refer to myself. There are many people who do not like this word and do not want to use it to refer to themselves.

Again, remember, we are always coming back to, it is what the person, the patient, says, right? We are respecting whatever we are told here. So if a patient says that they are genderqueer, that's great, and that's a term that they get to use. And if a different patient would never use that term to refer to themselves, again, that's okay. And that is a decision that they get to make. If you are not in the community, however, I would say do not assign that word to somebody if they have not said, "This is how I prefer to be referred to."

Okay, moving on to pronouns. So pronouns, they're just a part of our vocabulary, right? A pronoun is a word that we use to refer to somebody in place of their name, right? So their, that's a pronoun. So for instance, you could say Meris is an ER nurse, but my pronouns are she, they. So that means that I am also completely okay with you saying, "She is an ER nurse," or, "They are an ER nurse."

There is a lot of fake outrage over the use of the singular they. People get really uppity about the idea of referring to somebody with a singular they because it's not grammatically correct. But if you were on a bus and you saw a pair of glasses sitting on the bus seat, what would you say? You would say, "Oh, no, somebody left their glasses," because you don't know if the person who left the glasses is male or female, right? We use the singular they all the time. So this is actually not an uncommon thing. It might feel weird to you the first time that you try to use the singular they. But I promise it will get easier as you try.

So what other pronouns have you heard used? This is something that I'm interested to see the responses because most people have only heard she, he, and they. Anyone have ever heard-- neopronouns. Keegan is killing it. Yes. Neo meaning new pronouns. So neopronouns are things like ze or zir. So you will hear, for instance-- I could say my pronouns are she, her, they, them. Somebody else might say, "My pronouns are ze, zir." So, "Oh my gosh, you know my friend Mark. Ze is such a cool person." That would be a use of a neopronoun. So I hope that kind of makes sense. It's a pronoun that again exists beyond the options that we were given with the English language. So these are neopronouns, new pronouns.

The thing about pronouns is they are mandatory for the person. So if your gender matches the sex that you were assigned at birth, we say that you are cisgender. Your gender and your sex that you were assigned with, they mesh. And you might say, "I was born with a vulva, and so they assumed I was a girl, and I am a girl." That's awesome. So you are cisgender. And it probably would feel really foreign to you if somebody used he, him to refer to you. If you are female cisgender, and somebody said, "That's my friend Meghan. He's so cool." "What? That's not my pronoun. I'm she, her." Right. They're not preferred pronouns.

They are mandatory pronouns. That is the correct way to refer to this person in particular. So I want you to understand that when somebody tells you their pronouns, first of all, you're being given a gift that somebody trusts you to, "Here's the information that you need to know about me." But secondly, what I want to get across to you is this idea that it's not a choice you get to make. So if my friend comes to me and says, "Hey, actually, I know you have thought that I am female. I thought I was female for a little while too. And the more that I've reflected on who I am, I believe that actually I'm male. I would really like for you to call me a different name," whatever that may be. "And I would like for you to use he, him pronouns." I need to use he, him pronouns all of the time in every context.

So I'm going to tell you a story, and this is something that I think about all of the time. I had a patient. I got report on a patient, and the outgoing nurse told me, "I don't know. I think they're trans or something. The name in the chart doesn't match what they look like. I don't really know." And I said, "Okay, well, first of all, we're already starting off not great, but okay. I'm going to go see this patient, and I will talk to the patient." So I walked in, and I introduced myself, "Hi, my name is Meris. I use she, they pronouns. I'm going to be taking care of you today. I'm your day shift nurse coming on. I see your name in your chart is blah, blah, blah. And for legal purposes, when I ask you for your name and date of birth, for medications or anything along those lines, I will have to use this name. However, is there a different name that you prefer?" And the patient, who had a female presenting name in the chart said, "Oh, thank you so much for asking. Yes, I go by a male sounding name." And I said, "Awesome. Do you use he, him pronouns or she, her, or they, them?" And my patient said, "I use he, him." And I said, "Awesome. Thank you so much for telling me. Is it okay with you if I make a note in your chart so that other providers will know?" And he said, "Yeah, absolutely. That would be great. Thank you so much." So I put a note in the chart with the patient's name and pronouns, and I had asked another nurse to come in with me because we were starting a high alert medication, meaning that I needed a second RN there to witness the dose change and everything like that. And this nurse was very respectful and interacted wonderfully with my patient, and I thought, "Oh, thank goodness." I picked the right nurse to come in with me.

And after we left the room, the nurse said something to me along the lines of, "Do you need me to chart on her or him or whatever?" And my heart just like immediately hurt because it's not that you use the correct pronouns when you are speaking to the person. It's that you use those pronouns all of the time, all of the time. You use those pronouns when you are talking about that person to somebody else and that person isn't there. You use those pronouns when you are thinking about that person in your head. Those are their pronouns. They're not preferred. They're mandatory. And what that nurse did, first of all, misgendered the patient, did it so cavalierly in front of me, which told me I can't be trusted with the care of a patient in the LGBT community, which means that I cannot be trusted to care for me, right? And in fact, I'm thinking, "Wow, there's a lot of things that I'm never going to share with this person," even though I thought that we were going to be close and be friends and everything.

And I think about that frequently, and I think about the fact that, "Yeah, that patient doesn't know that that happened, right? But I know and that told me everything that I needed to know about that nurse." And I don't want you to be that person, right? It's okay to make mistakes, right? Things happen. We slip up, especially if you knew somebody when they presented as a different gender. If you knew somebody when they used she, her pronouns, and then they come to you and say, "Actually, I would like to use he, him pronouns," it's muscle memory. You're going to make a mistake. That doesn't make you a bad person. It's what you do with the mistake that matters.

So what do I do if I make a mistake? Okay, very easy. The first thing is to stop, audibly acknowledge the mistake, say, "Oh, I'm so sorry," correct the mistake, and then, move on. Just move on. If you sit and self-flagellate, if you sit and make this about you, you're missing the point. It's not about you. It's about the person that you misgendered, right? That's a big deal. If I say, "Oh my gosh, have you met my friend April? She is so cool. Oh my God. Oh my God. Oh my God, I meant he is so cool. Oh, God, I screwed it up again. I'm so bad at this. Oh my God, you must think I'm the worst." Okay, first of all, all you're doing is centering yourself and making it about you, and it doesn't need to be like that, right?

We make mistakes all the time. If I have a friend whose name is Robert and he says, "I go by Bob," and I call him Robert, I'm not going to sit there and freak out when I get it wrong. Nope. I'm going to say, "Robert, could you? Oh my gosh, I'm so sorry. Bob, could you?" Right? We just stop, acknowledge the mistake, correct it, and move on. Another thing that I want to share is that I like to-- if I make a mistake along those lines, if I have the opportunity in my head, I'm going to use it correctly three times. So if I said, "She's such a cool patient," and then I realize I meant he. In my head or out loud, I'm going to say, "He is such a cool patient. He is here for cardiac problems. He is being started on heparin," right? Very quick. Three quick sentences. It's going to help me get it right in the future.

Okay. So we just talked about sex, gender, sexual orientation, and pronouns. So of those four, which ones can change over time and which ones are set in stone? Gender, totally. Gender can change either because I now trust you to share that information with you or because I've come out, right, or because I understand myself differently now. Gender can change. Oh, Keegan says, "All of them can change," and that is 100% right. All of them can change. So a patient's gender can change, right? We just talked about that. Sexual orientation, maybe again, I discovered something about myself. I realized that this is who I am. That can change. My pronouns, right? I used to exclusively use she, her. Now I use she, they. I'm totally cool with being referred to either one. I don't have a preference. Either one of those is okay, but sex can change also. And there are some reasons for this. One is that we could have gotten it wrong, right?

We could have made an assessment based on an external presentation of genitalia and said, "That's female." And then we discover later that actually this person is intersex or male, right, has male genitalia. Those things are possible and they do happen every single day. We can also have a gender confirming surgery, right? So this could be someone who has changed Ito their genitals or their secondary sex characteristics. Maybe they have laser hair removal treatments, all of these things. So our external genitalia can change. My internal reproductive organs can change, right? I could have a hysterectomy. I could have a hysterectomy with a bilateral oophorectomy. You could take out the whole kit and caboodle, and I would still be who I am, right? Have the same gender, same sexual orientation, using my same pronouns but now my parts are different. So all of these can change. The most important thing is just to be respectful of what a person tells you. Just respect whatever it is that they say about who they are.

Okay, so now here's why we're here, right? The LGBT community experiences significant disparities when it comes to healthcare, and this can lead to a lot of negative outcomes for these patients. So I want to kind of break it down category by category for you. Psychological health. Now, if you are in nursing school, if you are a nurse, if you are in any sort of healthcare, you know that psychological health is a huge part of a person's overall health and wellness. If I am physically healthy, but I have psychological health problems, I am still going to have health problems.

So with psychological health, let's talk about the fact that members of the LGBT community face higher rates of suicide, alcohol and tobacco use, substance use, homelessness, and psychiatric disorders.

Before we move any further, I want to remind you about the difference between correlation and causation. When we talk about the fact that members of the LGBT community face higher rates of these psychological issues, I don't want you to get the impression that this is because they are gay or trans, right? That is not the case. It is not caused by their transness or their gayness, right? It's not a causative thing. It is a correlative factor.

So I'm going to skip ahead slightly and we're going to talk about social health here because the LGBT community faces high rates of bullying, peer victimization, and family rejection. So what long term outcomes do you think a person would face with these experiences? If I went to my parents and said, "I am gay. I am trans. I am any variation thereof," and my family said, "You are dead to me. Get out of my house right now," what do you think is going to happen to me in the long term? What's going to happen overall? Do you think that I'm going to end up psychologically well facing that sort of rejection from the people who are supposed to love me, and care for me, and be there for me, no matter what? Major emotional damage, trauma, 100%. And think also about homelessness, right?

If I am an LGBT youth, and I come out to my family, or I'm outed to my family, and I am kicked out of my home, what am I going to do? I'm a child. I'm supposed to be given a home, right? I'm a child. What am I going to do? Now, do we maybe see why the community faces higher rates of these psychological health issues, why I might choose to self-medicate this trauma, this emotional damage with alcohol or drugs, why I might have higher rates of suicide or comorbid mental health conditions? This is a huge, huge thing because, we're going to talk about this in a minute, but how am I going to get help for this, right? We'll get there in a second.

Sexual health. Okay, this is my soapbox issue is about the LGBT community and reproductive healthcare and how we fail over and over and over every day. LGBT youth are more likely to have poor sexual health education engaging in risky sexual behaviors, including a younger age of first sexual contact, and experience higher rates of STIs, along with being more likely to experience sexual violence. Every single thing on this list makes me absolutely devastated.

It makes me devastated because let me tell you that my dad was an OB-GYN, so I grew up knowing all of the birds and the bees and everything like that, right? I had very high quality reproductive healthcare right in my own home. And I also went to a middle school where they separated us by our sexes and told us all about the reproductive health things that were going to happen to us and all of that. And I was told all about what would happen when I began having sexual contact with someone who has a penis. And nobody told me anything about what to do if that was not my preferred partner.

I have known that I was bisexual since I was five years old. It's one of my earliest memories is I just knew. I just knew that that's who I was. I didn't realize that other people didn't feel the same way that I did. And I kept waiting for somebody to tell me about things I needed to know if I was going to be sexually active with someone who had a vagina instead of a penis, and it just never happened. It never happened. So I was the child of an obstetrician and a gynecologist, right? I had all of the resources at my disposal, and I knew that I couldn't get pregnant, but I didn't know that I could still end up with sexually transmitted infections until I was an embarrassingly old age, right? I didn't know because no one told me.

So when we provide heteronormative education to patients, to children, to anyone, when we put in terms of-- when we put sexual health in terms of heterosexual couples, we are leaving out every single person who doesn't have heterosexual contact, right? We're leaving those people out. And so, there's a perception that the LGBT community is promiscuous or engages in these risky behaviors because they are so crazy, and risky, and whatever. And that just really gets under my skin because I just want to say, "But did you teach them? Did you teach them how to be safe? Did you teach them what risky sex behaviors were and what safe sex behaviors are?" I'm betting not. And also, it devastates me this line here about a younger age of first sexual contact, because to me, this again says I was not given the information that I needed to understand, to contextualize sexual contact. And I very likely may have been taken advantage of or unable to consent. This makes me very sad.

So let's talk about physical health. And I want to be clear that sexual health is physical health, but I wanted to focus on that specifically. So when we talk about the physical health of the LGBT community, older adults in the community are more likely to report their own health as being poor than non LGBT adults, older adults, and they're more likely to have chronic health problems. Community members also face higher rates of cancer, STIs and obesity. So again, why is it?

Is it that because you are gay, you're more likely to get cancer? No, absolutely not. It's because, because you are gay, you probably are not able to or willing to access the healthcare that would prevent or identify early these sorts of diseases. "Why? Why can't I access healthcare?" First of all, we talked about one reason already, right? If I don't have the resources that I need to survive, if I am homeless, if I am struggling with substance abuse or addiction, I may not have the ability to access that healthcare because if I am homeless, it is going to take a lot of effort to locate the information on how to apply for Medicaid or to find the information for a free clinic, right, when really I need to be focusing on where am I getting water and food from? Do I have a safe place to sleep tonight? Am I physically safe? All of those things are going to preclude my access to healthcare.

But then, look at this last point, and this is awful. But members of the LGBT community are less likely to have health insurance - we just talked about that - and more likely to delay seeking healthcare. Well, why would you delay seeking healthcare? And I'm going to tell you that this is something that I hear every single day working in the emergency room.

Somebody comes in, and they're very sick, and it's something that we could have caught early and treated and they would've been okay. And every day, I hear somebody say, "Well, why didn't they come in sooner?" And I just think there's just so many reasons, right? There's so many reasons that patients delay seeking healthcare. But one of them is right here, and it's because patients are more likely to say that they have providers with poor LGBT competence and poor quality of care and unfair treatment.

So not only do we have difficulty accessing healthcare, but once we do access the healthcare, my provider has no idea how to take care of me, no idea how to address me, no idea what my healthcare needs are as a member of this community. And maybe they even treat me unfairly or poorly because of who I am. Why would I seek healthcare? Why would I seek healthcare if that has been my experience or the experience of people like me? Why would I do that? I would wait until I can't wait any longer, right? And then, you end up in the emergency room or something similar with a very serious illness. So this is just scratching the surface. This is just the very basic, bare beginnings of reasons why I am so passionate about LGBT healthcare and reasons why this community is underserved and needs competent healthcare professionals like you at their bedside.

Okay, cultural competence. If you went to nursing school, you have heard of it, but it's everyone's business. I do not care if you work in environmental services, if you're a trauma surgeon, if you work in respiratory therapy, if you're a dietician, if you're a nurse, if you work in direct patient care, cultural competence is your business. And even if you don't, even if you work in healthcare that is not direct patient care, you still must be culturally competent. There are things like lab values that matter based on who a patient is inside of them, right? Like what their DNA is. Things change, and it is unacceptable that any patient ever should delay or avoid seeking healthcare treatment because of the fear of inequitable treatment or poor quality of care, just because of who they are as a person. It's unacceptable. Full stop. And it's our job to change it. So what can we do about it?
Okay, so first and foremost, we're going to talk about changing your language. Avoid using gendered terms just all of the time, just all of the time. So, for instance, here on the side, I say, rather than saying, "Do you have a wife?" you can say, "Are you married or do you have a partner?" A partner is not a gay thing, right? It's just a thing. Do you have a partner? I'm married to a cisgender man. He's my partner. It's just a term, right? Another is, I use the term pregnant patient, right? I don't say pregnant woman. I say pregnant patient because they're a patient who is pregnant. It is inclusive of all, and it leaves nobody out.

So if you are a pregnant woman, you're still a pregnant patient. You're covered.
Ask for pronouns and provide yours. So you can introduce yourself using your pronouns, "Hi, my name is Meris. I'll be your nurse today. I use she, they pronouns. What pronouns would you like for me to use when I address you?" Very simple. It lets them know this is who I am, and I am asking who you are. It's a good way to address anybody who you're meeting for the first time, not just someone who you think might be gay or trans, right? Because you can't tell by looking at somebody. So just incorporate this into your daily life.

And then, we're going to move on to never assume, ask what you need to. So when I say to somebody, "Are you sexually active?" and they say, "Yes," that's not the end of the conversation, right? "Are you sexually active?" "Yes." "Okay, so with people of the same or different genders from yours?" I used to say the same or opposite gender, but that is binary. So it is exclusive, or just ask, "With which genders?" This is going to inform a lot of things about your patient's care. But if my patient is here in the emergency room for chest pain, I don't need to be asking them about their sex lives or what genitals they have currently. There's a limit. I need to ask what I need to know. So when I was working in the OB-GYN's office, 100%, I asked this question every single day of every single patient. It was pertinent, relevant, and I needed to know. But in the emergency room, I don't ask this question of every patient, right? This is not necessarily part of my focused assessment. We may talk about that if they bring it up, if they have concerns. But if my patient is here for chest pain, I'm not going to be nosy and asking things that I don't need to know.

Okay, so here are some subtle ways that you can signal to your patients that you are a safe person for them. So this one, I think, is the easiest. Wear a pronoun pin because I get it. It is a lot to say, "Go out into the world and start introducing yourself to people with your pronouns and asking for theirs." That's an awesome thing if you're there. If you're ready to start doing that, that's fantastic, and I would absolutely invite you to do it. But if you're not, that's okay, too. You may never get there, and you may get there later. So wearing a pronoun pin is a really great way to subtly say, "This is me telling you these are my pronouns," because I guarantee you the people who don't care about pronouns aren't going to see it, right? They're not looking at it. But the people who do care are going to laser focus in on it. And that's me included. When I see someone wearing a pronoun pin, I am just like, "Okay, awesome. Awesome. Awesome." I get really, really excited because I feel confident that this person is a safe person for me to be around, at least at a cursory glance.
Another one that's not on here is put your pronouns in your email signature. It's so, so easy. It costs nothing. It takes zero time. My email signature for Level Up says, "Meris Shuwarger, BSN, RN, she, they nurse team leader at Level Up RN," right? And then that way, everybody sees my pronouns, knows how to address me correctly. And it's, again, that subtle signal that, "Hey, I get it. I'm a safe person."

Having a rainbow pin or sticker somewhere visible, this is more of a facility thing. If I go to a new doctor's office and I see a little rainbow sticker in the window, again, this is something that most people are going to just walk right past. But I guarantee you, I have seen it. I've acknowledged it, and I've gone, "Okay," right? There is more to being in the LGBT community than rainbows. It's not as simple as just putting the rainbow there, but it is something that lets me know they know I exist, and they are trying to tell me that I'm welcome here. Very subtle signal. It's not the be all end all of things, but it is enough for me to say, "Okay, I feel welcome here."

Introduce yourself using your pronouns. We've said that one already, and then avoid that gendered language in all conversations, not just with people who you think are in the community. So I say pregnant patients all of the time, right? All of the time with everyone that I speak to. And yes, it takes a lot of work to filter these gendered terms out of your day to day life. But I promise you, if you start thinking about it and making these small, conscientious attempts at changing it, you're going to be really surprised and impressed by the fact that you're able to identify them and filter them out of your own language.

Now, here are some ways that very not subtly indicate that I am safe and a member of the LGBT community. I have rainbow glasses, right? I love rainbows. Again, the LGBT community is more than rainbows, but it is something that is very near and dear to my heart, and I wear rainbows on everything. I have rainbow soled shoes, which you can kind of barely see here. My Apple Watch band is rainbow. I have a pronoun pin on my badge, and I also have tabs that stick up over my badge that say my pronouns. Again, most of my patients never notice them, but the people that do, call them out to me every day. It's amazing, and it makes me so happy. And then also, you'll see-- you can barely see it here on this one, but you'll see in a later picture, I have a BIPOC inclusive LGBT rainbow piece sign embroidered on the left sleeve of every single one of my scrub tops. Again, it's not a thing most people notice, but when they do, I guarantee you it's because they're looking for those signals that I am a safe person and I'm in the community. One time, I went into a patient's room, and I introduced myself. She scanned me up and down. She said, "I like your glasses." I said, "Oh, thanks." And then, she said, "I like your watch band." And I said, "Thanks." And then she said, "Are you in the family?" And are you in the family is a very old school way of asking if you're in the community, and I said, "I am in the family." And she said to me-- I mean, it still gets me a little bit. She said, "I was really scared to come in today. I don't like going to the doctor. I haven't had good experiences, but knowing that I have someone in the family taking care of me, I think I'm going to be okay here." And that was huge to me because you don't have to be in the family to take good care of somebody who is LGBT. But it just meant the world to me that she felt I'm here against my better judgment, maybe because I've had poor experiences historically, but I think I'm going to be okay because I have you taking care of me.

Okay, and as nurses or anybody working in healthcare, one of the things that we should be all the time is advocates, and we should be advocates for change within our own facilities as well. So here are some things you can do to make your facility more of a safe space, more inclusive. So updating forms is a big one. Using these terms is going to be very helpful to a patient knowing that they are in safe hands, that this is a facility that is aware of the difference between sex, and gender, and sexual orientation, and my legal name, and my preferred name. That's going to be huge. Like I said, a rainbow sticker or a human rights coalition sticker in the window is something I see right away.

Having gender neutral or unisex bathrooms, that's just like-- it's just such an easy thing to do to not gender a bathroom so that nobody ever has to feel uncomfortable going to the bathroom. Such a simple, basic thing no longer has to be awkward or uncomfortable. If you have educational materials displayed, like, "Here's about high cholesterol, and here is about your birth control." Put some LGBT stuff in there too, because again, I'm going to see that right away. I'm going to laser focus on it and say, "Okay, cool. I'm in the right place." This one here is the biggest one to me, make sure that your people are being educated as to LGBT competence, right? Make sure that the healthcare professionals working for you are up to date and understand how to be an inclusive healthcare provider. That's for LGBT, that is for all marginalized communities, guys.

I just I really feel so strongly about this that cultural competence education should be mandatory. It should be annual, and it should be for all healthcare professionals. And then posting a visible nondiscrimination policy. Again, most of your patients are going to scan right past it, but I'm going to see it, right? And I'm going to say, "All right, that's there for me. I know that I'm safe here."

So we will send these links out in the email that you will get later. But these are some of those resources to share with your facility. These groups have done the work for you, and they've put together these guides or these booklets on how to be more inclusive, and how to create an LGBTQ affirming clinic, and all of those sorts of things. So if you want to share these things with your facilities, they've already done the work for you. We'll send those links out to you later.

So, okay, let's check did we accomplish our objectives. So tell me some ways that the LGBT community faces healthcare disparities. You can list any of them that we talked about. The language use, feeling unsafe with their healthcare providers, 100%. Any others? Access, poor healthcare access, delaying care. Absolutely, yes. So all of those things that we talked about. Yeah, poor sex education, higher rates of substance abuse, suicide, homelessness, obesity, STIs, bullying, chronic health problems, sexual violence, poor health, lower rates of health insurance, sexual health education, access to healthcare services, and family acceptance.

Okay, so a patient tells you that they were assigned female at birth, what does this refer to? Does this refer to your patient's sex, gender, sexual orientation, or pronouns? Absolutely right. That refers to your patient's sex. That is what they were assigned at birth based on their genitals.

And lastly, how can a healthcare professional or facility provide a more inclusive environment? What are some things that you could do to provide more inclusive or competent care or that your facility could do? Wear a rainbow pin, love that. Visual cues, mission statements, absolutely. Yes. Yeah, introduce yourself with your pronouns or ask your patients for their pronouns. Update forms to have more accurate questions, I love it. Yes, 100%. Changing language to be more inclusive to everyone, yes, absolutely. Avoiding that gendered language, this one is the one that I think is the easiest to start with because it doesn't have to be a super obvious thing. You can do it every single day with every single person that you interact with and try and change your language and see what happens. It's not that hard, and it's not something you're going to face a lot of pushback from. So saying pregnant patient, almost nobody is going to have a problem with that. And you can try practicing that before making bigger changes, like introducing yourself with your pronouns.

Okay. So thank you so much for your time and attention. I know that you had a lot of places that you could be on a Wednesday night, and you chose to be here with me, and that means everything to me. So what questions do you have? What do you want to share? Is there anything that you want to share with us? I'm very thankful to you for being here.

Yes, the recording will be available. Absolutely. I'm not sure exactly when, but you should get it in an email. And also, I got to wait just a minute. We'll wait until all questions are answered, but I do have three winners for Level Up RN flashcard deck of your choice. Speaking of which, let me pull that up.

How would you approach discussing changing language and nursing courses with faculty? Oh my goodness, first of all, I love this question. So this is actually a great question that I think of a lot in terms of not all nursing professors or programs are going to be there, right? Not everyone is going to be receptive to changing their language or anything like that. And that can be very frustrating, especially when you know that this is the correct thing to do or the right way to talk about a patient or something along those lines. So I would say, first and foremost, nursing is a research based profession, right? So I would come with research. I would come with peer reviewed studies that say when this, then that, right? So when we use gender affirming language or when we use gender neutral language, then we see greater outcomes of blah, blah, blah. So that's one way.

The second would be looking into these groups that have put together these strategy guides or these things like that and sharing those and sharing the success that others have had when doing these things, or if you feel comfortable, if you identify as part of the community, and you want to self-identify and self-disclose as someone who is trans, or gay, or whatever the situation may be, it's really hurtful when you say, "Blah, blah, blah," and it would be more inclusive or more appropriate to say these things or do these things. It's tough. That is a very tricky situation. I grew up in small town Virginia, and I wanted desperately to start a gay-straight alliance at my school, and I went to the principal to try and do that, and he literally laughed in my face and said, and I quote, "Good luck with that." And then, I asked him what I had to do to get it started. He said that I had to have a faculty advisor. So I went and I found a faculty advisor, and she said, "Yes, absolutely. I would be happy to be the advisor for your group." And the next day, she found me and was crying and said, "I'm so sorry, I won't be able to do that, so then I found another person and the same thing happened. And as it transpires, the principal was threatening the teachers with being fired if they agreed to be the faculty adviser.

So there's always the chance that it goes poorly and it goes like that. And I then had to take a step back and decide that I was going to pick my battles and not go for it. But I tried, and I think that the trying is the important part. But again, peer reviewed research, I love that as a starting place so that we can kind of argue with the evidence and then using existing guides and organizations to help guide the conversation or to provide the facility with more information.

I've been an LPN for a few years and never thought of how affected the LGBT community was about our lack of knowledge. Currently going through RN school, and I'm glad that I got to participate today. That makes me so happy. Thank you so much. It's one of those things that I think you wouldn't think of unless you're in that community. And it's tricky to consider the ways in which our language and our behavior may be harmful. But it is so awesome that you were here today and willing to be educated and to make changes because that's where it starts, right? It's the understanding of the problem.

Yes, something to remember is that if we don't try or ask, the answer will always be no. That is 100% correct. If the worst thing they can say is no, it's worth asking, right? We have to start somewhere. Yeah. And sometimes, it's not going to go well. And like I said, you can choose to back down from that if it becomes an uncomfortable or unsafe situation for you. Always prioritize your own health and safety over anything else. But it's just awesome to start because I think too, you'll be surprised what people are willing to do. It's so easy to put a pronoun pin on, right? That's very easy, or it's so easy to put a rainbow sticker in the window. Again, that's not going to necessarily change everything about healthcare, but it's a starting place. And so, if we can even just start somewhere, we can only go up, right?

Yes, Ellis is in a smaller rural area and says, "Many of my coworkers were simply never educated on this content," and that is absolutely the case. But the good news is that we're talking about these things so much more, and I think that as we talk about them, it's all about that tiny incremental change building like a snowball, right? So if you watch my maternity playlist on YouTube, you will see that I try really, really, really hard to avoid all gendered terms at all times. Sometimes, it doesn't happen. Sometimes, I slip up, right? But if one nursing student out there can see that and say, "I can tell she's purposely saying pregnant patient. I'm going to start saying that too." That's a huge thing, right? So any sort of change is good change in this direction if we can be more inclusive, and more compassionate, and provide more competent care to our patients.


1 Response

Maria Pena
Maria Pena

October 18, 2021

I would like to receive notice all webminar.

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