Welcome

Providing Culturally Competent Care to Lesbian, Gay, Bisexual, and Transgender

IndividualsDomestic Violence/Sexual Violence

Knoll Larkin MPH

Mautner Project-”Removing the Barriers”

Funded by the Centers for Disease Control and Prevention

Affirmations—”The Community Center for Lesbian, Gay, Bisexual, Transgender People and their Allies”

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Part IModule One

Setting the Stage - Making the

Case

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Training Guidelines

1. Confidentiality

2. Agree to disagree

3. Use “I” statements

4. You are responsible for your comfort

5. Ask questions and be willing to take risks

6. Have FUN!!

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Assumptions

You currently provide quality services to people.

You are interested in increasing your ability to provide quality services to people.

If you are working with people, you are also working with lesbians, gays, bisexuals and transgender and same gender loving individuals.

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Part IModule Two

Defining Cultural Competence In

the Healthcare System

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How does culture impact healthcare?

Culture is the complex interplay of all the facets of individual’s experience, which informs:

Specific health concerns

How they present for care

Style of communication

Access to medical services

Level of trust in the medical system

Compliance

Outcome of patient encounters

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What is individual cultural competence?

Individual cultural competence is a set of:

congruent behaviors, attitudes, and knowledge

that enable a person to effectively interact with an individual or a group different from them.

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What is organizational cultural competence?

Organizational cultural competence is a set of:

congruent behaviors, attitudes, and policies that come together in a system, an

agency or among professions

that enable the system, agency or profession to work effectively in cross cultural situations.

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What is culturally competent care?

A system of:

clinical practices, standards of care, management policies, and institutional philosophies

that takes into consideration and is responsive to the cultural factors that influence the attitudes and behaviors of every patient.

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Cultural Sensitivity

Awareness of impact of culture

State of desiring to provide culturally appropriate services.

Where the journey begins

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Benefits of Culturally Competent Care

Increased access to services

Improved prevention/early intervention

Better communication and rapport

More accurate diagnoses

Improved adherence and compliance

More effective treatment outcomes

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Benefits of Culturally Competent Care (cont.)

Greater consumer satisfaction

Increased patient retention

More word-of-mouth referrals

Cost savings

Reduced malpractice liability

Greater provider satisfaction

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Part IModule Three

Understanding Language:Sex, Gender and Orientation

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Sexual Orientations

Lesbian: A women who is emotionally, romantically, spiritually attracted to women.

Gay: A man who is emotionally, romantically,

and spiritually attracted to men.

Bisexual/bi-attractional: Attraction to members of either sex

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Sexual Orientations

Same Gender Loving: A term used in communities of color to describe women who partner with women or men who partner with men.

Queer: a more inclusive term used to describe folks who don’t fit “neatly” into the LGB categories.

Identity vs. Behavior

Who we say and feel ourselves to be might be different than what we actually do.

Identity-the “label” one applies to oneself and one’s community of affiliation

Behavior-the specific activities a person engages in.

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Levels of Identity

Involved in gay, lesbian, bisexual politics or culture

“Closeted and isolated from valuable support resources”

Sexual orientation may be only a minor part of personal identity

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Gender Identity

May be: Feminine / Femme Androgynous Masculine / Butch Transgender

Gender identity refers to ones own sense of gender

Gender identity is distinct from sexual orientation.

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Gender Identity (cont.)

Transgender:

Gender expression incongruent with expectations of biological/assigned sex.

MTF (male to female) / FTM (female to male)

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Using Language: Summary

One way to demonstrate inclusiveness in a healthcare setting is through use of language.

Use terms preferred by your patients. These may be different for each person, regionally or generationally based.

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Common language: Summary (cont.)

Preferred vs. Other Terms Lesbian, Gay, Bisexual Homosexual Partner Lover/Roommate Sexual orientation Sexual preference Crossdresser Transvestite Transgender Transsexual Intersex Hermaphrodite

WHEN IN DOUBT… ASK!

Words/Phrases Often Used “Within” the CommunityDyke, Queer, Family, In the Life

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Part IModule Four

The Coming Out Process

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Coming Out:

Refers to the experiences of some, but not all, LGBT people as they work through and accept a stigmatized identity.

Transforming a negative self identity into a positive one

Self-ActualizationSexual Orientation vs. Gender Identity

Coming Out (cont)

There is no correct way to come outSome people may decide they do not want

to take on a LGBT identity and may choose not to disclose their feelings and experiences to anyone.

Cass Model of Identity Development

Stage 1: Identity ConfusionStage 2: Identity ComparisonStage 3: Identity ToleranceStage 4: Identity AcceptanceStage 5: Identity PrideStage 6: Identity Synthesis

Part IIModule One

Intimate Partner Violence in

LGBT Communities

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Prevalence

In preliminary data, the Gender, Violence, and Resource Access Survey of trans and intersex individuals found 50% of respondents had been raped or assaulted by a romantic partner, though only 62% of those raped or assaulted identified themselves as survivors of domestic violence when explicitly asked.

Current studies have shown that same gender relationship abuse occurs at the same rate or more often than heterosexual abuse.

What is the Same:

Abuse is always the responsibility of the abuser and is always a choice. Victims are often blamed for the abuse by partners, and sometimes even

family, friends and professionals can excuse or minimize the abusive behavior.

It is difficult for victims to leave abusive relationships. Abuse is not an acceptable or healthy way to solve difficulties in

relationships, regardless of orientation. Victims feels responsible for their partner's violence and their partner's

emotional state, hoping to prevent further violence. Abuse usually worsens over time. The abuser is often apologetic after abusing, giving false hope that the

abuse will stop. Some or all of the following effects of abuse may be present: shame, self-

blame, physical injuries, short and long-term health problems, sleep disturbances, constantly on guard, social withdrawal, lack of confidence, low self-esteem, anxiety, depression, feelings of hopelessness, shock, and dissociative states.

What is different:

Very limited services exist specifically for abused and abusive LGBT people. LGBT people often experience a lack of understanding of the seriousness of

the abuse when reporting incidences of violence to a therapist, police officer or medical personnel.

Homophobia in society denies the reality of lesbian and gay men's lives, including the existence of lesbian and gay male relationships, let alone abusive ones.  When abuse exists, attitudes often range from 'who cares' to 'these relationships are generally unstable or unhealthy.'

Shelters for abused women may not be sensitive to same-sex abuse (theoretically, shelters are open to all women and therefore, a same-sex victim may not feel safe as her abuser may also have access to the shelter).  Abused gay men have even fewer places to turn for help in that there are no agency-sponsored safe places to stay.

In lesbian and gay male relationships, there may be additional fears of losing the relationship which confirms one's sexual orientation; fears of not being believed about the abuse and fears of losing friends and support within the lesbian/gay communities.

Common Myths about Abuse in Lesbian Relationships: Women are not abusive - only men are." "Lesbians are always equal in relationships.  It is not

abuse, it is a relationship struggle." "Abusive lesbians are more "butch," larger, apolitical or

have social lives that revolve around the bar culture." "Lesbian violence is caused by drugs, alcohol, stress,

childhood abuse." "Lesbian abusers have been abused/oppressed by men

are therefore not as responsible for what they do." "It is easier for a lesbian to leave her abusive partner that

it is for a heterosexual woman to leave her abusive partner."

Common Myths About Abuse in Gay Male Relationships: "Gay men are rarely victims of abuse by their partners."

"When violence occurs between gay men in a relationship, it's a fight, it's normal, it's 'boys will be boys.'"

"Abuse in gay male relationships primarily involves apolitical gay men, or gay men who are part of the bar culture."

"Abuse in gay male relationships is sexual behavior: it's a version of sadomasochism and the victims actually like it."

Part IIModule Two

Barriers To Treatment and

Solutions

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How Professionals Can Help

All professionals need to examine their own attitudes and feelings and how these have been influenced by homophobia and heterosexism.

Become aware of the silence and prevailing myths about partner abuse in lesbian and gay male relationships.

Do not assume with either males or females that their partner is of the opposite sex.

Respect your client's anxieties about disclosure of sexual orientation, which may be based on real fears of discrimination and its effects on child custody, family support, job security, and/or deportation.  Choices about disclosure of orientation and same-sex relationships are those of your clients and theirs alone.

It is important to impart acceptance of your client's sexual orientation. Clients who have been abused by a same-sex partner may initially have

issues of trust with a professional of the same sex. Learn about and encourage the use of supportive social networks within and

outside the lesbian and gay male communities.

Barriers to Accessing DV/SA Services:

Marginalization and labeling of sexual orientation or gender identity as deviant or pathological in medical or psychiatric communities.

Anticipated, perceived, or actual discrimination Fear of mistreatment Lack of research about use patterns, treatment needs, etc. Provider lack of information Fear of being outed will result in loss of job, custody, housing, or

social supports. Exclusion of family of choice from health care/service settings Low self-esteem or belief that sexual orientation or gender identity is

wrong Strong need to show that same gender relationships are “healthy”

“normal” “good”---overshadowing abusive situations.

Trans and Intersex Specific Barriers Trans or intersex status, if previously hidden, might become known and expose them to

more violence, lead to the loss of a job, as very few jurisdictions provide employment discrimination protection.

Some information suggests that trans and intersex survivors have frequently been multiply

abused for years or decades. Often a trans or intersex survivor has a unique body and/or a unique vulnerability to the emotional aftermath of sexual violence; either can make difficult or impossible discussing this abuse with an unfamiliar victims' advocate.

Related to this problem is the shame and self-doubt that is endemic in these communities, due to the pressures trans and intersex persons have felt from their earliest years to deny their feelings and conform to others' expectations.

Although every domestic violence survivor with children worries about the safety and custody of those children, the problem is much greater for trans parents, who know that because of prejudice and ignorance about trans persons, courts are extremely unlikely to grant them custody no matter how abusive the other parent is.

Gender segregation of survivor services. Virtually all trans survivors go through a significant period when they are in legal or medical transition. Some intersex survivors have a unique body that prevents identification with either a male or a female gender. Some trans individuals, including such notable examples as authors Kate Bornstein and Leslie Feinberg, have a gender identity and gender expression that is neither male nor female, but mixes elements of both. For all of these people, turning to a gender-segregated service agency may be inconceivable.

Solutions:

Before the Client encounter Marketing materials, brochures, ways services

are introduced. Are they representative of the diversity of the populations within the service area? Will LGBT people feel like the advertised facility is a comfortable place for them? How is this communicated? What is the current reputation in LGBT community? Is there a need to address past negative experiences?

Creating an Affirming Environment:

Display health info, magazines, posters, and other decorations that reflect the faces and interests of clients served. Staff should also be representative of clients served. Consider posting a written non-discrimination policy that includes sexual orientation and gender identity.

Inclusive Paperwork

Getting beyond “Married, Single, Divorced” Consider “partnered, significant relationship, significant other”

-Are you involved in a significant relationship?

-Is there someone you would like involved in your care/treatment/safety plan?

-With whom do you live?

Culturally Competent Approach:

Is client centeredUses client’s own languageNon-judgmentalNo assumptionsOpen ended questionsBegins with less threatening questionsIt’s okay to not know!

Conclusions

Contracting for Change

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Affirmations LGBT Community Center

Knoll Larkinklarkin@goaffirmations.org

248-398-7105www.goaffirmations.org