Traditional Chinese Medicine - NJSNA

Traditional Chinese Medicine - NJSNA

LGBTQIAxyz The Alphabet Soup of Community Healthcare Andrew Appello MSOM, L.Ac., RH(AHG), BSN, RN [email protected] NJSNA/IFN Convention Atlantic City, NJ October 12, 2017 Learning Outcomes: Nurses will: Note disparity of the LGBTQIA community Learn terminology and be introduced to LQBTQIA

culture Discover the unique biopsychosocial health needs of the LGBTQIA community Improve culturally competent nursing care to the LGBTQIA community National Institutes of Health October 6, 2016 -The director of the National Institute on Minority Health and Health Disparities announces (PerezStable, 2016): Sexual and Gender Minorities Formally Designated as a Health Disparity Population for Research Purposes

Less access to care Higher burden of disease Stigma, hate-violence, discrimination Barriers Preventing Access to Care Stigma Discrimination Violence Rejection by families and communities Inequality in the workplace

Inequality in health insurance sectors Provision of substandard care Denial of care because of an individuals sexual orientation or gender identity (Ranji, Beamesderfer, Kates, & Salganicoff, 2014) What Should Nurses Do? Lets Start with Cultural Competence Definition: Having the knowledge, abilities, and skills to deliver care congruent with the patients cultural belief and practices (Purnell, 2013, p. 7) Were Nurses!

Implementing the American Nurses Association Standards of Care 8: Culturally Congruent Practice (Marion et al., 2017) Show RESPECT, EMPATHY, and EQUITY Self Assessment and Reflection Teach nursing colleagues (+ many others) Cultural Proficiency Higher-Order concept that involves overcoming barriers of cognition and affect (de Chesnay, Hart, &

Brannan, 2016) How do YOU feel? My Story: A girl walks into the bar Sexual and Gender Identity Labels, labels, labels. OR Fluidity *NOTE: Identity is not equal to culture and culture is not equal to identity but both inform LGBTQIA community nursing care!

Yin and Yang Yang Light side of the mountain Yin Dark side of the mountain AN INFINITE SPECTRUM A Note on Stereotyping It is critical for practitioners to keep in mind that groups are composed of individuals we

should not stereotype individuals in terms of group characteristics (de Chesnay, 2016, p. 4) A Personal Account Stereotypes: Gay men are not handy or sporty Gay men are fabulous (sequins and glitter implied) A REAL MANS TOOL BOX Sometimes stereotypes are true! (?) Introducing the ABCs of the Community

How do you identify? The Alphabet LGBT Lesbian Gay Bisexual Transgender The New Alphabet

LGBTQIA Lesbian Gay Bisexual Transgender Queer Intersex Asexual

The Expanded New Alphabet LGBTQQIAAP Lesbian Gay Bisexual Transgender Queer

Questioning Intersex Ally Asexual Pansexual Sexuality Three components (FredriksenGoldsen et al., 2014): Sexual identity Sexual attraction

Sexual behavior Sexuality and Labels MSM (Men who have Sex with Men) WSW (Women who have Sex with Women) MSMW, MSWM and WSMW, WSWM Terms introduced especially in research to convey that sexuality is a broad concept where

behavior, desire, and identity do not always coincide (Young & Meyer, 2005-seminal source) The terms Gay and Lesbian often refer to Caucasians while MSM/WSW are more inclusive of people of color (Young & Meyer, 2005-seminal source) Gay/Lesbian etc. imply identity and community MSM/WSW speak to behavior Coming Out! Can be: A celebration and liberating OR Painful and terrifying But definitely life changing

RN interventions: Be supportive Listen Allow the client to come out when ready Lesbian Culture WSW There are many types of Lesbians!

Baby dyke The butch-fem divide Girl next door Lipstick lesbian Ursula *Note: Dyke can be used as a terrible insult or a reclaimed identity of empowerment. RN: Dont use! Lesbian Culture Stereotype joke: What is a lesbian couples second date?

Renting a U-Haul to move in together (U-Haulin it) Opening a book store together Adopting a cat Lesbian Health (Office on Womens Health, 2017) Lesbians and bisexual women are at an increased risk for: Obesity, smoking, stress. Breast, endometrial, and ovarian cancer

Polycystic ovary syndrome Depression and anxiety Bacterial vaginosis Lesbians are less likely to get: Mammograms and clinical breast exams Cancer screening RN Interventions: Screen for all above risks Screening for heart disease, lung cancer Reproductive One Womans Experience

Be sensitive! Dont ask me about my donor You go broke or into debt because insurance does not cover it Nurse: Why doesnt your wife carry? She is younger and thinner Patient: Because carrying a child does not match her gender identity Gay Culture MSM So many types of gay men!

Bears Wolves Otters Twinks Jocks Cubs Boy next door Know Your Positions Relevant to STD screening and risk

Top = prefers insertive anal intercourse Bottom = prefers anal receptive intercourse Versatile (Vers) = enjoys topping and bottoming HIV and MSM (Centers for Disease Control and Prevention, 2017a) Gay and bisexual men represent the most vulnerable group in the US

55% of the HIV infected population Risk of being diagnosed with HIV in a MSM mans lifetime: 1 in 6 All races 1 in 2 African-Americans 1 in 4 Hispanics/Latinos 1 in 11 Caucasians HIV and MSM Youth

(Centers for Disease Control and Prevention, 2017a) In 2014: 92% of new HIV diagnoses in the 18-24 age range were gay/bi men 27% of new HIV diagnoses in the gay/bi population were men age 18-24 STD Screening MSM Questions:

Have you performed oral sex? Have you received anal receptive intercourse (bottomed)? Have you had multiple sexual partners? Has your sexual partner had multiple sexual partners? Assess for risky behavior and condom use. Is he knowledgeable about what constitutes risk? STD Screening for MSM

(Centers for Disease Control and Prevention, 2017c) Chlamydia: At least annual screening; every 3-6 months if at high risk Screen at site of contact regardless of condom use urethra or rectum Gonorrhea:

At least annual screening; every 3-6 months if at high risk Screen at site of contact regardless of condom use urethra, rectum, or pharynx *High risk = 1. Those with HIV + persistent risky behavior or 2. Patients or their sexual partners with multiple partners STD Screening for MSM (Centers for Disease Control and Prevention, 2017c) Syphilis:

Herpes: At least annual screening; every 3-6 months if at high risk Type-specific serological test if status unknown or previously undiagnosed genital infection HIV: At least annually if status unknown or negative and patient or patients sexual partner has had multiple partners since last test

*High risk = 1. Those with HIV + persistent risky behavior or, 2. Patients or their sexual partners with multiple partners STD Screening for MSM (Centers for Disease Control and Prevention, 2017c) Hepatitis B: Test all for HBsAg Hepatitis C:

Test those born between 1945-1965 Test those with other risk factors: injection drug use, blood transfusion before 1992, long term hemodialysis, born to mother with Hep. C, intranasal drug use, receipt of an unregulated tattoo, and other percutaneous exposures Test annually + HIV infection PrEP (Centers for Disease Control and Prevention, 2017b)

Pre-Exposure Prophylaxis Truvada (tenofovir and emtricitabine) Taken daily to reduce the likelihood contracting HIV by more than 90% Much less effective when not taken daily and consistently and more effective when used with condoms and other safe sex methods A PrEP Problem My story: The lawyer A PrEP Problem MSM focus groups:

Majority of men feel that PrEP use means they do not need to use condoms (Taylor et al., 2014) RN Interventions: Reinforce need for safe sex and that PrEP does not prevent other infection! Bisexual

MSMW or WSMW Identify as having sexual and romantic attraction to both genders Degree of attraction to each gender can vary Common misconception/stigma: You are just on your way to figuring out if you are gay or straight Bisexual Bisexual women have higher rates of depression as compared to lesbians and heterosexual women (Bostwick, 2012) Queer

Dictionary definition: Abnormal or strange History of use as a word showing hate toward those who do not conform to dominant norms of gender and sexuality For LGBTQIA community: A reclaimed term of empowerment (inside of the community)

The pride involved in not conforming to gender or sexuality expectations An identity Often has socio-political connotations RN recommendation: Do not use unless the client uses first! Questioning Exploring ones gender identity and expression and/or Exploring ones sexual orientation Interventions:

Provide a supportive and open environment Create a school-based or web-based LGBTQIA inclusive sex education program for all youth (Pingel, Thomas, Harmell, & Bauermeister, 2013) Intersex Those who have primary and/or secondary sex

traits of both male and female genders It is not socially acceptable to use the term hermaphrodite Disorders of Sex Development (DSD) A controversial term Research is insufficient concerning the benefit of early gender assignment surgery (Diamond & Garland, 2014) Recommendation is to delay cosmetic surgery until the patient can appropriately consent (Diamond & Garland, 2014) Ally A cisgender, heterosexual person who supports LGBTQIA social equality (Cisgender: Gender identity = socially recognized

sex) Asexual A sexual orientation One who feels lack of attraction or desire for a sexual partner Differs from the practice of celibacy Pansexual AKA omnisexual Those who have romantic or sexual desire for

others of all genders and sexuality Disparity and Other Difficulties Trauma? Research by Hatzenbuehler and McLaughlin (2014) Tested LGB youth exposed to structural stigma Structural stigma = stigma encoded into state legislation.

Example: no marriage equality laws Conclusion: LBP youth living in states with structural stigma experience cortisol blunting reminiscent of post-traumatic stress Healthy People 2020 LGBT Disparity (U.S. Department of Health and Human Services, 2017) Increased rate of suicide and homelessness (LGBT youth) Increased rate of HIV infection (gay men)

Especially men of color Increased risk of obesity (lesbian and bisexual females) Less likely to have preventative cancer services (lesbians) Increased use of tobacco, alcohol, and drugs (all LGBT) Healthy People 2020 LGBT Disparity (U.S. Department of Health and Human Services, 2017)

Increased HIV/STD, victimization, mental health issues, suicide (transgendered people) Less likely to have health insurance (transgendered people) Increased isolation, lack of social services, culturally competent providers (elderly LGBT) What is your gender? Transgender Disparity (Singh & Dickey, 2016)

Increased risk for suicide, anxiety, depression, substance abuse, HIV/AIDS Youth: bullying and harassment in school leading to poor academic outcomes and drop-out Trans* people of color: Increased homelessness, job discrimination, and mental health issues Guidelines For Care (Sedlack, Veney, & OBryan Doheny, 2016) Hormone prescribing: The Endocrine Society

Overall care guidelines: WPATH Introducing the WPATH (WPATH, 2011-current revision) World Professional Association for Transgender Health Interdisciplinary Mission: To promote evidence based care, education, research, advocacy, public policy, and respect in transgender health

Annual conferences Clinical training program Transgender Terms (University of California, 2017) Transsexual Lives opposite gender as birth. Often refers to a trans* person pursuing gender confirmation (sex reassignment) Transgender 1. 2. 3.

A person whose gender expression does not match societys birth sex expectation Outside of the binary male/female No or multiple genders Gender queer/gender non-conforming gender identity or expression outside of dominant society norms Transgender Terms Trans* man = FtM (female to male) or F2M Trans* woman = MtF (male to female) or M2F Please do not use the term tranny!

Inappropriate slang Term of hate and oppression Transitioning the process of changing from one gender to another (University of California, 2017) Medical hormones, surgery, speech therapy Social pronoun use, name use Legal name change, gender change on documents Not Related to Gender Identity

Cross-dresser Transvestite has a negative connotation as a former mental health diagnosis term. Please do not use. Drag king Drag queen Trans* Terms Gender non-conforming Gender identity outside of

dominant social norm Vs. Gender dysphoria Refers to the distress caused by gender non-conformity The Trans* Healthcare Paradox Diagnosis: Gender dysphoric disorder A trans* person must be diagnosed as disordered in order to receive medical treatment. Does this concept further stigmatize the transgendered population? **Stigma of pathologizing of trans* people is a

barrier to care (Singh & Dickey, 2016) Solution?? Gender Dysphoria and Other Complicating Mental Health Issues (WPATH, 2011-current revision) Trans* people can experience: Substance abuse Chronic minority stress Anxiety Depression

Self-harm History of abuse and neglect Compulsivity Sexual concerns Personality disorders Eating disorders Psychotic disorders Autistic spectrum disorders

Adolescents (WPATH, 2011-current revision) Gender dysphoria can be confused with psychosis Comorbidities often found: anxiety, depression, oppositional defiant, autistic spectrum disorders

Family needs psychosocial support Interventions may include puberty suppressing hormones Educate the community (schools, camps, courts, teachers etc.) Peer support groups Do not impose a male/female binary view on gender Encourage role change exploration first Trans* Therapeutic Modalities (WPATH, 2011-current revision) Surgery Hormone therapy

Average transition takes 2 years Highly individual in duration and extent to transition Voice and speech therapy Change in gender role living in role consistent with gender identity Trans* Therapeutic Modalities (WPATH, 2011-current revision) Mental health counseling helps to:

Explore gender identity, role, expression Work on consequences of stigma and dysphoria Minimize internalized transphobia Enhance social support Improving body image Promote resilience Note Treatment to alleviate dysphoria is individualized Therapy may consist of any combination of

modalities or all of the above Hormone Treatments (WPATH, 2011-current revision) MtF Estrogens (transdermal) Anti-androgens Sprionolactone Cyproterone acetate (not in US) GnRH (Gonadotropin

Releasing Hormone) agonists 5-alpha-reductase inhibitors Block gonadotropin releasing hormone receptors Prevent DHT conversion Progestins

FtM Testosterone Progestins Used to stop menses Hormone Therapy Risks MtF (WPATH, 2011-current revision) *Ratings for increased risk: Likely, possible, and no /inconclusive

Likely: Venous thromboembolism, gallstones, elevated liver enzymes, weight gain, increased triglycerides, cardiovascular disease Possible: Hypertension, hyperprolactinemia, prolactinoma, type 2 diabetes, No/inconclusive: Breast cancer Hormone Therapy Risks FtM (WPATH, 2011-current revision) Likely: Polycythemia, weight gain, acne, androgenic

alopecia, sleep apnea Possible: Elevated liver enzymes, hyperlipidemia, psychiatric disorder destabilization, cardiovascular disease, hypertension, type 2 diabetes No/inconclusive: Loss of bone density, breast cancer, cervical cancer, ovarian cancer, uterine cancer Monitoring Health During Hormone Therapy (WPATH, 2011-current revision) MtF Cardiovascular impairment

Venous thromboembolism FtM Blood pressure Weight Pulse Tobacco use*** Heart and lung exam Extremity evaluation

Peripheral edema, local swelling, pain Excessive weight gain Acne

Uterine breakthrough bleeding Cardiovascular issues Psychiatric symptoms Blood pressure, pulse, weight Heart and lung exam PCOS Pregnancy Surgical Interventions (WPATH, 2011-current revision) MtF Upper:

Breast augmentation /mammoplasty Penectomy, orchiectomy Vaginoplasty, clitoroplasty, vulvoplasty Facial feminization, liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal

augmentation, hair reconstruction Subcutaneous mastectomy, male chest creation Lower: Other: Upper:

Lower: FtM Hysterectomy, ovariectomy, vaginectomy Metoidioplasy/phalloplasty, scrotoplasty, erecion and testicular prostheses Other: Voice surgery, lipofilling, liposuction, pectoral

implants Call to Providers (Singh & Dickey, 2016) Make sure the clients voice is heard Pursue training in trauma, resilience, and minority stress Be aware of potential violence and hate crime Work with a trans-affirmative mentor

Use cisgender privilege to speak out about oppression Clarify that trans* is not a pathology Pray the Gay Away In NJ conversion psychotherapy of minors is illegal and is thought to cause damage (Singh & Dickey, 2016) NJ bill 2012-2013 A3371 Jasmine One Womans Experience 60 year old MtF Ive had my heart broken so many times I just had to stop working as a youth role model

Prostitution is a big issue (especially MtF) Generations of girls before me got their hormones on the street and got sick Surgery in Mexico or Thailand, only a few in North America of reputation how to finance? When you are an other you find ways to isolate

Her rationale for working in night clubs, a way to avoid society There is no one to say I can connect you to something so they just vanish Jasmine One Womans Experience Passing vs. not passing different levels of stigma One surgeon said you are a man, why dont you just be a man? Respect is really the issue!

Its okay to ask- dont play the pronoun game It can be very empowering for a trans person to tell you how they identify if they do not feel judged Post breast surgery bleed. Went to a Catholic hospital the next day and was turned away Pronouns, Pronouns, Pronouns Standard English Pronouns: I You He, She We You (all)

They **What pronouns do you use? Gender Neutral Pronouns Practice sentence: _____was very proud of _____. He She Ey

Ve Fae Per They Xe Ze/zie Himself Herself

Eirself Verself Faerself Perself Themself Xemself Hirself Roselyns Breasts RN: You havent had a mammogram in how long?!?! RN Interventions

Consider your own beliefs, feelings, and judgments on sexuality and gender Support, listen, and suspend judgment Educate others and advocate for the LGBTQIA community Develop a referral network of LGBTQIA affirmative practitioners Primary care practitioners Mental health providers RN Interventions

Provide resources as appropriate The Pride Center of New Jersey WPATH find a provider www.hrc.org NJ Department of Children and Families

www.wpath.org Human Rights Campaign www.pridecenter.org http://www.nj.gov/dcf/adolescent/lgbtqi/ Community and LGBT Culture https://outinjersey.net/ Anti-Bullying Campaign

School Nurses Can Help! On-line support group Student organizations LGBT affirmative/inclusive sex-ed Welcome the Community! References:

Bostwick, W. (2012). Assessing bisexual stigma and mental health status: A brief report. Journal of Bisexuality, 12(2), 214222. http://doi.org/10.1080/15299716.2012.674860 Centers for Disease Control and Prevention. (2017a). HIV among gay and bisexual men. Retrieved from https://www.cdc.gov/hiv/group/msm/index.html

Centers for Disease Control and Prevention. (2017b). PrEP. Retrieved from https://www.cdc.gov/hiv/basics/prep.html Centers for Disease Control and Prevention. (2017c). Screening recommendations and considerations referenced in treatment guidelines and original sources. Retrieved from https://www.cdc.gov/std/tg2015/screeningrecommendations.htm De Chesnay, M. (2016). Vulnerable populations: Vulnerable people. In M. de Chesnay & B.A. Anderson (Eds.), Caring for the vulnerable: Perspectives in nursing theory, practice, and research (4th ed.) (pp. 1-18). Burlington, MA: Jones & Bartlett Learning. De Chesnay, M., Hart, P., & Brannan, J. (2016). Cultural competence and resilience. In M. de Chesnay & B.A. Anderson (Eds.), Caring for the vulnerable: Perspectives in nursing theory, practice, and research (4th ed.) (pp. 33-47). Burlington, MA: Jones & Bartlett Learning. Diamond, M., & Garland, J. (2014). Evidence regarding cosmetic and medically unnecessary surgery on infants. Journal of Pediatric Urology, 10(1), 2-6. DOI: http://dx.doi.org/10.1016/j.jpurol.2013.10.021 Fredriksen-Goldsen, K. I., Simoni, J. M., Kim, H.J., Lehavot, K., Walters, K. L., Yang, J., & Hoy-Ellis, C. P. (2014). The health equity promotion model: Reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities. The American Journal of Orthopsychiatry, 84(6), 653663. http://doi.org/10.1037/ort0000030 Hatzenbuehler, M. L., & McLaughlin, K. A. (2014). Structural stigma and hypothalamic-pituitary-adrenocortical axis reactivity in lesbian, gay, and bisexual young adults. Annals of Behavioral Medicine : A Publication of the Society of Behavioral Medicine, 47(1), 3947. http://doi.org/10.1007/s12160-013-9556-9

Marion, D., Douglas, M., Lavin, M., Barr, N., Gazaway, S., Thomas, E., & Bickford, C. (2017). Implementing the new ANA standard 8: Culturally congruent practice. OJIN: The Online Journal of Issues in Nursing, 22(1). doi: 10.3912/OJIN.Vol22No01PPT20 Office on Womens Health. (2017). Lesbian and bisexual health. Retrieved from https://www.womenshealth.gov/a-ztopics/lesbian-and-bisexual-health References:

Perez-Stable, E. (2016). Directors message: Sexual and gender minorities formally designated as a health disparity population for research purposes. Retrieved from https://www.nimhd.nih.gov/about/ directorscorner/message.html Pingel, E. S., Thomas, L., Harmell, C., & Bauermeister, J. (2013). Creating comprehensive, youth centered, culturally appropriate sex education: What do young gay, bisexual and questioning men want? Sexuality Research & Social Policy : Journal of NSRC : SR & SP, 10(4), http://doi.org/10.1007/s13178-013-0134-5 Purnell, L.D. (2013). Transcultural health care: A culturally competent approach (4th ed.). Philadelphia, PA: F.A. Davis. Ranji, U., Beamesdurfer, A., Kates, J., & Salganicoff, A., (2014). Health and access to care and coverage for lesbian, gay, bisexual, and transgender individuals in the U.S. Retrieved from https://nursing.unc.edu/files/2014/04/8539-health-and-access-to-careand-coveragefor-lesbian-gay-bisexual- andtransgender-individuals-in-the-u-s.pdf Sedlack, C.A., Veney, A.J., & OBryan Doheny, M. (2016). Caring for the transgender individual. Orthopaedic Nursing, 35(5), 301-306.

Singh, A. A., & dickey, L.M. (2016). Implementing the APA guidelines on psychological practice with transgender and gender nonconforming people: A call to action to the field of psychology. Psychology of Sexual Orientation And Gender Diversity, 3(2), 195-200. doi:10.1037/sgd0000179 Taylor, S. W., Mayer, K. H., Elsesser, S. M., Mimiaga, M. J., OCleirigh, C., & Safren, S. A. (2014). Optimizing content for pre-exposure prophylaxis (PrEP) counseling for men who have sex with men: Perspectives of PrEP users and high-risk PrEP nave men. AIDS and Behavior, 18(5), 871879. http://doi.org/10.1007/s10461-013-0617-7 University of California. (2017). LGBTQIA resource center glossary. Retrieved fromhttps://lgbtqia.ucdavis.edu/educated/glossary.html U.S. Department of Health and Human Services. (2017). Lesbian, gay, bisexual, and transgender health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health WPATH. (2011). Standards of care for the health of transsexual, transgender, and gender non-conforming people (7 th ed.) Retrieved from http://www.wpath.org/site_page.cfm? pk_association_webpage_menu=1351&pk_association_webpage=3926 . Young, R. M., & Meyer, I. H. (2005). The trouble with MSM and WSW: Erasure of the sexual-minority person in public health discourse. American Journal of Public Health, 95(7), 11441149. http://doi.org/10.2105/AJPH.2004.046714

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