Real Talk: Community Health Care in Action
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Real Talk: Community Health Care in Action
LGBTQ+ Care
On this episode of Real Talk, Quincy invites Dr. Kristin Gianelis to talk about caring for the LGBTQ+ community. Dr. Gianelis is a Dual Board-Certified Women's Health Nurse Practitioner and Adult Nurse Practitioner with 20 years of experience. She and Quincy talk in depth about when and where to get care. ❤️
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SPEAKER_01:Welcome back to Real Talk Community Health Care in Action. Today, I want to talk about caring for our LGBTQ plus community members. Gender affirming care, as defined by the World Health Organization, encompasses a range of social, psychological, behavioral, and medical interventions designed to support and affirm an individual's gender identity when it conflicts with the gender they were assigned at birth. The interventions helped transgender people align various aspects of their lives, emotional, interpersonal, and biological, with their gender identity. The interventions fall along a continuum as well, from counseling to changes in social expression to medications such as hormone therapy. Joining me today is faculty member at Frontier Nursing University, Dr. Kristen Gianellis. Dr. Gianellis is a dual board certified women's health nurse practitioner and adult nurse practitioner with over 20 years of clinical experience. She also holds certifications as a menopause society certified practitioner, a certified nurse educated, and she is certified in perinatal mental health. She received her MSN from Simmons University in 2005 and a post-master's DMP from Frontier Nursing University in 2020. Dr. Gianellis has dedicated her career to providing equitable person-centered women's and gender-related health care. She has worked in various settings, both outpatient and acute care, providing reproductive and sexual health care to persons of all genders. Dr. Gianellis is passionate about advancing the role of the women's health nurse practitioner and incorporating quality improvement practices into the role of the advanced practice nurse. Dr. Jan Ellis currently owns and operates a small volume menopause and sexual medicine consultant practice and lives in Rhode Island with her husband and two teenagers. She's a lifelong learner and avid reader and a perpetual student. Dr. Jan Ellis, thank you for joining me.
SPEAKER_00:Thanks so much for having me. I'm happy to be here.
SPEAKER_01:So during the month of June, we are celebrating Pride, and we honor the lives and work of the LGBTQ plus community and renew our commitment to equality for people of genders and sexual orientation. In healthcare, it's a time for us to reflect on health disparities, specifically for the LGBTQ individuals, and to look for ways to improve care for all patients. Could you start by explaining to our listeners what we mean when we talk about health disparities?
SPEAKER_00:Thank you so much for that question. And I think this is a really foundational piece that we need to all be on the same page with. Health disparities are differences in access to health care or health outcomes. so overall health, that are based in systemic discrimination and oppression. But the most important part of this is that these outcomes are preventable, meaning that they could have happened differently if the racism, sexism, heterosexism, classism, ableism didn't exist. And I need to clarify that this isn't always just discrimination that's happening today. It's often rooted in longstanding cultural inequities that are built into our cultural narrative. And so again, we could be doing better,
SPEAKER_03:but
SPEAKER_00:these disparities exist. So we know that LGBTQ people persons as well as racial and ethnic minorities and folks from lower incomes, people with disabilities, rural populations, women, I mean, I can go on all day, typically have less access to care and generally have more health risks and worse health outcomes as a whole. And each of these groups have different health disparities and nothing's ever across the board, but we know this to be true from population data and healthcare delivery. And it's our job to be trying to narrow these disparities.
SPEAKER_01:So specifically with the LGBTQ community, what are the health disparities they're encountering and then what are their barriers to healthcare?
SPEAKER_00:Yes, so LGBTQ communities face really significant disparities in healthcare, most often related to discrimination, stigma, bias. And so these are all externally imposed factors that are creating a very real impact on their access to care and the quality of care that they receive, and then their overall health at the end of the day. So we know that LGBTQ folks have, they have higher rates of unemployment or underemployment which means they are not insured at the same rates that straight and cisgender folks are. And because of this alone, this workplace discrimination and hiring discrimination, we know that one third of transgender adults are living below the poverty line in this country. Sadly, these folks just can't afford a healthcare. We also know that more than half of people who are LGBTQ report at least one negative experience in the healthcare setting in the past year. And this could be something as simple as misgendering as, and I say simple, but it is real. Misgendering, providers making an unfair, like just assuming something without asking to just, we also see outright refusal of care. And with these staggering statistics, if you didn't have a negative experience this year, you certainly know someone who did have a negative experience and they told you about it. So that wouldn't make me want to come to care at all.
SPEAKER_01:Right, right.
SPEAKER_00:And I think the outcome of that is that we see delayed, or I know the outcome of that is that we see delayed or avoided care, especially when it comes to wellness. And so we don't see folks coming in for physicals or chronic disease management, like for diabetes or hypertension or regular cancer screenings like PAPs and mammograms. And we know that all of these measures improve health outcomes. So if you have hypertension and you're just not coming in for care, again, I'm not gonna blame you for not coming in for care if you are discriminated against every single time you come in. But certainly if we aren't taking care of that high blood pressure, that is going to put you at much higher risk. I think the next place we need to look at when it comes to these disparities is our healthcare workforce. And so this is where we're part of the problem. And we see very mixed levels of like knowledge and skills and overall attitudes in our healthcare providers across the country. And certainly there are variations by areas of the country, but I will say that on average, it looks like providers that are currently practicing have received on average 4.5 hours or less of training in LGBTQ care in school. That's not a lot. And many of them are less. And while a lot of those healthcare providers will say, yes, I feel comfortable when it comes down to it, they actually don't feel comfortable talking about sexual orientation, gender identity. So they feel comfortable, but then they don't feel comfortable. And their bias comes with them into the exam room. And if we don't think we have any biases, then we're kidding ourselves because we all have biases. So I think that, you know, when we think about access to care, it's not as simple as, do you have a clinic nearby? But this really encompasses like, first of all, can you afford the care? Are you comfortable getting care there? Are they going to respect you? And will the provider even know what type of care you need? Will they know how to care for you? Will you have to teach them how to care for you? You know, all of those contribute to health disparities. That's just scratching the surface.
SPEAKER_01:Now we've talked a little bit about stigma and bias. So let's talk about mental health and how the stigma and the bias impacts mental health for the LGBTQ community.
SPEAKER_00:Yes. Thank you for bringing that up because it's such an important topic. And I think that the experiences that LGBTQ people have in the world absolutely affect mental health and contribute to significant mental health disparities compared to the general population. And I want to reiterate that this is not, this is like related to minority stress and experiences they have just moving through the world. This doesn't mean that homosexuality or transgender identity causes someone to be mentally ill. That is not at all related. This means that it's their experience that puts them at increased risk for having depression, anxiety. We know that LGBTQ adults are twice as likely to have depression or anxiety. They also have higher rates of PTSD and trauma, higher rates of sexual abuse in their childhood, eating disorders, intimate partner violence, substance abuse. And again, this is not because of who they are, this is because of what is surrounding them related to who they are and how the world reacts to who they are. For youth, Stakes are even higher. We know that LGBTQ youth are more than four times more likely than their peers to have suicidal thoughts. And up to 50% of transgender youth will have a suicide attempt, which is really, it's horrific. We do know that one of the protective factors for that is having support of family and friends. And so I think that's really important to know is that that risk goes down with even one supportive adult in their life. So yes, mental health is a huge area of disparity and certainly an area that we as healthcare providers need to work on and really support equity efforts.
SPEAKER_01:So switching gears a little bit, I mentioned gender-affirming care earlier, you did, and that's, I feel like a hot topic in the media these days. So tell us what actually is gender-affirming care and why it might be important.
SPEAKER_00:Yeah, so... Within the LGBTQ community, the trans community, that T in there, is a community that's really at increased vulnerability. But let's just back up for a second because, and I just want to define gender identity for a moment, because I think people who do not have a lot of experience with the trans community, maybe they don't know trans individuals or they don't know that they know trans individuals, have a little bit of confusion or misunderstanding about gender identity.
SPEAKER_01:Right.
SPEAKER_00:So first of all, we all have a gender identity. A gender identity is how you feel inside your internal sense of what your gender is. So a person's gender identity can't be defined externally by other people. I can't determine what someone's gender identity is. It is their unique lived experience and internal sense of self. And so for many of us, our gender identity matches the sex assigned at birth, which is basically just what either the midwife or the obstetrician saw for genitals when we came out of the uterus. That's what we were assigned. And for a lot of us, that's what we identify with. But for trans folks, there's a mismatch. And that is a deep personal feeling and experience. And we really cannot refute that or deny it because that's their internal experience. I'll also say that gender exists on a spectrum. And so it's not just male and female. And then when we have transgender folks, they're either trans male or trans female. There's lots of interesting and different stuff in between and so we have really put people into this binary of male female pink blue and really there's a lot in between there and so many people will identify as non-binary meaning neither or a combination of both and some people have identities that are are very diverse and they may, I could spend a whole podcast talking about different identities along the gender spectrum. But again, that doesn't, that's not something that I can, I can, or you can define for them. That is something they define for themselves. And we don't, necessarily have to understand it. That's the hard thing is that sometimes they will talk about something, like sometimes a person will say something and I don't quite understand their experience in the world, but I don't have to because it's their experience. I just have to listen and believe them that their experience is real. So coming back to gender affirming care, Cause I think that's what you asked about, correct?
SPEAKER_01:Yes.
SPEAKER_00:Okay. I got off on a tangent
SPEAKER_01:there. No, I think, I think all of that is helpful to define because again, it's, it's an internal thing and a lot of people just see what's on the surface and that is what it is. And it can't be anything different, but exactly. So
SPEAKER_00:coming back to that gender affirming care, this is any care that affirms or, confirms, like helps a person feel more comfortable with the gender that they feel on the inside. And so it may be a change in their external physical appearance. It may be a change in the way that they are presenting to the world. It may be a change in the way that the names or the pronouns that they use, and it may be something medical as well. So we've been doing gender affirming care for a really long time in regular practice. So I think, first of all, we have to remember that we all have gender identities and anytime we are affirming a person's gender, we are doing gender affirming care. So menopause hormone therapy, when women lose their natural hormones at menopause and we give them hormones back, That is gender affirming hormone. That's gender affirming care. Same thing for men. When we see signs of hypogonadism and they lose their testosterone and we give them some back, same thing. That's gender affirming care. We're affirming their maleness at that point in time. Breast reconstructive surgery after a mastectomy for breast cancer. That's standard of care. That is like, everyone says like, yes, let's do that. That is gender affirming care. So for trans and non-binary individuals, it's the same. We just have to listen to what they want first. We can't assume it, which I think it's silly that we assumed it in the first place, but it can take many forms. So we need to respect that. people's, what they're saying to us. So a lot of times it starts with using correct pronouns and their chosen name. And I say correct pronouns rather than preferred pronouns because this is one of my little pet peeves here. And it's not a preference. It's their pronouns. So we can't refute it. We can't say it doesn't exist. Those are their pronouns and we have to use them. And just using pronouns, having forms that allow for different, you know, pronouns, different gender identities, different experiences in our office is affirmation to start with. From a medical perspective, gender affirming care is often things we're very comfortable doing already. Like we routinely suppress menstrual cycles for cisgender women who just either have horrible menstrual cycles or don't want periods. Transgender men and non-binary individuals usually don't want periods. I shouldn't say usually, I should say many of them do not want periods because of course we cannot generalize. And so- Suppressing menses, regardless of what the gender identity is exactly the same, you know, exactly. If you're a GYN provider, whether midwife or women's health nurse practitioner, you know how to do that. And so that is gender affirming care and you should not hesitate to do that.
SPEAKER_01:Because that's what you've already been doing.
SPEAKER_00:It's what we already do. Like we're listening to our patients.
SPEAKER_01:And it's, is it fair to say that gender affirming care is is primary care
SPEAKER_00:yes and it can't be care that is special or different or outside the box like we can't send people to special care or like this isn't specialty care because we all have a gender identity and so We all fit in primary care, which means that we all need our care taken care of in primary care. So it does mean that we need to get comfortable with all aspects of taking care of all of our patients. When it comes to gender-forming hormone therapy, I think that's really beyond the scope of this podcast. However, I'm happy to talk about it at any time. I really want clinicians to know that all of the medications we use are medications that you have seen, probably prescribed before, definitely prescribed before a lot of times, They have been used for years and years and years. These are not new medications. Totally. We know the side effects. We know the risks. We know the benefits. We know how to counsel people on them. So we can't be afraid of giving medications that we know how to use. Estrogen, testosterone, spironolactone. We know how to use these things. So why are we afraid? And yes, it is a new indication. It is a different indication, different dose, all of that. And so we look to the guidelines for that. But we have been doing that a lot. I mean, we all the time use drugs for new and different reasons. I often think about the fact that we use Propanolol, which is a hypertensive drug for stage fright. You know, like for public speaking, that wasn't the intended effect to begin with. But we had to learn how to do that by going to a guideline, right? And the dose of that is not the same as the dose of trying to control someone's blood pressure that way. So just because you didn't learn it in school doesn't mean that you can't learn it now.
SPEAKER_03:And
SPEAKER_00:I will say what I learned in school 22 years ago, very little of that is actually relevant to current practice today. A lot has changed in medicine in two decades. It makes me feel like a dinosaur, but at the same time, if we were still doing care like we did it 20 years ago, we'd be in big trouble. So We are supposed to come out of school with the basic minimum competency and the ability to look at guidelines and look at new situations and meet the needs of our patients. And so this is just one more area of that where we
SPEAKER_01:have to do this. I'll go back to your bio to be lifelong learners and perpetual students, right?
SPEAKER_00:Yes, yes. That's key. It is key, and I think that a lot of us, we all do some continuing education every year, or we should, but we need it for certifications. A lot of us tend to do our continuing education in areas that we're comfortable with because it's fun, because we want to learn more. We want to see our friends at these conferences. I want to encourage everyone to go outside their comfort zone and learn something they don't know about, because I think that's what continuing education actually is about. It's very easy to learn something new about something you're passionate about. It's harder. It takes a lot more effort to learn something that you aren't sure about. That's where you need to go to the conference or get the CE credits for. That's part of that lifelong learning is saying like, I don't know, but I'm gonna find out now.
SPEAKER_01:Right. So going back earlier, you mentioned the importance of having a support person or a supportive family or friend. So how can we be supportive?
SPEAKER_00:Yeah. So I think, you know, in the community, I think I mentioned this with the youth. We do know that, especially with kids and teenagers, having a supportive adult, a single supportive adult, it does not have to be a parent, although it would be lovely if it's their parents, but a single supportive adult in their life is protective against suicide. And so that to me, is like we all have to be that single supportive adult. Hopefully we can all be more than one single supportive adult, but we all have to be that supportive adult. And so if you know a kid, support that kid 110%. If you don't know how to support them, figure it out. In this month of Pride, I think we kind of get excited about doing some allyship and wearing rainbow colors and getting excited and going to parades and stuff. But gay and trans people exist all year round. And so we need to carry this throughout the entire year. I think our support is more than just a statement on Instagram or Facebook. Our support needs to be in our actions, in our votes, in how we show up for people. And we need to explore our own biases. Like I said before, we all have them.
SPEAKER_03:Right.
SPEAKER_00:And you may not know what they are. And so explore them. And that's part of Lifeline learning is learning who you are and how you were formed and learning to be a better version of yourself. And I will never be done looking at myself and looking to improve myself. So, you know, in our, as healthcare providers, we need to create gender affirming, policies in our offices. We need to make sure our forms, like our intake forms look good and they have like, they're not just centered on, you know, heterosexual, cisgender people. We can't have all the decorations in, you know, in a women's health practice. Be all, you know, pink and all centered around what we think is a typical family. Cause I'll just tell you, that's not like, what is typical anymore? I don't even know. We need to work on making sure that we have gender inclusive bathrooms for people. Just because they could go in a bathroom that is labeled for something that is not their gender does not mean they feel comfortable going in a bathroom. And how like that is basic, basic human needs there. We also need to make sure that our staff around us is trained as well. And that will take some intention and some effort. And sometimes we have to lead the charge on that. As educators, because of course I am an educator, that's my first role here. This has to be part of our education. And it has to be a big part of our education. I said before, you know, like nationwide, people say they have less than, you know, four and a half hours of education in their whole training. In a study just last year put out by the American Journal of, the Journal of American Association of Nurse Practitioners, they found that 78% of nurse practitioner students 78% who were getting close to graduation, I think they were in the last term or two, had not received any LGBTQ-specific training. Now, I would like to say, I don't think that these are frontier students, because I do think we are talking about this. We can talk more, for sure. We absolutely need to talk more. But that... is horrific. We as a profession need to do better. And so we need to increase our education. We need to increase our own personal continuing education. We need to look at our own biases. We need to like really recognize that this is the population. I will tell you when you look at gender, like gender and sexuality statistics, and you look at the way that generations are moving. When you look at the current generation right now, who's in like grade school and middle school, when that generation gets to our offices, as like our primary care offices and our women's health offices, it will be close to one in four of them will be LGBTQ. That's not specialty care. That's everybody care. You can't send a quarter of the population to specialty care.
SPEAKER_01:Right,
SPEAKER_00:right. So we better be ready because they're knocking on the door right now. And those of you who work in pediatrics, you already know they're here. So If we're not ready for them, we have to get ready. And it's not like the quarter of the population just gets here in the next 10 years. It's gradually going up. And I'm sure you're seeing that in your offices. And if you aren't seeing that, then you're not asking the questions. When we know better, we do better.
SPEAKER_01:And I think this podcast is a good start if you are unaware or if you need a check on where you're standing, especially within your office or within your community or family. So we're wrapping up on time. What key takeaways or anything else that we need to add? How about, what are some good resources for LGBTQ folks and their families for healthcare and advocacy?
SPEAKER_00:So for people who identify as LGBTQ, if you're looking for care, finding someone who is well-trained and really good person for you to see can be challenging. Sometimes it is word of mouth and that is hard, especially when you're in a rural area. I will say that there are some national directories. There's a national directory through GLAMA, which is the Health Professionals for Advancing LGBTQ And we'll put their website in our notes. There's also the National Queer and Trans Therapists of Color Network. And there's the National LGBTQ Cancer Network, which is a provider directory. And OutCare is another list. It's actually a global list of LGBTQ therapists. affirming providers, and they have a lot of telehealth options on there with lots of different specialties. I will always recommend the Human Rights Campaign as a great place to get benchmark information, to know what your rights are, and to know what questions to ask when you go into new places. And and to know how to advocate for yourself. I will also say, bring someone with you because it's important to have an ally with you in these appointments to really be your voice when maybe you don't have a voice.
SPEAKER_01:It would be good for them to do this research as well and to do some grading up beforehand so they know to speak up and they can speak up.
SPEAKER_00:Exactly. For providers, we really need to make sure we know who our local community providers are. And because we can't be referring people to specialists who are not affirming, that would be a really bad thing. So we want to know who those specialists are. We want to make sure that we are referring to specialists who are affirming. We want to know what their insurance acceptance is. We want to know what their availability is. So connect with these people in your community But also, you know, we also need to do some training ourselves and maybe training our staff. And one of the great places to get that training, the LGBTQ Health Education Center, which is through the Fenway Center in Boston, they have a wonderful repository of toolkits and webinars that go through a lot of training for healthcare professionals and their staffs on care. how to be more affirming and how to provide care that's really, really good for this population.
SPEAKER_01:Well, thank you so much for joining me today.
SPEAKER_00:It's been a pleasure. I've enjoyed this conversation and I hope to come back and talk about other things.
SPEAKER_01:Yeah, this was very informative and helpful to bring awareness to gender-affirming care and the needs of our community.
SPEAKER_00:Yes. And we need to remember, it's not just June. It happens all year long. So we want to support people all year long.
SPEAKER_01:Thank you. And thank you for joining us today. We'll see you next time. This podcast is brought to you by Frontier Nursing University and the Woodford County Chamber of Commerce.
