Culture of Health: LGBTQAI+ Health Care Transcript

Dr. Nwando Anyaoku
Hello everyone and welcome to Culture of Health, a show that zeroes in on healthcare matters that disproportionately affect some of our communities, and we highlight ways to break down systemic barriers to quality care. On this podcast, we talk with health care professionals and hear stories that inspire and inform listeners to bravely navigate healthcare with dignity, care, and humanity in order to achieve equity.

I'm your host, Doctor Wando, and your group Chief HealthEquity and Clinical Innovation Officer at Providence and here with me today, Doctor Kevin Wang, Medical director of our Providence clinical network, LGBTQIA plus program, and Bentley Fox, senior program manager for LGBTQIA+ health care initiatives at Providence.

I invited them on the show today to help us understand healthcare issues for people who identify as LGBTQIA+ and why the work they're doing is so very important.

Hello and welcome Dr. Wang and Bentley. It is so great to speak with you today. Can you tell us a little bit about yourself and the work you're doing at Providence? Perhaps I'll start with you Dr. Wang

Dr. Kevin Wang
Well, first of all, Dr. Anyaoku, we thank you so much for inviting us. It's an honor and a thrill to be here and to get to talk with you today as Dr. Anyaoku who mentioned, I'm Kevin Wang, and I use he/him pronouns and first and foremost, I am a family medicine physician. So, there is my background.
Training is what really drives me to provide care for our patients and communities, but as a self-identified cisgender gay male and as a child of Chinese immigrants, I felt it was really important for me to have it as part of my clinical practice and my role as educator.

I initially started out as faculty for Family Medicine residency training, lo and behold, years later I get the opportunity to serve as the medical director for Swedish health services LGBTQA+ and then ultimately become the medical director for Providence's Clinical Network for the medical director position of LGBTQAI+ Healthcare. So my role mainly has always been in education in providing wonderful services to our LGBTQAI+ communities. And now to be able to do it throughout the system level, It's just really amazing and I'm looking forward to seeing what we can accomplish together.

Dr. Nwando Anyaoku
Awesome, thank you. Bentley?

Bentley Fox
Hi my name is Bentley Fox. My pronouns are they/them. I'm the senior program manager for the LGBTQ plus program, and I'm also a HealthEquity Fellow at Providence. I've been with Providence for several years, working on a variety of different initiatives, but most recently in the last few years we've really been focusing on caring for our transgender and gender diverse patients and creating a welcoming environment for all of our LGBTQIA plus patients across all of these states that we serve in our enterprise.
My background is in policy systems and environmental change, and I've done that work for about 15 years.

Dr. Nwando Anyaoku
So glad to have you both on this program today. You know as we do the work of advancing HealthEquity and Providence, we people sometimes think we're only talking about one subset of population. But we're really talking about all the ways in different in which different populations are discriminated against and have a system that doesn't really cater uniquely to them, so perhaps we can start by talking about what are some of the issues that we have to think about in care of LGBTQIA plus healthcare.

Dr. Kevin Wang
Maybe I'll take a start, Bentley and then you can fill in the gaps. So at least from the clinical perspective, you know, I went to Med school from 2000 to 2004 and back at the time there really wasn't much of A discussion on LGBT to A+ community.

And so from the perspective of access to care, there continues to be a shortage of clinicians who have experience providing care for our LGBTQA+ communities. This results often in the provision of care which is stereotyped. So for example, when I saw not care when I was in college and Med school, every time I saw a clinician, it was always focused on do you use substances? Do you want to get screened for any sexually transmitted infections or HIV? Or what sort of mental health condition?

And so it often ends up becoming more stereotypical medicine than it is. The provision of care for an entire person knowing they are a part of a particular community. And this can't be more emphasized than for our our transgender gender diverse communities, our patients who identify as intersex, or those board variations and sexual develop.

Meant and so it's it's often been something which has been overlooked, and the stereotyped medicine ends up becoming quite harmful and becomes to the point where patients don't feel comfortable seeking out health care and may end up waiting too late and may end up having their diagnosis of cancer, which is in much later stages. So you know, to be honest, you know, I know it sounds pretty foundational when it comes to access.

And to ensure our clinicians have the toolbox and the skill set to be able to provide care with the unique healthcare needs of our patients in a way which is inviting and welcoming and not stigmatizing.

Dr. Nwando Anyaoku
Fantastic, thank you. Bentley?

Bentley Fox
I'll just add to that perspective that Doctor Wang shared even beyond the clinical care, the environment and the policies that are in place in our healthcare settings can contribute to that discrimination or that stigmatization of our patients.

As a transgender queer person myself, you know, having experienced that firsthand and hearing about that experience from others within our community at Providence, we've really tried to take an approach to consider how, you know, we we create clinical guidances, but also how we create a welcoming environment through things like expectations for asking people's pronouns or using the name that they present with at a clinical visit, and that extends beyond even just the clinical care.

But you know within our teams how we care for each other. So and the policies that are in place really expecting that kind of care be consist regardless of why a patient is coming in to see us and regardless of what they might be presenting for, but treating people with dignity across the spectrum of their experience here at Providence.

Dr. Nwando Anyaoku
I just love how you both mapped out how stigma and discrimination affect health access experience and ultimately outcomes for LGBTQIA plus people, right? Because if we don't think about these things, we will don't pay attention to those details. But exactly as you described from the environment, from walking into the place. And the way we say hello to the way we actually ask questions; political questions make all the difference in whether someone is able or willing to receive care in our facilities.

So you know how do we? Is this what we mean when we talk about inclusive healthcare, right? Is this you know the the the issues that you've raised here addressing them is that can you talk a little bit about what you mean by inclusive healthcare Dr. Wang

Dr. Kevin Wang
So in terms of inclusive healthcare and it goes back to a lot of what Bentley just mentioned as well, it's being informed of the historical context to how LGBTQIA+ communities have faced healthcare disparities in the setting where we provide healthcare, right. So not just the clinics, hospitals, and emergency rooms. You know, the the, the provision of medical services for LGBTQ+ communities is relatively straightforward.

Of course, knowing we have to tailor medicine for each of our patients, you know there's not always necessarily A one-size fits all, but the inclusive part that really does focus on understanding the historical context. We provide training at our at our healthcare systems and with our residency.

Programs often focuses on how healthcare disparities arose, at least in the United States. There are many other examples globally, which I know is a is probably more than we can go into on this podcast, but knowing how the health care system has set up barriers, how societal pressures have also resulted in people having difficulty accessing healthcare or housing employment insurance status.

So having that historical context often will set the foundation for providing an environment which is informed of our LGBTQAI+ through plus communities in the history. Once you go once you are there, I think it really sets people up for success in providing care which is well informed and inclusive.

Bentley Fox
Yeah. And I would just add that foundation of understanding the context is what allows us to really deliberately and intentionally provide informed and sensitive care for our patients, make those accommodations, improve the way that we are providing care for a whole person coming to us within the clinic. Their experiences with us in the clinic and then their experiences when they leave the clinic and how they might be living their lives in an authentic way outside of that clinic. So really thinking about our patients, unique perspectives and their experience as a whole person.

Dr. Nwando Anyaoku
And as we talk about education and information, in this day in which we live, online misinformation is a very real challenge. Can we talk about how the increasing amount of misinformation found online and in other areas could affect care for the LGBTQIA+ community?

Bentley Fox
Can I ask just clarifying, you know, with online, do you mean misinformation about clinical things that might be available for patients or do you mean you know, I know there's a lot of representation in media about LGBTQAI+ people that might be incorrect that could be influencing how caregivers see patients, the Internet is full of lots of great information and a lot of misinformation.

So I'm just curious if we can dive a little bit deeper into what exactly we want to discuss around that topic.

Dr. Nwando Anyaoku
Sure. I think all of it makes a difference, right? So to that's the way earlier point that we end up practicing stereotypical healthcare instead of person centered care. How do we think about that when we think about what, what information people are getting in other places?

Bentley Fox
Yeah. I think that's a great question. You know, and like Dr Wang had said, there are a lot of ways that the Internet or information online can perpetuate some of those stereotypes.

And you know lead people down a path where that information isn't informed by patient voice or by evidence base. And so I think when we look at education here at Providence, we really focus on that evidence base and we also focused really strongly on patient experience and patient voice. So using our patient and Family Advisory Council experience to center the patient.

And really, use that authentic experience to help us drive and ground how we're providing care. So that information is checked with community and of course is based in evidence and best practice and based on what our literature really points us towards to care well for patients. And I'll let Dr. Wang speak a little bit more about that specifically.

Dr. Kevin Wang
Yeah, you know, Bentley, what you just said in terms of centering our nation and our communities really can't be emphasized enough. I'm going to answer this in, in, in a few different pillars, but one of which is not to underestimate the knowledge experience of our LGBTQAI+ communities, particularly when it comes to the provision of gender affirming healthcare.

Our transgender gender diverse community, they had to seek out healthcare and provide themselves the healthcare they needed. And this is where a lot of our evidence-based recommendations stem from is the experience of our transgender gender diverse community. Same thing with our communities for patients who identify as intersex or those born with variations in sexual development?

Unfortunately, as you mentioned, there is a lot of disinformation out there, whether it's found in on websites, whether it's also the continued, whether it's bias or stigmatization, which has been handed down from generations of healthcare clinicians and professionals.

Which you know I am a product of the people who taught me and needing to use the skills I learned in terms of analyzing and really, delving deep into the information which is out there to see if it's well vetted. If its evidence based, if it's community informed.

Unfortunately, this disinformation does impact not just our patients, also our patients, families especially for our adolescents where family members or legal guardians may have concerns about the provision of certain aspects of LGBTQAI+ medicine.

We have caregivers and employees and other healthcare professionals who also have similar concerns, which may be influenced by where they grew up, may be influenced by their own experience and history. And what I have often found to be useful is to and I don't know if I'm allowed to mention famous persons or TV shows, or to name them. But one line which often echoes in my mind is to go into these situations with curiosity and not necessarily judgment. We all want to provide really great care for our patients and our communities. It's just sometimes in these in these particular sites.

Finding common ground and sharing the experiences and the evidence and the provision of of LGBTQ+ healthcare can often set a foundation for us to move forward and to ensure LGBTQ+ patients get the care they need they deserve, which is often life saving.

So the approach to this information oftentimes has to be multidisciplinary, multidimensional, but first and foremost as that we mentioned have to be patient centered and well informed by our communities.

Dr. Nwando Anyaoku
I love it. Focus on the patient, that individual encounter. I'd like to put a particular spotlight on mental health concerns and how that is manifested or challenged. You know, the the challenge in delivering mental health care to LGBTQA plus community.

How are we as a mental health professionals, you know separate from it, because we we think about well, we're dealing with all of healthcare, right, not just physical, but also particularly the mental health space and mental healthcare for everybody as a whole is a challenge and a good day, but what particular issues do you face in making sure we have adequate mental health care for LGBTQAI+ person community?

Dr. Kevin Wang
Let me I'll take a go at this first but would love absolutely always love your your perspective as well. From your, from your history and your experiences and advocacy and such mental health. And I think this, you know, there is a corollary to the provision of other LGBTQ+ health services. I think the difficulty with it goes back to having healthcare professionals which are LGBTQAI+.

As Bentley mentioned, there are lots of barriers for our communities to access healthcare services, non discrimination when it comes to employment, even coverage of certain healthcare services for states where Medicaid wasn't expanded. There is there are specific exclusions for the provision.

For example, gender affirming health care. And so when you when you stack each of these on top of each other, it goes back to what do people know about the history of our LGBTQ+ communities? How does it feel to have a whole profession have in the DSM manual to stay, you know, being gay is pathologic, being transgender, gender diverse pathologic.

And it wasn't until 2013, where the American Psychiatric Association and their DSM ended up stating Trance isn't the problem, it's the societal pressures and the discrimination against our transgender gender diverse communities, which results in mental health harm on our patients who are transgender.
So I feel it really goes back to being informed about the ways in which LGBT plus communities have been harmed, not just again by healthcare system, but In a minute in an administrative component from, you know, executive order 10450 during the during the Communist era where people were fired for being LGBTQ+ identified or they had thought someone was LGBT plus identified. And they thought, oh, they may share government secrets if they were out there or something.

And so I think it just goes back to being informed of what happened and how we will play a role in the mental health of our LGBTQ+ communities.

Bentley Fox
I agree, Kevin, and I think that there is a I think this is the case for mental health, but also for physical health, because these things are so connected. Again, caring for someone and as a whole person as they are, there's a degree of psychological safety.

I think is important regardless of whether you are seeing a patient for mental healthcare or physical health care. We know that our patients, particularly transgender patients, avoid or postpone medical care because they feel disrespect or because they feel discrimination due to those things that Dr. Wang brought up. The lack of understanding of the experiences, you know, systemically that our patients have experienced prior to coming to receive physical or mental healthcare.

And then there are patients who feel that they have been actively refused care by a provider because of their gender identity. And so I think again understanding the history and the background, but then also how we as providers are showing up in the space and what we are doing to bridge that gap and to be aware of how we are interacting with our patients even if that intention is not there to be discriminatory or to you know refuse care but our unconscious biases.

Can really impact how our patients see us and receive care and that historical trauma that has come with our patients when they come to see us can be triggered by those unconscious biases. So I think that's really critical when we're thinking about providing effective mental health care or physical healthcare if we aren't showing up and being considerate of how those things are impacting our patients and what their history is, they may not come to us in the first place.

Dr. Nwando Anyaoku
So powerful and I I can only imagine that when we think about the intersectionality of race, gender identity, and socioeconomic status, these concerns even get more amplified. But can I ask you both to share a little bit for us what policies and interventions we're putting in place at Providence to address health disparities and improve the care of our LGBTQIA+ communities.

Bentley Fox
Kevin, do you want me to start from a system?

Dr. Kevin Wang
Yes, please.

Bentley Fox
So Providence has been working really diligently on a lot of the education components and the education that we have created focuses on creating that welcoming environment for our patients, particularly transgender and gender diverse patients because of the history of discrimination and stigma that that clientele has experienced in the past.

So we have several system wide trainings available at Providence that we have through our platforms, we are working on a lot of different options for requirements around those trainings. We're seeing more and more that state are requiring certain aspects of cultural competency care for LGBTQI+ patients, which is fantastic.

So that gives us the opportunity to implement those policies to bring that training to our caregivers and have them meet those requirements that they would have to meet externally anyways with those incredible trainings that we've put together.

We also have been working on different pilot sites throughout the system to practice the implementation of care pathway policies. So how a patient navigates through our care particularly in our primary care settings to create care pathway models so we can provide the best care for our patients regardless of where they might be within our system, Southern California or Washington or Montana.

Looking at the way our patients navigate, importing our caregivers and allowing them to have the tools and resources at their fingertips to provide those patients with here, because I think what we've run into a lot is people really want caregivers really want to provide competent care.

They just don't have the resources always available or the education available to feel confident providing care in those spaces. So working a lot on practices and policies that contribute to increasing the education that's available and increasing the tools and the practices and policies available for caregivers to know that they are providing that best care for our patients.

Dr. Kevin Wang
I really can't emphasize enough the work Bentley is doing. As we mentioned earlier, the provision of the medical services is is pretty straightforward. But if you don't have an understanding and a foundation to to provide the care in a way which is welcoming and providing a safe space for patients, it'll pretty much be useless, will end up causing more harm, having a place where patients.

And really be their authentic themselves being in the clinic, you end up being very vulnerable for sharing information with your healthcare clinician. The work Bentley is doing really can't be emphasized enough with the work we do from the medical perspective really is that on top of the foundation Bentley is doing from the medical director position, we're kind of taking it in a few different directions, one of which is we have healthcare clinicians and their training who are really passionate about this work.

And one of the things we're going to be doing is how can we roll out this foundational training throughout all the residency programs in the Providence network. You know, these are going to be our future healthcare clinicians. These are going to be our future leaders in this space and we want to show our communities. Providence is a place where patients who are LGBTQ+ just can seek out compassionate, welcoming, well informed, and evidence-based care.

So can we do it from a graduate medical education perspective? Of course. We also have to involve our current practicing clinicians and what can we do to provide training to provide that foundational approach to the provision of, say, gender affirming healthcare. This is the work we're doing.

We started out at Swedish and one of the pilot sites and now the one of the roles I get to play is what can I do to provide the foundational training across the entire Providence system, this is something I'm super excited about and how can we utilize all of our networks to provide support for each other in places where people may be interested and are wanting to get started versus other places which are more client focused, so the to set the stage for clinician training is something which is going to be quite key in rolling out LGBTQAI+ health care services.

I would also just like to quickly note as well from a policy perspective we're exploring how we can also ensure our patients facing and our caregiver facing policies using patient first and inclusive language to really demonstrate we are not just saying what we're doing, but we are living by in our mission, vision and values and all the policies in place to support care for our patients and to provide our LGBTQ+ caregivers a safe working environment as well.

Dr. Nwando Anyaoku
I love it. Thank you.

Bentley Fox
Could I add just one more thing to that? Providence has invested really significantly in Health Equity in the last few years and all of this work that Dr. Wang and I have been doing, you know it's been taking place for the last several years is a direct result of that investment in Providence's Health Equity dollars.
That Health Equity emphasis to live that mission and values.

As Dr. Wang mentioned is really what has put into play the possibility for us to dive deeper in carrying wall for these LGBTQ+ patients. So I just wanna highlight how important that has been that Providence has really taken this picture of Health Equity as a whole to consider what's what are the barriers and we have brought that into this particular space. So those things are very connected.

Dr. Nwando Anyaoku
Absolutely. I thank you for that spotlight, Bentley. And you know, one of the things I was try to do in this conversation is is to ask what can provide us, what should we all try to do, what what are next steps, what are steps we can do in our practice in our communities.

Bentley in one of the educational videos you created, Holly, a mother of a transgender child who used to work as a mental health therapist, talks about why something that seems as mundane as using correct pronouns is so important in healthcare. So maybe we start from there. It is that that maybe something that we can all begin to do. Why is using correct pronoun so important?

Bentley Fox
Sure, I love that video. And that really comes back to something that we talked about. You know, that content was directly spoken from one of our parents of a patient. So it really centered on the patient experience. And I think this is true for a lot of our patients and a lot of individuals in general. We want to be seen when we show up to get care. We want to know that our caregiver is going to provide us with care considers our name that uses the pronouns that we have said that we use and that helps us feel seen.

It treats us with dignity, treats our patients with dignity. It's a very simple and very small change to make in our practices. It's very accessible to ask someone during their check-in what's your name or how would you like to be called? Would you like your pronouns documented in the chart? Or if we we'd made our introductions even just today on this podcast, said our names and our pronouns right away, it can.
It can happen really quickly. And what that does is it opens up, it creates that breath, that space to say that you are welcome LGBTQ+ people are welcome. We have set the precedence that speaking your honest truth about who you are is accepted and is encouraged here. And we will respect that. And I think that's a huge thing for our patients to come in and just feel that right away that they have the opportunity to be their whole selves.

When they come to see us, something as small and as simple as introducing yourself with your pronouns or asking for those pronouns can make an enormous difference.

Dr. Nwando Anyaoku
Awesome. Anything else we should be doing as providers?

Dr. Kevin Wang
I would say much in the same way as we talked about earlier, which is being curious and wanting to learn more, especially for our patients who are trans and gender diverse. You know there's no reason for us to require patients to prove their LGBTQAI+ identity and where they are really to engage with them and walk along beside them on their healthcare journey, which may involve somebody who's LGBT plus identified.
But just like anybody else, it's providing them whole person care which is informed by their their history and their identity, and so forth. So as a clinician, as a healthcare professional whether you're somebody who works at the front desk, someone who works in environmental services, whether you work in foodservice.

It's being curious, wanting to learn more and to just engage with our LGBTQAI+ communities to ask questions, to engage with any community based organization, just to be inquisitive. And to also feel comfortable being challenged from previously held beliefs and to also just recognize we are, we want to ensure our LGBTQI plus communities are recognized and have a place where they can feel comfortable and be authentic especially at a time where they may be feeling ill, may not be feeling well are just seeking help.

Dr. Nwando Anyaoku
Fantastic. Well, we I can't believe how fast the time has gone, but before we wrap up, is there something we haven't talked about that you would like to mention? Bentley?

Bentley Fox
I think something that always sticks with me from one of our Patient Family Advisory Council members who's also an employee here at Providence, and I I feel this very deeply, and I agree with what this person has said I want folks to know that there are people at Providence who want to care so deeply for the LGBTQI plus community.

We are here caring for that community is really central and really important in our mission. It's critical within our mission to care well for all people with that dignity and respect. And LGBTQAI+ patients are a centerpiece to that. So I'm so honored to get to speak about it on this podcast because I'm I want folks to know that quality care is here and we're here to provide that support regardless of where people come into our care.

Dr. Nwando Anyaoku
Awesome. Thank you.

Dr. Kevin Wang
And I think the only thing I want to say is stay tuned. I'm just really excited and thrilled to see where we're going to be able to take our LGBTQIA+ program at Providence to be able to have such a large region and to be able to provide services for patients who may not have previously felt comfortable receiving health care at Clinton Clinic settings we're just getting started.

I can't wait to see where things go in 6 to 12 months. In one year, two years, three years, and would love to come back on this podcast and to demonstrate the commitment we have to our our LGBTQ+ community and to see how far we go, knowing we still have quite a bit of ways to go as well.
And just really grateful to be here today to share our goals and and and what we're hoping to accomplish, but really can't wait to see where we're going to what we're going to be able to report back in a few months in a few years.

Dr. Nwando Anyaoku
I have worked with you and Bentley and seeing how far you've already taken this, I cannot wait either. So consider this a standing invitation to come back and share more with us as this work continues to spread and progress.

Thank you for your leadership across Providence making us an institution that leads through to our mission and our values to provide care for all, especially the poor and vulnerable.

Thank you everyone. Thank you for joining us today on culture of help. We look forward to continuing the important conversations on HealthEquity issues with more experts from Providence and future.

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And Please remember the information provided during this program is for educational purposes only. You should always consult your healthcare providers if you have any questions regarding your medical condition or treatment.

Thank you so much for listening.