4/14/2017

LGBT-INCLUSIVE OBSTETRICS AND NURSING SUPPORT (L.I.O.N.S.) A program for healthcare providers, staff, and students

Brought to you by:

INTRODUCTIONS

Kelli Selwyn, BHS Jennifer Evans, PsyD Abigail Fletcher, LM

l.i.o.n.s.webinar dr.jenniferevans @gmail.com @gmail.com

OUTLINE

Cultural- Healthcare Inclusion Competency

Terms101 Research Materials & Marketing

Conception & Sex & Gender SOGI Data Collection

Behaviors & Identity Post-partum Wellness Support

Pathology Nursing Resources

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LEARNING OBJECTIVES

Explain at least 3 differences between , , and sex assigned at birth

Identify 2 obstacles to providing care to LGBT patients and clients

List 3 ways to provide more inclusive care to LGBT patients and clients

CONTINUING EDUCATION CREDITS

Suwannee River Area Health Education Center is a Florida Board of Nursing, Dietetics and Nutrition, Dentistry, , Respiratory Care, CAN, Clinical Social Work, and Family Therapy and Mental Health Counseling approved provider of continuing education, CE Broker #50-1922.

Credits available: 1.0

LGBT CULTURAL-COMPETENCY

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DECIPHERING THE RAINBOW

Sexual Orientations Gender Identities Non-Binary Bisexual

For more identities, see downloadable resource sheet.

SEX AND GENDER

• Sex: Assigned at birth by • Transgender: All encompassing term for anatomy/physiology using those whose birth-assigned sex and chromosomes, hormones, sex gender are not congruent. Not all non- characteristics, and binary people consider themselves genitalia…examples: male, , transgender. intersex • Transman: Someone who was • Gender: Social organization and assigned female at birth, but who construct distinguishing the relationship identifies as male between sexes • Transwoman: Someone who was assigned male at birth, but who • : A person whose birth- identifies as female assigned sex is congruent with their gender identity • Intersex: A person with reproductive or sexual anatomy that doesn’t seem to fit • Non-Binary: A person who does not the typical definitions of female or identify with a particular gender (man male, or who develops secondary sex or woman) characteristics during puberty that are incongruent with birth-assigned sex

PERSONAL PRONOUNS

Feminine Masculine Non-binary

She He They

Her Him Them

Hers His Their

For more gender pronouns: http://forge-forward.org/2010/02/01/gender-neutral-pronouns/

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SEXUAL IDENTITY AND SEXUAL BEHAVIORS

• Some men who have sex with men (MSM) and women who have sex with women (WSW) consider themselves to be straight, or not part of the lesbian, gay, or bisexual spectrum

• It’s important to remember that making assumptions about someone’s sexual behaviors based on their sexual or gender identities may mean important health information is not being gathered.

• Being thorough in your health intake can help you avoid missing important medical information

GENDER PATHOLOGY

Gender Identity Disorder Gender Dysphoria

Gender identity disorder (GID) is The dysphoria (distress) a person used to describe a male or female experiences as a result of that feels a strong identification the sex and gender they with the opposite sex and were assigned at birth. In these cases, the assigned sex and gender experiences considerable distress do not match the person's gender because of their actual sex identity

WHAT CAN YOU DO?

• You can ask a patient/client what • You can refrain from making name and pronouns they would like assumptions about a for you to use. patient/client’s sexual identity and • You can refer to a patient/client by behaviors. their preferred name • You can use the resources and • (no matter what name is on their handouts provided whenever you chart/ ID/ insurance card) need a reminder. • You can use a patient/client’s • You can share what you learn preferred pronoun about LGBT cultural-competency • (may prefer he, she, they, or with your professional networks and another pronoun) colleagues

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LGBT HEALTHCARE RESEARCH

HEALTHY PEOPLE 2020

• “Healthy People provides science- based, 10-year national objectives for improving the health of all Americans.”

• “Research suggests that LGBT individuals face health disparities linked to societal stigma, , and denial of their civil and human rights.”

www.healthypeople.gov

HEALTHY PEOPLE 2020 OBJECTIVES

LGBT-1: LGBT-2: • Increase the number of population- • Increase the number of states, based data systems used to monitor territories, and the District of Healthy People 2020 objectives that Columbia that include questions include in their core a standardized that identify and set of questions that identify lesbian, gender identity on state level gay, bisexual, and transgender surveys or data systems populations

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NIH – SEXUAL AND GENDER MINORITY RESEARCH OFFICE

COULTER, KENST, BOWEN, SCOUT EVALUATION (2014) • NIH-Funded • 86.1% focused on sexual minority men • January 1, 1989 to December 31, 2011 • 6.8% focused on transgender health • 628 LGBT health studies • 1 study focused on the health of transmen

IOM REPORT ON LGBT HEALTH

• The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding (2011)

• Some of the barriers to accessing quality health care for LGBT adults is a lack of providers who are knowledgeable about LGBT health needs, as well as a fear of discrimination in health care settings.

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EXAMPLES OF LGBT HEALTH DISPARITIES

• Approximately 20% of transgender • Individuals with minority identities are at individuals have been denied services risk for pre-term birth and lower by a doctor or other provider due to birthweight babies their gender and this percentage increases among people of color • Minority stress, stemming from real or perceived discrimination and • Transgender individuals have a higher , can often intersect with prevalence of HIV/STIs, but are less other minority identities based on race, likely to have health insurance than ethnicity, or social class to exacerbate cisgender individuals other medical conditions

• LGBT populations have higher rates of • are less likely to get preventive tobacco, alcohol, and other drug use services for cancer than their heterosexual peers

2015 U.S. TRANSGENDER SURVEY (USTS)

Report on Health and Health Care (2015) : • 27,715 transgender individuals in the U.S. participated in the survey

• Conducted by the National Center for Transgender Equality and the National Gay and Lesbian Task Force

• The report can be viewed at: http://www.ustranssurvey.org/

KEY FINDINGS FROM 2015 USTS • 33% reported having at least one negative experience with a doctor or other health care provider related to being transgender, including having to teach the provider about transgender people in order to receive appropriate care

• 23% of respondents reported that they did not seek the health care they needed in the year prior to completing the survey due to fear of being mistreated as a transgender person, Robert Eads (1945-1999) KS1

7 Slide 21

KS1 was repeatedly refused care for his . The documentary “Southern Comfort” is about his story. Kelli Selwyn, 4/7/2017 4/14/2017

KEYS FINDINGS CONTINUED

• 24% report being asked invasive • 17% of respondents had an or unnecessary questions about insurer refuse to change their being transgender not related to name and/or gender in their the reason for the visit insurance record when requested • Respondents were three times more likely to have to travel • 13% reported that they were more than 50 miles for denied coverage for services transgender-related care than often considered to be gender- for routine care specific

LGBT HEALTHCARE DELIVERY

CONCEPTION FOR CISGENDER WOMEN

• Cisgender women (CW) may • CW may choose home or provider- identify in a number of different assisted donor , ways, including but not limited to: , , or other bisexual, lesbian, queer, gay, methods of conception. straight, and asexual. • CW may or may not have a partner • CW may choose a variety of or partner(s) they want closely options for conception, based upon involved in their prenatal care. their fertility, socioeconomic status, These partners may have any sexual orientation, relationship variety of sexual and gender status, among other factors. identities.

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WHAT CAN YOU DO?

• You can refrain from making • You can ask if any partner(s) will be assumptions about the fertility of your involved in the process and you can be patient/client. welcoming of their inclusion if there are.

• You can remember that pregnancy • You can assist them in determining does not dictate sexual orientation or when they are most fertile or what gender identity. might be needed to increase fertility.

• You can provide resources to LGBT- • You can ask your patient/client which friendly support groups for those trying methods of conception they are to conceive. interested in learning more about.

FERTILITY, CONCEPTION, AND TESTOSTERONE

• Not all transmen or non-binary individuals take hormones. Not all transmen and non- binary individuals have surgery.

• After taking cross-hormones, future fertility may be extremely difficult for some people.

• Sometimes fertility is regained after several months off of hormones.

• Some transgender and non-binary individuals may undergo procedures to harvest and store their eggs prior to starting cross-hormones.

FERTILITY, CONCEPTION, AND TESTOSTERONE

• All transmen or non-binary individuals on regular • After long time androgen therapy, ovaries are at testosterone should be amenorrhoeic within 5 increased risk of developing PCOS (Polycystic months of testosterone treatment Ovarian Syndrome) and may require fertility treatment to become pregnant • Although typically transmen and N-B individuals on testosterone are likely to be infertile, testosterone should NOT be considered a reliable • Testosterone therapy should be discontinued prior form of birth control, because break-through to and for the duration of the pregnancy ovulation can occur • If a transgender man or non-binary individual has not undergone or they may be able to regain fertility with cessation of testosterone therapy

cited from: Medical Therapy and Health Maintenance for Transgender Men: A Guide for Health care Providers by Nick Gorton MD

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PHYSICAL EFFECTS OF TESTOSTERONE TREATMENTS

Artwork from the Brown Project Health Guide - Freeing Ourselves: A Guide to Health and Self for Brown Bois http://brownboiproject.org/

WHAT CAN YOU DO?

• You can discuss preferred words for • You can ask your patient/client body parts before performing a about any use of hormone pelvic exam. therapies, including fertility • A trans/ non-binary client may treatments. prefer • “front hole” instead of • “gonads” instead of ovaries • You can ask open-ended questions • Or vague terms like to discuss reproductive options in a non-presumptive way. • “external genitals” • “internal part of the exam” • Others may be comfortable with • You can continue to educate medical terminology yourself on transgender health.

PREGNANCY AND BIRTH

• Some pregnant clients may identify as “” • Many may prefer father/dad, , carrier, gestational parent • “Mapa”- mix of mama and papa • Some parent/s may feel uncomfortable discussing their child’s gender • There is no way to know a baby’s gender identity

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WHAT CAN YOU DO?

• You can ask your patient/client what role they identify with as a parent.

• You can ask your patient/client how they would like for you to refer to their child (she/he/they/”the baby”).

• You can correct yourself and move on if you accidentally use a non- preferred term.

MENTAL HEALTH

• Some patients/clients may experience fluidity of gender identity during pregnancy

• Some may experience dysphoria/discomfort with their body changes caused by pregnancy

• Transgender patients/clients are at a higher risk of postpartum depression

MENTAL HEALTH CONTINUED

• Baseline depression and suicide rates among • Regardless of mental health history, it is transgender individuals are higher than adult possible for any parent to experience averages postpartum depression. • In one small study of 22 trans masculine • A prior history of depression or stress can individuals who gave birth, 35% experienced increase this risk. postpartum depression- • Lesbian-identified cisgender mothers may also • (compared to 15% of cisgender women) - be at an increased risk of developing stat from Postpartum Progress postpartum depression, compared to heterosexual mothers. • Data is still lacking when it comes to non- binary mental health and postpartum care. • Some research suggests that sexual minority women who are partnered with men may be at an elevated risk of postpartum depression, compared to sexual minority women partnered with women.

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WHAT CAN YOU DO?

• You can ask your patient/client how they have been feeling mentally/emotionally

• You can have a list of LGBT-friendly mental health providers available for your patients/clients experiencing mental health struggles

• You can listen and refer, as necessary

NURSING FOR TRANSMEN AND NON-BINARY INDIVIDUALS

• Chestfeeding is more possible with keyhole surgery, more difficult with mastectomy & nipple grafts • (with nipple grafts, milk may come in, but not have a way to exit the breast, potential increased mastitis postpartum) • After any top surgery, it may be difficult to get a full milk supply. • In this case, a supplemental feeder (with donor milk or formula) may be very helpful.

NURSING FOR TRANSMEN AND NON-BINARY INDIVIDUALS

• Some transmen and non-binary individuals will not be interested, or feel uncomfortable with the idea of nursing • In this case, a partner/co-parent of birthing parent may be interested in inducing lactation • Partners/co- of all genders may be able to lactate and nurse • If someone has had implants, this may decrease success

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INDUCING LACTATION

Lenore’s Method for Inducing Lactation (developed by Jack Newman, MD and Lenore Goldfarb, IBCLC)

Six months before birth of Five months before birth of Six weeks before birth of infant infant infant

•Take birth control pill •Take Domperidone •The Birth Control Pill should containing Estrogen and •Domperidone is a be discontinued 1mg of Progesterone galactagogic, not •The drop in progesterone continuously without any approved by the FDA, but mimics the hormonal breaks has undergone effects of childbirth. •These hormones mimic the randomized double-blind, Prolactin levels will then process of pregnancy, placebo-controlled increase, stimulating milk encourage the studies production. proliferation of lactation ducts, hypertrophy of alveoli and lobes in the chest

(Source: www.asklenore.org)

WHAT CAN YOU DO?

• You can ask your patient/client if they • You can admit when you don’t have all plan to nurse. the answers and you can be willing to look for them. • You can ask them if their partner(s) plan(s) to nurse, if they have a • You can use the term chestfeeding or partner/partners. nursing, if your client is uncomfortable with the term breastfeeding. You can ask which they prefer. • You can provide information on inducing or increasing lactation. • You can provide support, encouragement, and LGBT-friendly • You can ask about any surgeries that referrals, if necessary. may complicate the nursing process.

LGBT INCLUSION

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MATERIALS AND MARKETING

Signage Brochures/Fact Sheets Advertising

SEXUAL ORIENTATION AND GENDER IDENTITY (SOGI) DATA COLLECTION

Intake Forms Discussion Insurance Forms • You can ask for sex • You can ask what the • You can work with the assigned at birth patient/client’s concerns or patient/client to have their questions are regarding services covered, regardless of sexual health their gender identity • You can ask about • You can explain that you may “gender now” or gender • You can ask about the use have to bill services under their identity of all protection (condoms, sex assigned at birth, while gloves, dental dams) respecting their gender now

• You can ask about • You can ask about • You can learn more about how “partner(s)” instead of preferred terms (as to bill insurance for transgender spouse mentioned previously) and non-binary patients/clients

ADDITIONAL SUPPORT

Partners Other Family Friends • You can be aware that • You can be aware that in • You can be aware that some cultures children are some patients/clients may raised by family from more many in the LGBT have more than one than one generation community consider close romantic or sexual partner friends to be family • You can welcome other family who may be • You can acknowledge providing support to the • You can be welcoming and welcome the patient/client and supportive of these patient/client’s partner(s) relationships in regards to fostering a positive • You can keep in mind that some LGBT patients/clients atmosphere during may be estranged from pregnancy and nursing biological family.

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THANK YOU FOR YOUR TIME

15 Vocabulary References

This list of terms is not comprehensive, as language about identity and sexuality is constantly changing. This list also includes terms that are considered outdated and potentially offensive. Do not use any of these words to describe a person unless they have given you clear permission to do so.

Gender

Gender: Attitudes, feelings, and behaviors that a culture associates with someone’s sex assigned at birth. System: a social system that requires everyone to be raised as a boy or girl (dependent on what sex you are assigned at birth), which in turn forms the basis for how you are educated, what jobs you can do (or are expected to do), how you are expected to behave, what you are expected to wear, what your gender and gender presentation should be, and who you should be attracted to/love/marry, etc. /Gender Presentation: the way a person expresses their gender through gestures, movement, dress, and grooming. Gender Identity: a person’s understanding, definition, or experience of their own gender, regardless of biological sex. Sex: Determined at birth by anatomy/physiology – chromosomes, hormones, secondary sex characteristics, and genitalia (examples: male, female, intersex).

Androgynous: Describes someone who has both masculine and feminine characteristics, or neither. Similar to genderqueer. Agender: Describes a person who is without gender, or genderless. Boi, Birl, Boy-, Butch, : A person who identifies themselves as masculine, whether physically, mentally, or emotionally. Bottom Surgery (Reassignment/Gender-Affirmation Surgery): Surgery on the genitals designed to align one’s body with a person’s gender expression (phalloplasty, metoidioplasty, orchidectomy, vaginoplasty, labiaplasty, etc.). Cisgender (Cissexual): People whose gender identity and gender expression align with their assigned sex at birth. Non-transgender people. : The process by which one accepts one’s own sexuality or gender identity (“coming out” to oneself). Can also refer to the process of sharing one’s identity with others (“coming out” to friends and family). This is not a one-time event, but rather a continual, life-long process that happens every time someone shares their identity with a new person. Crossdresser: Someone who dresses in the clothing that has been socially designated for the “opposite” gender. Formerly called transvestite, which is no longer an appropriate term to use. /: Someone who cross-dresses for entertainment, typically involving an exaggerated gender presentation, acting, dancing, and lip syncing. : Feminine-identified person. Gender (Verb): To assume someone’s gender based on their appearance and gender cues. Vocabulary References

Genderfluid/ Genderqueer (genderbender, genderblender, gender outlaw, polygender, bigender etc.): Gender variations that are not the traditional, dichotomous view of men and women. Refers to people who do not identify or express themselves within this gender binary. They may or may not identify as transgender. Genderfuck: Refers to the action of playing with traditional notions of gender identity, gender roles, and gender presentation. Gender Non-conforming/ Gender-Variant: Those who do not conform to societal gender norms with their birth-assigned gender. Gender –Affirming Surgery/ Gender Confirmation Surgery (Sexual Reassignment Surgery/SRS): Medical surgeries used to modify one’s body to be more congruent with one’s gender identity. Gender Cues: What people use to attempt to tell the gender/sex of another person (hairstyle, gait, clothing, body shape, body hair). These cues vary by culture. Gender Neutral Pronoun: A pronoun that is not associated with a particular grammatical or social gender, and does not imply male or female. “They” may be used as a gender neutral pronoun to describe a single individual. See chart of pronouns. Gender Oppression (Genderism or Cissexism): The societal, institutional, and individual beliefs and practices that privilege cisgender (gender-typical people) and subordinate transgender or gender variant people. : An out of date and offensive term for an intersex person. Hormone Replacement Therapy (HRT): Any form of hormone therapy wherein the patient, in the course of medical treatment, receives hormones either to supplement a lack of naturally occurring hormone, or to suppress or substitute the secretion of specific hormones. Identity Sphere: The idea that gender identities and expressions do not fit on a linear scale, but rather on a sphere that allows room for all expression without weighting any one expression as better than another. In the Closet (, on the Down Low/DL): Refers to an LGBQT individual who does not disclose their sex, sexuality, sexual orientation, or gender identity to friends, family, coworkers, or society. There are varying degrees of being in the closet. For example, someone can be out to their family, but in the closet at work. Intersex: A person born with reproductive or sexual anatomy that does not fit typical definitions of female or male. Intersex anatomy does not always show up at birth, and may not be discovered until they reach the age of puberty, discover infertility as an adult, or die and are autopsied. : Disclosing an LGBQT+ person’s identity to others. This is discouraged unless the individual has given clear permission to do this. Packing: Wearing a phallus device for any purposes including: validating or confirming one’s masculine gender identity, seduction, and/or sexual readiness. Passing: Describes a person’s ability to be accepted and seen by others as the gender they see themselves as.

Vocabulary References

Queer: An umbrella term encompassing a matrix of sexual preferences, orientations, and habits of people who are not exclusively heterosexual and monogamous. This word historically has been used as a slur and still is today, but many members of the marginalized group have reclaimed it and view it as an empowering identity. Many people to whom this term may apply still consider ‘queer’ to be offensive and derogatory. Questioning: Describes an individual who is questioning whether their sexual orientation or gender identity is what they once believed it to be. Stealth: Refers to a transgender person choosing not to publicly disclose their gender history. Stem: A person whose gender expression falls between stud and femme. Top surgery: Surgery on the chest designed to align one’s body with a person’s preferred gender expression. Transactivism: The political and social movement to create equality for gender-variant persons. Transitioning: The process of moving toward expression of one’s gender identity. This may include (but does not necessarily have to include) undergoing physical changes such as hormones or surgeries. This is more holistic than SRS, and usually includes physical, psychological, and emotional changes. Transfeminine: Used as a catchall term for people assigned male at birth who identify as feminine. Transgender (or trans): An umbrella term used to describe gender-variant people who have gender identities, expressions, or behaviors not traditionally associated with their gender assigned at birth. This term allows a person to state a gender-variant identity without disclosing hormonal or surgical status or intentions. Transgender can also mea anyone who transcends the conventional definitions of man and woman. Transgender replaces several words that are now outdated and inappropriate, including , transvestite, and tranny. It is important to note that “transgender” is an adjective (“transgender person”), not a noun (“a transgender”). Transition: This term is primarily used to refer to the process a gender variant person undergoes when changing their bodily appearance either to be more congruent with the gender/sex they feel themselves to be and/or to be in harmony with their preferred gender expression. Transman: Someone who was assigned female at birth, but who identifies as male. Also referred to as ‘transguy(s)’. Transmasculine: Used as a catch-all term for people assigned female at birth who identify as masculine of center. : The irrational fear of those who are gender variant and/or the inability to deal with gender ambiguity. Transsexual: A person who identifies psychologically as a gender/sex other than the one to which they were assigned at birth. often wish to transform their bodies hormonally and surgically to match their inner sense of gender/sex. Transwoman: Someone who was assigned male at birth, but who identifies as female. Two-Sprit, Third Sex, : Native persons who have attributes of both genders, have distinct gender and social roles in their tribes, and are often involved with rituals. Their Vocabulary References

dress is usually mixture of male and female articles and they are seen as a separate or third gender. The term ‘two-spirit’ is usually considered specific to the Zuni tribe. Similar identity labels vary by tribe and include ‘one-spirit’ and ‘wintke’. Sexuality LGBTQ+: A common abbreviation for lesbian, gay, bisexual, transgender, queer, and intersex culture. : Who one is attracted to romantically or affectionately. Sexual Orientation: The type of sexual, romantic, emotional/spiritual attraction one feels for others, often labeled based on the gender relationship between the person and the people they are attracted to. Sexuality: A person’s exploration of sexual acts, sexual orientation, sexual pleasure, and desire.

Asexual: Person who is not sexually attracted to anyone or does not have a sexual orientation. Bicurious: A curiosity about having sexual relations with a same gender/sex person. : The fear of, discrimination against, or hatred of bisexuals, which is often times related to the current binary standard. Biphobia can be seen within the LGBTQI community, as well as in general society. Bisexual: A person emotionally, physically, and/or sexually attracted to males/men and /women. This attraction does not have to be equally split between genders and there may be a preference for one gender over others. Butch: A person who identifies themselves as masculine, whether it be physically, mentally or emotionally. ‘Butch’ is sometimes used as a derogatory term for lesbians, but it can also be claimed as an affirmative identity label. Demisexual: A person who does not experience sexual attraction unless they form a strong emotional connection with someone. It's more commonly seen in but by no means confined to romantic relationships. The term demisexual comes from the orientation being "halfway between" sexual and asexual Gay: A term used in some settings to represent males who are attracted to males in a romantic, erotic and/or emotional sense. Not all men who engage in “homosexual behavior” identify as gay. Can also describe the LGBQT community as a whole, or as an individual identity label for anyone who does not identify as heterosexual. It is important to note that “gay” is an adjective (“gay person”), not a noun (“the gays”). Gray-Sexuals: and sexuality are not black and white; some people identify in the gray (spelled "grey" in some countries) area between them. People who identify as gray-A can include, but are not limited to those who: do not normally experience sexual attraction, but do experience it sometimes. : The assumption, in individuals or in institutions, that everyone is heterosexual, and that is superior to other sexual identities. : against individuals and groups who display nonheterosexual behaviors or identities, combined with the majority power to impose such prejudice. Usually used to the advantage of the group in power. Any attitude, action, or practice – backed by institutional power – that subordinates people because of their sexual orientation. Heterosexual (Straight): A person sexually attracted to persons of the opposite sex. Or a person who has sexual relations with the opposite sex. Colloquially known as "straight." Vocabulary References

Homophobia: The irrational fear or hatred of homosexuals, , or any behavior or belief that does not conform to rigid sex role stereotypes. It is this fear that enforces sexism as well as heterosexism. Homosexual: A somewhat outdated term referring to a person who is primarily emotionally, physically, and/or sexually attracted to members of the same sex. Lesbian: Term used to describe female-identified people attracted romantically, erotically, and/or emotionally to other female identified people. Metrosexual: First used in 1994 by British journalist Mark Simpson, who coined the term to refer to an urban, heterosexual male with a strong aesthetic sense, who spends a great deal of time and money on his appearance and lifestyle. This term can be perceived as derogatory because it reinforces stereotypes that all are fashion-conscious and materialistic. MSM: Abbreviation for men who have sex with men. Pansexual: A person who is sexually attracted to all or many gender expressions. (non-monogamy, open relationship, polyfidelity, subrelationships): Refers to having honest, usually non-possessive, relationships with multiple partners and can include: open relationships, polyfidelity (which involves multiple romantic relationships with sexual restricted to those), and subrelationships (which denote distinguishing between a ‘primary" relationship or relationships and various "secondary" relationships). Same-Gender Loving: A term sometimes used by members of the African-American / Black community to express an alternative sexual orientation without relying on terms and symbols of European descent. The term emerged in the early 1990's with the intention of offering Black women who love women and black men who love men a voice, a way of identifying and being that resonated with the uniqueness of Black culture in life. (Sometimes abbreviated as ‘SGL’.)

References: http://www.isna.org/faq/what_is_intersex http://www.lgbt.ucla.edu/documents/LGBTTerminology.pdf https://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf https://gsanetwork.org/files/resources/gender_orientationterms.pdf Additional References

Bogart, L. M., Revenson, T. A., Whitfield, K. E., & France, C. R. (2014). Introduction to the Special Section on Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Disparities: Where We Are and Where We're Going. Annals of Behavioral Medicine, 1-4. Bowleg, L. (2012). The Problem With the Phrase Women and Minorities: Intersectionality- an Important Theoretical Framework for Public Health. American Journal of Public Health, 1267-1273. Buchmueller, T., & Carpenter, C. (2010). Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000– 2007. American Journal of Public Health, 489-495. Burke, S. E., Dovidio, J. F., Przedworski, J. M., Hardeman, R. R., Perry, S. P., Phelan, S. M., . . . Ryn, M. v. (2015). Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People Among Heterosexual First-Year Medical Students? A Report From the Medical Student CHANGE Study. Academic Medicine, 645-651. Coulter, R. W., Kenst, K. S., Bowen, D. J., & Scout. (2014). Research Funded by the National Institutes of Health on the Health of Lesbian, Gay, Bisexual, and Transgender Populations. American Journal of Public Health, 105-112. de la Cretaz, B. (2015, November 30). The Troubling Erasure of Trans Parents Who Breastfeed. Retrieved from The Huffington Post: http://www.huffingtonpost.com/the-establishment/the-troubling-erasure-of- _b_8673664.html Diley , J., Simmons, K., Boysun, M., Pizacani, B., & Stark, M. (2010). Demonstrating the importance and feasibility of including sexual orientation in public health surveys: health disparities in the Pacific Northwest. American Journal of Public Health, 460- 467. Drabble, L., Keatley, J., & Marcelle, G. (2003). Progress and Opportunities in Lesbian, Gay, Bisexual, and Transgender Health Communications. Clinical Research and Regulatory Affairs, 205-227. Eliason, M. J., Dibble, S. L., DeJoseph, J., & Chinn, P. (2009). LGBTQ Cultures: What Health Care Professionals Need to Know About Sexual and Gender Diversity. Philadelphia: Jennifer E. Brogan, MA. Forge. (2010, February 1). Gender Neutral Pronouns. Retrieved from Forge: http://forge- forward.org/2010/02/01/gender-neutral-pronouns/ Gibson, B., & Catlin, A. J. (2011). Care of the Child with the Desire To Change Gender--Part I. Urologic Nursing, 222-229. Additional References

Goldberg, A., & Ross, L. E. (2016). Postpartum Mental Health among Visible and Invisible Sexual Minority Women. Retrieved from Abbie Goldberg, Ph.D: http://wordpress.clarku.edu/agoldberg/files/2013/04/Newsletter-10-Spring- 2016-PPD_SITES.pdf Greenberg, J. S., Bruess, C. E., & Oswalt, S. B. (2014). Exploring the Dimensions of Human Sexuality. Burlington, MA: Jones & Bartlett Learning. LaFleur, E. (2016, January 20). Infant and Toddler Health. Retrieved from Mayo Clinic: http://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/expert- answers/induced-lactation/faq-20058403 Lee, G., Griffin, G., & Melvin, C. (2009). Tobacco use among sexual minorities in the USA: 1987 to May 2007: A systematic review. Tobacco Control, 275-282. LGBT Health Equity. (2015, May). STUDY: LGBT Americans Spend $7.9 Billion On Cigarettes. Retrieved from Think Progress: http://thinkprogress.org/lgbt/2014/01/17/3178291/study-lgbt-americans-spend- 79-billion-cigarettes/ Magrini, D., & Brooks, J. (2016, July 19). Interview with D. Magrini & Jacquetta Brooks, Whitman Walker. (A. Zucker, Interviewer) Makadon, H. J., Mayer, K. H., Potter, J., & Goldhammer, H. (2015). Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. Philadelphia: American College of Physicians. Meyer, I. H. (2013). Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychology of Sexual Orientation and Diversity, 3-26. Meyer, I. H., & Frost, D. M. (2013). Minority Stress and the Health of Sexual Minorities. In C. J. Patterson, & A. R. D'Augelli, Handbook of Psychology and Sexual Orientation (pp. 252-266). New York: Oxford University Press. Office of Disease Prevention and Health Promotion. (2016, July 1). Lesbian, Gay, Bisexual, and Transgender Health. Retrieved from Healthy People 2020: https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay- bisexual-and-transgender-health Smedley, B. D. (2012). The Lived Experience of Race and Its Health Consequences. American Journal of Public Health, 933-935.

Smith, E. A., Offen, N., & Malone, R. E. (2005). What makes an ad a cigarette ad? Commercial tobacco imagery in the lesbian, gay, and bisexual press. Journal of Epidemiology and Community Health, 1086-1091. Additional References

West, D. (2016). FAQ About Transgender Breastfeeding. Retrieved from Diana West: http://dianawest.com/trans-breastfeeding-faq/ Witten, T. M. (2008). Transgender Bodies, Identities, and Healthcare: Effects of Perceived and Actual Violence and Abuse. Research in the Sociology of Health Care, 225-249.

Resources for Providers

OB/GYN & Birthing: • Fenway Health - http://fenwayhealth.org/care/medical/obstetrics/ • University of California (Berkeley) - https://uhs.berkeley.edu/medical/primary- care/womens-health/well-woman-care-and-gynecological-screening Nursing: • La Leche League International - http://www.llli.org/ • Milk Junkies - http://www.milkjunkies.net/ Other Trainings: • Suwannee River Area Health Education Center - http://srahec.org/professional- education-solutions/ Professional Organizations: • American Medical Association - https://www.ama-assn.org/delivering- care/creating-lgbtq-friendly-practice • Gay and Lesbian Medical Association - http://www.glma.org/ • World Professional Association for Transgender Health (WPATH) - http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_as sociation_webpage=4655 • The American Congress of Obstetricians and Gynecologists - http://www.acog.org/Resources-And-Publications/Committee- Opinions/Committee-on-Health-Care-for-Underserved-Women/Health-Care-for- Transgender-Individuals Other Resources: • Out for Health Inclusion Audit - http://www.outforhealth.org/files/all/out_for_health_lgbt_inclusion_audit.pdf • - http://www.hrc.org/resources/professional- organizations-on-lgbt- • University of California (San Francisco) - http://www.transhealth.ucsf.edu/ • Improving the Health Care of Lesbian, Gay, Bisexual and Transgender People: Understanding and Eliminating Health Disparities - http://www.lgbthealtheducation.org/wp-content/uploads/12- 054_LGBTHealtharticle_v3_07-09-12.pdf • HealthyPeople.gov - https://www.healthypeople.gov/2020/topics- objectives/topic/lesbian-gay-bisexual-and-transgender-health • 2015 U.S. Transgender Survey - http://www.ustranssurvey.org/report