• Making Us Visible •

Promoting Access to Breast Health and Breast Cancer Services for Lesbian and Bisexual Women A guide to delivering a workshop for health care and social service providers to increase their knowledge, skills and sensitivity in working with lesbian and bisexual women in the area of breast health and breast cancer

By Cheryl Dobinson, Project Coordinator

About the Making Us Visible project:

“Making Us Visible: Promoting Access to Breast Health and Breast Cancer Services for Lesbian and Bisexual Women” was a two-year innovative health promotion project launched in September 2004 at Sherbourne Health Centre in Toronto. The project goals were to increase the capacity of lesbian and bisexual women to respond to the risk of breast cancer and to increase the capacity of the breast cancer community to respond to the needs of lesbian and bisexual women.

Making Us Visible addressed lesbian and bisexual women’s breast health through two volunteer programs designed to increase community involvement and understanding. One program focused on developing culturally appropriate educational materials and the other on creating a series of volunteer-led breast health events for lesbian and bisexual women.

The project also worked to increase accessibility of breast cancer services through offering a support group for lesbian and bisexual women with breast cancer as well as developing a training program to increase knowledge and sensitivity for peer support volunteers when working with lesbian and bisexual women who have had a breast cancer diagnosis. This training was further developed into a workshop for a broad range of health care and social service providers and piloted throughout Ontario.

Ontario Breast Cancer Community Research Initiative

Making Us Visible was a partnership between Sherbourne Health Centre, Ontario Breast Cancer Community Research Initiative, Gilda’s Club Greater Toronto, Willow Breast Cancer Support Canada, and the Metropolitan Community Church of Toronto. Published by Sherbourne Health Centre

© 2007 Canadian Breast Cancer Foundation, Ontario Chapter

First Printing 2007.

Portions of this manual may be copied for educational purposes. Commercial use is not permitted.

Copies available from: Sherbourne Health Centre 333 Sherbourne Street Toronto, ON, M5A 2S5 Ph: (416) 324-4180 www.sherbourne.on.ca/programs/programs-m.html TABLE OF CONTENTS

Section 1 – The Making Us Visible Workshop Curriculum ...... 7

• Introduction ...... 8

• Advance Preparation ...... 9

• The Curriculum ...... 11

• Tips for Using the Curriculum Based on Your Audience ...... 18

• Issues to Expect and Ideas for Handling Them...... 19

Section 2 - Appendices ...... 21

• Appendix A - Promotional Poster ...... 22

• Appendix B - Definitions ...... 23

• Appendix C - Terminology Suggestions...... 24

• Appendix D - Ways To Open The Door: Asking The Right Questions ...... 25

• Appendix E - Case Studies ...... 26

• Appendix F - Lesbian and Bisexual Women’s Breast Health Resource List ...... 28

• Appendix G - Additional Resources for Service Providers ...... 29

• Appendix H - Evaluation Form ...... 30

SECTION 1: THE MAKING US VISIBLE WORKSHOP CURRICULUM

• Introduction

• Advance Preparation

• The Curriculum

• Tips for Using the Curriculum Based on Your Audience

• Issues to Expect and Ideas for Handling Them

7 workshop module and deliver the initial pilot training at bisexual women in the area of breast health and breast cancer. A message from Anna Travers The idea for the Making Us Visible project came about because a group - Manager, of us had beenLGBTTwith involved Program, the Lesbians Sherbourneand Breast Cancer Project,Health Centre a community-based participatoryOntario study conductedin 2003. inWe had learned about queer women’s experiences with cancer, the health caresystem, their sense of themselves as women and dykes and so much more and we wanted to putthat all learning into a practical application and share it with others. We applied to the Canadian Breast Cancer Foundation, Ontario Chapter for a Community HealthPromotion Grant that would last two years. It had two areas of focus: 1) to develop lesbianresources and for bisexual women and for service providers that addressed breast health population,in this specific and 2) to develop and pilot support services for lesbian and bisexual womenhad whoa breast have cancer diagnosis. This manual emerged from the work that was done to developtraining a program to increase knowledge and sensitivity of service providers lesbianwhen working and with Our original intent was to develop and pilot a workshop with Peer Support Volunteers at WillowBreast Cancer Support Canada and then to finalize the workshop based on the evaluationsfeedback and from those participants. This plan changed when staff at Canadian BreastFoundation Cancer encouraged us to “take the show on the road” and deliver the workshop in additionalsettings across Ontario in order to provide training for more service providers anddevelop to further and revise the pilot version of the workshop. So in summer 2006 we began promotingthe workshop province-wide and immediately the calls and emails started coming in.Coordinator, The Project Cheryl Dobinson, delivered the workshop to six different groups of servicein Hamilton, providers Windsor, Sudbury, Sault Ste Marie, Kitchener and Toronto. We are very grateful to thepeople and organizations in these communities who invited us in and who made these workshopspossible through coordinating the local logistics of promotion, venue, registration and more. I want to thank all the people who helped with the Making Us Visible project – from theCommittee, Steering the Resource Development Group and the Peer Education Group – you did yourselvesand your community proud! For this piece of the project, a special thank you is due to DanielleVandezande of Willow Breast Cancer Support Canada, who sat on the Steering Committee workedand who closely with Cheryl to develop the Willow. This manual is a reflection of a large piece of the work of the Making Us Visible projectwhich we are of very proud. I hope it will be useful to those working in cancer services,social health services care, and beyond. Introduction This curriculum was developed in the summer and fall of 2006 by myself (Cheryl Dobinson,Coordinator Project for Making Us Visible: Promoting Access to Breast Health and Breast Cancer Servicesfor Lesbian and Bisexual Women) and Danielle Vandezande of Willow Breast Cancer SupportCanada. We developed the original version as a pilot workshop for Peer Support Volunteersat Willow Breast Cancer Support Canada and delivered it in August 2006. The Peer VolunteersSupport were a wonderful and welcoming group and a lot was learned from their constructivefeedback on how the workshop could be improved. During the months of September and October 2006 I had the opportunity to offer thea varietyworkshop ofin settings across Ontario, and to revise and fine-tune it as I learneddelivered from the each workshop session. in Icommunity health centres, cancer centres, university healthto broader centres groups and of interested health care providers. I traveled to Hamilton, Windsor, Sudbury,Sault Ste Marie, and Kitchener, as well as offered the workshop in other settings in Toronto. The final workshop as outlined in this manual is based on consolidating everythinglearned that fromwas delivering the workshop in all these settings.

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca to expect. to people many how know you so advance in you with register participants have to want may You cancer. breast and health breast of areas the in women with work providers service where community your in places other any and centres, cancer centres, health community • • • • • • • • • • available: have you funding of level what on depending for, budget to want you may items of list a is Here $25. under be should cost total the refreshments, provide not do venue, and free a access to able are you If budget. low very a on workshop this do to possible is It Considerations Financial women centres, screening breast organizations, service cancer local to mail and/or email by notice a sending include could methods Promotion materials. promotional distribute and create to need will you attend, to providers service interested any inviting and broadly more workshop the offering are you If poster.) sample a promotional for A Appendix (see organization. the at distribution internal for workshop the of description brief a provide to need likely will you organization, particular a of staff the as volunteers and/or such providers, service of group existing an to workshop the offering are you If tools. promotional different need will you broadly, providers more or service of group existing an to workshop this offering are you whether on Depending Promotion venues. local other or appropriate universities, or colleges organizations, (LGBT) transgender and bisexual gay, lesbian, libraries, centres, health community centres, community as such area your in options cost workshop. conduct to the you for space provide likely most will organization that case which in organization, specific a of support the with or for workshop the delivering be may you instances, some In • Venue a Finding • • • • • • including: workshop, this in from participating benefit and in interested be might providers service social and health of range wide A Audiences Potential preparation Advance Refreshments (optional) Refreshments whiteboard or chalkboard no is there if minimum) pieces large (two paper Flipchart cards Index Tape Markers Pens inexpensive) relatively are and well work labels address (stick-on Nametags handouts Photocopying Venue professions health in Students patients cancer breast to service direct provide who others and chemotherapists workers, social surgeons, oncologists, Radiologists, staff program screening Breast broader) is work whose those and cancer breast or health breast in specifically work who those (both professionals health other and nurses Doctors, teams support cancer breast of Members facilitators group support cancer Breast volunteers and staff support peer cancer Breast If you do not have a host organization providing space, you can try free or low low or free try can you space, providing organization host a have not do you If ’ s health organizations, LGBT health service organizations, organizations, service health LGBT organizations, health s 9

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca 20 minutes – while suggested wording , 15 minutes –

10 minutes – italics.

10 minutes s Breast Health Resource List (Appendix F) s health – ’ ’ 10 minutes – 5 minutes – 5 minutes – Provide the handout but do not spend time working on the – 5 minutes – 5 minutes – (no break) no break) (

for what the trainer would actually say to participants is printed in normal font. scenarios in the workshop (no time allotted) As above, but add in the case scenarios (30 minutes) Additional Resources for Service Providers (Appendix G) Evaluation Form (Appendix H) In the curriculum that follows, any items which are not used in the 90 minute or two hour versions are printed in Definitions (Appendix B) Terminology Suggestions (Appendix C) Busting Out: Breast Health for Lesbian and Bisexual Women brochure Ways Open To The Door: Asking The Right Questions (Appendix D) Case Studies (Appendix E) Lesbian and Bisexual Women Name tags, markers, index cards, pens, flipchart or chalkboard Agenda - written on a flipchart or chalkboard Guidelines - written on a flipchart or chalkboard Copies of handouts for all participants The maximum time indicated after each section heading below is for the full section as it would be delivered in a three hour training. Notes and instructions to the trainer are printed in bold 4. Lesbian and bisexual women 3. Definitions and assumptions 2 Hour Workshop 6. Ways to open the door - Asking the right questions 2. Cultural competence 8. Tips for inclusive practice - 9.5 minutes Referrals and resources • 11. Evaluations • You may also want to provide materials on local groups and services, • such as cancer supportgroups for lesbian and bisexual women or LGBT health centres if these exist in your area. 5. - Brief brainstorm Lesbian and bisexual women and breast health/ breast cancer 7. Case scenarios Using the Curriculum • Time The full workshop described in this manual takes about three hours, including a 15 minutebreak. It is also possible to adapt it for 90 minute or two hour sessions if needed: 90 Minute Workshop 1. Introduction and welcome Handouts List • • • • - www.sherbourne.on.ca/programs/programs-m.html • • Items Needed at the Workshop • • • • 10. Questions • •

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca Agenda agenda. posted the Review yourself. introduce and workshop the to everyone Welcome provided. if refreshments to themselves help to them invite and themselves, for nametag a make to them ask arrive, people As 7. Honour our time by keeping the schedule schedule the keeping by time our Honour 7. questions stupid no are There risks take 6. to willing be and questions Ask break) (no comfort own their 5. for responsible is person Each 4. Guidelines guidelines. these follow to agree can they if group the ask and guidelines posted the Review • • • objectives: Learning • • are: workshop interactive this of goals The Chapter. Ontario Foundation, Cancer Breast Canadian the from funding with 2004-2006 from Toronto in Centre Health Sherbourne the Barriers: Providing Culturally Competent Care Care Competent Culturally Providing Barriers: the Removing from permission with adapted is 1 guidelines of set This Use 3. disagree to agree can We shared information personal of 2. confidentiality the Respect 1. 1. Curriculum The Health and Breast Cancer Services for Lesbian and Bisexual Women Bisexual and Lesbian for Services Cancer Breast and Health women bisexual and Lesbian 4. assumptions and Definitions 3. competence Cultural 2. welcome and Introduction 1. 1 Evaluations 11. project the by developed was Questions workshop This 10. resources and Referrals 9. practice inclusive for Tips 8. scenarios Case questions right 7.the Asking - door the open to Ways cancer health/breast breast 6. and women bisexual and Lesbian 5. Health Organization and the United States Department of Health and Human Services. Human and Health of Department States United the and Organization Health Women with Partner Who Women and Lesbians to

Introduction and welcome welcome and Introduction

1

presentation in participant's own practice. own participant's in presentation this from gained knowledge practical apply to able be will Participants rates. screening and factors risk specific of prevalence including health, breast women's bisexual and lesbian about learn will Participants experience. cancer breast the and health breast to specifically and health, to relevant is orientation sexual which in ways the about learn will Participants women bisexual and lesbian for services cancer breast and health breast of accessibility the increase to cancer breast and health breast of area the in women bisexual and lesbian with working when providers service for sensitivity and knowledge increase to “ I ” statements rather than than rather statements (10-20 minutes) (10-20 , 1997-2004. Copyright The Mautner Project, the National Lesbian Lesbian National the Project, Mautner The Copyright , 1997-2004. ’ health “ You “ Making Us Visible: Promoting Access to Breast Breast to Access Promoting Visible: Us Making ” statements ” which was based at at based was which 11

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca 3

values s ’ , 1997-2004. s behaviour or beliefs to provide them with ’ we all come with different relationships to – ” are used interchangeably to describe a person receiving care or client “ (5-10 minutes)

” and 2

2 patient “ respectful, sensitive and well-informed care lesbian and bisexual women. Some of us may have a little knowledge and some may have a lot. care to all women. clients, even if they have not revealed themselves as such. influence the attitudes, behaviours and life experience of every patient or client so it includes things like race, ethnicity, religion, age, ability, and gender services interact effectively with people who are different from them organization to serve people of different cultures in respectful and appropriateways provide culturally competent care to all women you serve Cultural competence

the Barriers: Providing Culturally Competent Care to Lesbians and Women Who Partner with Women Copyright The Mautner Project, the National Lesbian Health Organization and the United States Departmentand of Health Human Services. In this manual the words service from a health care or social service provider. • You deliver quality • care to women. You are interested in exploring ways to increase your competence to provide better • Hand out index cards and explain that these are for questionsIf you or commentsare already and will providing be care to women, youcollected have lesbianlater on. and bisexual women Ask if anyone knows what cultural competence means. If there are some nods or yeses, ask if anyone would like to share what they understand it to mean. Cultural competence is: • being responsive to and respectful of cultural factors and other differences that 2 The assumptions for2 training and the cultural competence section are adapted with permission from Removing 3 • relevant to all types of cultural and social difference, not just sexual orientation, • There is knowledge in the room 2. • a flexible • and inclusive approach to every client reducing or eliminating barriers = improving accessibility and acceptability of • individually: a set of behaviours, attitudes and knowledge that enable a person to • institutionally: a set of behaviours, attitudes and knowledge that enable an Cultural competence training is about developing skills, not about changing • people a journey, not a destination Participant introductions If the participants do not already know each other, you may want to go around the room and have people say their name and where they work or volunteer. With any group of participants you can also ask people to share either: 1. Assumptions for training What brought you to the training? or 2. Why you think this training is important for your work? or beliefs • regardless of your values or beliefs about lesbian and bisexual women, you can • you do not have to agree with someone

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca . People i. intersex, two-spirit, identity sexual transsexual, vs. behaviour transgender, Sexual e. - bisexual, gay, lesbian, LGBTTTIQQ here: captured been not have which others and possibly letters, following the of all or any include may These acronyms. different use may locations ii. This handout provides more detail about respectful language use and the reasons reasons the and use language respectful about detail more provides handout This ii. i. ii. use language Respectful b. i. Definitions a. f. We should not make assumptions about: assumptions make not should We f. the Barriers: Providing Culturally Competent Care to Lesbians Lesbians to Care Competent Culturally Providing Barriers: the Removing from be permission 4 with may adapted is list factors This risk health to relationship their what v. be may concern of issues their what iv. sexually does anyone what relationships iii. important has patient a whom with possible) way every in diverse are (they are women bisexual and ii. lesbian who i. satisfaction provider Greater referrals mouth • of word More 3. satisfaction • client Greater rapport and • communication Better services to access • Increased • competence: cultural of Benefits In the definitions section we included the acronym acronym the included we section definitions the In acronyms of Diversity d. she uses. language the use then and life her and herself about talks she how of terms in lead her follow to is woman individual each with use language to may regard women with to consider to thing attracted key are The who women that ways different many are There i. identity in Diversity c. ii. Sexuality has many aspects aspects many has Sexuality ii. Organization and the United States Department of Health and Human Services. Services. Human and Health of Department States United the and Organization Women with Partner Who Women and

Definitions and assumptions and Definitions use the terms terms the use will I workshop this in that notice will You others. over preferred are terms some C) (Appendix handout Suggestions Terminology the Provide out. them reading by definitions the review Briefly B) (Appendix handout Definitions the Provide others ways, or they may not use a sexual identity label at all. at label identity sexual a use not may they or ways, others in or dyke, woman, gay queer, bisexual, bi, lesbian, as identify may They identify. options. respectful and have had sexual relationships with men. men. with relationships sexual had have may lesbian-identified are who Women partner. female a with involved sexually be only but bisexual as identify may woman A example: For expect. we ways identity are some of the parts parts the of some are identity ’ s sexual behaviour and sexual identity may not always match up in the the in up match always not may identity sexual and behaviour sexual s queer and questioning and queer “ sexual orientation sexual , 1997-2004. Copyright The Mautner Project, the National Lesbian Health Health Lesbian National the Project, Mautner The Copyright , 1997-2004.

(10-15 minutes) (10-15 – sexual behaviour, sexual attraction and sexual sexual and attraction sexual behaviour, sexual – 4 and any of these parts may change over time. over change may parts these of any and ” and and “ “ LGBT. sexual identity, sexual ” Different organizations and and organizations Different ” as both are appropriate appropriate are both as 13

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca s ’ (20 minutes)

(keep the brainstorm s own, more masculine- ’ (10-15 minutes) s breast health as well as one s health ’ ’ including different ways of bringing children into families – estrangement, lack of support, conflict around health care – this may be lesbian/bisexual specific or may be missing for some – can include issues around coming out, being closeted, isolation, identity – their breasts that are not addressed in other materials or educational efforts.For example: Lesbian and bisexual women in relationships with women may feel concern for a partner lesbian and bisexual women. Targeted resources are one way to reach lesbian and bisexual women. partners (ie. couples counseling) or partner abuse Some lesbian and bisexual women have had negative experiences in health care settings such as poor treatment, refusal of service, negative verbal or nonverbalreactions, misinformation, hostility, exclusion of partner, and rough treatment. Some lesbian and bisexual women may cope with having had negative experiences or with the fear of having such experiences by not disclosing their sexual orientation, avoiding seeking care, or not talking about social support networks,partners, sexual practices, specific support or information needs, or anyitems other related to sexual orientation. identified or butch women may have ambivalent feelings about having breasts and may be reluctant to pay attention to or care for their breasts. ii. Lesbian and bisexual women may have some unique issues and feelings about s talk about breast health and breast cancer specifically in relation to lesbian and ’ Lesbian and bisexual women Lesbian and bisexual women and breast health/breast cancer such as reproductive technologies, adoption, children from past relationships women delaying seeking care. decision making between family and partner

development processes, self esteem and self care

8. Community of support8. 5. Issues with family5. of origin bisexual women. What are the issues? a. Breast health education Very few materials on breast health focus on, or are even inclusive of, lesbian and bisexualwomen i. Even if most of the breast health information is the same, it needs to get to health? Ask people to brainstorm, and then go over the list below (which is not meant to be exhaustive) to cover any topics which did not come up in the brainstorm. brief in the 90 minute and 2 hour versions) 1. Sexual practices and safer sex practices 2. Relationships a. Who is important to include b.in their care 3. Experiences of anti-gay violence, Who can harassment visit them or indiscrimination the hospital c. Availability of appropriate support servicesParenting for options4. dealing and with needs issues between a. Consequences for physical and mental/emotional health 6. Legal issues with families – both family of origin and the familiesMental theyhealth create 7. • 9. Homophobia and9. biphobia can lead to lesbian and bisexual women avoiding medical care or How homophobia and biphobia affect health care: •

5. Now let 4. What are the ways that sexual orientation could be relevant for lesbian or bisexual women

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca 5 Valanis BG, Bowen DJ, Bassford T, Whitlock E, Charney P, Carter RA. Sexual orientation and health: comparisions in in comparisions health: and orientation Sexual RA. P, Carter Charney E, T, Whitlock 5 Bassford DJ, Bowen BG, Valanis case the not is indicates research recent more (which factors risk of rates higher times 2-3 had lesbians if Even true. not is This cancer. breast of incidence the times 2-3 have would lesbians that meaning as media the in up this taken and was factors, risk certain of rates the times 2-3 have may lesbians that suggested of research body limited very a of reviews Preliminary women. heterosexual and lesbians factors between risk cancer breast some of rates in differences the of review research 1990s early an of misinterpretations media on based is This population. general the in women 9 in 1 to compared cancer breast get will lesbians 3 in 1 that stated weight mistakenly body have high writers Some cancer. for risk breast higher iii. dramatically at are consumption 30 particular age alcohol in high after lesbians child that first to misconception birth popular a is giving or There children ii. biological no having i. are: factors risk These women. heterosexual than factors risk cancer breast some of rates higher have women bisexual and Lesbian factors Risk b. iii. i. Why do you think this might be? might this think you do Why i. mammography. and exams breast having clinical including women, heterosexual as often as health their around behaviours and preventative screening practice not do group a as women bisexual and lesbian that shown have 45) Studies age after women with only (sex lesbians adult 7.0%of ever) women with only 4. (sex lesbians lifetime of 5.8% Screening d. 3. women bisexual of 8.4% 2. women heterosexual of 4.9% 1. orientation: sexual of definitions behavioural 2. Less contact with the medical system around routine gynecological/ routine around system medical the with contact Less 2. avoiding women bisexual and lesbian to lead can biphobia and Homophobia 1. Simply being lesbian or bisexual does does bisexual or lesbian being Simply cancer. breast of rates into directly translate not do factors risk of Rates higher. times 2-3 be would cancer breast lesbian and bisexual women bisexual and lesbian in cancer breast of incidence higher a showed 50-79 aged women US 93311 of study 2002 A rate. higher slightly a of evidence some but this, on research little very is There women? bisexual and lesbian among cancer breast of rates actual about know we do What rates cancer Breast c. cancer. breast for factor risk a of not and is in itself orientation sexual her and factors, risk other and these to relationship particular own her have will woman bisexual or lesbian individual each However, women. heterosexual than factors risk cancer breast some of rates higher have do women bisexual and lesbian group, the Women the ’ s Health Initiative sample. Arch Fam Med. 2000;9:843-853. Med. Fam Arch sample. Initiative s Health as an example of a targeted resource. targeted a of example an as Provide – the differences are much smaller), this still would not mean that rates of of rates that mean not would still this smaller), much are differences the reproductive health care than heterosexual women heterosexual than care health reproductive serious. quite are they until problems breast for help seek not may they means also This care. seeking delaying or care medical the Busting Out: Breast Health for Lesbian and Bisexual Women brochure brochure Women Bisexual and Lesbian for Health Breast Out: Busting the 5 . The following rates of breast cancer were reported, based on on based reported, were cancer breast of rates following The . not put a woman at higher risk for breast cancer. As a a As cancer. breast for risk higher at woman a put

(ask participants if they have any ideas) any have they if participants (ask 15

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca

s lives that ’ s ’ s husband. ’ t have to worry ’ (15 minutes)

(http://dawn.thot.net/lbcp/) ” in same sex relationships ” ve been talking about so far in terms of lesbian and ’ s identity and lifestyle ’ factor, where female partners and other lesbian and bisexual ” there are different views on whether this matters more or less s unique issues and experiences ’ – body sameness “ could be me “ for lesbian and bisexual women compared to heterosexual women, as well as ideas around breast prostheses or reconstruction related to gender identity and presentation communities appearance during treatment may be right for some lesbian and bisexual women but may not fit at all for others bisexual woman Short hair may be more accepted in lesbian and bisexual women Coming Out About Lesbians and Cancer. “ Feelings of already limited options for dating or relationships being reduced further Heterosexism, homophobia and/or biphobia in medical or support settings. This can include reactions such as disbelief, disgust, poor treatment, discomfort or assumptions of heterosexuality, such as being asked about one Decisions around coming out or not coming out in medical or support settings. This can include weighing whether disclosing lesbian or bisexual identity will make things better or worse. Because being lesbian or bisexual is an important part of some women about coming out/not coming out, trying to figure out if a provider is LGBT- positive, or creating a moment to disclose should be validated and supported Research indicates that lesbian and bisexual women want to have clear opportunities to disclose their sexual orientation so they don Disruption of bisexual women Because of all the things we women may identify very strongly with the possibility of getting breast cancer. This can have both positive effects (understanding and support) and negativeeffects (distancing and fear). Lack of appropriate support for female partners and children and lack of recognition for same-sex partners in medical or support settings Fallout from treatment: Lack of family support due to estrangement based on sexual orientation Support could come from other places, such as LGBT communities or chosen family The 15 minutes

– Ways Ways to open the door: Asking the right questions

• • • • - Programs that offer make-up tips to help women feel better about their - Loss of physical strength may be particularly challenging to a lesbian or • Specific issues and experiences for lesbian and bisexual women with breast cancerinclude: may • - Breast loss 6. BREAK e. Specific issues following a breast cancer diagnosis This section draws in large part from themes that emerged in the Lesbians and BreastProject Cancer report Remind people to write questions on their index cards, which will be addressed at the end of the workshop. Why is it important to open the door to talking about sexual orientation with your clientspatients? or • • • - • • •

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca • • • • person doesn a that person say to want may You everyone. of ask you that and above) reasons the on (based asking • • • tips: Language choose. they if things these about talk to them 8. 7. • Allow 10-15 minutes for the small group discussions and 15-20 minutes for the groups to report back. group. larger the with questions the to answers their share and scenario case their out read group each have scenarios, their discussing finished have groups After group. larger the to back reporting for discussion their about notes some make to groups Ask answer. to groups for questions 2-3 with comes scenario case Each discuss. and review to scenario case a with group each provide and groups small into participants Divide workshop. minute 90 the in included not is section This • • • • • • If you ask a direct question about sexual orientation you need to be able to explain why you why explain to able be to need you orientation sexual about question direct a ask you If participants. to it read and D) (Appendix handout Questions Right the Asking Door: the Open to Ways the Provide • • • orientation sexual about talking to door the opening of ways of range a are There • •

Case scenarios Case Tips for inclusive practice inclusive for Tips Ask about sexual identity and/or sexual activity, depending on what on depending activity, sexual and/or identity sexual about Ask resources for referrals for resources local other and groups support cancer specific bisexual and lesbian of aware Be orientation sexual mentions which policy nondiscrimination visible a Post Use the word word the Use partnered or married single, is client or patient if Ask terms neutral gender Use Lesbian and bisexual women have said that they don they that said have women bisexual and Lesbian type of sex you sex of type Educate yourself and your organization about lesbian and bisexual women bisexual and lesbian about organization your and yourself Educate way safe a in orientation sexual their disclose to women allow which questions and forms intake inclusive Use sticker) downloadable www.positivespace.utoronto.ca (see stickers space positive LGBT or communities) LGBT represent (which symbols rainbow materials, and magazines room waiting posters, including friendly, LGBT being of signs visible Show issues health other and cancer breast health/ breast on women bisexual and lesbian for materials resource health Provide say activity, sexual about talking or about asking If a safe/LGBT positive atmosphere. positive safe/LGBT a creating to questions direct from options, of range a with familiar be to helpful is It setting and relationship person, every for fits that way right one no is There person whole the for possible care best the provide to you Toenable time the all up it bring to intercourse Don partner ’ t have to answer the question, but that you want to provide the opportunity for for opportunity the provide to want you that but question, the answer to have t ’ t assume that partner = same sex partner sex same = partner that assume t

(0-30 minutes) (0-30 ” or or “ partner ’ “ re talking about, make that clear. that make about, talking re have sex. have

(5-20 minutes) minutes) (5-20 ” and, if appropriate, ask the gender or name of the person the of name or gender the ask appropriate, if and, ” Don ’ t assume sex = penis in vagina. If this is the only only the is this If vagina. in penis = sex assume t “ sexual activity sexual ’ t want to be the ones to have have to ones the be to want t ” for a a for ’ not not s relevant s “ sexual sexual ’ s issues s ’ re re ’ s s 17

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca

s health as well. ’ (10 minutes) s Breast Health Resource List (Appendix F) ’ . (5 minutes)

Lesbian and Bisexual Women (5 minutes) – from index cards and other –

Spend less time on items related to risk and screening and more time on the experiences of lesbian and bisexual women who have had a cancer diagnosis. Use case scenarios which relate specifically to peer support work. If the people you are presenting to do not work specifically in breast health/breast cancer, you may sometimes need to bring the focus back to breast health/breast cancer and remind participants of how the things you are talking about relate specifically to breast health and breast cancer. It may be helpful to frame the workshop as both general cultural competency for working with lesbian and bisexual women as well as a workshop on breast health and breast cancer issues for lesbian and bisexual women, as much of what is covered is relevant for other areas of lesbian and bisexual women services? bisexual specific information, while participants will bring their focus on breasthealth and breast cancer Questions Evaluations

Referrals and resources

Hand out evaluation form and ask participants to fill it in and return to you. Thank everyone for attending. Ask people to hand in their index cards with any questions they have written on them. Address these questions, if any, and take questions verbally as well. When using the training for peer support volunteers working with women who have had a breast cancer diagnosis: • When using the training for people working in health care generally: • • • Tips for using the curriculum based on your audience 11. 10. 9. Small group activity: Divide participants into small groups and ask them to answer the following questions: • What are two or more changes you are willing to make in how you provide • What might help • you make these changes? Allow 5 minutes for providing the list of tips, then 15 minutes for the small group discussions. What might hinder • this? What support and resources can you draw on in overcoming obstacles? When using the training for people working in breast health and breast cancer specifically: • In this setting, it is likely that you will primarily be bringing the lesbian and Provide handouts and Additional Resources for Providers (Appendix G) and share any specific local information on support groups or other relevant services.

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca d. There is little research on trans people trans on research little is There d. Breast identity. gender not orientation, sexual about is workshop particular This c. a. First of all, labels are words which help us understand or explain things. Most of of Most things. explain or understand us help which words are labels all, of First a. responses: Possible “ 2. i. Definitions: b. available, transsexual and transgender for definitions have to helpful be can It a. responses: Possible women. and men trans for cancer rates breast and screening factors, risk about ask may They people. trans or women trans and not women, bisexual and lesbian covers only workshop the why ask may They from transsexual. different is transgender how or means transgender what about questions ask may People people trans about Questions 1. Them Handling for Ideas and Expect to Issues (Clinical guidelines, with a section on breast cancer) breast on section a with guidelines, (Clinical www.vch.ca/transhealth/resources/library/tcpdocs/guidelines-primcare.pdf ii. www.vch.ca/transhealth/resources/library/tcpdocs/consumer/medical- i. specific this about more know to want who people for resources excellent Some e. ii. ii. b. For some people, sexual orientation labels are important to who they are. Whether Whether are. they who to important are labels orientation sexual people, some For b. Why do we need labels? Aren labels? need we do Why communities. these to specific is and women bisexual and lesbian with project research community a of out came workshop This care. health in transphobia of experiences and hormones surgery, to due different quite be can people trans for issues health us use many labels in our everyday lives lives everyday our in labels many use us handout. definitions the in included not are they though even area are: area rates. cancer breast or screening factors, risk of rates sexual orientation. orientation. sexual cancer survivors, tennis players, dancers and so on… so and dancers players, tennis survivors, breast cancer nurses, doctors, partners, wives, or husbands fathers, or mothers men, or important to acknowledge and respect people respect and acknowledge to important is It them. value and use people many not, or labels orientation sexual like you woman and man, but who do not identify as transsexual. as identify not do who but man, and woman of genders traditional the fit not does expression gender and/or identity gender whose people to refer to way specific more a in used is transgender man. and woman of genders traditional the of outside identify may people ways other and cross-dressers genderqueer, king, drag queen, drag transsexual, as such identities of range wide a includes it word, the of use this In birth. at assigned were they gender the from differs expression gender and/or identity gender whose individuals of range a to Transgender: Transsexual: (Consumer information on trans people and cancer) and people trans on information (Consumer cancer.pdf characteristics such as breasts/chests and genitals. genitals. and breasts/chests as such characteristics sexual of function and appearance physical the change to surgery and/or removal, hair therapy, hormone through identity gender their match better to bodies their change) to want (or change people transsexual all, not although Many, birth. at them to assigned one the than other gender the of member a as

A person who self identifies and desires to live and be accepted accepted be and live to desires and identifies self who person A This word is sometimes used as an umbrella term to refer refer to term umbrella an as used sometimes is word This ’ t we moving away from labels anyway? labels from away moving we t ’ s health, so we don we so health, s – we may refer to ourselves as women women as ourselves to refer may we ’ s use of language around their their around language of use s At other times, the word word the times, other At ’ t know about their their about know t ” 19

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca - Coming Out About Lesbians and “ t some specific issues for lesbian and ’ ) women indicated that they wanted to be ” s sexual orientation. ’ t mean there aren ’ (http://dawn.thot.net/lbcp/ ” asked about their sexual orientation. flexible and inclusive approach to every client. If I treat everyone the same, but that means that I ask every woman about her husband, this is not culturally competent care. asked uncomfortable. But generally this is more about the comfort level of the person asking and if they feel discomfort about talking about sexual orientation aboutor knowing someone get the care and support they need. Cancer, bisexual women that are unique. breast cancer, such as: ence can have impact on her experience of breast cancer. ” Breast cancer is devastating to any woman, not just to lesbian and bisexual We We treat everyone the same “ women. b. In the Lesbians and Breast Cancer Project report Possible responses: a. Yes, but that doesn 6. 5. “ Possible responses: a. Refer back to the cultural competence framework and the importance of having a b. Discuss how providing good care does not mean treating everyone the same. 4. Discomfort with asking direct questions about sexual orientation Possible responses: a. People may frame this as not wanting to be intrusive or to make the person being 3. Belief that focusing on sexual orientation is divisive of women Possible responses: a. There are many differences between women. Ignoring them does not help women b. Refer back to the cultural competence framework. b. Discuss the ways in which different women may have specific issues related to - young women and fertility issues - parentsThere and are concerns many c. ways about in which the variousimpact of canceraspects on their of childrena woman’s identity and experi - single women and concerns about dating/future relationships women living in -rural or remote areas who have to travel for treatment

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca SECTION 2: APPENDICES Appendix A - Promotional Poster

Appendix B - Definitions

Appendix C - Terminology Suggestions

Appendix D - Ways To Open The Door: Asking The Right Questions

Appendix E - Case Studies

Appendix F - Lesbian and Bisexual Women’s Breast Health Resource List

Appendix G - Additional Resources for Service Providers

Appendix H - Evaluation Form

21 ������������������ �������������������������� ���������������������������������������� ��������������������������������������� �������������������������������������������������������� �������������������������������������������������� ������������������ �������������������������������� ��������������������������������������������������������� ������������������������������������������������������������ �������������������������������������������� ��� ��������������������������������������������������������������� appropriate resources and referrals why sexual orientation is relevant to health, breast health and the breast cancer experience why sexual orientation is relevant orientation how to talk to women about sexual are of particular relevance to lesbian and bisexual risk factors for breast cancer which women and bisexual women rates of screening among lesbian the impact of homophobia on lesbian and bisexual women’s health and health care � � � � � � Appendix A: Promotional Poster ���������� ��������������������������������������������������������������� � ��������������������������������������������������������������� ����� ������ ������������ Through information sharing and interactive exercises, the workshop will cover: Through information sharing and interactive

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca 2. Can refer to disclosure of one of disclosure to refer Can 2. Coming out: Coming Queer Biphobia: Heterosexism: Homophobia: LGBT: Bisexual: Homosexual: Gay: Lesbian: Definitions B: Appendix

term A : Someone who is sexually and romantically attracted to men and women. and men to attracted romantically and sexually is who Someone

previously used against them, stripping the term of its power to insult. to power its of term the stripping them, against used previously was that term a reclaim to way positive a is queer term umbrella the using many However, them. to application its reject and usage, this resist communities these of members Some (LGBT). transgender and bisexual gay, lesbian, are who people for term umbrella inclusive an is usage contemporary in and people, some by reclaimed been has It males. 1. The developmental process whereby gay, lesbian and bisexual people people bisexual and lesbian gay, whereby process 1. developmental The Acronym standing for for standing Acronym effects of both. of effects the experience often people bisexual and homophobia and biphobia between overlap of lot a is There bisexuals. against prejudice and Discrimination otherwise indicated. otherwise unless heterosexual is everyone that assumption the and orientation sexual includes It T relationships. and expression attraction, sexual same-sex against bisexuals; and gays lesbians, against discrimination and Prejudice themselves. describe to lesbian or gay like words prefer people most sickness, a as homosexuality of model medical a with historically associated is term the Because sex. same the of people to attracted romantically and sexually is who Someone men. to only refer to used increasingly is but women, and men by used be Can sex. same the of people towards is interest romantic and sexual whose person A women. other towards is interest romantic and sexual whose woman A he social, cultural and institutional privilege of heterosexual orientation. orientation. heterosexual of privilege institutional and cultural social, he recognize their own sexual orientation. sexual own their recognize used in the past as a derogatory term for effeminate and/or gay gay and/or effeminate for term derogatory a as past the in used the belief that heterosexuality is superior to any other forms of of forms other any to superior is heterosexuality that belief the Lesbian, Lesbian, G ’ s sexual orientation. sexual s ay, Bisexual and Transgender. and Bisexual ay, LGBT people believe that that believe people LGBT 23

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca

? ”

’

” ”

” is a good term to combat ” ” to change it to changes the family of choice Heterosexism ” ” “ “

heterosexism. or “

” sexual preference. Partner “ “ treated

and “ ” Homosexual used either as ”

” communicates a discomfort or Heterosexism ” “ lesbian, gay, bisexual, and sexual preference “ “ roommate. family of origin “

“ s family of origin are who she considers

homophobia ’ “ or

homosexual. roommate ” “ “ or ” friend, is often perceived as being a term that invalidates “ are the terms preferred to with your clients.

” ” ” ” friend Given with mixed response to this term on the

“ ” , 1997-2004. Copyright The Mautner Project, the National Lesbian 6 lover, “ Are you referring to ” queer. are preferred over “ ” family. as you determine their real support network. “ and to personally note the connotation a client who uses the term ”

sexual preference sexual orientation ” sexual orientation “ “ “ Bisexual

“ developed in response to the phrase

” or and and

LGBT,

” “ ” ” focuses on prejudices against lesbian, gay and bisexual people from or ” it from being used as a tool of oppression. Some women still respond strongly

Gay, ” ” “

is generally preferred to ” family of choice ” is controversial. Women who use this term in reference to themselves are seems to give it. “ ” ” s ’ Lesbians and Women Who Partner with Women Health Organization and the United States Department of Health and Human Services. Sexual identity Sexual orientation Homophobia Lesbian, Partner Queer reclaiming sexual identity queer transgender Because of heterosexism, including forms of rejection from members of the family inwas which raised one (family of origin), people may create familial relationships among friendsof choice).(family Do not assume that members of your client has both external manifestations as well as internally felt experiences of shamepeople for some with a non-heterosexual identity. Be aware of how you use to the negative connotations of family. Frequently partners, former partners, friends, or even supportive members of others LGBT community, you will be safest to use phrases such as 6 This handout is adapted6 with permission from Removing the Barriers: Providing Culturally Competent Care to “ “ “ “ “ “ “ “ “ Appendix C: Terminology Suggestions Confused About What To Say? Due to experiences with homophobic prejudice and discrimination, lesbians and bisexualwomen are often quite sensitive to any signal that indicates that a health care provider maybe not familiar or comfortable with same sex relationships and sexual behaviour. As we have seen with many different cultural groups, self-referential language evolvesissues as of status and identity change. One way you can demonstrate your willingness lesbianto provide and bisexual affirmative care is by the language you use. Here are some generallyterms that fit what is preferred right now, and that will increase your confidence thatlanguage your is culturally competent: a noun or an adjective is too clinical, and for your clients it may connote anti-gay attitudes. arguments that sexuality is a choice and that homosexuality can be focus to the larger culture, to heterosexist discrimination and assumptions. individuals. It refers to overt negative reactions from people. families feel and operate as family to lesbian and bisexual women. Inquire about who isclient in your how true a lesbian, gay or bisexual identity feels for the individual. You can generally use both It is important to understand the difference between to use with all clients. Use of terms like unwillingness to regard a same sex partner with the same validity as an opposite sex partner. heterosexuality. Today

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca . 1. Interviews: Client for Questions Sample 8 7 4. that or you to important are that communities or groups any in involved you Are 3. 2. Don write) to f. client for space (leave Other e. Bisexual d. Gay c. Lesbian b. Straight/heterosexual; a. identity: Sexual 2. answer) an write to client for space (leave orientation? sexual your describe you would How 1. Forms: Intake for Questions Sample Questions Right the Asking Door: the Open to Ways D: Appendix . 5. Health and Human Services. Human of and Health Department States United the and Organization Health Lesbian National the Project, Mautner The Copyright 2004. Women with Partner Who Women and Lesbians to Care Competent Culturally Providing Barriers: the Removing Cancer Community Research Initiative. http://dawn.thot.net/lbcp/ Initiative. Research Community Cancer Cancer and Lesbians About Out Coming 2004. Team. Project Cancer Breast and Lesbians questions won questions example example For needs. your meet best to resources and services with you connect to able be to face may women things the all to respond to try we organization) of (name At etc.) colour of women for group a group, lesbian a group, neighbourhood a group, activity-based an group, religious a examples: with prompt (Can support? provide the services and resources that make sense… make that resources and services the “ friends? and family from support enough “ relationship. your “ other women, services or resources that might be more specifically relevant to you? to relevant specifically more be might that resources or services women, other with connecting around have you needs particular any there Are women. of groups other and disabilities with women colour, of women women, bisexual and lesbian housing situation? your age … etc … age your situation? housing your is what needs, financial have you do disability, a have you do woman, trans or bisexual or lesbian a you are group, cultural or ethnic particular a with identify you Are you involved in a significant relationship at this time? (if yes) tell me about about me tell yes) (if time? this at relationship significant a in involved you Are In order for us to best support you, I you, support best to us for order In Tell me about the people who are important to you. Do you feel like you get get you like feel you Do you. to important are who people the about Tellme ’ t know t – services and resources for young women, women of specific cultures, cultures, specific of women women, young for resources and services ’ t relate to you, but I want to make sure I sure make to want I but you, to relate t ”

7 ” 8 ’ m going to ask a few questions. Some of the the of Some questions. few a ask to going m ”

8

” Then ask a series of questions: questions: of series a ask Then ’ m connecting you with all all with you connecting m . Toronto: Ontario Breast Breast Ontario . Toronto: , 1997- do “do 25

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca s partner? Why or ’ ? What could the worker ? What could the ’ ’ test the waters test the waters ‘ ‘ t tell the phone line worker this. She has ’ , 1997-2004. Copyright The Mautner Project, the National Lesbian but she doesn – s not a lesbian. ’ s sister convinces her to meet with an oncologist and this is her first visit. ’ 9 oncologist be listening for? How would you suggest that the nurse explain the relationship between sexual identity and breast cancer risk to Jas? What information could the nurse provide to help Jas better understand her risk? be listening for? How can the phone line worker create an environment in every call which is open so that Helena and others would know it is safe to come out? why not? Why kinds of things could the doctor say or do that would indicate openness to the potential that they might be a couple? Why might it be helpful for the doctor to ask Zara if she would like to invite Leah into the room? Would it be useful for the doctor to know whether Leah is Zara What assumption has the support worker made? What could she have done differently? How could she repair this relationship? How could the phone line worker let Helena know that it is safe to come out? What sorts of things might Helena say to How important is it for the oncologist to know explicitly that Angela is a lesbian? How might the oncologist signal that it is safe for Angela to come out? What sorts of things might Angela say to because she is bisexual and has heard that lesbian and bisexual women are at higher riskthe fordisease. as a lesbian with breast cancer and to find out whether there are any groups, resourcesor referrals for her as a lesbian experienced homophobia in the past with health care providers and in a support groupwomen for with breast cancer. She is reluctant to come out unless it feels very safe to do so,even though she wants to talk about these things. appointment with a new practitioner, she does not indicate her marital status on the intakeform. The practitioner notices that she keeps referring to her friend, Leah, whowaiting is in the room. has fears about how her oncologist will react to her being a lesbian. She is worried about the possible impact of revealing her sexuality, but it is important to her that she is open about who she is. Angela female partner. The support worker thanks her for sharing that she is a lesbian and asksthere areif any specific resources or information she would like for lesbians with breast Anncancer. interrupts to say that she to Lesbians and Women Who Partner with Women Health Organization and the United States Department of Health and Human Services. 4. During an appointment,4. Jas tells her nurse that she is worried about getting breast cancer • Helena calls5. a breast cancer support line because she wants to talk about her •experiences • • Angela was diagnosed3. with breast cancer and has not returned for treatment because she 9 Case studies 2 and 3 are adapted9 with permission from Removing the Barriers: Providing Culturally Competent Care • • Appendix E: Case Studies Ann calls a 1.breast cancer support line and in the conversation she discloses that she has a • • Zara is a client2. who has recently been diagnosed with breast cancer. When at an • • • • • •

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca • • • 5: study Case • • 4: study Case • • 3: study Case • • • 2: study Case • • • 1: study Case Studies Case for Notes Facilitator resources and information appropriate to Ann to appropriate information and resources provide to and identity sexual around open be to was intent her that know her let Refer to the the to Refer language and inclusivity tips on page 17. page on tips inclusivity and language the to Refer experiences. the of aspect homophobic the revealing without way general a in group support a or in providers care health with experiences negative had having about talk might she or women, of groups specific for resources on information has worker the if ask might she language, neutral gender using partners past or partner her about talk might Helena F. Appendix in listed resources the of some with Jas provide could nurse The 15. page on outlined as risk cancer breast and women bisexual and lesbian on information the words own their in explain to participants workshop for chance a provides case This world. the in is she who about open being of importance the about talk might she or groups, or events LGBT mention might she p or partner her about talk might Angela is. she who of part this about open be to wants Angela because lesbian a is Angela that know to oncologist the for important is It 17. page on tips inclusivity and language the to Refer relationship. her about know to for doctor Leah the to important is it if particularly and person whole a as Leah understand better Zara is Leah whether know to doctor the for useful be would It care. her in involved be to Leah for option the want may she and life, her in person important an is Leah that seems it lot, a Leah to referring is she because room the into Leah invite to like would she if Zara ask to doctor the for helpful be would It Ann what assuming for apologize could worker support The women. with relationships in women for information or resources in interested was she if asked and relationship her about information sharing for Ann thanked perhaps and partner, her about talk to used Ann language the used have could worker support The way. some in other or queer as gay, as bisexual, as identify may Ann lesbian. as identifies she that partner female a has woman a if that is made has worker support the assumption The language and inclusivity tips on page 17. page on tips inclusivity and language Ways to Open the Door: Asking the Right Questions Right the Asking Door: the Open to Ways Questions Right the Asking Door: the Open to Ways Ways to Open the Door: Asking the Right Questions Right the Asking Door: the Open to Ways ast partners using gender neutral language, language, neutral gender using partners ast

’ s needs. s ’ s sexual identity was and and was identity sexual s ’ s partner in order to to order in partner s handout and the the and handout the and handout handout and the the and handout 27

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca

Perseus San Francisco: Spinsters My Breasts, My Choice: A (2006) DVD. Ramsay Media (1997). Butterfield and San Francisco: Aunt Lute Books. New York: Firebrand Books. Toronto: Sumach Press. Cancer in Voices.Two Coming out of Cancer: Writings from the s Breast Health Resource List ’ Living Downstream: An Ecologist Looks at Cancer and The Complete Natural Medicine Guide to Breast Health. Seattle: Seal Press. Dr. Susan Breast Love’s Book, 3rd edition. A Burst of Light. The Cancer Journals. New York: Addison-Wesley Publishing Company. www.breastcancerfund.org . (2000) VHS. Pope Productions Ltd. (57 minutes, documentary) Exposure: Environmental Links to Breast Cancer. Coming Out Again: Lesbians Speak Out About Cancer. (25 minutes, documentary) My Left Breast Lesbians and Cancer: Resources & Support (Ontario) State of the Evidence: What is the Connection Between the Environment and • Lorde, Audre (1980). • Book Company. Lorde, Audre (1988). Toronto: Robert Rose. Resources - Environmental Issues • Films - Lesbian and Bisexual Specific • Books - General • Love, Susan. (2000). • Books - Lesbian and Bisexual Specific • Aslin, Maureen; Brown, Barbara; Carey, Betsy. (2003). Photographic and Narrative Journey. • Publishing, Cambridge, MA. Kaur, Sat Dharam. (2003). Websites - General • Imaginis – The Breast Health Resource (USA) • www.imaginis.com Ontario Breast Screening Program • www.cancercare.on.ca/index_breastScreening.htm The Healthy Breast Program – A Naturopathic Resource • www.healthybreastprogram.on.ca/ Breast Cancer Care (UK) www.breastcancercare.org.uk/Breasthealth • • http://lesbiansandcancer.com The Lesbians and Breast Cancer Project (Ontario) • http://dawn.thot.net/lbcp/ The Mautner Project For Lesbians with Cancer (US) • www.mautnerproject.org Cancer in Women Who Have Sex With Women www.gayhealthchannel.com/wswcancer/ • Brownworth, Victoria (Ed.) (2000). Lesbian Cancer Epidemic. Appendix F: Lesbian and Bisexual Women • Butler, S. and Rosenblum, B. (1991). Zuckerman, in association with Women’s Healthy Environments Network. • Toronto. (53 minutes, documentary) Steingraber, Sandra. (1997). • the Environment. Breast Cancer? Websites - Lesbian and Bisexual Specific

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca Rankow EJ. EJ. Rankow 385. Survey. Questionnaire Women: Heterosexual A. Diamant AS, Koh Study. 2002; 843-853. 2002; Sample. Initiative Women’s Health the in Comparisons Health: RA. P, Carter Charney E, T, Whitlock Bassford DJ, Bowen BG, Valanis 123-129. http://mautnerproject.org/programs_and_services/healthcare_provider_education/133.cfm Women with Partner Who Women and Lesbians to Care Competent Culturally Providing Barriers: the Removing AL.pdf 4.citysoft.com/_data/n_0001/resources/live/GLMA%20guidelines%202006%20FIN http://ce5 Patients Transgender and Bisexual Gay, Lesbian, of Care for Guidelines Association Medical Lesbian and Gay Resources: US http://www.lgtbcentrevancouver.com/pdf_s/theManual_vFinal.pdf Resource Training and Education Matters, Health LGTB http://www.rainbowhealthnetwork.ca/node/24 Toolkit Educational Health Rainbow Resources: Canadian Providers Service for Resources Training and Education Additional SA. Roberts SL, Dibble Care. Health of Use L. Gelberg K, Spritzer C, Wold AL, Diamant Women. Bisexual and Lesbians J. White EJ, Rankow A, Robison RS, Goldstien SJ, Roberts D, Bybee S, Gage D, Bowen VM, Mays SD, Cochran Behaviour Screening and Health Breast Women’s Bisexual and Lesbian Providers Service for Resources Additional G: Appendix Oncology Nursing Forum 2003; 30: 71-79. 30: 2003; Forum Nursing Oncology Breast and Cervical Cancer Among Lesbians. Women’s Health Initiative Women’s Health Lesbians. Among Cancer Cervical and Breast Archives of Family Medicine 2000; 9:1043-1051. 2000; Medicine Family of Archives Cancer-Related Risk Indicators and Preventive Screening Behaviors Among Among Behaviors Screening Preventive and Indicators Risk Cancer-Related Use of Preventative Health Behaviors by Lesbian, Bisexual, and and Bisexual, Lesbian, by Behaviors Health Preventative of Use Improving Cancer Screening Among Lesbians Over 50: 50: Over Lesbians Among Screening Cancer Improving American Journal of Public Health 2001; 91: 591-597. 91: 2001; Health Public of Journal American Health Behaviors, Health Status, and Access to and and to Access and Status, Health Behaviors, Health The Western Journal of Medicine 2000; 172: 379- 172: 2000; Medicine of Journal Western The Archives of Family Medicine Medicine Family of Archives Sexual Orientation and and Orientation Sexual Results of a Pilot Pilot a of Results

1995; 5: 5: 1995; 29

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Making Us Visible Training Evaluation Form s questions and concerns were addressed. ’ ______6. The presenter was knowledgeable. The presentation7. was interesting and useful. 8. Group participation and interaction were encouraged. 9. The group ______10. I would recommend this training a friend to or colleague. 11. In terms of the work that I do, I found this training be to helpful. 13. I feel I will be better able serve to lesbian and bisexual women as a result of this training 3. The training objectives were clearly identified and followed. 4. The content was organized and easy follow. to 5. The materials distributed were pertinent anduseful. 16. Additional comments: 15. Please15. describe any changes that could be made improve to future trainings: ______14. Please list three to up things you liked about the training: 2. I will be able apply to what I learned my work. to Location: ______Date: Please rate the following aspects of the training using the scale below: 1=strongly disagree 2= disagree 3=not sure 4=agree strongly 5= agree ______1. The training met my expectations. Appendix H: Evaluation Form 12. Overall, I think that this training is worthwhile.

2007 : Toronto, Canada : Making Us Visible : Sherbourne Health Centre : www.sherbourne.on.ca