Providing Culturally and Clinically Competent Care for 2SLGBTQ Seniors: Inclusion, Diversity and Equity

Devan Nambiar, MSc. Acting Program Manger & Education & Training Facilitator E: [email protected] October 22, 2019

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LT outcomes Group Norms

• Give yourself permission to make • Create practical steps to inclusive and safe spaces for SOGI mistakes & have a process to -Deconstruct your address mistakes • Understand 2SLGBTQ+ health disparities , values, • Use “I” statements beliefs systems • Use correct pronouns (he, she, • Competencies in clinical, cultural safety, from religions, cultural humility attitude, morality and they….) implicit biases • Agree to disagree • Become an ally • Create safe space for all to learn -Being comfortable with not knowing • Respect confidentiality and questioning your • Share wisdom & Share airtime discomfort with SOGI

3 SOGI- and 4

Trans Mentorship Call biweekly -1st & 3rd week on Wednesday 12 noon -1 pm Must register 5 online 6

1 Does Discussions Myths on 2SLGBTQ end at senior • At school, either college and/ or university have you learnt about LGBT2SQ age? clients or in population health? • When did you decide you are heterosexual? How do you know you are 100% heterosexual? • You stop being 2SLGBTQ if you are older, a senior, • Are you familiar with gender neutral pronouns? retired, have an illness • Are there staff who are out at work as LGBT2SQ? • Do you know LGBT2SQ people outside work? • • Have you done an assessment for HRT? SRS/GCS/TRS, puberty blockers? LGBTQ have “excessive” sexual practices • Do you know of resources available for LGBT2SQ clients? • Is there an equity or diversity committee at work? • Wanting/ desiring intimacy (holding hands, hugging, • Does the policy at work include sexual orientation & gender identity? sitting together, cuddling, kissing, etc.) means they • Have you taken AOAR, AOP training? want to have sex • Has your health care provider ever discussed with you about sexual orientation, gender identity or sexual behavior? 7 8

LGBT2S Seniors Introspection (5 mins)

• At your table speak to your peers about someone “I can be me. I can talk about anything I want to. And that in important in your life and/or you care about itself relives a lot of mental stress. I mean it’s very good for without gendering the person. your mental stress to be able to be who you are. It is very damaging to be not be able to. • Do not use names, she/he, husband/wife, And if you feel that you are losing yourself to some form of girlfriend/boyfriend, daughter/son dementia, then to me the one thing that I would want to put against that is, the bits of me that are still there, I want to celebrate! I want them there and I want people to see that I • Or describe a client without gendering them am still here. Let’s celebrate it for now. Not a year down the line.” • How was the experience?

Re:“Over the Rainbow” , , Bisexual and Trans People and Dementia. 2015 9 10

1969- 2019 LGBTQ Global Perspective: Africa, China, Egypt, Greece, Lesbos, Japan, India, Persia, Pakistan

China, Qing dynasty, 5th dynasty of Egyptian Alexander the Great & 18th -19th century pharaohs circa 2400 B.C Hepaestion 356-323 BC

Pakistan: Shah Abas, 1627 Sappo, 570 BC, Samurai & kabuki Madho Lal & Shah India Persia island of Lesbos actor 1600-1868 Hussain 538-1599 11 12

2 Import of homo/ via European Colonialism & the Penal code: from 1533 buggery law of K. Henry Vlll- drafted in 1834 by Britain, implemented in 1861… “ Two-Spirit, and non-binary genders before any act of carnal intercourse against the order of nature.” colonialism 157 years later: colonial laws criminalize 2SLGBTQ persons

2019- Kenya High Court upholds penal code Uganda • Ancient tradition: neither to criminalize same sex relations anti-gay law in process male nor Chechnya, 2017 and Egypt-mass arrest of from 2013 • Pre-western colonialism, ongoing gay genocide LGBTQ to now played strongly spiritual role Brunei, 2019- Death penalty, arrest, as advisors, medicine execution and/or torture: Iran, Saudi stoning for adultery women/men, healers, , Arvani, Arabia, Yemen, Sudan, and gay sex visionary, warriors, advisors Kushra, Somali, Nigeria, Iraq to chiefs, queens, kings Some of the countries in the Caribbean and in Cultural Competency in Practice: Africa and eastern Russia Name one process/ initiative to consider Europe criminalize when providing care to Indigenous LGBTQ+ people clients? In 71 countries it is a criminal offense be LGBTQ (www.ilga.org) 14

History of oppression, criminalization, state sanctioned & : Videos • Intersectionality https://www.youtube.com/watch?v=O1islM0ytkE 2-Spirit Indigenous • Trans And Native: Meet The Indigenous Doctor Giving Them Hope. Dr. Makokis created a unique approach to Nov 28, 2017 care, combining Indigenous and Western teachings. In Canada for 40 yrs: “ was grounds for surveillance and interrogation • https://www.youtube.com/watch?v=MSnvtj0G3cA by the RCMP under the directive of the newly-established Security Panel. Over the • Seniors; The Fruit Machine: Canada's Cold War gay purge course of four decades, thousands of men and women had their privacy invaded, their • https://www.youtube.com/watch?v=CRvjgevw2Sw careers ruined, and their lives destroyed because of a “scientific” machine and a • Gen Silent >50,000 men to 100,00 men disgraceful mandate.” • https://www.youtube.com/watch?v=fV3O8qz6Y5g

HIV/AIDS Activism via AIDS Action Now= catastrophic drug program = Trillium Drug Program 15 16

Timeline of Oppression on LGBT2S seniors Why Pride? Current age 70 years Born 1948 Age 21 years Decriminalization of homosexuality • “When you hear of , remember, it was not born out of a (1969) need to celebrate being gay. It evolved out of our need as human beings to break free of oppression and to exist without being Age 25 years Removal of homosexuality from DSM criminalized, pathologized or persecuted. (1973) Age 28 to 50 years Territories/provinces prohibited Depending on a number of factors, particularly religion, freeing discrimination on basis of sexual ourselves from gay shame and coming to self-love and acceptance, orientation (1977-98) can not only be an agonising journey, it can take years. Tragically some don't make it. Age 55 years Marriage recognized (2003) Instead of wondering why there isn't a be grateful you have never needed one. Celebrate with us.” Age 66 years Gender Identity and added to Ont. H.Rights (2014) • Anthony Venn-Brown Age 69 Federal protection on gender identity and expression (2017) Recognized in senior environments – Invisible : Fernando & Lito Pride –Sense 8 17 https://www.youtube.com/watch?v=0JtLzzR5h3Y & Gen Sillent 18

3 Ontario Human Rights Commission Human Rights for LGBT2SQ people in Canada

. 1969 Consensual sex between same sex adults removed from Criminal Code of Canada . 1973 Homosexuality no longer classified as a mental Illness . 1974 Gays and permitted as immigrants to Canada . 1977-98 Territories/provinces prohibited discrimination on basis of sexual orientation (Ontario in 1986) . 2003 Ontario legalized same sex marriage . 2005 Canada opens doors to LGBT marriage and immigration . 2012 Ontario recognizes gender identity, gender expression in its human rights 2006 legislation (13 June 2012) . 2017-Bill-C16 Canadian Human Rights Act to include gender identity and expression

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Every Resident - Bill of Rights for people who Access to Washrooms live in Ontario long-term care homes (2015) “Trans people should have access to washrooms, change rooms and other gender specific services and facilities based on their lived gender identity.…Organizations should design or change their rules, practices and facilities to avoid negative effects on trans people and be more inclusive for everyone….The duty to accommodate the needs of trans people is a shared responsibility.”

Ontario Human Rights Commission Policy on Gender Identity and Expression, 2014

Duty to accommodate: OHRC’s policy section 13.4 (p.38) 13.4.1- access based on lived gender identity) 21 22

Impact of isms in health care systems Homophobia – Sexism-Transphobia – Misogyny-

• : The unrecognized and assumed privilege that people have if they are heterosexual. Examples: holding hands, or kissing in public without fear; talking about their partners, etc. • “Because many 2SLGBTI Q+ people have learned to live with • Homo/bi/transphobia: An extreme and irrational the stresses of being different over a long period of time, aversion to homosexuality, and trans gender they may not be aware of the toll that this experience of people. It can also mean hatred of LGBTQ people, sexual chronic low-level stress creates…... But slowly both the client behavior, gender identity, gender expression and /or and the provider may discover – together – that the residual culture. effect of this stress is a big part of a presenting problem • Cissexism: the belief and treatment of transgender such as depression.” people as inferior to cissexual (non-trans) people.

23 Re: Working therapeutically with LGBTI clients: a practice wisdom resource (2014)24

4 Outcome of acute & chronic stresses due to SOGI Minority Stress

Of this experience of “acute and chronic, low-level stress – from external and . The chronic psychological strain resulting from stigma and internalised events and process – contributes to the notably high levels of stress expectations of rejection and discrimination, decisions about related physical illness, anxiety, depression and even suicidality reported in LGBTI disclosure of sexual orientation or gender identity, and clients.” internalization of homophobia and transphobia that LGBTQ people face in a heterosexist and cissexist society – I.H. Meyer “ and discrimination tells LGBTI people that they are less important than their peers and can lead to experiences of shame, isolation, lack of confidence or trauma.” . Minority stress increases with marginalized 2SLGBTQ identities- racialized, Indigenous, immigrant, refugee, mental “But many will present with some residual expressions of trauma simply because they have lived with a sense of chronic stress due to their position in society as a health illness, disabilities, etc. member of a minority group.” . Contributes to acute & chronic stress

Re: Working therapeutically with LGBTI clients: a practice wisdom resource (2014) Intersectionality https://www.youtube.com/watch?v=O1islM0ytkE 25 26

Life span – childhood to seniors/ palliative care

The Internalization of Oppression Research on shame based trauma & 2SLGBTQ+ • From infancy- adolescence –adulthood- seniors

Anxiety • Whole self is condemned Psychological Symptoms Depression • Met with indifference or disapproval Suicidal ideation Anger/Frustration • Through shame – individual learn the boundaries of socially accepted behaviors Loneliness/social isolation/loss Lack of self esteem /self respect Psycho-social impact of oppression Internalized homo/bi/transphobia Shame, guilt, hopelessness • Treated in degrading manner (humiliation, self-loathing, disgrace, dishonor) Difficulty trusting others • Shame schemas- PTSD and dissociation Homo/Bi/Transphobia • Higher rates of suicidal attempts, suicide ideation, current suicide plans Oppressive socio-cultural factors Heterosexism/Cisgenderism Family/friends/partner rejection Discrimination at work, church, etc. Violence, poverty, racism, stigma

Diaz, (2006) HIV Stigmatization among Latino in the US. 27 28

Understand 2SLGBTQ+ lived Variety of daily stresses experiences • 1. External stressful events • An intersectional framework • These could include a range of discrimination and prejudice • Inquire about social and historical context of their lived from ongoing alienation by family to physical violence experiences (childhood, experiences, internalized issues • 2. Expectations of such events of being ‘different’, impact on self-esteem , trust, shame, • This not only produces anxiety but also calls for hyper- etc.) vigilance which produces its own stresses • Social issues, support, disowned, physical violence, • 3. The possible internalization of negative societal attitudes assault and impact on behaviors (censorship/ silencing • Potential shame, guilt and negative attitudes about sexuality, of self, ) sex and gender difference • 2SLGBTQ- who have depression, anxiety, phobias, • 4. Concealment concurrent disorders, eating disorders • Even for those who are in some ways “out” they may still engage in some level of concealment as part of their vigilance strategies

29 Understanding Intersectionality https://www.youtube.com/watch?v=O1islM0ytkE30

5 2SLGBT Seniors - Less Social Support U = U campaign

• “A person living with HIV on antiretroviral therapy (ART) with an • LGBTQ seniors have significantly diminished support networks vs. general undetectable viral load who is virally suppressed cannot sexually transmit senior population HIV.” • LGBTQ seniors are: • Specific to sexual contact only • 2 x as likely to age as a single person • 4 x as likely to have no children to call upon in times of need • 2 x as likely to live alone • Many older LGBTQ people have experienced rejection by their families of origin • For gay/bi men, loss of partner(s), lovers, friends and extensive social networks as a result of the AIDS pandemic • Cumulative grief and stress of dying, death and loss

The Fruit Machine: Canada's Cold War gay purge https://www.youtube.com/watch?v=CRvjgevw2Sw 31 32

Canadian Guidelines on HIV Pre-exposure Prophylaxis and Non-Occupational Crisis competence skills Post Exposure Prophylaxis

• Due to stigma, discrimination, alienation, (family disruption, intensive feelings, sometimes disowned and /or alienation • URL to download PDF from family, etc.) some 2SLGBTQ people develop “a • http://www.hivnet.ubc.ca/clinical- perspective on major life crisis.” studies/knowledge-translation/treatment- guidelines/ • Crisis competence is “development or enhancement of life • skills as a result of having to deal with being a sexual minority and all that entails living in a heterosexual society.” • URL for full guidelines on CMAJ website • Very sensitive to cues about safety or danger • http://www.cmaj.ca/content/189/47/E1448

33 Institute of Medicine. pp. 272- 273 34

Scenario 1: Jack & Tim

• Jack & Tim are in their 80’s and have been together as a couple for 47 years. They live together in an upscale part of the city. Over the years their dementia has progressed and they do not recognize each other. Their LGBTTIQQ2SpiritAA ‘responsive behaviors’ have included physical fights and aggression LGBTTIQQ 2Spirit PP towards each other . On many occasions the police were called by neighbours. Their recent fight spilled over to the hallway and police were LGBTTI called. Jim was arrested and found himself in the criminal system with 2SLGBTQ young inmates (the rationale to reduce harm and violence to each other in QPOC Reclaimed words: , fag, dyke their condo.) • Does Jim belong in the criminal system or in the behavioral unit of LT QTPOC Care? BIPOC Intergenerational terms: , queer • Is there a behavioral care centre where they can receive appropriate care LGBT • Can they receive affirmation and validation of self & identities and care for progression of ‘moderately severe dementia’ • Contact next of kin, chosen family, friends

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6 “Sex is between the legs, while gender is between the ears.” . TRANS gender: . CIS gender: Sex and gender Someone whose gender Someone whose Sex (sex assigned at birth) Gender Identity identity and/or gender gender identity hormones, chromosomes, girl/ woman, boy/ man, presentation does not and gender anatomy, genitals, transgender, transsexual, match their assigned sex presentation is genetics, , female, 2-spirit, androgynous, and gender. Often used consistent with male, genderqueer as an umbrella term to their assigned include many other sex and gender Sexual Orientation Sexual Behavior gender variant identities. assigned at birth heterosexual, queer, MSM, WSW, serial bisexual, lesbian, gay, etc. monogamy, , , kink, etc. https://www.youtube.com/watch?v=QHjXdn M7c44 37 38

Exercise /Quiz on LGBTQ terms and definitions

Conversations about SOGI • How would you describe your gender? • What was coming out like for you? • Why is coming out important for you? Pros & cons • What was puberty / adolescent like? • Are you attracted to men, women, both or neither? (clinicians)

SOGI= sexual orientation , gender identity 39 40

Conversation about gender identity and expression Conversation about gender identity and expression

• What was puberty/adolescence like?  Do you have any concerns about safety? Do you have access to • What pronoun(s) do you use? What is your chosen name? safe(r) spaces to be yourself? • How would you describe your gender identity?  How does your gender identity impact how you feel about work, • How do you want to be perceived in terms of your gender? relationships, family, or other aspects of your life? • Does this impact your choices around gender possibilities? • What are your feelings about the parts of your body that are often • Have there been changes to your gender identity over time? associated with gender (eg. genitals, chest/breasts)?

• Which changes are you most looking forward to? Or not sure • Have you taken any steps to change your outward appearance to about? make it more closely match your identity? If so, what was that like • If you could change your external appearance in any way you for you? wanted, what would this look like in terms of your gender? • Are you on HRT? What leads you to want to start hormones at this time in your life? Are you considering SRS/GCS/TRS?

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7 Examples of Inclusive Language Coming Out…

Instead of: Use: Comment: • Coming out happens continually Do you have a spouse or Does not assume sexual Are you married? partner? orientation or gender of • Methods, location, testing the water… sexual partners • Managing sexual orientation and gender Are you the parent (s), Fear, relief, Are you the caregiver(s), or guardian More inclusive of different mother/father? (s)? types of families identity discrimination, prejudice, name That person in the (red Does not risk misgendering • Preparing for best case and worst case calling, stress, That man/woman hat/green coat/etc.) someone • Connecting the dots-homophobia-sexism- disowned, stigma, anxiety, Partner Ask above misogyny Boyfriend/girlfriend sadness, rejection, Patients who (have a Recognizes that gender • Finding allies blamed, disgust, prostate? Can get identity and sex-specific acceptance, joy, Male/female patients pregnant?) anatomy not always • Resources aligned shame, dishonor, support, unconditional love, ……………

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Childhood Gender-Typed Behavior and Adolescent Sexual Orientation: A Longitudinal Population-Based Study Scenario 2 : Client comes out to you as LGBT2SQ N=2,428 girls, 2,169 boys Duration of study 15 yrs • A client has come out to you in your • Preschool Activities Inventory at 2.50, 3.50, 4.75, and 15 years of age practice/care. • What is your response? • Found that the levels of gender-typed behavior at ages 3.5 and 4.75 years • When Someone Comes Out to You as significantly and consistently predicted adolescents' sexual orientation at age LGBT identified 15 years (< at 2.5 yrs old) • Thank the person for having the • By 15 yrs sexual orientation was conceptualized as 2 groups or as a spectrum. courage to tell you. • Understand that the person has not changed. • In addition, within-individual change in gender-typed behavior during the preschool years significantly related to adolescent sexual orientation, • Ask question –but realize they may especially in boys. not have all the answers and it is your work to learn more

Li, Hines & Kung, 2017 45 46

Helpful Responses for Discussion Around 2SLGBTQ Identity:

• Its okay if you are 2SLGBTQ identified. • I can appreciate how difficult it must have been for you to tell me this. • If you are 2SLGBTQ, what are the kinds of things that worry you most? • What kind of support do you think you need from me? • I may not have all the information, but I can find more for you?

https://rnao.ca/events/know-rnao-respectful-care-and-support-lgbtq-clients-and-colleagues47 https://rnao.ca/connect/interest-groups/rnig 48

8 Always ask Transgender Health Definitions… pronoun –do not assume or guess Ways to Transition • Socially: e.g. Name, pronouns, hair, clothing, make up (disclosing to • FTM = Female to Male = families, partners, friends, , workplace issues, transphobia) Binary • MTF = Male to Female= • Legally: e.g. Name, sex marker on ID • TGNC (trans and/or gender nonconforming) • Gender nonconformity is expressing oneself in ways • Mental/Emotional changes – shifting sexual orientation, negotiating that are not consistent with the societal norms for relationships one's sex assigned at birth (McCauley et al. 2018) • Medically e.g. Hormones (estrogen, testosterone), electrolysis, hair transplant, • ASAB, AMAB, AFAB surgeries • TRS: Transition Related Surgeries • GAS: Gender Affirming Surgery Gender dysphoria : Lito & Nomi (sense8) 3 mins • SRS: Sex Reassignment Surgery https://www.youtube.com/watch?v=OOR-kqtrLBg

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Gender Dysphoria Transition, passing & age PASSING: • Gender dysphoria refers to discomfort or distress that is Being identified as belong to a group with more privilege and power . Being caused by a discrepancy between a person’s gender identity identified as your gender by individuals who do not know you are trans, and that person’s sex assigned at birth (and the associated aka being read as cis gender. Appropriated from race discourse and gender role and/or primary and secondary sex characteristics) very contentious. (Fisk, 1974; Knudson, De Cuypere, & Bockting, 2010b).

• FYI: Not all gender-variant individuals experience gender • FTM gain power • MTF lose power.. dysphoria (DSM-5; Bonifacioa et al, 2019) SDoHealth Transmisogyny Employment barriers Scrutiny of femininity/ passing

WPATH –Standards of Care, Version 7, p.4 51 52

Scenario 3: Patient identifies as Concerns & fears: Dementia & TNBGF trans seniors • “I am worried that I will development dementia and • A client identifies to you as transgender non-binary gender fluid (TNBGF). What is your response? will not remember that I have transitioned. I am worried that I will not be able to support myself and that there will be no one to take care of me. I am • Ask the client what TNBGF means to them. already becoming so forgetful and unable to • Ask what pronoun they use and note it down and concentrate at 55yrs that I worry I will not be able to inform other providers of the pronoun used by hold or keep a job at some point within the next five client with their consent. years or longer. I worry that I will not have the • Proceed with your care resolve to kill myself when I cannot support myself any longer.”

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9 Benefits of Gender Affirming Medical Treatment (GAMT) for Mental Health Outcomes Improve for Transgender Elders: Later life Alignment of Mind and Body Transgender Individuals After Surgery N=2679 N=2420 • Transgender participants from the US National Transgender Discrimination Survey 2015 ( n=28,000) who had either recently or never undergone medical treatment • Review of 10 yrs of medical data (2005-2015) were included • Examine whether old life moderates the association between GAMT and QofL. • 3 groups • LT effect of HRT & TRS – trans elders on GAMT – trans elder not on GAMT – young trans on GAMT • “For those who underwent surgery, however, the likelihood that they would receive mental health treatment for • Trans elders participants who initiated medical treatment had higher QoL than depression and anxiety disorders was reduced by 8 percent those who did not and higher QofL compared to younger trans for each year after the procedure.” ( 2019)

• The QoL difference was greater for older than for younger transgender individuals American Journal of Psychiatry https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2019.19010080.

Re: Cai, X et al.(2018). https://doi/10.1089/lgbt.2017.0262 56

Provincial funded (OHIP)- Transition related surgeries

Orchidectomy MTF Removal of testes NOTE: Not All trans persons undergo Salpingo- FTM Removal of ovaries & surgery. It is a oophorectomy fallopian tube very personal Vaginoplasty MTF decision for each Phalloplasty FTM trans person.

Metaoidioplasty FTM Alternative to phalloplasty Mastectomy FTM • Erectile &/or /chest testicular implants reconstruction • Scrotoplasty Augmentation MTF • Clitoroplasty Mammoplasty • Labiaplasty Hysterectomy FTM

Videos on TRS • Vaginoplasty (5 mins) • https://www.youtube.com/watch?v=SH-j3r_Rwsw • Vaginoplasty (2 mins) with print words https://www.youtube.com/watch?v=l_T13su6iKQ (Eur opean Society of Urology) • Phalloplasty (2mins) https://www.youtube.com/watch?v=bDiw2UOyYIU • Phallo 2 months post-op (stop at 6 mins) https://www.youtube.com/watch?v=YI9xpfCoJ6A • Facial Feminization Surgery (1.53 mins) • https://www.youtube.com/watch?v=JMy_hvYhWg8 59 60

10 Resources for families in transition Transition Related Surgery process • Referral for prior approval with supporting assessment(s) • Working with individuals who are from MD, NP, RN, psychologist or RSW trained in exploring their gender identity, and assessment , diagnosis & treatment of GD in accordance how they can talk to their parents or with WPATH SOC V.7 others when they decide to • Preparedness for surgery, post-op care plan & social transition. How to deal with their support reaction when they may not be • WPATH criteria for surgery approval for TRS understanding /supportive/ positive • Referral Letters to Surgeon • See WPATH criteria for Surgical Referral Letters

https://ctys.org/information/resources/ctys-publications/ 61 http://www.wpath.org/

Scenario 4: Patient referred to Scenario 5: Tina hospital Tina is a trans woman and has lived as a woman for most of her adult life. She has worked on and off as a waitress and used to supplement • Linda, a trans woman, 62 yrs has been referred to local hospital her income by doing sex work in her younger days. Tina has a son from and admitted to general internal medicine floor. She needs to an early marriage and two grandchildren. She sees them quite often have a intermittent catheter inserted because she is experiencing and is known as “Nan”. urinary retention. Linda has not had bottom surgery. What should the staff consider? How do you proceed? For years Tina obtained feminizing hormones from friends, then found a physician who prescribed estrogen but never provided any preventative care. Tina had breast implants which she paid for herself • What are some of the key steps to make sure Linda receives but could never access genital surgery as she could never meet the respectful and inclusive clinical care? clinic’s strict criteria. Tina has now been diagnosed with Alzheimer’s. • Ask what pronouns Her son is very worried and wants her treated with utmost care and • Name of body parts and understand gender dysphoria respect in the long-term care home. The home has not had a transgender resident before. • Have a Positive Sticker /signage in the area What are some of the key issues you need to be aware of, to provide Tina culturally and clinically competent care during therapeutic

63 activities? 64

Concerns & Fears: Dying alone Key issues and/or without family

• Inclusive language • Impact of dementia and gender identity and gender expression • Family physician who is knowledgeable in Hormone Replacement Therapy for “As a immigrant gay man, my fear is that trans clients my family will not be able to be around as I • Advocating, lobbying and educating other staff and clients as required • Extreme transphobia leading to difficulties keeping jobs, poverty, need to do sex don’t live in the same city or country. Dying work alone without family would be • Many older LGBT people have been in straight marriages and some have children unbearable.” • Lack of health care for gender transition and self-medication. Lack of knowledge of care provider • Majority of trans people have NOT had genital surgery, there may be inconsistencies between their gender presentation and their anatomy

65 Whitten, 2014 66

11 Typical order of next of kin & Substitute Decision Tips for clinicians & healthcare workers Maker

Core competencies: 1. Clinicians reflect upon their own values and Heterosexual clients LGBTQ clients preferences • Spouse/ partner/ • Chosen family*/friends husband/wife • Partner/spouse* 2. Apply current theories of aging & social gerontology • Relatives • Children • Children 3. Integrate lived experiences of 2SLGBTQ when conducting a health & social assessment • Relatives *A group of people to whom you are emotionally close and consider ‘family’ even though you not biological or legally related 4. Use culturally sensitive & age appropriate • Friends language to build rapport *partnered LGBT may have varying living arrangements

Institute of Medicine, pp. 275-277 67 68 Eckstrand. (2016).Lesbian, Gay, Bisexual and Transgender Healthcare. p.178

Residents’ Bill of Rights Assess for six effects of lifetime stigma,

discrimination & violence Unique needs regarding HIV-positive residents • Social isolation • Stigma, discrimination and disclosure (legal issues) • Depression and anxiety • Long term impact of side effects of antiretrovirals (ARV) and compromised immune system • Poverty – HIV associated neurocognitive disorder (HAND) (Liboro et al, 2018) • Chronic illness – CVD, mental health, bone health – Poly pharmacy & adverse side effects & drug interactions • Delayed care-seeking • Poor nutrition

Re: Simone and Appelbaum, 2008; Liboro et al, 2018 Eckstrand. (2016).Lesbian, Gay, Bisexual and Transgender Healthcare. p.175 69 70

Residents’ Bill of Rights Residents’ Bill of Rights •care services (i.e. administration of drugs, care services (i.e. administration of drugs, assistance with bathing, dementia care); Trans residents assistance with bathing, dementia care); Unique needs regarding trans residents • Use name and pronoun of chosen gender (regardless of hormone or operative status) • Older trans may develop gender dysphoria later in life (Eckstrand, 2016,p.182) • Residents should be accommodated with others – HRT may produce less pronounced physical changes according to their chosen gender as per OHRC • Dementia and gender identity

• Dress and grooming should support the person’s chosen gender • Barriers can include apparent mismatch between genital • Care providers need to continue to prescribe and anatomy and gender of presentation and or expression can administer hormones (oral or injection) result in disclosure : creates difficulty in obtaining appropriate sensitive health services • Screening and preventative care is essential

71 Institute of Medicine, p. 275 72

12 Clinical care of older LGBT2SQ Behavioral health needs

• Address physical, social, spiritual, mental and • Anxiety, depression emotional, sexual health • Suicidal ideation • “Young-old” (50-65 yrs)- goals are ID and mgn. of • Mental health needs disease to achieve and maintain optimal QofLife • Substance use, • “Frail older”-mgn of symptoms that impair self- smoking, alcohol and efficacy and social interactions dependence • Establish a therapeutic relationship – open, respectful, honest communications for patient to disclose medical & social info

Eckstrand. (2016).Lesbian, Gay, Bisexual and Transgender Healthcare. p.177 73 Eckstrand. (2016).Lesbian, Gay, Bisexual and Transgender Healthcare. p.178 74

Admission/Registration/ Intake Cancer screening forms: sex and gender

• Higher levels of lung cancer are likely a consequence of increased smoking rates There is not one right choice. Consider- does the form? • Among L and Bi women, studies show higher rates of breast, . Option for preferred /chosen name, gender pronoun, SOGI cervical and ovarian cancers . Provide you with medically necessary information (e.g., sex • Among gay and bisexual men there are increased rates of rectal assigned at birth, sex indicated on OHIP card)? and anal cancer especially in those who are HIV positive. . Give more than two gender options? M, F, T, self identify as…. • Trans people participate at lower rates in cancer screenings and therefore experience poorer outcomes and delayed diagnoses. . Identify transitioned people who only identify as male or female? • Trans men may be at risk of uterine, ovarian, and breast cancer depending on their surgical status . Make sense to non-trans clients & staff? . Important to train staff to answer questions about 2SLGBTQ • trans women remain at risk for prostate cancer identities

Makadon 2012; Spicer 2010 75 76

Intake forms: sex and gender options OHIP: Legal vs. real name

• Two-step method: Do not use “Other” unless . Use appropriate pronoun rather than sex designation on you’ve provided >3 other OHIP options! 1) How do you identify your gender? . Use stated name on form vs. on OHIP card . Conversations about what information may be recorded New OHIP as of □ Female □ Male □ FTM (female-to-male) □ (chart, blood work, referrals, OHIP billing) and why, as June 2016 has no where are where you can advocate for change sex marker MTF (male-to-female) . Use the same screening and verification tools that you □ questioning □ prefer not to answer □ Other, would for anyone showing their OHIP card specify…………. . Some EMR have an area which allows “preferred name”. Use last name if 2) What was your assigned sex at birth (i.e., on your birth unsure about gender certificate?) /pronoun of client □ Female □ Male 77 78

13 TC-LHIN-Hospitals-Demographic-Questions-English

http://www.rekaicentre.com/ http://torontohealthequity.ca/wp-content/uploads/dlm_uploads/2014/12/TC-LHIN 79 80 -Hospitals-Demographic-Questions-English-visible-v2.pdf

Inclusive language: cultural competence tips Tips for Primary Care Providers and Counsellors

• Ask open-ended questions to all residents, non-judgmental affirming questions • Begin by creating a welcoming environment (forms, language, materials) • Use the pronoun that matches the resident’s gender identity • Ask clients about sexual orientation and – how they identify, if they have partners, want to have/do • Mirror the resident’s language and terminology have children, etc • Build trust and respect disclosure • Talk to clients about stressors e.g. having to hide identity, • Keep personal beliefs, opinions, morals, religion out of the conflict with family or friends, religious beliefs, discrimination within both ethno-racial and LGBT discussions communities • Friends, partner(s), chosen & bio family to be part of care • Be aware of specific health needs and risk factors and educate clients on these

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When working with 2SLGBTQ clients When working with 2SLGBTQ clients 1. Use inclusive language, correct pronouns 5. Avoid both over and under pathologizing –provide support to explore, express resilience, courage, provide authentic feedback 2. Be comfortable in your own sexuality and gender identity and gender expression 6. Welcome the clients chosen connections : romantic partner (s), extended family, network of friends are all 3. Be aware of subtle signals you may be sending potential members of your treatment team and should be that are not accepting or supporting of them welcomed into meeting as consented by the client

4. Welcome and normalize disclosure of sexuality and gender identity and gender expression Re: Huygen, C. (2006). Understanding the Needs of LGBTQ people living with mental illness 83 84

14 Summary • Important to treat the whole person, not a collection of risk factors-a client centered approach Thank you Contact Info: • Have policies that are inclusive of sexual orientation and Devan Nambiar gender identity; Admission/Intake forms, PA, Substitute Decision Maker, Will, Living Will Education Coordinator T: 647-730-3360 • For residents to be physically and psychologically safe from E: [email protected] violence and harassment

• To have their relationships and experiences understood and fully accepted

• In clinical and /or palliative care- a welcoming and culturally appropriate environment

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Making LTC Homes LGBT2SQ+ Inclusive Unique health needs . Step 1: Training • Appropriate safer sex counselling & STI screening . Step 2: Communication- Inclusive language • Access to PrEP (pre-exposure prophylaxis-Truvada) . Step 3: Intake forms and processes • Immunization recommendations . Step 4: Mission & vision • HPV vaccination . Step 5: Programs & services • Hep A/B • . Step 6: The website Family planning (eg. transgender patients, same sex couples) • . Step 7: Policy documents Assistance with HRT and/or TRS for trans persons • . Step 8: First impressions & physical environment Preventative screening for natal sex –trans persons • Pap smears for T persons & L, Bi women . Step 9: Implementing change & ongoing reflection • Anal cancer screening for G, Bi men

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References References • Whitten. (2014) It’s Not All Darkness: Robustness, Resilience, and Successful Transgender Aging.Vol.1.No.1. DOI: 10.1089/.2013.0017i • Brotman S,e Ryan B, Meyer E. (2006). The Health and Social Service needs of • Eckstrand,K.L., Ehrenfeld,J.M. (2016) Lesbian, Gay, Bisexual and gay and lesbian seniors and their families in Canada. McGill School of Social Transgender Healthcare. A Clinical Guide to Preventative, Primary, and Work. Montreal. Specialist Care. Springer. Switzerland. • “Over the Rainbow” Lesbian, Gay, Bisexual and Trans People and • http://www.mcgill.ca/files/interaction/Executive_Summary.pdf Dementia. 2015. The Dementia Engagement and Empowerment Project, Part III - Barriers and Specific Population Groups. Access to Care: Exploring University of Worchester, UK the Health and Well-Being of Gay, Lesbian, Bisexual and Two-Spirit People in • The Health of LGB &T People. Building a Foundation for Better Canada. "Certain Circumstances" Issues in Equity and Responsiveness in Understanding.(2011). Institute of Medicine. The National Academies Access to Health Care in Canada. McGill Centre for Applied Family Studies, Press. Washington. US Health Canada.(2000) http://www.hc-sc.gc.ca/hcs-sss/pubs/acces/2001- certain-equit-acces/part3-doc1-eng.php

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15 Contact information Recommended reading

For further information and educational sessions:

Devan Nambiar [email protected] Tel: 647-730-3360 Institute of Medicine

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