When LGBTQ+ individuals seek medical care, they face challenges beyond just questions of diagnosis or wait times. The nuances of their sexual or gender identity mean that they are more likely to receive lower quality of care: health care workers might misgender them, misunderstand their family relationships, and not understand how hormone treatments will interact with other prescriptions.
The results can be damaging, said Annesa Flentje, PhD, associate professor in the UCSF School of Nursing and director of the Center for Sexual & Gender Minority Health at UC San Francisco. “Patients when they go to a health care provider are very vulnerable,” she said. “If they are mistreated in that setting, that can be a really distressing experience, and it can discourage them from coming back and getting the health care they need.”
“We know that there is a lack of LGBTQ+ curriculum and training hours across basically the entire field, and not just at UCSF,” said Matthew Beld, MPH, who identifies as non-binary. “What that means is students receive very minimal training on LGBTQ+ health – and even the basics of LGBTQ+ identity: What is considered sexual orientation? What is gender identity? What is gender expression? And why are pronouns important, especially in the examination room or the research office?”
We wanted to advance care at UCSF generally, to make sure that the staff were able to get the training that they needed to make sure that clinical spaces and education spaces were really inclusive for LGBTQ+ people.
According to forthcoming research, some 30 percent to 42 percent of people in a sexual or gender minority (SGM) report experiencing discrimination in health care settings, said Flentje, and those experiences can lead to hesitancy in receiving medical care, which can have all sorts of long-term negative effects, like higher rates of cardiovascular disease and smoking, as well as delaying checkups. All of this is especially relevant now, when vaccine hesitancy has contributed to the ongoing COVID-19 crisis.
Addressing this disconnect between health care providers and SGM communities inspired Flentje to develop the LGBTQ+ Health Certificate Program through the Center. The certificate program builds on UCSF’s pioneering work in LGBTQ+ health care and is open to all UCSF staff, faculty, students, fellows, and residents. The program has had one cohort of individuals, and one entire clinic to date, with plans to enroll an additional cohort once it receives additional funding.
“The health certificate was really designed to be a way for people who wanted advanced training in LGBTQ+ health,” she said. “We wanted to advance care at UCSF generally, to make sure that the staff were able to get the training that they needed to make sure that clinical spaces and education spaces were really inclusive for LGBTQ+ people.”
Flentje and Beld spent a year hosting discussions and focus groups “to learn what people really wanted to know and what their level of knowledge was,” said Beld, and from those discussions, they developed the certificate.
Program participants across disciplines complete four hours of classwork together and then dive deeper into focused study. “The idea was to build a really customizable certificate, so that there could be a standard level of training plus specialization in a person’s specific area of focus,” said Flentje.
That focus culminates in a project proposal to encourage change across the institution. For example, recognizing that LGBTQ+ patients can have unpleasant experiences at intake with misgendering or ignored partners, a clinical staff person might propose a project to see how to improve that intake process, said Flentje. This customizable approach allows for more targeted interventions at exactly those points where health care is most likely to fail LGBTQ+ people.
Working Against Decades of Stress
The certificate program was born out of Flentje’s own research into minority stress. “We have a pretty good body of evidence that shows that a lot of these mental health disparities, and even some physical health disparities, that were discovered among LGBTQ+ populations have direct relationships with stigma and discrimination – with what I think of as minority stress,” she said.
Her research, led by her colleague Nicholas Livingston at the National Center for PTSD, was able to find, among other things, a connection between mistreatment and the likelihood of subsequent substance abuse and other adverse outcomes.
“In our clinical trials testing interventions to reduce minority stress we’d see that people were modifying their behavior based on an experience that they had 20 years before, doing things like never holding hands with a partner at a certain block in the city because they were called a name there once and it felt very dangerous. That was 20 years ago – we’re carrying that type of stress for 20 years,” she says. “We know that stress can exert a really strong effect on the body and affect development of illness and a whole range of biological processes.”
Over the last few years, it’s become clear that these stresses aren’t just individual burdens, but create “adverse outcomes” at a population level, too. With vaccine hesitancy a factor in COVID-19 hospitalizations and deaths, the Center hosted discussions earlier this year on how LGBTQ+ folks might view the COVID-19 vaccine.
“We discussed what barriers there might be to getting the vaccine, and personal experiences with friends who are LGBTQ+ that just don’t necessarily trust medical institutions,” said Beld, “and the work we’ve done to try and convince them that the vaccine is safe – you really should get it.”
Bay Area and Beyond
The first program cohort was 29 people: 13 students, 13 staff, and three faculty. “And they come from almost every area at UCSF: We had School of Medicine, Nursing, Pharmacy, and Physical Therapy represented,” said Beld.
While other LGBTQ+-focused programs in the United States focus on clinicians, UCSF’s program integrates students, staff, and faculty and can be adapted to a variety of health care environments, said Beld. “Rural clinics, teaching hospitals, research groups that are interested in including LGBTQ+ populations and their studies. Our goal is to expand this out.”
“We built a certificate program that is flexible enough that a full professor who’s been in academia forever can complete it, but also, a security guard can complete it, a new medical student can complete it,” said Flentje. “So we’ve tried to make it flexible enough so that it can be customized to really enhance everybody’s knowledge and meet them where they are.”