Building Health Equity: Improving Health Equity in the LGBTQIA+ Community
Podcast Transcript

Intro Narrator: Welcome to Share Public Health, the Midwestern Public Health Training Center’s podcast, connecting you to public health topics, issues, and colleagues throughout our region and the country, highlighting that we all share in public health. Thank you for tuning in to Building Health Equity, the Institute for Public Health Practice’s series highlighting health equity practice throughout Iowa. Over the course of the series, we will be inviting speakers to dive deeper into their experiences in health equity practice to serve as a learning enrichment opportunity for health department staff and anyone interested in building health equity. As a heads up, these podcasts have been reformatted from the original Building Health Equity Webinar Series recordings.  

Tricia Kitzmann: Welcome to the sixth installment of the Building Health Equity Webinar Series, Improving Health Equity in the LGBTQIA+ Community. I'm Tricia Kitzmann. I am a program coordinator with the Institute for Public Health Practice at the University of Iowa College of Public Health. Now, I'll have our guest speakers introduce themselves. And then, after that, we will move into some discussion questions. Maxwell, I'll kick it off with you.

Max Mowitz: Y'all, my name is Max Mowitz. My pronouns are they and he, and I am the program director at One Iowa. In addition to that work, I'm a community health worker and a full spectrum abortion and transition doula.

Tricia: Welcome. Thank you. A-M?

A-M Racila: Hi, I'm AM Racila. I'm a postdoctoral research fellow in internal medicine at the University of Iowa, and I'm a trained medical anthropologist. And my pronouns are they and he.

Tricia: Wonderful. Thank you. I guess, I did forget to add my pronouns. They're also on my screen, but I am a she/her. All right, so we'll go ahead and get started. Give us a little bit of your background. How did you start working with this community? And what do you do? What specifically do you do working with this community? A-M, we'll start with you. We'll kick it off there.

A-M: Sure. I have been working in, I guess, gender-affirming healthcare since at least 2014, I guess, in a graduate setting, in graduate school. My dissertation research investigated how gender-expansive patients and clients and gender-affirming providers navigated gender normative healthcare bureaucracy. And all of this is through, it's qualitative research. So, what I did is I observed practices and clinics and I interviewed patients and that work's continuing now. So, part of my work, I'm still working in gender-affirming health. We recently complete a project in the department of urology, a qualitative project interviewing participants about experiences they've had on gender-affirming hormone therapy and expectations they've had about it. So, that was my research project. Yeah.

Tricia: Wonderful. Thank you. Maxwell?

Max: I just wanna say, every time I hear you share about your experience and your work, I get really, really excited. So, I'm just so excited to be here with you and share space and knowledge. So, I started LGBTQ advocacy work back in 2010 when I came out, and really focused on community education and engagement. Since then, my activism and my advocacy work has changed a lot. But I would say that I started to really focus in on working with trans and non-binary individuals and doing the work that I do at One Iowa in the 2018, 2019 range. So, I came out as a trans person in 2018 and that's when I really decided that that was advocacy work that I wanted to commit my life to. I had done a lot of different work in different areas before then, but really wanted to zero in at that point. Then, I was hired on as program coordinator at One Iowa in 2019. And that is a dream job, I have to say. I love being in this role. And so, with that, I've been able to reach my community health worker certification, which has been amazing. So, I actually provide wraparound services to LGBTQ individuals. I have been a community health worker at the LGBTQ UnityPoint Clinic here in downtown Des Moines, which has been a really, really cool experience. In that time, separate from my work at One Iowa, I have received certification to be a full spectrum birth doula and abortion doula, and then work on my own as a transition doula, helping to provide trans and non-binary people with support as they transition. So, a lot of my work has to do with understanding how folks transition and the ways that they might need support and advocacy in that process, but also recognizing the ways that LGBTQ people are disproportionately impacted by healthcare barriers in the state of Iowa. One of my favorite parts of my job at One Iowa is that I get to provide training and support to doctors and physicians and mental health providers that want to be more LGBTQ-inclusive. So, there's a lot of sharing of best practices, support and counsel that comes with that as well. And we really try to also pay attention to and target rural healthcare providers as well, in addition to creating a resource guide, so that LGBTQ people can actually access those inclusive providers once they've been appropriately trained and vetted. So, that's a little bit about what I do and the different roles that I hold.

Tricia: Maxwell, I'm gonna have you just briefly, since we do have quite a few folks that are outside the state of Iowa, could you just describe what One Iowa is?

Max: Yes. (laughs) As you can see, I get ahead of myself!

Tricia: No, no, you're totally fine.

Max: Yeah, absolutely. So, One Iowa is the statewide LGBTQ advocacy organization working primarily with adults. There's another amazing LGBTQ organization that works with youth called Iowa Safe Schools and the queer center in Des Moines. But we work primarily with adults in the area of healthcare access, workplace culture, and leadership development.

Tricia: Awesome. Thank you so much. I appreciate that. Okay, so just to make sure everyone is on the same page as we kick off today, and I wanna make sure folks in our community that are watching today, also be able to understand who in the population we're talking about. So, to start off, can you define what LGBTQIA stands for and the groups that align with this community? And I don't know who has the preference to kick that one off to define for me, but that would be great.

Max: I find that everyone has slightly different answers to this. So, A-M, feel free to pop in and correct me if there's a variance here, but I'm happy to take this one. So, we can start at the very beginning. L stands for lesbian. A lesbian is typically a woman that is sexually and/or romantically attracted to other women. G stands for gay. A gay person is typically a man who is sexually and/or romantically attracted to other men, although gay is often used as an umbrella term. So, you might be familiar with Ellen DeGeneres. She identifies both as a gay woman and as a lesbian. So, that's cool when that happens. A bisexual person is what the B stands for, and a bisexual person is a person that is sexually and/or romantically attracted to people of two or more genders. That's where we get the bi in bisexual. And T stands for trans or transgender, which describes a person that does not identify with the sex that they were assigned at birth. Q can stand for both queer and questioning. A questioning person is a person that's figuring out their sexual orientation, their gender identity, or both at the same time. And a queer person is a person that's part of the broader LGBTQ community. And there are as many ways to be queer as there are queer people. A couple of other terms that sometimes come up, A can often come up and that stands for asexual. An asexual person is a person that does not have persistent sexual attraction to other folks. And that exists on a spectrum in and of itself. The I that you might interact with stands for intersex, and intersex person is a person whose biological anatomy and/or genes vary from the expected male or female hormones, chromosomes, internal and external reproductive anatomy. And you might also see two S which stands for two-spirit, which is specifically a native or indigenous individual that might identify, depending on their tribe, so I don't wanna paint with too broad of a brush here. There's so many different ways to be two-spirit. Might identify as a third gender or multiple genders in their tribe or even as a fourth or a fifth gender, and often have an honored or revered role in their tribe. Did I miss something, A-M? I just said a lot of words.

A-M: No, I thought that was super comprehensive. I've seen a little bit more rarely maybe, but A also for agender if folks want to stay, maybe not necessarily identify as transgender, but agender. So, not identifying with gender identity. Yeah, other than that, yeah.

Tricia: Wonderful. Well, I know when I started working with HIV and AIDS way back in the '90s, A also stood for ally, and that we are advocates as well. So, I know long time ago that was also an A that was added at the very end as somebody who would advocating be an ally for this community. So, thank you, both. It's a lot to learn and it's a lot to understand. So, I appreciate us taking time to make sure everyone is on the same page as we move forward. So, kind of our first little bit tough question for you. And, A-M, I will let you start off with it: What are the most pressing health concerns among the LGBTQIA+ populations in the Midwest?

A-M: The big one is access that I've, I guess, encountered through my work and have read about in rural areas. And it's the small amount of providers that are trained to provide the care are scarce. And so, people are traveling quite a distance, I know, to the clinics at the University of Iowa, it's one hour or more people are traveling for care. And so, that's a big problem, because there's a lot going on, I guess, behind the scenes of that of not even, being at the clinic before that there is trying to schedule transportation maybe if you don't have a car and scheduling your work, workday around taking time off to be able to go to the clinic to attend appointments. So, healthcare access is a huge issue. And the consequences of that are, the health consequences are less frequent, preventative screenings since you're not, maybe you're not keeping the same, you're supposed to be seen every year, every couple years for something and you can't be. I think the healthcare discrimination that this community has faced, leads to conversations that are not being had, for example, about, sexual health. And so, that's a problem, and that can lead to issues like health consequences. Those are the two that I... And I've also read that LGBTQ folks are less likely to have health insurance and coverage. So, those are the issues that come to mind for me.

Tricia: Maxwell, do you have anything else to add?

Max: Yeah, I mean I think A-M hit the nail on the head. I think that access is one of the things that I see most often in my work in clinics and in my work working with trans and non-binary individuals. I've seen people have to drive three, sometimes even four, you know depending on what part of the state you're in. It's so wild how far people have to drive and just like they said, that's a half day off of work, that's time off of school. That might be a hotel room, gas, like all these different things. I think, the other thing is that we are seeing that LGBTQ folks are less likely to access things consistent in recurring screenings for things like cancer as was already mentioned. And I think, a part of that is of course access and a part of that is also intentionality in the way that folks approach talking to LGBTQ people about that. So, we've actually worked with some incredible folks at the Iowa Department of Public Health, especially in the Care for Yourself program that are really trying to do the hard work to make sure that trans and non-binary people are included in breast, chest, and cervical cancer screenings, for example. And additionally, I think, that there are a lot of providers that really want to provide this kind of care, but don't know how to, and don't also know how to connect with the folks that need that care as well. So, again, all these different kind of components of access. And then, of course, the other thing that I think about are the barriers as it relates to being discriminated against in these healthcare systems. This is a nationwide statistic, but we've seen 41% of rural LGBTQ folks have been turned away from hospitals. So, that's for basic healthcare needs. And so, that's something we have to pay attention to as well in addition to medicalized racism, medicalized ableism, medicalized fat phobia, which also all intersect with LGBTQ identities as well. So, I think, if we're going to see LGBTQ people as whole people, we wanna make sure that we're also paying attention to disparities as it relates to their other identities and recognize that that's an intersectional kind of approach we have to take.

Tricia: Great, thank you. I'm gonna throw this question in there as well. So, do you find that a lot of the LGBTQA population not being able to find a primary care provider? 'Cause that's what insurance companies want, that your point of care, your primary care provider. And are they struggling being able to even find that kind of access, because you... Even if you have insurance, you can't necessarily go to a specialty clinic or additional clinics if you don't get the referral from your primary care provider. So, what kind of barrier do you see with that when it comes to that kind of healthcare or additional healthcare, I should say? A-M, you wanna kick that one off?

A-M: So, I think, like from my work and the work I did, the primary care providers were very... Specifically, I worked with gender-affirming healthcare primary care providers. I think, the kind of communication and conversation that happens, the rapport that's built, is different. And that's what's... It's like a... And we'll talk about this later too, but suspending assumptions about relationships and being open about different ways of being. And when that rapport doesn't happen, that's what makes people struggle to find someone, a primary care provider.

Tricia: Absolutely.

Max: Yeah, one thing I think of in terms of root issues too is that so many, we've already talked about this a little bit, but so many LGBTQ people don't have insurance and don't have stable housing, don't have stable access to food, don't have stable supports that they need. So, we're finding that not only are folks not getting routine checkups, they're not thinking about what's gonna happen with a breast or chest cancer screening. They're worried about where their income is coming from for the next week. And so, I think, when we pay attention to how people are connecting with a primary care provider, I think, the lack of health insurance is a big piece of that. And then, the lack of the basic needs being met is also a big piece of why folks are just... Maybe in a lot of the situations where I will chat with clients, they're only seeing a primary care provider, so they can actually access gender-affirming care, because that is what's pulling them to that place, and not the ongoing preventative care that we wanna be seeing, because again, it's just a matter of what do you have the time, capacity, and income for. So, that's something I think about a lot as well, but we see throughout the state of Iowa that many primary care providers don't know how to work with LGBTQ individuals. Now, there are many, too many to shout-out that are amazing and wanna do that hard work, but a lot don't have the education and support needed to provide care to LGBTQ individuals. And so, what we see is harmful healthcare experiences. From the National Center for Transgender Equality, we've seen 33% of trans and non-binary people have had one or more negative experiences with a healthcare provider in the last year alone. It bumps up to over 60% for within someone's lifetime. So, it's very likely that somebody has had a negative experience with a healthcare provider and that's also weighing that they're not getting a primary care provider because they've had these negative healthcare experiences and don't wanna go back. So, we see the barriers just in terms of basic income, basic needs being met, but also these harmful experiences with providers keeping folks away.

Tricia: So, with that, what can be done to reduce the stigma in healthcare settings and make this population feel more welcome in accessing healthcare services?

A-M: So, I was thinking about this one this morning, but kind of curating the space. In the actual hospital environment, if you have brochures or things like that, really representing different kinds of people in those brochures, having inclusive intake forms that include gender options beyond male and female. Those kinds of things show that you're thinking about, that you're committed to working through these issues. And there was one more thing that I wanted to mention too. Gender neutral restrooms in the space is a big one. Oh, and resource lists, that's the one that I wanna talk about. Wherever you're located, I know there are folks that are outside of Iowa, too, if you can collect lists of mental health services, other services in the local area and have those brochures readily available in the office or in your healthcare environment, that's super helpful as well. 

Max: I love all of those. I think those are really important components and I also think that appropriate training not only for providers and nurses, people who will be working with clients and patients and in that kind of way, but also one thing we recommend is training and extra information for administration. Right? So, if a person walks in, no matter if the provider knows their correct name and pronouns, if that front desk person who's very important, the receptionist, that administrative assistant, if they don't know the basics of using someone's correct name and pronouns, that's going to keep that person away. I mean I know people that have gone in to see the doctor, it's taken them a lot of effort just to get there, because they're so nervous. And then, the second they get deadnamed, they're like, okay, I'm outta here. And they don't go back. So, making sure that everyone from the phlebotomist to the provider knows how to provide care as well. But one of the things that I think of that's less nuts and bolts but is to slow down. I think, that the thing that a lot of providers come across is having to go pretty quickly throughout sessions. And with that comes almost the need to know exactly how to treat someone and exactly how the session's gonna go. And so, by slow down, I mean ask good questions about the way that somebody wants you to refer to their body parts, explain what you're going to do thoroughly, so that person can ask questions. Make sure that you are checking in and doing thorough and thoughtful reproductive healthcare screenings, which ask about the body parts used during sex, not the gender of the partners. All these different little things that can come together along with paying attention to your own biases around gender identity and sexual orientation, and not assuming the gender identity or sexual orientation of anyone that comes into your doors. And being consistent in asking everyone you see about their pronouns, everyone you see about their gender identity, things like that. So, I really try to recommend to providers to slow down a little bit and if you're not sure of the answer, if you're not sure how to give that client or patient the best care, just bring them in on that process and ask them, hey, I wanna provide you this care, I want to refer to you respectfully. How do I do that? Help me in that process. And connect with them as a human in that way.

Tricia: Thank you. I wanna share a comment that was made: "I will add that it is harmful for clinics to post rainbow flags and provide inclusive brochures if staff do not actually understand or embrace the inclusion." And seeing some head nods that yes, it's not easy if not everyone's on the same page or understands what services and that. So, being able to provide additional training and services for staff before you take that leap. I think, that's, as you said, Maxwell, that can be detrimental if you don't slow down and be able to address the proper manner. Okay. "As a non-binary provider, this is so important not to assume the deadname - the client's or the provider's." So, great comment. Thank you. Next question. So, what programs, policies, or interventions have you seen implemented that have worked to create a more welcoming environment for the LGBTQIA+ populations?

A-M: One thing that I've personally seen that has changed over time and I saw get implemented are SOGI so sexual orientation, gender identity collection fields in medical records. That integration into the healthcare bureaucracy itself is super helpful. I know the UIHC, we have that capability to capture this level of detail and then you can also see it how it changes over time. It's been very helpful. And also, there's a patient-facing portal that you can enter that detail in and then it shows up on the front of your medical records. So, people, whichever providers are accessing it can see identities there.

Max: Yeah, I, not to be a huge dork, but I have gone to UIHC for medical care before, for gender-affirming care, and had that experience with that and it was so cool to be in a space like that where I knew that my provider would get the correct kind of communication about who I was and how to treat me, so I can just speak from personal experience about that system and we see that in the Epic system, with UnityPoint, Planned Parenthood, all of these different healthcare providers are recognizing the ways that that can be really meaningful and impactful. The thing that comes up for me with this is: Include LGBTQ people in the work that you're doing. I have seen the most positive impact happening when state departments, hospital systems, whoever it is, brings actual LGBTQ people into the fold and ask them, and bringing in folks in with expertise in that area. So, it has been an incredible privilege to get to work with places like LGBTQ clinics, the Iowa Department of Public Health, to be able to develop more comprehensive healthcare materials and outreach because they actually have LGBTQ people on the team, and really paying attention to who's at the table when those decisions are being made. I can lose track of the amount of people that have come and done that and seen really positive outcomes. And that's how we kind of change the narrative around LGBTQ health and wellness is trying to create more equitable systems that actually include and involve LGBTQ people, not just what cis and straight people think LGBTQ people want. That's something that always pops up for me too.

Tricia: Wonderful. So, we have a question in the question and answer. "So, a lot of Linn County's forms have the option to include a salutation, Mr, Ms, et cetera. Are there any non-binary salutations that we should include or update on our forms or are there any salutations that they should get rid of entirely?" Who wants to kick that one off?

A-M: I guess I can go. A non-binary option I've seen is capital M, little x, pronounced mix. So, that is one kind of salutation that I've seen. I think, if you need to keep them, keep them, but if not, I mean that that's okay as well. So, I guess, that's my answer to that one. (laughs)

Max: Yeah, fully agree. "Mx" is great to have, but again, how are you gonna collect all that information for all people? If you can, then you can, but you can always just remove it and most people don't notice. So, it takes one less thing off of your plate to be thinking about. And that way, you're just using their first and last name.

Tricia: Wonderful. Well, and thank you for the question and appreciate your guys' input. What would you change about these programs policies or interventions to improve the LGBTQIA+ health? So, what we just discussed, what changes would you recommend, if any?

A-M: Yeah, so I guess, two things about the healthcare bureaucracy. One is, and I think, we talked about this a little bit earlier maybe, but having an organ inventory. So, that is like more, you know what do we need to know from the body standpoint in terms of health? And then the organ inventory also, because people go through life and you're having surgeries, you're removing organs, et cetera. And so, after some time for a lot of people, sex assigned at birth does not mean... You know, you make assumptions. There's assumptions attached to that phrase, sex assigned at birth, of what organs are there, et cetera. And so, having more nuance in that area would be great. And then, regarding systems like Epic that are great right now, you can take that further with adding pronouns to that as well.

Max: All good answers. I was just pondering, 'cause I didn't wanna repeat anything that I said. I'm just chatty, so I could easily do that again. So, (laughs) yeah, I think, that one of the things that I see that we focus on a lot at One Iowa is paying attention to what's happening with upper administration in your healthcare setting. I have so often seen some providers, some nurse practitioners that are really excited, that really wanna give the right care, and they are not backed up by the right people that can actually create systems change. And so, that's where we see providers feeling overwhelmed. They feel already like they're going to fail because they don't have that backup from upper administrators, HR, people like that. Because ultimately, the folks that need that training, the folks that need to be dedicated to this work need to come from all parts of the hospital system and the healthcare system, not just the the provider. Although that's a really, really key person, right? So, one thing that we really pay attention to is how do we create system change within these larger healthcare settings, so that not only do front desk staff and providers know how to care for somebody, but the folks that work with them to manage insurance, know how to work with them, and upper administrators are really paying attention and are incentivized to make those changes as well. Because often, you need buy-in from those folks to change things in Epic, for example, to involve tech in that, things like that. So, that's one thing that I think, is a really big piece that I often don't think about, but we're trying to flip the script on.

Tricia: Wonderful, thank you. So, what roles can health departments play in ensuring that the LGBTQIA+-identifying individuals are able to access the resources that they need and feel comfortable doing so?

Max: Okay. So, a couple of different things that come to mind is first, health departments just do anything for LGBTQ people, (laughs) which is not to say that there's not a lot of things happening, but so often, I'll work with organizations that are like, "This is our first time ever considering working with LGBTQ people." So, that's the place to start. Any amount of thoughtfulness in that area is gonna be really important. But beyond that, I would say do LGBTQ-specific care work, do LGBTQ-specific campaigns. There's, again, I can speak to so much of the amazing work that like the Care for Yourself program in the state of Iowa does around breast, chest, and cervical cancers. They do LGBTQ-specific posts. They talk about LGBTQ-specific statistics and pay attention to those intersections, right? How are we seeing public health be impacted not only by homophobia and transphobia, but also by racism, et cetera, et cetera? So, my recommendation would be to start the process even if it feels overwhelming. Connect with people and resources that you have that can be me and A-M, but it could also be other folks that do work within your communities, 'cause they're gonna know even better. And change your language and start doing targeted campaigns and outreach for LGBTQ individuals. So, yeah, that's what comes to mind for me.

Tricia: Awesome.

A-M: Yeah, in addition to that... Part of that was feeling comfortable doing so, having something readily accessible. I know at UI, we've got, and I'm gonna drop it in the chat, we have a page dedicated to resources for trans communities. They're allies at Iowa. And as part of this page, there's a map of campus. Non-gender specific or gender neutral bathrooms are included on that map. And so, there's a ton of resources available there. So, maybe having some way to have an easily accessible page on your public health site or your local webpage is helpful.

Tricia: Wonderful. So, we talked about what role can they play. And I think, you both touched on this, but just to make sure we provide any additional support to local public health that may be on today: Are there specific steps that you would encourage them to do, especially, I think, Maxwell, you touched on the fact that, you know, just starting the conversation is the first step, wanting to be actively involved in being a part of the openness of making your clinic feeling safe and welcoming. But what do those steps look like? What might that be for local public health agencies that need to feel empowered to make that first step, even if they're not maybe the administrator or the higher ups that need to have that buy in? What can an individual do to start the process to be more welcoming, I guess, I should clarify that, to be a more welcoming clinic. (laughs)

Max: Yeah, absolutely. I think a few first steps can happen. First, look at your local community and see if there's any LGBTQ groups there. It's gonna be really helpful to be connected with the folks that are doing that good work in your community first. If there aren't any folks or if you have connected with them and need additional support, hit us up at One Iowa. So often, I'll get emails from that one person that's like, I wanna do better, how can I? And that has a huge ripple effect within their organization. So, I would love to hear from you. Please reach out. And One Iowa does a lot of that training, that support for organizations that want to be more inclusive and thoughtful in working with LGBTQ community, we can share best practices, things like that. And then, I would also connect with other people in other communities that have done the work you're trying to do. So, U Iowa is a really, really good example, UIHC, UnityPoint, Broadlines, all these different organizations. And those are just to name a few. I recently worked with Black Hawk Public Health, and they are doing really cool things within their organization to try to change things. There are small community health centers that are doing incredible work. So, I'm trying to connect with others because sometimes, it can be nice to say, "Okay, well, Max from One Iowa thinks we should do this." But it's even more powerful to say, "Okay, this provider in this other community has done this, how can we look at that as well?" So, sometimes, you can get some more sway if you show an example of another organization similar to yours that is doing the work as well.

Tricia: Wonderful. A-M, do you have anything to add to that?

A-M: That was a very comprehensive... (laughs) I don't know, I'm thinking a lot about, I guess, in what I'm doing. One of the things I really want to help change the script on is how to move research forward in this area, too, intentionally in the way that Max mentioned earlier of having it be a community engagement process and making sure that it's actually a... That people that the research is supposed to impact is, it's actually responsive and not like you were saying earlier, what researchers think that communities want. So, anything in that area that can push that forward I think, is really important too. And that, for me, I think looks like first of all, like transparency about what you're doing in your research and how it will impact the community. So, those are things that I'm thinking about.

Tricia: Great. Thank you. Are there any common misconceptions about members of the LGBTQIA population among public health or health professionals, educators, or advocates that should be corrected?

Max: One thing that I like to ground and center in is that, you know, we've talked a lot about disparities today and of course that's the focus of what we're doing, but the one thing that I think, is a misconception, is that there are disparities in pretty much every area of health for LGBTQ people, but we are deeply resilient patients and clients. Right? We have community and family systems that exist outside of what you might normally see. We have chosen family and chosen communities, and I believe that there's a lot of LGBTQ joy that comes to the table as well, and a really profound sense of self-advocacy. Because in order to come out even to yourself, you have to want to advocate for yourself. You have to care about who you are in some way, shape, or form. And so, I think, that one thing that is not often thought about or is a misunderstanding is that LGBTQ people aren't interested in having better health outcomes or don't care, but really, it's those barriers that we see so often because there is such a high level of resiliency and self-advocacy that comes with being LGBTQ. And you will find that LGBTQ patients and clients are very driven to care for themselves and self-actualize as well. So, that's something I see a lot in my doula work as well, is this really beautiful part of LGBTQ healthcare that is getting to work with LGBTQ people, 'cause we are awesome. So, that's something that comes up.

Tricia: Wonderful.

A-M: Yes, I echo that a hundred percent. And also I want to add that, even before people are coming to the clinic, there's a lot of community knowledge about what people are experiencing. And so, people are coming with that to their appointments. They're not necessarily learning from their providers. People are learning from each other and their own experiences, healthcare experiences. And then, someone wrote in the chat that asexual sexual health is one thing, a hundred percent, that has been just, I think, there's still framings that it's, like you were saying, Cameron, that it needs fixing, that there's something wrong when it's a just a variation of natural diversity. And so, it's a really important point as well.

Max: What you just said made me think of this as well. I think, there's a rich history in LGBTQ relationships with healthcare and mental healthcare providers in pathologizing being LGBTQ. Right? As a thing that's wrong with us that we need to fix. And of course, that applies to asexual folks as is mentioned in the chat. But being trans isn't something that you fix through gender-affirming care. Right? That's not the goal. So, I think, sometimes, providers view it as, okay, something's wrong with you and we have to fix it. Whereas we wanna see being LGBTQ as like a beautiful gift and a part of a larger person, a person that has a lot of different components and experiences as well.

Tricia: Wonderful. Thank you. Maxwell, A-M, you have this platform and this opportunity to share your expertise. What else haven't we touched on that you would wanna make sure that they're leaving with? What would be some of the key messages that you wanna make sure they're walking away with?

Max: Well, I want to really bring home that you being on this webinar, you making the little changes that you're making in whatever component of the system that you're part of, those things really matter and they are sometimes life-saving. Right? Whenever I'm part of a panel like this or whenever I get to talk to providers, administrators, researchers about these issues, I just want to instill this sense of gratitude that I have, because I've seen in my own life, in the life of my clients and in the life of my loved ones, my friends, my partners, that this work is really, really important. And it doesn't just happen in a vacuum, right? You are impacting folks' health and wellbeing in ways that you might not even realize by trying to move forward and make some of these changes. So, I would remind that. And then, I would also say in this work, be sure to stay human, and connect with what makes you human, what calls you to this work, and ground in that. I find, like I said before, so often with providers, they feel like they need to know all the answers, they feel like they have to be perfect when really what we wanna be is human and bring our patients and clients in on the process of getting care, and slow down and ground in that first. So, to summarize, I would say, you're doing amazing things no matter what those things are, you are pushing the needle forward. And you should remember that that is going to really change some folks' life. And also, that being human and showing up as yourself with your lived experiences is also valuable to this work as well.

A-M: Yeah. A hundred percent agree. And then, I guess, for the final point, from my end is really what we've been talking about a couple times is making sure that the people who are, I guess, impacted by the change are present in these discussions too. So, yeah. So, the communities that are affected by these changes are part of the changes and their voices are being heard. Just overall, I think, that's really important and then that's how we can shift historically - what we've already talked about the pathologization historically of these communities is really creating that kind of communication between healthcare systems and communities.

Tricia: I think, in my past, when I've worked at the local public health level and being a part of trying to make change and making us a more welcoming community, I've been at local public health agencies for the last pretty much 20 years of my life and I think, one of the things that I've always told my team when I've worked with them is that, Maxwell, to go back to your point, we're human. So, I think, it's okay if you make a mistake. It's just acknowledging that and being able to move forward and make sure you're sensitive and being able to apologize that there are things that happen as we learn and grow. But also knowing that I think, it's better to-- I'd rather make a mistake than not to make anything at all and not make any effort to work with the LGBTQA community. I'd rather fumble. I don't mean to, but also to be able to say, hey, I'm human, I'm learning this, but I wanna be open, I wanna help you, I wanna be there, I wanna be supportive. And I think, that that's a key piece as I think, a lot of times, a lot of local public health agencies, team members, they're intimidated. It's scary when you're learning something for the first time and also knowing that sometimes you get that one chance as a provider. You get that one opportunity and if someone doesn't feel comfortable, it can be very scary worrying that you may impact something in a negative way. But I think, as long as you can walk in with an open, honest conversation, I think that's one of the things that we've always worked on when I've been working with my teams on those issues.

Max: I did wanna shout-out, I got a private message question, so I'm just gonna share that really briefly. So, the person says, "I'm curious to hear about your experience working as a doula and the maternal health sector that can be more inclusive and non-cisgender individuals accessing that kind of care. Would I be able to share more?" Yes. So, it's called maternal health. Right? That in and of itself is pretty gendered. And it's really important that there's a lot of different things that we can talk about when it comes to being more inclusive of folks that give birth, birthing individuals of all different genders, from small changes like changing your language to parental health, birthing people, et cetera, et cetera, nursing rooms instead of mother's rooms. There's also all little different things that you can do, but I also think that if you are a provider that provides prenatal care for example, and if you've never worked with a trans or non-binary birthing person before, there are a lot of different resources for you to take care of that person and provide care for that person, alongside the healthcare best practices that we see anyway. But I would say that those systems are really not safe for trans and non-binary individuals. It's really scary to give birth as a trans or non-binary individual. And so, we want to be paying attention to that, especially when we also pay attention to the ways that, for example, black parental health is an issue that we're facing in the state of Iowa, and we're one of the worst states in the nation for black parental health. So, how do we pay attention to those things as well, those intersections? But I have so many thoughts and best practices in this area, so if you're ever interested in learning more, I'd be happy to connect as well in that area, too. But there's so many interesting ways that you can provide support to trans and non-binary birthing folks that you might not otherwise think about.

Tricia: Great. Thank you. I just wanna share another comment that was put in the Q and A just so our audience sees it or hears it as well. "Yes, straight cis people are so toxic. Also, doctors assuming that because someone has a partner of a certain gender that they don't have or haven't had partners of other genders." And so, just wanted to share that comment that it can be frustrating and that's one of those things to never make assumptions.

Max: It's a great point. I'm really, really glad that that person brought that up, which is why I just believe in the power of a really good reproductive healthcare screening. Not only talking about the genders of partners that are involved, but also the body parts used during sex. So, we're not assuming like, oh, I have a girlfriend, and that means that that person has a cervix and a vulva, and all these different things, right? Because we know that that's not the case for people of all genders. So, really kind of deconstructing some of those notions around what a sexual health screening can look like and being more thorough in sexual health histories too, and not being afraid to use the word vulva and cervix and anus and penis, and things like that. Being really specific and providing care by really becoming an expert on the person sitting right in front of you can be really helpful. But again, I think, the number one thing that I say in trainings is just stop making assumptions. Don't make assumptions about people's sexual orientation or gender identity based on how they look, talk, or act. And don't make assumptions about somebody's sexual health history based on any of those things either. So, always be fact-finding, always be learning more and don't ever make any assumptions.

Tricia: That's great advice.

A-M: A small point, I guess, going along with that is just a note that some people use different terms for their body parts and to just be aware of that as well. If you're a provider here today and you work with these communities, just to know that some people are using different terms, too.

Tricia: Absolutely. Thank you. So, in closing, Maxwell, A-M, thank you for your expertise. It's been a pleasure moderating this today. I appreciate your patience. I appreciate your enthusiasm and just your expertise. It's been a pleasure you sharing everything with us today. I encourage our participants to subscribe to our building health equity email list. You can find that on our website. The next webinars, they are always the second Wednesday of each month. Our next one will be discussing disability, justice, and health equity. Again, thank you, everyone, for your time today. I appreciate it. Have a wonderful day. Maxwell, A-M, you guys rock. You're awesome. So, thank you for spending the afternoon with us today.

Max: Thanks for having me.

A-M: Yeah, thank you so much. Thanks.

Tricia: Thank you.

Outro Narrator: Thank you for joining us today. Special thanks to Tricia Kitzmann, Cynthia Maharani, Natalie Peters, Melissa Richlen, and the speakers who have shared their expertise with us. Theme music for the Building Health Equity podcast series was composed and produced by Dave Hoing and Roger Hileman. Funding for the Building Health Equity initiative is provided by the Iowa Department of Health and Human Services. Please see the podcast notes for an evaluation link and transcript. For additional resources and information, or to view the video webinar recordings, be sure to visit www.buildinghealthequity.com