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Faculty combine research, practice to address LGBTQ+ health disparities

Paige Ricca and Wendy Bostwick

The UIC College of Nursing is home to some of the country’s foremost experts on sexual and gender minority health. We brought two together to discuss how research and practice meet to inform care for this population. Heading link

Clinical assistant professor Paige Ricca, DNP ’17, RN, is an LGBTQ+ community advocate who has worked as a wellness nurse for sexual- and gender-minority youth.

Associate professor Wendy Bostwick, PhD, MPH, has been conducting research on health inequities among sexual and gender minority populations for 20 years.

Wendy Bostwick (WB): Baseline, we know that sexual and gender minorities do experience discrimination, mostly in the form of microaggressions. We know that trans and gender-nonconforming or non-binary people are especially likely to experience discrimination in healthcare settings. Just generally, we know that bad care experiences mean people don’t go back to seek care.

Paige Ricca (PR): I hear these types of stories working with youth. I’ve been on the wellness team for the Illinois Safe Schools Alliance – Action Camp [a five-day camp that brings together LGBTQ+ youth leaders and allies] four times. It’s a camp for youth from all over Illinois. They tell me they’re driving two hours or more from the middle of Illinois to go to the Howard Brown Health Center [a federally-qualified health center serving the LGBTQ+ community], because that’s where they felt the safest. They’re not going to go because they don’t want to be traumatized by that discriminatory experience.

WB: There is a way in which healthcare systems and structures propagate health inequities. We tend to think of “healthcare” as a solution to disparities. That’s not always the case. Sometimes healthcare creates, promotes and exacerbates disparities. Research shows that discriminatory experiences in a healthcare setting will cause people not to go back, to delay seeking care, to delay treatment, which can worsen problems to such an extent that then people only show up in the ER. It’s a bad cycle that’s not what we want to be happening, especially if we’re trying to think preventatively.

In a city like Chicago, yes, we do have plenty of places that are LGBTQ focused. There can still be quite a dearth of either allied or actual queer providers in rural populations. That’s why systems and structures matter.

I think an upside of telehealth is that people may better be able to find affirming providers.

PR: When I worked with 360 Youth Services out of DuPage County [which offers housing, counseling and prevention services], there was only one provider that the director felt that she could recommend to her LGBT or non-binary youth. In DuPage County, a pretty-well populated county, that’s kind of scary.

WB: Welcoming and affirming healthcare settings are not just about the nurses and the physicians. It’s also about the literal environment. What are the posters on the wall? What sort of markings are on your bathrooms? Do they say “all genders,” or do they say men and women? What do your forms say? How does your front desk staff treat people?

I do think that there’s quite a shift in the language from cultural competency to structural competency, which gets at this idea that how well people are treated isn’t just enacted through person-to-person interactions. It is enacted through systems and structures. It is worth mentioning that these larger things that we’re talking about, issues of equity, it’s not like it just all stops and starts in an individual. It’s about systems and structures that promote equitable care.

We have many alums who are in higher level positions in systems and structures that can ensure that there are policies, such as non-binary signage, or forms that allow people to put in their pronouns. There are administrative level things that, that even non-practicing nurses can be engaged in and can advocate for. Advocacy is a huge part of what we’re talking about here. It’s not just practice. There’s a whole host of things that happen before someone even gets into the examination room.

PR: This was exactly the focus of my DNP project, which was enhancing LGBTQ sensitivity in a clinic setting. That included having a champion leader to ensure the continuation of trainings and other policies.

WB: This is why it’s important to have a conversation about both research and practice, because they’re, of course, meant to inform one another. I’m not a practitioner. In terms of changing norms and changing health inequities, my research can point it out, but the research on its own doesn’t solve the problem.

PR: Translating research into practice it’s, as Wendy said, a common problem. It’s a challenge. They say it takes about 17 years for research evidence to reach clinical practice.

WB: What I can tell you is that an in older study from 2013, BSN students get about two hours of content in their training related to sexual and gender minority populations – and that’s it. I think there’s room to grow within colleges of nursing, as it pertains to how and when we train our nurses on LGBTQ+ health issues. We need to ensure that principles of equity, whether that’s racial equity, gender equity, or queer equity, are integrated into our curriculum starting the minute that our students walk in the door.

Where the training needs to happen — or I should say, where it needs to start — is at the baccalaureate level without a doubt. And then of course, it needs to be threaded all the way through.

PR: We need to be better about infusing it early in the process, but we are getting better. I can speak to one example. I teach in the pediatrics/OB and leadership clinical courses for pre-licensure master’s students. When I first got here in 2018, I talked to the coordinators about making one of the simulations be a transgender child – in the middle of transitioning – presenting in the ER with signs of dehydration. We also included LGBTQ+ cultural sensitivity training prior to simulation day. In our simulation work group, I always take the opportunity to ask folks, ‘what can we do to make things more inclusive?’

I know in our community health courses, we’re introducing students to more gender nonconforming patients so that we have the opportunity to use a more affirming approach, an approach that enhances cultural safety. We’ve also gotten better about hiring authentic actors [gender nonconforming and trans] for simulations.

WB: I want to point out that while there’s absolutely a need for trans and gender focused trainings, it’s also the case that the needs of all sexual minority people [including those in the ‘L,’ ‘G’ and ‘B’ categories] need to be considered, affirmed, recognized, and acknowledged. There is absolutely variation within the [LGBTQI+] population and a good training will make the space to identify those distinctions for students so that they’re not treating populations as monolithic.

What my research has been about is carving out a space to really emphasize the fact that while bisexual people, people under the bi-plus umbrella, indeed have potentially different health issues, they also have different social and cultural experiences as it pertains to stigma, prejudice, and discrimination, which in turn influence health.

Someone who identifies as bisexual may experience bi-negativity or bi-phobia from both the lesbian and gay community, but also from the heterosexual community. People who are bisexual may experience bi-phobia from their own partners. Lesbian, gay and bisexual aren’t the same thing. There are ways in which the identities have different social and cultural prejudices and stereotypes associated with them.

That’s true along axes of gender, and that’s not even speaking to the ways in which that intersects with racial and ethnic identities. I think it would be important to mention that we are using this sort of moniker [LGBTQ+]as if it suggests that there’s a universality of experience. And while perhaps we could say that the universality is stigma and discrimination, even that is inflected differently, depending on which population we’re talking about, and that may have consequences for health and health care interactions.

PR: In the community health course, I know they also have opportunities to talk about different situations where patients are not heteronormative, so students get some practice with what is a safer and affirming approach.

I could give a little plug for Doctor of Nursing Practice degrees. There are more of those programs now and they focus on specific practice areas. I believe that’s helped. There are opportunities right now for a change in climate.

The American Association of Colleges of Nursing essentials have also changed, so this is an opportunity for the college to be more inclusive, transparent and use an anti-racist approach.

I’m only growing as an expert, so I rely on other experts who have given me a lot of guidance about translating knowledge into clinical practice. The National LGBTQIA+ Health Education Center [Bostwick is adjunct faculty with The Fenway Institute, which runs the center] has fabulous mini seminars for training. “The Clinician’s Guide to LGBTQIA+ Care” is a gold mine. [Clinical assistant professor] Randi Singer is a co-editor. It acknowledges how language is dynamic. It also offers a framework with the main tenants of cultural safety for LGBTQIA+ plus populations.

WB: I think for people not doing this work, it’s easy enough to say, ‘oh yeah, we’re doing LGBT competent competency training.’ We’re having somebody come in and talk about HIV and AIDS. Well, yes, there’s overlap there, but those aren’t the same thing.

For practitioners, I go back to my number one rule, which is basically, don’t be a jerk [laughs]: no judgment about sexual partners or behaviors, mirror people’s language, don’t make assumptions.

Practicing nurses, especially in areas that don’t have as many on the ground resources, can take advantage of the many online webinars and resources that are out there now. So much has changed in 20 years. I work in this area and I am the first to admit that language is changing very quickly!

PR: It’s dynamic. It always has been and always will be. For instance, people working within midwifery are working to ensure there’s a change in language that isn’t necessarily gender specific, but that allows for the fact that people of different genders can be pregnant.

WB: [It’s important to try] to stay abreast of language because how we address people is a fundamental sign of respect. That’s how you start your care interaction.

PR: There’s a fear of getting it wrong, or your implicit biases, that prevent you from having a receptive approach.

WB: I think there’s a lot of opportunity within our own College of Nursing when it comes to [sexual and gender minority] health. That’s exciting. There’s a core group of faculty whose research agendas are absolutely focused on sexual and gender minority health but also people practicing on the ground. I certainly see more and more students open – and having a desire – to focus on these sorts of issues in all areas of practice.

PR: I think it’s important to recognize people from the college who were earlier leaders, like [professor emerita] Tonda Hughes, Charlie Yingling and retired nurse Carrol Smith.

WB: I think this is a great prompt, Paige, for you and I and others in the college to start a [sexual and gender minorities] interest group, that transcends departments and our research or practice silo. We have some expertise and a great deal of knowledge in the college when it comes to this.

We have a lot of people in the college who are interested, willing and already working on this. And it’s just a matter of fostering and supporting those collaborative endeavors.