Your guide to building an inclusive practice
2SLGBTQ+ Healthcare by Selinda Berg is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, except where otherwise noted.
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The University of Windsor is committed to ensuring digital accessibility for people with disabilities. We are continually improving the user experience for everyone and applying the relevant accessibility standards.
The Web Content Accessibility Guidelines (WCAG) define requirements for designers and developers to improve accessibility for people with disabilities. It defines three levels of conformance: Level A, Level AA, and Level AAA. This module is partially conformant with WCAG 2.1 level AA, which means that some parts of the content do not fully conform to the accessibility standard (outlined below).
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In addition to the web version, this module is available in a number of file formats including PDF, ePUB (for Readers), and various editable files from the homepage; look for the “Download this Book” drop-down menu to select the file type you want.
This module also contains links to a number of external websites. For those using a print copy of this resource, the link text is underlined, and you can find the web addresses for all links in the back matter of the book.
While we have attempted to make all elements of this resource conform with international accessibility guidelines, we must acknowledge a few accessibility issues. This table will be updated as new issues arise or are identified.
Location of issue | Need for improvement | Timeline | Workaround |
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Various pages | The heading order for some headings do not conform to logical heading order (e.g., H1, H2, H4). | N/A | Lower-order headings are still always placed after higher-order headings, even if levels are skipped for various reasons. |
YouTube video on “Why LGBTQ+ Health” page | Captions are not entirely accurate, do not contain punctuation, and do not identify speakers | N/A (as the video was created and licensed separately from this project) | The general messages are still able to be understood from reading the captions. |
Case #1: Non-Binary Teen | Image in Image Hotspot contains written content that is inaccessible. | N/A | The hotspot activity can still be navigated, and the core messages are conveyed elsewhere in the case and the Key Takeaways page. |
YouTube video on “Trans Broken Arm Syndrome” | Captions are not entirely accurate and do not contain punctuation | N/A (as the video was created and licensed separately from this project) | The general message is still conveyed. |
We welcome your feedback on the accessibility of this LGBTQ+ Healthcare module. Please let us know if you encounter accessibility barriers or identify ways in which the accessibility may be improved.
You can provide feedback by contacting us:
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This accessibility statement has been adapted from the following resources:
This statement was last updated on February 28, 2022.
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This resource was first created for the Schulich School of Medicine and Dentistry at at the University of Western Ontario by Selinda Berg, Alex Levesque, and Scott Cowan. In 2020, the module was revised with the valuable input of Anastasia Yian Liu and the OpenMeds group at the medical school.
The current adaption was created in partnership with the University of Windsor’s Leddy Library and Office of Open Learning, in consultation with Trans Wellness Ontario. This resource is intended to be a starting point for further development, with the goal of evolving and changing the content in alignment with the most accurate and up to date knowledge and representation to ensure inclusive health care for the LGBTQ+ community.
This project is made possible with funding by the Government of Ontario and through eCampusOntario’s support of the Virtual Learning Strategy. To learn more about the Virtual Learning Strategy visit: https://vls.ecampusontario.ca.
Selinda Berg (she/her) identifies as a queer, cis-gendered, white woman. Selinda had extensive experience navigating the health care system when she and her former partner navigated the medical care associated with the conception, pregnancy, and delivery of their son. Navigating systems as a two-mom family continues to pose challenges. Selinda was an instructor at the Schulich School of Medicine for more than a decade. Throughout this work, she was deeply passionate about encouraging students to consider ways of creating a more inclusive health care environment. In addition to teaching, she also had the opportunity to learn from her students, some of whom contributed greatly to the evolution of this resource. Selinda hopes that by making this resource open that the content can further evolve and strengthen through the input and contributions of others passionate about inclusive health care environments.
Scott R. Cowan (he/him) identifies as a gay, cis-gendered, white male. As a librarian and researcher, his research has focused on the information needs, and access to information, for the LGBTQ+ community and anti-oppressive pedagogies. Based on his own experiences with healthcare professionals after coming out, and the stories of his friends in the queer community, he was excited to advise on the original project and help with the creation of this resource.
Ashlyne O’Neil (she/they) is a white settler who identifies mainly as queer, since it’s so hard to summarize one’s identity with a single phrase. They have adopted “queer” as a personal and political move against the gender binary and limited scope of LGBTQ+ labels. When pushed to reflect on how they identify according to the split-orientation model described in the glossary, Ashlyne would describe themself as pansexual and homoromantic. As a learning specialist in the Office of Open Learning, Ashlyne offered project management support for the project, ensured accessibility, and contributed to the design of the Pressbook and adaptation of content and scenarios.
“I was super happy to be brought into this project, and have very much enjoyed working with our collaborative team throughout this process! Given my own experiences in the healthcare system, and the stories I have heard from others, it is abundantly clear that resources such as this one are absolutely necessary. I don’t think our negative experiences are always related directly to physician prejudice, but rather failures in health care policies, and a lack of such information early in providers’ education.”
We would also like to acknowledge the history and guardianship of the place in which we were able to complete this project. As white settlers in the Windsor-Essex community, we live and work on the traditional lands of the Three Fires Confederacy of First Nations, comprised of the Ojibwe, the Odawa, and the Potawatomi Peoples.
We also recognize that the country now known as Canada was built on stolen African and Black labour and resources, and that this history has been whitewashed and erased throughout our collective memory.
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The suggested citation for this module in APA format is:
Berg, S., Cowan, S.R., & O’Neil, A.I. (2022). LGBTQ+ Healthcare. University of Windsor. CC-BY-NC-SA. https://ecampusontario.pressbooks.pub/inclusivehealth/
The suggested attribution for this module is:
LGBTQ+ Healthcare by Selinda Berg, Scott R. Cowan, and Ashlyne O’Neil, 2022, is licensed under a CC-BY-NC-SA license.
CC-BY-NC-SA: This license allows reusers to distribute, remix, adapt, and build upon the material in any medium or format for noncommercial purposes only, and only so long as attribution is given to the creator. If you remix, adapt, or build upon the material, you must license the modified material under identical terms.
The book cover was designed using Canva and can be edited using this template. The characters on the cover were adapted from sketchify and can be found using the following search phrase within Canva: set:nAEW7vWmoB8. Background images for H5P cases were also created using Canva and can be adapted by using the following templates:
We recognize the ever-evolving nature of this work, and hope that this resource will be used, adapted, revised, and updated as much as possible for, and by, those who use it to keep the work moving forward. If you are interested in revising/remixing/updating this module, you can use the Pressbooks “Clone A Book” function. You can request an account using the following link: https://openlibrary.ecampusontario.ca/create/pressbooks-account/
The H5P activities in this Pressbook are all licensed as CC-BY-NC-SA and were created by the project team with a slight variation in authorship order. Each activity is accompanied by the appropriate attribution. For example:
Sex and Gender Concepts by Ashlyne O’Neil, Selinda Berg, and Scott Cowan, is licensed under CC-BY-NC-SA.
If you adopt this module as a course resource, please report your adoption in order for us to celebrate your support! Report your commitment at https://openlibrary.ecampusontario.ca/report-an-adoption/
If this module does not meet your needs, please check out the full library at https://openlibrary.ecampusontario.ca/. If you still cannot find what you are looking for, connect with colleagues and eCampusOntario to explore creating your own open educational resource (OER).
At this time we are working with an expanded community to move this content forward in an informative, respectful, well-informed, and meaningful way. Those creating this content are reflected here and are deeply committed to making this content stronger. We truly welcome feedback about how we can continue to evolve this module to further strengthen this content. Comments and inquiries can be sent to Dr. Selinda Berg (sberg@uwindsor.ca). Please refer to 2SLGBTQ+ Healthcare in your subject line.
eCampusOntario is a not-for-profit corporation funded by the Government of Ontario. It serves as a centre of excellence in online and technology-enabled learning for all publicly funded colleges and universities in Ontario and has embarked on a bold mission to widen access to post-secondary education and training in Ontario. This module is part of eCampusOntario’s open textbook library, which provides free learning resources in a wide range of subject areas. These open textbooks can be assigned by instructors for their classes and can be downloaded by learners to electronic devices or printed. These free and open educational resources are customizable to meet a wide range of learning needs, and we invite instructors to review and adopt the resources for use in their courses.
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The 2SLGBTQ+ community is diverse. While L, G, B, T, and Q are usually tied together as a single homogeneous entity, each letter represents a wide range of people of different races, ethnicities, ages, socioeconomic statuses and identities (National LGBT Health Education Centre, 2019). Unfortunately, experiences of stigma and discrimination are a common theme that transcends across the entire 2SLGBTQ+ community. While discrimination exists across the community, the manifestations of oppression and discrimination are not a singular occurrence or experience. One area in which there is a long history of discrimination and lack of awareness is within the health care sector.
The content presented here was created by and in collaboration with members of the 2SLGBTQ+ community. The faculty lead and all collaborators have shared their experiences as members of this diverse community, building a starting point for medical students to consider how they can build an inclusive practice. Because of the incredible diversity within this vast community, not all experiences and perspectives of the 2SLGBTQ+ community are captured here. Specifically, we recognize that there are key components of intersectionality that are not directly addressed in this resource. We know that negative experiences related to gender and sexuality are often compounded for those with intersectional identities such as a black trans man or a disabled Muslim lesbian. For this and other reasons, we welcome adaptations to this resource by those who are committed to moving this work forward (see Using, Citing, Adapting this Module).
There are numerous identities involving gender and sexuality, making it challenging to pick a word or acronym that makes everyone feel included. Our team chose the 2SLGBTQ+ acronym because of the communities this module directly represents. Because we have not specifically built cases around the experiences of asexual or intersex folks (among others), we decided the 2SLGBTQ+ acronym more accurately represented the current focus of the resource.
This resource explores terminology, concepts, and word choice and it is important to emphasize that it is critical that health care professionals listen carefully to their patients to understand their individual needs. Every individual is unique. There is no singular experience and in turn, there is no singular term that will work for all individuals. As such, you must listen.
One specific example of this is the term “queer”. This is a term that is embraced by some and rejected by others. Historically the term “queer” was used as an anti-LGBTQ+ term. It has since been deliberately reclaimed and embraced by some members of the 2SLGBTQ+ community as a means of empowerment. However, it is imperative to recognize that the selection to use or not to use that term, is the choice of each LGBTQ+ person. Each person has an individual identity and their own personal experiences- all are valid and all are to be respected.
Listen carefully to patients and the terms that they use for their identity. If you have a question, ask the individual respectfully and ensure that you follow their direction consistently.
As we acknowledge, recognize and learn about the experiences of all people, our understanding and conceptions in this area will evolve. Through this evolution, language and concepts will continue to change. Not only do new words emerge, but our understanding of “old” words will change. We recognize that words are not neutral, and they are a part of our social understanding. We continue to do the work in increasing our understanding and it is imperative that this work be seen as a starting point from which we must evolve.
This resource is not able to provide an encapsulation of all experiences. This resource does not represent the entirety of all healthcare experiences for those who identify as part of the 2SLGBTQ+ community. It is our hope that this resource be used, adapted, revised, and updated to keep the work moving forward.
One of the most recognizable symbols of the 2SLGBTQ+ community is the rainbow flag. Most commonly we see the six-colour rainbow flag, however, the flag has gone through multiple iterations of development, originally developed with eight colours by Gilbert Baker in 1978. The hot pink was removed because of fabric unavailability, and royal blue replaced both the turquoise and indigo colours.
The Flag continues to evolve over time. Those in the 2SLGBTQ+ community who are members of further marginalized groups (e.g., transgender people, people of colour, people with disabilities) experience greater disparities. Increasingly the Progress Pride Flag (image below) is being used to bring focus on diversity, equity and inclusion within the 2SLGBTQ+ community. This flag designed in 2018 brings focus to those who experience further marginalization within the 2SLGBTQ+ community.
In 2021, there was an update made to the Progress Pride Flag to better represent the intersex community. The update, in multiple forms, further increases visibility and works towards better inclusivity within the community.
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2-Spirit, lesbian, gay, bisexual, transgender, queer and questioning (2SLGBTQ+) individuals experience high rates of health disparities.
As a result of social stigma and discrimination, 2SLGBTQ+ people report higher rates of mental health challenges, anxiety, and depression:
Transgender and non-binary people populations face many of the same health-related challenges that other members of the 2SLGBTQ+ community face, while experiencing greater barriers to social inclusion and higher rates of discrimination and stigma.
Health care providers have a role in identifying and addressing these disparities. The biases of medical providers encountered in health care settings can contribute to these disparities. Due to discrimination, harassment and barriers to equitable health services, 2SLGBTQ+ communities experience:
The barriers transgender people face in accessing necessary transition-related care and services are associated with poorer mental health and high rates of suicidality.
These stories are all too common, especially for trans and non-binary people. For more stories, take a look at the YouTube video below (5 minutes and 54 seconds). Although it depicts trans folks living in Oregon, their stories resonate with 2SLGBTQ+ individuals living in Canada and worldwide.
This video was created by the Oregonian, and copyright belongs to them.
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“There is no such thing as a lesbian knee, or a lesbian armpit, or a lesbian neck — at least I’ve never dated one — but each human being comes to health care with context and a story, and they are both vitally important.“
The above quote from Kelli Dunham emphasizes that one of the key elements to ensuring inclusive and culturally sensitive care to members of the LGBTQ+ community is understanding and respecting their context and story.
For many members of the LGBTQ+ community, their gender and sexual identity are key elements influencing their stories.
This module was designed to be an accessible, easy-to-use resource for medical students and professionals looking for an introduction into this important area. There are opportunities for interaction throughout, and you can choose how you wish to navigate through each component of the module.
Immediately proceeding this module outline are two sections to help orient yourself to this topic, including an exploration of why we need LGBTQ+ healthcare resources. This page will explain some of the key outcomes for LGBTQ+ healthcare patients, and provide some stories from real individuals about their experiences within the healthcare system. The following page is the Key Concepts section which highlights and expands on some of the key terms you may come across throughout the text. We have also created a glossary at the end of this Pressbook where you can find a list of terms and definitions for reference. When you come across a bold, underlined word or phrase, you can click it to pop up a definition without leaving the page to look it up.
After these two orientation sections, you will navigate through four (4) case studies that will:
By the end of this module, successful students will be able to:
Each case will illustrate the experience of someone who identifies as LGBTQ+ seeking health care in Canada. You will be presented with some background information about the patient, and then observe an interaction, identifying red flags that may be addressed. An alternative experience will be presented to help identify inclusive practices, followed by the key takeaways.
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Click on the information icons on the image below to learn more about major sex and gender concepts.
One or more interactive elements has been excluded from this version of the text. You can view them online here: https://ecampusontario.pressbooks.pub/inclusivehealth/?p=197
H5P Attribution: Sex and Gender Concepts by Ashlyne O’Neil, Selinda Berg, and Scott Cowan, is licensed under CC-BY-NC-SA.
Looking at the concepts above consider your own identity and expression within these categories.
Consider also those in the case studies. Each individual is unique and valid. The identity, expression, sex, and orientation of an individual must be respected and cannot be criticized.
The video below (7 minutes and 57 seconds) was created for trans* patients to advocate for themselves when seeking healthcare. We thought, however, that it would be meaningful for share this message with healthcare providers to help gain a better insight into the trans experience.
This video was created by Ben Haseen in 2021, and is licensed CC-BY on Youtube (please note that the creator and license is different than that of this Pressbook).
An interactive H5P element has been excluded from this version of the text. You can view it online here:
https://ecampusontario.pressbooks.pub/inclusivehealth/?p=197#h5p-1
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One or more interactive elements has been excluded from this version of the text. You can view them online here: https://ecampusontario.pressbooks.pub/inclusivehealth/?p=5
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One or more interactive elements has been excluded from this version of the text. You can view them online here: https://ecampusontario.pressbooks.pub/inclusivehealth/?p=69
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One or more interactive elements has been excluded from this version of the text. You can view them online here: https://ecampusontario.pressbooks.pub/inclusivehealth/?p=147
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Offer universal washrooms
Treat the patient as an individual, recognizing each experience is unique and valid.
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As underlined early in this module, the LGBTQ+ community experiences significant health disparities, including higher rates of depression, anxiety, suicidality, tobacco use, and substance use disorders.
An important way for physicians to reduce disparities is to recognize and address their own biases. We need to acknowledge that we are all vulnerable to biases. The most detrimental response is to deny or avoid our biases because they make us feel uncomfortable. In contrast, the only way to “change our thoughts and behaviour is to acknowledge our biases, become curious about them, and practice ways to transform them” (National LGBT Health Education Center, 2018).
When we notice prejudicial attitudes and beliefs arise in ourselves, we should pause and really consider:
The National LGBTQIA Health Education Center provides two exercises to assist health care professionals to reduce implicit bias.
Individuating is the process of focusing on specific information about an individual, as opposed to categorizing someone based on their social, racial, or other group belonging. The example used by the LGBT Health Education Centre is
“when we learn that a new patient is a transgender man, do we only think about his gender identity and when he transitioned, or can we think about how he is new to town and started working at the local library? “
Consider how assumptions can be set aside in order to get know a person just as they are right now.
In contrast, perspective-taking involves taking another person’s viewpoint intentionally. For example, try to imagine what it might feel like to be this particular patient who is LGBTQ+.
*Source: National LGBT Health Education Center. (2017). Learning to address implicit bias towards LGBTQ Patients: Case Scenarios. Boston, MA. Available at http://www.lgbthealtheducation.org/publication/learning-to-address-implicit-bias-towards-lgbtq-patients-case-scenarios/
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Canadian Centre for Gender and Sexual Identity. (2020). CCGSD Queer Vocabulary. Available at: https://ccgsd-ccdgs.org/wp-content/uploads/2020/11/CCGSD-Vocabulary.pdf
Henriquez, N.R., & Ahmad, N. (2021). “The message is you don’t exist”: Exploring lived experiences of rural lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ) people utilizing health care services. SAGE Open Nursing, 7, CC-BY, Available at: https://journals.sagepub.com/doi/epub/10.1177/23779608211051174
Hunt, E. (2019). LGBTQ+ people share their most awkward and embarrassing healthcare experiences. Refinery29. Available at: https://www.refinery29.com/en-gb/lgbtq-healthcare-stories
LGBT Health Education Centre. (2018). Learning to Address Implicit Bias of LGBT patients. Fenway Institute. Available at: https://www.lgbthealtheducation.org/wp-content/uploads/2018/10/Implicit-Bias-Guide-2018_Final.pdf
Scheim, A.I., Zong, X., Giblon, R., & Bauer, G.R. (2017). Disparities in access to family physicians among transgender people in Ontario, Canada. International Journal of Transgenderism, 18(3), 342-352. Available at: https://transpulseproject.ca/wp-content/uploads/2019/04/Trans-PULSE.-Disparities-in-access-to-family-physicians.-IJT-2017.pdf
TransPulse Research and Study Results: https://transpulseproject.ca/research-type/journal-article/
Wittlin, N. M., Dovidio, J. F., Burke, S. E., Przedworski, J. M., et al. (2019). Contact and role modeling predict bias against lesbian and gay individuals among early-career physicians: A longitudinal study. Social Science and Medicine, 112422. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6744977/pdf/nihms-1535912.pdf
Singh, A. A., Meng, S. E., & Hansen, A. W. (2014). “I am my own gender”: Resilience strategies of trans youth. Journal of counseling & development, 92(2), 208-218.
Available at: https://doi.org/10.1002/j.1556-6676.2014.00150.x
Wilkens, J. (2015). Loneliness and belongingness in older lesbians: The role of social groups as “community”. Journal of Lesbian Studies, 19(1), 90-101.
Available at: https://www.tandfonline.com/doi/pdf/10.1080/10894160.2015.960295
Perrin, E. C., Hurley, S. M., Mattern, K., Flavin, L., & Pinderhughes, E. E. (2019). Barriers and stigma experienced by gay fathers and their children. Pediatrics, 143(2), e20180683. Available at: https://www.publications.aap.org/pediatrics/article/143/2/e20180683/37346/Barriers-and-Stigma-Experienced-by-Gay-Fathers-and
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Lesbian Woman: After saying I do not need birth control pills, my GP asked what form of birth control I was using. I said “I don’t sleep with men” to which he responded “good girl”. Nothing about a concern for STIs, as I assume he thought I was celibate.
Trans-feminine Person: I was told I was causing my own asexuality because of the estrogen pills I was taking. Asexuality is a thing. It’s not a hormone imbalance.
Genderqueer Person: I haven’t gone to the dentist in over 5 years because it’s just the most uncomfortable experience.
Pansexual Woman: I have had clinicians refer to my partner as my sister, my friend, and my daughter! Even after clearly stating otherwise. We are partners, and they are non-binary. Their assumptions are super invalidating.
Trans-masculine Non-binary Person: I had a skateboarding accident, and instead of going to the E.R., I wrapped my own arm at home and just hoped it wasn’t broken… that’s how bad my experiences have been. It’s just not worth it.
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