National studies have demonstrated that LGBTQ adolescents are disproportionately impacted by negative health outcomes including STDs, HIV, and unplanned pregnancy. In 2014, Essential Access Health surveyed LAUSD school-based Wellness Centers; gaps in current knowledge and practice related to inclusive clinical care of LGBTQ patients were identified. In 2016, we implemented staff trainings to improve LGBTQ-inclusive services. Based on training evaluation, areas for further technical assistance were identified, and used to develop online training resources. This presentation will discuss tools and best practices for implementing trainings on inclusive care.

1. Providing Inclusive
Care for LGBTQ
Patients at SBHCs
May 17, 2018
Sarah Roush, MSPH, CHES
Senior Sexual + Reproductive Health Program Manager

2. Essential Access Health
 Champions and promotes quality sexual + reproductive health
care for all
 Partners with the CA STD Control Branch and LA County Division
of HIV/STD Programs
 Implements best practices in STD prevention and case
management statewide.

3. Overview
 Health disparities impacting LGBTQ youth
 Assessment of LAUSD SBHC services
 Tools + best practices related to inclusive care
 Resources

4. Background: Health Disparities

5. LGBTQ Demographics
 Demographics:
 United States: 3.5%
 Los Angeles County: 4.1%
 Teenagers & Young Adults (15-21)
 13.4% females self-identify as lesbian, bisexual or other
 7.1% males self-identify as gay, bisexual or other
Williams Institute. (2013). http://williamsinstitute.law.ucla.edu/research/census-lgbt-demographics-studies/gallup-lgbt-pop-feb-2013/
Brewster, McCabe & Tillman. (2011). Patterns and Correlates of Same-Sex Sexual Activity Among U.S. Teenagers and Young Adults.

6. Health Disparities
 LGBTQ individuals are less likely to have health insurance or
access to health services
 Many LGBTQ people aren’t comfortable disclosing their
sexual/gender identity with providers

7. Health Disparities
Heart Disease: major risk factors include alcohol and tobacco use;
obesity also more prevalent among WSW
Cancers: increased risk for cancers including breast, cervical,
prostate, testicular, colon, and anal cancers
Substance Abuse: studies suggest LGBTQ individuals are more
likely than the general population to use alcohol and drugs
Sexual Health: high rates of STD and HIV infection, particularly
among MSM and transgender women
Injury & Violence: violence based on sexual minority status, as well
as higher levels of intimate partner violence
Mental Health: higher rates of depression, anxiety, suicidal ideation

8. Health Disparities: Youth
 CDC: LGBTQ & questioning students are on average
63-76% more at risk for violence, attempted suicide,
tobacco use, alcohol use, drug use, and risky sexual
behaviors as compared with heterosexual peers.
CDC. (2011). Sexual Identity, Sex of Sexual Contacts, and Health-Risk Behaviors among students
in grade 9-12: Youth Risk Behavior Survey. U.S. Department of Health and Human Services.

9. Health Disparities: Youth
 85% of LGBT youth report having been verbally harassed in
the past year; 35% were physically harassed; and 16% were
physically assaulted because of their sexual orientation.

10. LAUSD Youth Risk
Behavior Survey Data
Health Risk Behavior
Heterosexual-
Identified
Gay, Lesbian
or Bisexual
Ever had sexual intercourse1 29.4% 49.4%
Did not use a condom at last sex2 36.2% 42.8%
Did not use any method to prevent
pregnancy at last sex2 13.8% 32.7%
Never tested for HIV1 89.8% 84.3%
Have experienced sexual dating
violence (including rape)1 3.4% 16.7%
1 2017 YRBS data
2 2015 YRBS data

11. Health Disparities: HIV
 26% of new HIV infections annually are among youth aged 13-
24; the greatest % increase in infection rates has been among
YMSM
 A majority (60%) of youth aged 13-24 are unaware that they are
HIV-positive
 60% HIV-positive YMSM considered themselves to be at “low
risk” prior to learning their status.
MacKellar, et al. (2005) Acquired Immune Deficiency Syndrome, 38(5), 603-612.

13. Health Disparities: STDs
 YMSM: disproportionate risk
 YWSW: often overlooked, but also have prevention, screening &
treatment needs
 Perceived risk for STIs is low among LGBTQ youth; particularly
among WSW

14. Trends in Teen Pregnancy Rates

15. Health Disparities:
Unplanned Pregnancy
Recent study of NYC YRBS Data:
 23% of lesbian and bisexual female students had experienced a
pregnancy, compared with 13% of heterosexual female students.
 29% of gay or bisexual male students and 38% of male students
reporting both male and female partners reported causing a
pregnancy, compared with only 10% of heterosexual male
students.
Lindley & Walsemann. 2015. American Journal of Public Health.

16. Why Do LGBTQ Youth
Experience SRH Disparities?
 Identity ≠ behaviors
 Stresses related to discrimination & harassment
 Lack of access to health services
 Lack of inclusive, affirming SRH education
 Risk perceptions
 Higher levels of STDs/HIV in sexual networks
 Power dynamics in dating older people
 Higher rates of sexual victimization

17. Background: Assessment of
LAUSD Wellness Center Services

18. Project Background
LAUSD serves ~650,000
students
 Student population is
largely urban + low income
2007: 14 Wellness Centers
created in areas of highest
need
Wellness Centers serve
students + community
members

19. Project Background: Clinic Assessment
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
LGBTQ-inclusive
materials
SOGI in
Nondiscrimination
Policy
Intake forms have
inclusive gender
options
LGBTQ screening
recommendations
EMR documents
gender identity
EMR documents
sexual orientation
Sexual histories
documented
Sexual histories
conducted
Provision of LGBTQ-Inclusive Services at Wellness Center SBHCs

20. Project Activities
 2015: Development of resource toolkit, “Providing Inclusive Care
for LGBTQ Patients”
 2016: Accompanying trainings for Wellness Center clinic staff

25. Implementation of Clinic Trainings

26. Clinic Training Objectives
1. Define current, culturally sensitive terminology related to
LGBTQ patients.
2. Describe major health disparities impacting LGBTQ
populations.
3. Implement recommended sexual & reproductive screening &
counseling recommendations for LGBTQ patients.
4. Utilize EHR systems to document screening and counseling
activities for LGBTQ patients.

27. Training Content: Terminology
Sex Gender Identity
Sexual
Orientation
Male Transgender Gay
Female Cisgender Lesbian
Intersex Gender Non-conforming Bisexual
Genderqueer Pansexual
Queer
Assigned sex Affirmed gender Questioning
Asexual

28. Terminology Example: Jazz



 
Pansexual

29. Sample Intake Form Questions

32. Training Content: Clinical Recommendations
Extragenital STD Screening
Patton, et al, Clinical Infectious Diseases, 2014
Extragenital Gonorrhea and Chlamydia Testing and Infection Among Men Who
Have Sex With Men – STD Surveillance Network, United States, 2010-2012

33. Clinical Recommendations:
Pre-exposure Prophylaxis (PrEP)

34. Training Content:
Documenting SO/GI Data

35. Evaluation of Clinic Trainings

36. Evaluation Methods
 6 clinics targeted for training
 Priority: clinics located in South Los Angeles; areas with high
STD rates; low-resource settings
 Data collection methods:
 Sign-in sheets; Pre/Post-tests; Evaluation surveys
 Questions assessed knowledge, attitudes and self-efficacy
related to the provision of LGBTQ-inclusive clinical services
 Analysis completed in STATA14.
 Consisted primarily of descriptive statistics. Descriptive
statistics were reported for quantitative assessment,
calculating frequency of responses on Likert scales

37. Evaluation Results: Training Participants
Date FQHC Clinical
Personnel
Non-Clinical
Personnel
Total
Participants
4/29/16
Watts Health
Corporation
5 4 9
5/31/16
St. John’s Well Child
and Family Center
4 1 5
6/6/16
South Bay Family
Health Care
2 3 5
6/22/16
To Help Everyone
(THE)
1 7 8
6/30/16
South Central Family
Health Center1 30 13 43
7/21/16
South Central Family
Health Center2 21 6 27
TOTAL 63 34 97

38. Evaluation Results
 Pre/Post Self Assessment: “Knowing a patient’s sexual
orientation and/or gender identity is important for providing
effective healthcare.”
 26% increase in those who “strongly agree”
60
21
7
12
86
5 3
6
0
10
20
30
40
50
60
70
80
90
100
Strongly Agree Agree Disagree Strongly Disagree
PercentageofParticipants
Pre-test Post-test

39. Evaluation Results
 Pre/Post Self Assessment: “I feel confident using LGBTQ
terminology in conversations with patients.”
 23% increase among those who report feeling “very confident”
29
48
21
2
52
44
3 2
0
10
20
30
40
50
60
70
80
90
100
Very confident Mostly confident Notveryconfident Notat all confident
PercentageofParticipants
Pre-test Post-test

40. Evaluation Results
 Pre/Post Self Assessment: “I am comfortable asking a patient
about their sexual orientation and/or the sex of their partners.”
 23% increase among those who report feeling “very confident”
29
48
21
2
52
44
3 2
0
10
20
30
40
50
60
70
80
90
100
Very confident Mostly confident Notveryconfident Notat all confident
PercentageofParticipants
Pre-test Post-test

41. Evaluation Results
 Documenting sexual orientation and gender identity (SOGI) data
 At pre-test, only 50% of participants indicated that they
regularly document SOGI in patient charts
 Reasons for not documenting SOGI included:
 Confidentiality concerns
 EHR system does not capture SOGI
 Forgetting to document

42. Key Takeaways
1. Training applies to all staff: encompass diverse knowledge +
comfort levels
2. Basic terminology (definitions + practice) is a critical starting point
3. Use data + stories to underscore importance of issues like
inclusive clinic environments to staff
4. Providers appreciate clinical updates + data on LGBTQ topics
5. Emphasize that language/information is constantly evolving –
don’t be afraid to make a mistake; use it as a learning opportunity
6. Data shows: offering training on this topic is effective!

43. Project Next Steps
 December 2016: partnered with LA LGBT Center to present
“Leveraging EHRs to Collect Sexual Orientation + Gender
Identity Data”
 January 2017: released online version of the clinic training
 August 2017: released brief series of videos on Terminology +
Communication, Inclusive Sexual History-Taking, and SOGI Data
Collection. Each video is 5-9 minutes long and can be used in
staff trainings/in-services.

45. www.essentialaccess.org/sites/default/files/Providing-Inclusive-Care-for-LGBTQ-Patients.pdf

46. Resources

48. Thank you!
Sarah Roush, MSPH, CHES
Sr. Sexual + Reproductive Health Program Manager
sroush@essentialaccess.org
213-386-5614 x4516