According to a 2022 Gallup poll, the percentage of adults in the US who self-identify as lesbian, gay, bisexual, transgender or something other than heterosexual has doubled in the last decade, and stands at 7.1%.
1 in 5 Gen Z adults identify as LGBT.
But health disparities persist among people who identify as lesbian, gay, bisexual, transgender, queer, questioning, intersex, or asexual and more (LGBTQA+).
And discrimination against LGBTQA+ people is a key social determinant of health that is linked with high rates of psychiatric disorders, substance abuse,and suicide. Discrimination is evident even as people in LGBTQA+ communities navigate healthcare.
My guest this episode is Dena Silva, an educator with a passion for creating education that enables clinicians to address the healthcare needs of LGBTQA+ communities. Dena is CME Director for an association management organization which includes oversight of 4 medical societies in California.
We talked about:
✔️ How to work with experts who really know about the challenges facing LGBTQA+ patients in health care
✔️ The role of education in supporting providers who are working with LGBTQA+ patients
✔️ What providers need to know in order to meet the health care needs of LGBTQA+ patients
✔️ Strategies to build more representative and inclusive education programs
✔️ How skilled facilitators are an asset
Straight Talk as a Starting Point
Sometimes the conversation was tricky (failing forward!). It's straight talk, after all, rather than talk among people who are LGBTQA+. We recognize that this conversation may be filled with things that we stumbled over.
But as Dena reminded me, in order to show up as an ally for LGBTQA+-affirming CME/CE, we need to learn how be sensitive about the ways we represent ourselves, the language we use, and the assumptions we make about who people are and what they need from healthcare providers. We welcome feedback for our own learning journey so we can improve the way we communicate about this topic and better advocate for LGBTQA+ health needs.
The CME community has an opportunity to create education programs that increase awareness around health disparities for LGBTQA+ patients and that equip clinicians with tools to have a conversation with their patients about how they would like to be addressed and what they need from their health care providers. CME/CE can offer a safe space for clinicians to mess up, to say the wrong thing, and to find a way to course co
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Alexandra Howson 00:00
Hello, and welcome to Write Medicine. I'm Alex Howson and today I am super happy to be spending time with Dena Silva, a CME expert who develops education in collaboration with medical societies. Welcome, Dina.
It's good to see you. Yeah, we were just commenting before we hit record, in the difference in our outfits. I'm in the Pacific Northwest, bundled up with woolens and a scarf, and Dina is somewhere much warmer. Not wearing woolens and a scarf.
Yes, dressed differently, dressed appropriately, appropriately for the weather, yes, but it just the deep contrast in our outfits today, it's, it's a lot of fun, showing up on Zoom or other webinars and seeing the differences in everyone. That's one of the great pleasures of I think moving virtually, is we get exposure to everyone's spaces a little bit more early on, it was so interesting and wonderful to be invited to so many people's homes, to see their life and what they chose to represent in their backgrounds. And I've now since moved on, as we spoke also about, you know, putting up the virtual picture background so that people don't necessarily have that access to my space. But I always feel great pleasure when people do invite you in.
Yes, I feel that too. And it's interesting what you say there about what people choose to put in their backgrounds, because in for a lot of people, you know, they haven't had that, that choice. And so I think that, you know, you're, you're kind of stuck with the space that you're in. So I think having those backgrounds is really helpful for a lot of people. And I find myself, just even on some days I I don't want to invite- I don't want to make that invitation. I just don't feel up to it. So you have to be in the right headspace.
What's interesting, even the topic we have on the table today to talk about the diversity of in their words, so much conversation around, oh, everyone needs to have their cameras on everyone should be-, you know, I actually went to a leadership workshop to where we talked about how people were beginning to judge you on the quality of your background. And I had to say, wait a second, we can't judge people based on the quality of their background, you don't know their story, you don't know what they are able to do. You don't know, if they've just run from three meetings or, you know, whatever their story is, you don't know it. And we should all just take a moment. And you know, I will bring the great Ted Lasso, into this early and say, be curious, not judgmental?
Yes, I like that distinction. And I think that that that's kind of a good segue into some of what we're going to talk about today, which is the role of education in supporting people in LGBTQIA+ communities where that sense of judgment is often part of the experience for people as they navigate healthcare, and presumably also providers as well, as they try to kind of deliver health care as someone who perhaps identifies as lesbian, gay, bisexual, transgender, queer, questioning, intersex, or asexual and more. So let's talk a little bit about who you are, first of all, and how you found your way into continuing healthcare education.
It's always a fun journey, right? As, as they often say, no one, there's no major for CME. And actually, quite a long time ago, I worked for a regulatory healthcare company. And I was responsible for securing licensure to operate in different states. And in order to do that, our medical director had to be licensed in those states. So a very young age, I have to help this physician get licensed in other states, I have to read law to determine whether or not there's any mandatory CME he has to take in order to complete the certificate process to get licensed. So I mean, I'm talking 20 years ago, I had my first introduction to CME. And then from there, I've always said I've worked healthcare adjacent. I've never been, you know, a clinician but I've always been right next to it. And I worked as a manager for volunteer services for four years. And I got laid off from that job because our census was slow. And I bring that up because there was an advertisement for a CME coordinator at a local university. And because I had to prove that I was trying to get jobs for unemployment, I had to log the- log that I made a phone call inquiry, and I made a phone call. And that piqued the interest of the assistant director, and, - I guess, Executive Director - and I got the interview. And I went in, and that was almost 10 years ago, where I started as a CME coordinator, and worked my way up through the department until I became the director of the department. And then I just recently left and have been working for medical societies, which I think is also really fun too because a lot of times in our CME career, we often stay in one zone of the industry, we don't typically see people move from, you know, academics to other types of industries, medical education companies. So I have enjoyed the last almost eight months working, now with medical societies and seeing this completely different side of the industry. How we, how we engage with our physician committees is different, how we develop content to create, it's just, it's been very exciting to see this entire different side of the industry.
It's so interesting, the way that you describe your story, I'm tempted to kind of gloss that by saying it sounds like the universe was working pretty hard to pull you. In particular, in a particular direction. Could you give an example of what some of the differences are between, you know, creating education in the first context that you described, and now with medical societies?
To be honest, one of the biggest things I see is attitude. For academic CME departments, you may be a part of one that is held in high regard and high esteem. But for the most part, I found that we were treated as the accreditation specialists, we're just here to be the bumpers to make sure that you don't get in trouble. And again, I want to say, these are my experiences. And again, there are various experiences around, and you may work for a place that loves you and treats you with great respect. And it's not that there wasn't some respect, it was just that that respect was very pigeonholed. And it was very difficult to get them to think of you in a different space. I actually have my master's in learning technologies, you know, you try and bring up conversations around how to engage in online education differently, how to create education for online activities. And I still was very pigeonholed into “No, no, you're you're here at this table to talk about accreditation, or to say what we can't do. You're not here to talk about what we can do”. Going into the medical societies space, I find that there is a little bit more of a conversation around well, what's the industry trend? Or what can we do to, to, to broaden our attractiveness? You know, we're, we're really trying to, to bring more people in, and I'm really— the seat at the table is, is expanded, really. It's not, I'm not just there to only talk about, well, what does ACC and Me require, or what, what shouldn't we do? It's I find, especially again, my experiences is that the conversation is much more around what can we do? So it's been it's been an exciting transition to see this and, and again, I will I have found and I actually worked for four different medical societies in this position. And each one of them, the level of respect in which I'm treated has been higher. And that's, you know, neither here nor there. It's just a statement.
But, you know, it's interesting, Dena because the Alliance conducted a survey a couple of years ago now, I think on CPD burden. And that issue of respect was one of the things or lack of respect was one of the things that we saw come up a lot in that in that survey, I'll make sure to put a link in the show notes to that. It's been published in the Almanac, I believe. In some of the work that you're doing at the moment, and I know that in the past, you've also kind of been involved in creating education content for- to address health disparities or health issues for LGBTQ+ communities, can you talk a little bit about some of the health disparities that you have seen, and some of the challenges that lesbian, gay, bisexual, queer folks experience in relation to trying to access health care?
Right? I do want to touch on just because I think it's important when you are in this space that you kind of declare yourself, I am not gay, I am not a lesbian. I was brought into this conversation because of my brother. We were having a conversation at dinner one night and talking to him about physicians and my job and all of those things. And he disclosed to me how horrible as a gay man, his relationships with doctors have been. And it was in that conversation that I recognized my privilege, I realized then that we don't talk about these issues enough. I could see it in conversations with physicians that it's, it's still a very taboo subject. So again, I just think it's important to declare yourself so that you know that I am simply an ally in this space, because I don't want to misrepresent myself as underneath anything other than that. So, again, as I talk about experiences, I want this to be my experience, not necessarily a global one. What I see as biggest health disparities, you obviously have HIV/AIDS as being one of the primary and historical issues that you've seen. But with, what, what the new disparity is, is the is around the medications that can be taken and actually get someone to an undetectable level. But is there education going on with all gay men to talk about what safe sex is, you know, testing all of those things. The other issue is that there are higher risks of cancers for lesbian women, cervical cancer, breast cancer, for lesbian women, just because they, they— typically, usually going through childbearing helps us be protected from those types of cancers. But lesbian women do not always have children. They can, they, but they do not always, but they're at higher risk for those cancers. And then men also see issues with prostate, and anal cancer. So those are definitely on the list. And then you start from the whole host of mental health issues that are frankly not addressed in most of us. Mental health issues are still really trying to be addressed and the pandemic has definitely raised the prevalence in mental health issues, starting from adolescence in LGBTQIA+, but then all the way it's, it doesn't stop at generational, it's, it's all the way through because there are so many societal issues that come up around creating safe spaces for, for the gay and lesbian community, the trans community, I mean, the, the publicity and media going around the trans community right now. It's very difficult for a trans person to feel safe. And then if those things are not addressed when you go into a physician's office, I think the health justice issue is a is a whole other side of things. We have to remember that in 2013, or actually let me go back in the sodomy laws just were struck down in 2003. 2003! You could not talk to your physician about being a gay man without extreme fear of being held for a crime until 2003, and even then, less than half of our states have specific protection for LGBTQIA patients. So it's and then you get into gender issues. And the less than half of those states that do have protection for the sexual orientation, they do not have gender identity protection. So the health justice issue around LGBTQIA is extremely important. And we have got to work on our laws around whether or not we are creating safe spaces for patients to even feel like they can express what's going on with them. So it's it's a really cyclical process, I think, is that the health justice keeps us from being allowed to create safes or having to present safe spaces. The awareness, I think, is another… the awareness is another issue. Because if there aren't the safe spaces for LGBTQIA patients to express themselves, then providers don't think that they have a population in which they need to then seek out continuing education, to then learn about these things. So it's a, it's a, it's a cyclical process that we really need to be paying attention to. And the good news is, I think our medical students are being admitted at a at a more diverse rate than ever. So we're going to see an evolution. Because when you have inclusion, when you have representation, these things do start to elevate. But in the meantime, the CE community has an opportunity to begin really working on efforts to increase awareness around the disparities for LGBTQIA patients.
There's so much in there, Dena. I want to ask, first of all, do medical schools collect data on gender and sexual identity? You mentioned that, you know, that we know that there's expansion and there's going to be a kind of revolution or is that data collected?
I do not know the answer to that. And I, but I would doubt it. I think we have seen an expansion in you know, there's the what measure was what measured, what is measured matters. And in I think that that's where health disparities in general has a challenge. Because we want to know, and I know this is actually happening with a lot of CE providers is “okay, we want to have an inclusive panel, you know, no more man-els!”, we want to have, we want to have that representation. But then you also have to start asking invasive questions. And I think that that's where LGBTQIA is kind of that weird disparity that is difficult to measure. Because it is not something you necessarily wear on your shoulders. You, you don't know if someone is gay, you don't know if someone is trans and I even read something the other day that is, you know, someone who chooses to identify as trans. Because the reality is, is that you probably have trans people in your life that you do not know. They don't want to identify themselves and they don't have to. Because there are so many health justice issues, there are so many discrimination issues still facing the LGBTQIA community. A lot of them do not disclose, and they don't have to, and they shouldn't have to. Right? But these new, this new trend to try to prove ourselves as a diverse community is also asking these invasive questions that you, you may or may not want to disclose. So it's a difficult thing to trend whether or not you are having representation on your CE panel because the reality is you don't know.
So that's interesting. I did work on a program with the Annenberg Center for Health Sciences on gender, you know, creating, gender affirming clinical environments. And, of course, the, the faculty, the experts who were part of, you know, helping to kind of shape that program where, you know, they're attached to The Fenway Institute, or they already had a very kind of public persona as people who work in a gender nonconforming space. But if you are working with a medical society or some other kind of continuing education provider, how do you get round the challenge of making sure that you are working with experts who really know about the challenges facing LGBTQ+ patients in health care? Without asking some of those questions that may or may not be experienced as intrusive, I'm not even sure that I- as we talk about this, and I have written in this area, somewhat, I realize my own lack of a language, and I'm a cisgender woman. I recognize, you know, my own position of privilege, and how difficult that actually makes it to have a conversation about how you create content for… I'm not even sure how to say what makes the next part?
Well, and I'll even I'll even say this, even preparing for this for this recording, it was a bit of an imposter syndrome, am I the right person? Should I be recommending someone else? I think the reality is, is you have to declare yourself as an ally, because activists are getting tired. And if we, if we don't help, say this is an issue, this is a problem.. the reality is to is, I'll be honest, when I was working at the academic institution, this was a question I asked, are we representing, and you get labeled, or you get pegged as the person who's always trying to bring up the queer issues, you know, and it's, it's, it's, it gets exhausting to where you also don't want to be labeled as that person, but I have the option of not being able to be labeled as that person, because I am not queer, I am not lesbian. And they say this about issues in racism, you know, a black person cannot not be black. And a gay man cannot not be gay.
In the conferences where you do have people have their pronouns. Inevitably, there was one person in the evaluations that says, “Enough with the pronouns.” That's, that's a privilege. It's a privilege for you to say “Enough with the pronouns”. The reality is, we have patients who are walking into physician's offices that only have pictures on the wall of straight couples, they only— They fill out the forms and there are no gender identity questions, which I'll say, from a healthcare provider standpoint, that should definitely be your intake forms, you should. Are you saying, Wife/Husband? Or are you saying spouse, from the minute someone walks in the door, they are evaluating whether or not this is a safe space. And when you question whether or not pronouns should be listed on a document or in a continuing education conference, you're coming from a sense of privilege, you're coming from a sense of feeling like you are always in a safe space. And even as women, we understand that there are spaces in which we are not safe, we understand that we've had to, you know, put our shoulders back and realize that this is a space where we can't be fully ourselves, we don't feel safe to do that. So we need to translate that into other ways to recognize how other people may not be feeling safe and doing everything we can - and this is what I think is hard for me to comprehend - I don't understand why anyone wouldn't want their doctor's office to be to not be a safe space. It there's just such prejudice, bias. And you ask the question and kind of preparing for this is, why hasn't diversity been, you know, really more of a? Or why are we just now thinking about it? And I think we've covered the soft answer the soft answers, that there's a lack of awareness, you know, that there's- people don't realize that people aren't coming forward as LGBTQIA+ patients, so they're not aware of their need to focus on these issues. The, the much harder answer is still the outright prejudice and bias, whether it's conscious or unconscious, that exists in our community against LGBTQIA patients.
I think one way of tracking that is, you know, in the in the education community, you know, we see a lot of programs around, you know, you mentioned HIV earlier, you know, we've seen a lot of programs around HIV in the last decade or so, as, as therapies for HIV have expanded. And a lot of education, I'm saying this carefully, follows the therapies.And because there aren't necessarily therapies available for some of the other challenges that you mentioned, when we first started talking around cancer, around some other issues, just- and just accessing primary care, right. As lesbian or a gay man that has, you know, that that, that allows continuing education to not really have to think about how best to support providers who are working with people in those communities.
Right. And, and one of the things that we do with, with issues of diversity is we put on a half day conference on insert issue of diversity here. But that's not- that's only attracting the people who are already in this space. It's not going to attract this, those providers that we need to attract and, and, level up their knowledge on issues surrounding the LGBTQIA community, level up their competence. And we have to integrate this into our clinical discussions and conversations in every context, not just the specific health disparities affecting- that we talked about earlier, because we can't wait to just have it be, oh, if you're talking about cervical cancer, here's, you know, that if we have a four hour conference on health disparities affecting the LGBTQIA community, we're only going to be bringing into that space those clinicians that are already aware, or have already broken down some of their privilege, their bias. In order to access all clinicians, it has to be incorporated into any appropriate clinical conversation possible. And that's true for any disparity, and actually, California just passed a law where CME providers are required to demonstrate commitment to health care disparities in their CME activities. We are required to demonstrate how our CME committees are discussing it, how have we incorporated it into our activities. And on the surface, it can sound you know, like documentation, which is unfortunate, but it is also in our documentation-heavy world you know, a very real part of what we do. We document to prove that we've done it. But I am hopeful that over the course of time, it allows us this space to say, we have this requirement. Ask the question, are there any disparities, we are not covering? Is there any type of conversation we can have around this clinical moment? Because that is how we are going to get all clinicians to have the basic level of understanding and awareness that they need to have around these issues.
So it's interesting that you that you kind of mentioned the California law on disparities in education, California has also had the- had a cultural competency requirement in continuing education for, for some time, and I think it's certainly my experience of that has sometimes been, as you put it, just a piece of documentation. It's flagged up but not necessarily substantively addressed, you know, in the education itself. So what, so law is one thing? What do you see as some of the strategies that continuing education providers could be using to broaden the conversation around gender and sexual disparities and raising awareness among providers about the key role they play in not only reducing some of those disparities, but starting from the ground up creating, creating a safe space for their LGBTQ+ patients?
What are things that providers need to know, to make sure that they are at least thinking about or addressing issues that might be of concern in terms of gender and sexual identity for their patients?
I'll touch on this more from a little bit of this CME providers and the people who work in that space. My observation has been that a lot of times we keep ourselves narrow in the room, we only hold space for our ability to speak so to say, on accreditation issues, or how do we address, you know, how we're going to document these things. And I would encourage us all to remind ourselves that we add more than that to the room, we are allowed to speak up, we are allowed to voice concerns, opinions, thoughts, on more than just accreditation rules, and what, what we need to do in those situations, we are industry experts, we attend meetings that tell us what's happening in this space, nationwide, worldwide. And if you want your team to be a part of the best, you need to keep up with what is happening globally. And so I challenge anyone working in the CME space, to remind themselves that they can also take on the role of a potential patient. We don't we know it's one of our standards of commendation to have patients. But CME providers can also be that person in the planning room that helps be the voice of the patient and asks the questions from a prospective patient. Well, how do you communicate this to a patient? Or, or are all of the patients represented as we address these issues clinically, so you can be that, and I would also invite you to examine the makeup of your office, because that's another thing, if you are in- have represented an inclusive office, that alone is an action that's, that spurs change. You want to- if you want to have more representative, more inclusive, continuing education programs, is your office reflected of that desire? And that kind of change takes time. We evolve, we know. But ask yourself the question, are you taking responsibility for creating a diverse and inclusive space for your own team? As you start to make that change within your team, it begins to spread, it can't help it. Being inclusive is spreadable. So when you make the decision to be that person, it just continues to grow from there. I just think we just want to be careful. Just always ask the question. You just said it yourself. How do we ask the question? You ask the question. A lot of times we get wrapped up in the, the nervousness around asking the question, but it's just so important to put it out there. So ,same thing, is using the pronouns as-at a continuing education activity. Yes, you are always going to get that one person on the evaluation that says, we don't need pronouns. You're going to have the person in the planning meeting that says, Oh, we don't need to talk about that. And, you know, maybe the first planning meeting, you don't need to talk about it. But the more you ask the question, the more people are going to start reflecting on their own work, and realizing that they too should be asking the question, and it's just holding, holding that space for others, even if it's not a space you occupy. It's, it's for other people and being present for other people. On an education standpoint, one of the things I still think we need to work on is the active learning strategies, and really incorporating those as much as possible because the line from research, to CE activity to bedside, is communication. When clinicians do not know how to have the conversation with their patients, they opt not to. And our continuing education conferences or online activities are the safe space for clinicians to mess up to say the wrong thing. And if we're not holding space for active learning strategies, and that practice, it won't carry through to the bedside.
That's great advice. I think one of the things I see again and again, coming up in gap analyses and needs assessments is “how critical communication is”, but often, that's the statement. And then, and then, you know, the content moves on to something else. And when I talk to providers, what I hear again and again, is help us, help us with a communication script. And when you're talking about active learning, are you talking about that kind of tool? Are you talking about role play? Can you just say a little bit before we kind of wrap up what some of those active learning strategies might be to really allow people to, as you put it, mess up.
And I'll say this, too, we often ask our subject matter experts to be the role of the facilitator. And those are two completely different skill sets. So another, just when you bring it back to your planning, don't ask necessarily your subject matter expert to be your facilitator. We often put the chairperson of the conference in the role of managing the Q & A. Is that always the right person who needs to manage the Q & A? Is there someone who is a more skilled facilitator that can thoughtfully respond to questions, to ask the audience to probe deeper, to gain their trust, to put them in a space where they feel comfortable turning peer to peer, and asking the questions. I was getting to a point where when we were planning our conferences, back at my academic institution, it was okay, you are the conference chair. But I'm not going to make you responsible for all of the Q & A. Because it wasn't a skill set they had. And you don't come right out and say that, you know, you guide the conversation, but it's just, it's just knowing our competencies, and knowing the people we're working with, and really trying to find that one skilled facilitator that you know you can call on to create that safe space for clinicians to practice. And yes, the active learning strategies can be just as simple as you know, here is the case presentation and turn to your partner and work through, you know, how, how would you approach this situation with your patient, and you let them fumble over the words you let them laugh and giggle and, and realize, because it's in that moment, that they realize they don't know; and what a better opportunity for them to realize that they need more education in an educational space, than in front of a patient where then we feel regret, remorse. Or worse, the patient never comes back. Because they said the wrong thing, or they didn't handle it well, or they didn't have humility when they approached it. But if we can incorporate those active learning strategies into our continuing education, I'm just a huge believer that our activities are those spaces for clinicians to fail forward.
I think that’s a great, a great wrap up and it also sounds to me- I'm conscious of my own challenges and having this conversation that sciences though, creating safe spaces within the field of continuing education for practitioners would also have some value in allowing us as a community to develop the understanding and the language and the questions that we need to be asking in a safe space. Dena, so thank you so much for sharing your expertise and your own understanding with Write Medicine listeners. I've enjoyed every word.