Share Public Health Transcript: Tackling Equity, Lesbian, Gay, Bisexual, Transgender, Queer & Questioning

Season 1 Epiosde 19

Hannah Shultz 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 this 10-part series on health equity. Over the course of this series, we will discuss a broad range of topics connected to health equity. For additional resources and information, be sure to check the podcast notes or visit mphtc.org/healthequity.

Paul Gilbert I’m Paul Gilbert and my pronouns are he/him/ and his. I’m an assistant professor in the department of Community and Behavioral Health at the University of Iowa College of Public Health. Today, I’ll be serving as host of our podcast episode devoted to sexual and gender minority health. We’ll be focusing on issues relevant to lesbian, gay, bisexual, transgender and gender diverse, and queer individuals under this podcast series’ general theme of health equity. I’m joined in this conversation by Dr. Katie Imborek and Max Mowitz. Dr. Imborek, whose pronouns are she/her and hers, is a family medicine physician, clinical associate professor, and director of off-site primary care at the University of Iowa Hospitals and Clinics. She was a co-founder of the first clinic in Iowa specifically dedicated to serving sexual and gender minority patients, which is still going strong at the University of Iowa Hospitals and Clinics system. It is even expanded since establishment in 2012. Max, whose pronouns are they/them and theirs is a program director for One Iowa, which is a statewide nonprofit organization. One Iowa takes as its mission to improve the lives of LGBTQ Iowans by advancing equality and inclusiveness. Some of One Iowa’s action areas are focused on health care access, workplace culture, and a Leadership Institute to develop LGBTQ community capacity among others. Max and Dr. Imborek, welcome. Now as I was thinking about today’s discussion, I realized that I wanted to answer three overarching questions: who exactly are we talking about, what are the health-related issues we need to be aware of, and what actions can we take to ensure health equity? By using we I mean a diverse group of people who may be engaged in various ways as part of the public health or healthcare workforce, as well as community members at large. So let’s start by considering who we’re talking about and I’ve already used a couple of terms, sexual and gender minorities and LGBTQ people, and is probably worth sorting out what we mean by each one. So would either of you like to help define these terms and the populations that they refer to?

Max Mowitz Yeah, I’d be happy to speak a little bit about the LGBTQ acronym. I’m Max Mowitz and part of my work at One Iowa includes training LGBTQ folks and allies in the state about what the community looks like, but LGBTQ is actually an acronym that describes two different things. It describes sexual orientation and gender identity and sometimes people get that a little bit confused because they think that all LGBTQ people are gay, for example, or things like that, so sometimes people can get confused. It’s actually really important to understand the distinction between sexual orientation and gender identity because legally those are things we have to pay attention to because usually they’re protected legally under the name of sexual orientation and gender identity. So plainly put, the LGBTQ community describes people that identify as lesbian “L”, gay “G”, bisexual “B”, transgender or trans “T”, and then “Q” describes people that identify as queer or questioning. I’m not sure how into how much detail you’d like to get on each one of those identifiers, but it can be helpful to also think of them in two separate groups. So lesbian, gay, and bisexual people, those are all descriptors of sexual orientation right, so the people that you’re attracted to. Whereas when we’re talking about the trans community that describes gender identity, which is who you are, right. So you can be both trans and bisexual, for example, but you know, the whole LGBTQ community doesn’t identify as the exact same thing, for example.

Katie Imborek And well, this is Katie. I would just add in there because I know that as I’ve done a lot of lectures and been speaking to students and medical residents or medical faculty or staff members that one question that always comes up is around the “Q” in queer. In our LGBTQ clinic, just like Max had described, we kind of have two “Q’s”, both queer and questioning. When we first opened we would often get folks who are commenting or who were sending us emails or they were quite alarmed because they felt like the article that was written got it wrong because they said that that the “Q” stood for queer and surely we would not want that word used because they felt like it was still quite derogatory. While that is the case for some folks even of the community, I think that that claim has been largely reclaimed by a lot of people in the younger generation within the community. It is in its truest sense an umbrella term that could describe anyone who is a gender or sexual minority, and so that is the one that that I think can some what kind of cross lines between sexual orientation as well as gender identity, which in some ways makes it confusing and in other ways makes it quite liberating. I, who live in the world of electronic medical records where we have a lot of check boxes that we need to click and not a lot of free text lines, I think identifying as queer is kind of the ability to sort of say fine I’ll give you a label without really telling you what that label means because it can mean anything to anyone who identifies as kind of a gender or sexual minority person.

Paul GilbertI’m glad you mentioned that. I’ve heard that the, I guess, different attitudes towards that word, “queer”. I’ve heard about that before and it’s almost like a generational difference. Maybe some folks who grew up with it being used as a slur and really insulting don’t like it and then younger generations seem to have embraced that as reclaiming the term and empowering, but I think the intent is to be more of an inclusive and umbrella term a lot of times, so thanks. You know a follow-up question that occurred to me is are there any other terms or identities or words that we should be on the lookout for? You know, one that I’ve heard, thinking about other groups that may identify differently as same-gender loving among African-American, at least men that’s where I’ve heard it, but anything else that we should be on the lookout for or be able to recognize as “ahah, you fit under this broad umbrella of sexual and gender minority“.

Max Mowitz Mm-hmm well I think that there are a lot of terms that are left off of the LGBTQ acronym that really are just as important as LGBTQ, but one thing that I think a lot about, and the conversation about the word “queer” makes me think of this, but something that I always recommend people think about is, especially if you’re feeling overwhelmed by all of the different words and terms or you’re very hesitant to use the word “queer”, for example, because you don’t know how a person is going to respond to it . . . Something I recommend is listening for the language that people use about themselves and just mirroring it back to them. So we could go through quite a long list of different identifiers today and we might miss one, but if you’re doing that really intentional listening and you’re mirroring back the language people use for themselves, be it like queer or lesbian or intersex, for example, those are all going to be really important to pay attention to, so you know how to address someone. It’s really great to have that as a tool that really paying attention to how someone refers to themselves because that way you don’t necessarily have to know all of the different identities that you might interact with, you just have to know about the identity of the person sitting in front of you and that could be a really good way to make sure that you’re using language that fits them and makes them feel comfortable too.

Paul GilbertThat’s a really good point, thank you. Now I have another question. Thinking back to the introductions that I just recently gave, why did I mention the pronouns that we use? Why is that important? Would anyone like to answer that?

Katie Imborek I have one – this is Katie. I have one story that I often think about with regards to pronouns, especially when working in a medical context with people and how working with folks who may identify under a trans umbrella often times have experiences either personally or they know of experiences with some of their friends, family, or peers or they’ve been discriminated against in a healthcare setting. Because of this we know that that’s one of the reasons that they may not access healthcare quite as much as their cisgender or non-transgender counterparts would. So the story is when I was in a focus group that was specifically looking at how different organizations that care for survivors of sexual assault specifically tried to be inclusive of folks who are transgender or non-binary. One of the groups broke up and wrote on the whiteboard and they drew a picture of the University of Iowa Hospitals and Clinics and they drew barbed wires surrounding that. It was such a poignant example of how people feel like they have to potentially walk through barbed wire fences that almost physically, while often, you know, clearly emotionally harms them just to receive health care and that’s not because they didn’t receive, you know, competent medically competent care from their providers. That’s because they were misgendered, that’s because they used names that weren’t the names that they refer to themselves as, that’s because they used pronouns that don’t align with their own identity. So when I think about some of the things that we can do to really create an environment that’s affirming and respectful of all of our patients, I think that using the names and the pronouns that most align with people’s identity is such a very small step that we can do that can really make a big difference in terms of reaching our hands out and saying this is a place where we respect you and your humanity and that you can trust us to really care for you well.

Paul Gilbert Thank you for sharing that story, you know, I approach it to always, with the intention of telegraphing or signaling that I’m going to be attentive in this group, in this meeting or wherever I am that our organization is going to be attentive to, you know, addressing people correctly so how put forward first, you know, the pronouns I used and doesn’t have to be a big deal, just say my pronouns are he/him and his. It’s just matter of fact but I hope it does telegraph that sort of sensitivity. So I may be getting ahead of ourselves thinking about action steps, but it could be something that, you know, folks could do in their own organizations, in their work, and wherever to help set the tone, I guess.

Max Mowitz Well and, you know, just in case I think that most of us learned what a pronoun was in like maybe sixth or seventh grade grammar, which it’s been a little while since I’ve been in that class, but it’s really just how you refer to a person in a sentence without using their name. So like we mentioned our pronouns – this just earlier in the program – so of course she/her and hers, he/him and his are gonna be pronouns you interact with a lot and usually those are what a lot of people think are the only two pronouns, but we know more and more that there are more pronouns that we can use to refer to people that don’t identify as men or women, or for whom she/her/her and he/him/his really don’t tell the story. So those pronouns that you might interact with are those like . . . my pronouns are they/them and theirs, they being the singular “they”. You might also interact with pronouns like the/their and theirs or ze/zir and zirs. There’s quite a few and that’s another time when that mirroring of like how people refer to themselves is really helpful. But also if you’re doing exactly what you said and introducing yourself with your pronouns and asking for someone’s name and pronouns, it means that you’ll always know what that person uses and it’s just the best practice that way you can refer to people correctly because pronouns are just as essential as somebody’s name, for example. So that’s how I like to think about it.

Paul Gilbert Great, thank you. Now I wonder if we could maybe switch topics a bit, moving from the question of who we’re talking about to thinking about what concerns that they have and, you know, our focus is health and health care and the well-being and working to promote good health for sexual and gender minority people. So I wonder if it may be helpful first to recall a definition and I happen to like the World Health Organization’s definition of health. The WHO says that health is a state of complete physical, mental, and social well-being, that it’s not simply the absence of disease. So keeping that more comprehensive, holistic definition in mind, what do you think are the most pressing health concerns for sexual and gender minority populations in the Midwest?

Katie Imborek This is Katie. So I largely work with folks who identify as transgender or non-binary and so a lot of, kind of, what I’m passionate about or a lot of what I sort of feel are high-priority is definitely colored just by, kind of, the slice of folks that that I see and knowing that of LGBTQ folks, many of my patients do identify as non-cisgender. So amongst people who are trans and non-binary, much of what I would say has been an issue over and over again for them would be around their mental health, which I think is directly related, for many of them, just to gender dysphoria and that interplay between those two. It specifically has to do with the fact that they oftentimes cannot access some of the medically necessary procedures or treatments that they need to adequately treat their dysphoria and so those would be things that are often not covered by their insurance either a private insurance or if they have state-funded Medicaid. So this would be something like top surgery or male chest reconstruction for someone who identifies as a transgender-masculine person or facial feminization or bottom surgery, like a vulva or vaginoplasty for someone who identifies as a transgender-feminine person. So, what I have definitely seen, you know, and specific to the state of Iowa where the state Supreme Court unanimously ruled that Iowa Medicaid needed provide coverage for those surgeries and then when before even paying for one of the procedures our legislators kind of wrote that into a Health and Human Services budget bill and then kind of gave Medicaid a loophole where they didn’t have to pay for those. I definitely saw a really intense uptake of mental health issues at that time because patients, when they did at one time have kind of this little bit of hope then, that was kind of . . . they felt like the rug was pulled out from underneath them. So all of that being said, I mean, I would say that mental health concerns, depression, anxiety, post-traumatic stress disorder, substance use, that many of those are, I think, some of the most concerning things that I see in some of those disparate things that I see in medical practice around the transgender and non-binary communities.

Paul Gilbert I think it’s worth noting that it’s not that you have for mental health or have these other concerns because you are transgender, queer, or whatever. It’s more the stresses, the discrimination, the day-to-day experiences that grind away at you that’s part of this sort of chain of causation. It’s not, you know, transgender folks ipso facto have mental health problems, but it’s because of the social response, the discrimination, and so on.

Katie ImborekAbsolutely, absolutely. So, yes, kind of your classic minority stress theory and that there’s just all of these levels of, you know, systemic injustice and discrimination that just from things like having a challenging time with employment, either keeping that job especially after they might have transitioned or going out and getting a job, if they do identify as trans or as non-binary . . . to housing to public accommodations to healthcare to then feeling like at times that they may be estranged from friends or family or from their place of worship, whatever that that might be. Those are the things that day after day really leads to some of those mental health problems. It’s not that that just because someone identifies as trans or as non-binary or as LGBTQ that that then means that that causes any of that mental health. It’s really kind of their experience living in a world that treats them as somewhat less than.

Paul Gilbert Max, since you do so much around the whole state of Iowa, I wonder if you’ve anything, any other perspectives to add on top concerns or priorities?

Max Mowitz Yeah, I think that there are a couple of areas that I see the most. One of the parts of my role is that I get to act as a community health worker at the LGBTQ clinic at Unity Point here in Des Moines, so that means that I meet with folks after they meet with a physician and see what kind of wraparound services they might need. One of the things that I get overwhelmingly, also in emails and phone calls from folks around the state, is a huge part – and we’ve kind of touched on it already – is social isolation and the feeling that you’re very very alone. So, often the resource that people really need that I can’t find for them and that are consistently not being met is social support and meeting other LGBTQ people, especially if somebody is trans or transgender. That is one of the areas that I see the most need and it’s one of the things that is hardest to find because it does take so much community support and community growth. If you are in, you know, certain parts like northwest Iowa, you might have to drive an hour and a half to go to a trans support group, for example. Even here in the city of Des Moines we have quite a few different options and still those options are always full and there’s constant demand and need. So that community support, that reaching out and being able to interact with other individuals that understand that shared experience of being LGBT, specifically trans for sure, that is absolutely paramount. It’s one of those . . . one of the biggest barriers to some of those positive mental health outcomes, for example, because of that isolation, especially if you’re estranged from your family or your friends after you come out. You may have had to move from a more rural part of the state to a less rural part of the state to be able to come out safely. It’s just that social support that’s so important, of course on top of the most basic needs and mental and physical health needs.

Katie Imborekyeah, this is Katie and I also just really would also add to that list, you know, things that are kind of more well-known probably with regards to sexually-transmitted infections among people who identify as gay, if they have a sex that is male, but largely though men who have sex with men and/or transgender people, so I would include them in that category as well as being at higher rates of things like sexually-transmitted infections, including HIV. Even though the state of Iowa does not have a lot of HIV as compared to some of our other states, even some in some of our neighbors, it’s still something that I feel like we have a lot more opportunity to be prescribing pre-exposure prophylaxis, so that once a day HIV medicine that can prevent HIV. There are still definitely patients that have never heard of it and we know that we have a lot of providers who don’t feel like they either have enough medical knowledge that they can prescribe it and/or they don’t feel like they have the resources in place where they feel like they can kind of competently spend the time that’s needed to be able to make that a reality for some patients. So I think that there’s still a lot of work to be done and a lot of opportunity that we can do to keep our patients that are at highest risk for things like HIV safe.

Paul Gilbert Along those lines, one question I had in my head was are there misconceptions or misunderstandings that you think we need to correct maybe, you know, among clinicians, educators, advocates, prevention workers, anybody else?

Katie Imborek I think that some of the misconceptions out there around things like STI’s would just be some of those assumptions that are made. Even when we really talk about cisgender folks, so folks who have the sex assigned at birth that aligns with their gender identity, and even if those people are in a heterosexual relationship that the assumption is that they’re monogamous and that the assumption is that they may be low risk for any types of STI’s that . . . we often as health care providers, rely on someone’s relationship status to then kind of drive how we evaluate their risk for any type of sexually-transmitted infection. Their relationship status is really just a piece of the puzzle, so I advocate for really thinking about sex and someone’s sexual identity in a much more comprehensive and holistic manner. This means really taking a great sexual history and knowing and understanding how your patient may be at risk and then being able to appropriately provide screening tests and anticipatory guidance to keep them safe. There’s no such thing as safe sex, but there is safer sex and there are many tools in that toolkit. We need to make sure that we’re letting patients know about all of those including things like HIV prophylaxis. If it is somebody who identifies as or has a sexual behavior that would include MSM, men who have sex with men, or I would argue anyone who identifies as a trans or non-binary person and maybe having sex with someone who’s in that higher risk cohort.

Max Mowitz Another thing – this is Max. Well, I think there are like two stereotypes or assumptions that I interact with a lot. The first I think has to do with general health outcomes, but the assumption is that all LGBT people, like when the average Iowan thinks of an LGBT person, they think of a white person and often think of a middle-class person and often aren’t thinking about trans folks. So I think understanding the core tenet of intersectionality and understanding that, you know, what intersectionality means is that people are made up of a lot of different intersecting identities that are either privileged or oppressed. I think better trying to meet the health needs of LGBTQ folks that are black, Latinx, and Native American or indigenous American is really important, but also paying attention to how access to education or higher education impacts health outcomes and then also income level as well. Those things all play a part and I think if we’re only looking at the fact that someone’s LGBT, but we’re not paying attention to if they have a GED or not, those things . . . they really need to be brought together to really get a good picture of what some someone’s health risks or health outcomes might look like. But I can also, along those lines, the other assumption I interact with so often is that there’s like one real way to be like trans or transgender and that every trans person wants hormones and surgeries, will change their name and pronouns and I really hope that as we move forward folks understand that there are a beautiful and vast and different array of ways to be trans. Every trans person is going to need different care and a different kind of individualized approach to their journey. If more providers knew that I think that that would be really helpful because it’s less about knowing what all of those different experiences might look like and more about knowing what the client right in front of you needs, too.

Paul Gilbert You know, what you said, Max, reminded me of that WHO definition of health that I started with, that it’s multi-dimensional, there’s all these things happening all at once, people hold multiple identities, it’s not just your sexuality or just your gender identity, but all of these things all at once that are happening that we have to keep in mind. So thanks. Now let me let me shift just a bit to the last area that I wanted to pick your brains about and that’s getting into action steps. So this to me is very much in mind with my public health training where I was taught that once we discover a problem we are compelled to do something about it. So what are some of the things that we could do and you could be creative or as imaginative as you like, but if you wanted to change anything, say programs, policies, other sort of intervention ideas, what might we do to improve LGBTQ health?

Katie Imborek I think that some of the things that we need to really think about with LGBTQ health – and this harkens back somewhat to what Max was saying about social isolation – is that it’s just not true that LGBTQ+ people live in urban environments only. You know, specifically here at the University of Iowa healthcare in Iowa City, our administrators felt like our LGBTQ clinic would probably have patients because we live in Johnson County and this tends to be a place where there’s lots of gay and lesbian folks. They thought there’s probably lots of trans folks, but the reality is that seventy to eighty percent of our patients travel to see us from outside of Johnson County. They’re coming to see us from rural Iowa. They’re coming to see us from places where they haven’t been able to obtain culturally competent health care from their local providers, so I think that one of the things that we really need to think about to be able to better serve these populations is figuring out how do we provide care to folks in their primary locations. We are at an age right now – we’re doing this great podcast over a video chat service where we can see each other and we can talk and hear and do that type of thing – and that we need to think about medicine and think about healthcare and some of those same ways, where it may not be that you physically have to be in the same room as your patient or your client, but you can still provide them with a service that they then can access a little bit easier without having to drive there and have the expensive travel, without having to potentially take the day off of work, where we can help patients stay in their place where they live and have that same access. So being able to provide that health care across all of our states and into every pocket and corner of those I think can be a really important thing that will change folk’s health status. Then, I would also have to say that that kind of back to one of my first issues with the inability of many transgender and non-binary folks who feel like they need procedures and/or surgeries to treat their gender dysphoria, and just with the little asterisks there, kind of like Max said, that this doesn’t pertain to every trans person. There are some trans folks who don’t at all need surgeries or procedures to treat the dysphoria that they have, but for those who do, being able to really figure out how we can provide them with those necessary procedures or surgeries, and/or sometimes it maybe can’t be that but maybe it’s chest binders for folks who identify as trans-masculine. Maybe it’s makeup kits and makeup lessons, and just some of those things that can really help people transition socially and/or help them have less dysphoria with their bodies. When just relying on their insurance company to come through and to pay for those services, we will continue to be waiting for a while. I can’t predict the future, I wish that I could and that I could tell you that I think by year X all of these things will be covered and paid for, and we won’t have this issue. But until then I think that it would be amazing if we could have more community orgs or more nonprofits coming to the forefront and saying this is our whole deal, we will accept donations and we will help trans people have surgeries to treat their dysphoria and to improve their mental health and to really improve their quality of life.

Paul Gilbert Alright, thanks.

Max Mowitz You know, another thing that I think of too . . . yeah, I think that – just like Dr. Imborek said – like it can’t be understated how important it is . . . those little things. One thing I try to make sure I talk to folks about that are maybe starting, for example, hormone replacement therapy, it’s their first time seeing a doctor for that, I think sometimes for those that would like to pursue hormones or surgery, that’s great. It’s really cool that they’re taking those steps, but I also find that sometimes they think that that we’ll be able to you know fully change them overnight and so sometimes it’s the coping and the waiting and the process of working with insurance that can be really frustrating. So I also think talking with folks that you’re working with about how they take care of themselves again if they know where to find a chest binder, if they know how to start using makeup, if that would be affirming to them. One thing that I interact with a ton is I work with folks that are looking for healthcare and mental health care but right behind that, after those supportive services, they’re also looking for like “where do I get laser hair removal that will support me as a trans feminine-person, where can I go to get my nails or my haircut that understands who I am and isn’t going to be discriminatory towards me?” I’ve spent whole afternoons helping folks in all different parts of the state try to find laser or different services that help them feel more like themselves in the moment and that can help them cope a little bit, but also places that they can be fully themselves. So, I think that those services . . . we can’t underestimate the impact that having those kind of services in our communities can be and the ways that we train those folks to interact with people. I also think, too . . . there’s LGBTQ-specific care, but then I also would hope that we would have doctors all across the state as well, that even if someone’s just coming in for a strep test they know how to talk about pronouns and they know how to talk to a trans patient without using their old name or their dead name when referring to them, right, so kind of understanding the different levels at which LGBTQ people need care and making sure that people have appropriate training in all of those different levels.

Paul Gilbert Yeah, thank you. So I’m going to include in the show notes links to the LGBTQ clinic website at the University of Iowa Hospitals and Clinics and to One Iowa so people have a place to go for some of these resources, but are there any other resources that you would recommend to listeners for whatever it might be, whether it’s finding a healthcare provider, other services or resources? Are there other places that folks might go?

Max Mowitz Yeah, the trans lifeline is great. That was a resource I was going to recommend and also their website’s been a little wonky recently, but the Trans Student Educational Resources is wonderful. They are the group that developed the gender unicorn, which is a little bit more like a 2.0 of the genderbread person, but that website is also just really well-stocked with resources. It was developed by trans people, which I think helps and so-

Paul Gilbert What’s the name of that again?

Max Mowitz Trans Student Education Resources, TSER.

Katie Imborek So one of the resources that I think could be really beneficial for anyone who’s interested in maybe diving in and learning a little bit more about LGBTQ health is the National LGBTQ Health Education Center, which is a program of the Fenway Institute in Boston. They have amazing learning resources including webinars, learning modules, they offer CEU and CME credit for them and those are really a great resource. Another resource just in terms of finding providers would be WPATH, so wpath.org, the World Professional Association for Transgender Health. They have a provider directory on there where you can search by zip code or by state to find providers who are members of WPATH and provide care for transgender patients. Another place that you can find health care providers that have self-identified as providing competent care to LGBTQ+ people would be at glma.org and that’s the Health Professionals Advancing LGBTQ Equality.

Paul Gilbert Alright, these are some great resources, thank you very much. We’ll include in the show notes, links and other descriptions so people can find them. One of my final questions to you both is for our listeners, what might be one or two easy steps that they could take to promote good health, whether it’s individually or as a community, for LGBTQ populations, for sexual and gender minorities?

Max Mowitz One thing that I think about – and this is Max – but my recommendation is – and this will help folks in a lot of different areas – but of course asking folks about pronouns and also mirroring folk’s language back to them is really important. Finding new ways to talk about people in a gender-neutral way can be really helpful, so one thing that I focus on . . . I’m working towards doula certification and giving birth is one of the most gendered experiences that we have in our society and if we were to change a lot of the way that we talk about giving birth, for example, to be more gender neutral it would include folks that are trans or trans-masculine that are also giving birth as well. So thinking about the gendered ways or the ways that we see the gender binary, aka men and women, masculine and feminine in our society and trying to go into a more gender-neutral path with that I think can be really really helpful. It’s one of those very small and kind of covert ways that we can make LGBTQ people feel more safe and comfortable whereas the average straight or cisgender person might not notice it, an LGBTQ person will notice the difference. Then, again, I think especially if you are a straight or cisgender ally, constantly asking and advocating for LGBTQ specific services because so often the reason that we have clinics pop up or people get interested in this is because a lot of different people from a lot of different areas are advocating for those kind of services. Even if it’s not a game that you have skin in, like trying to advocate for that and recognize that that is really really important is going to speak volumes above what the average LGBT person could say. Having straight and cisgender allies that are willing to do that hard work is paramount.

Katie Imborek I would add two more really concrete things that folks could do to improve the healthcare and the experience of LGBTQ+ folks and that would be one, just to take a look at any kind of intake forms that you may have as part of your organization. So this may be electronic or it may be paper-based, but really look at those and try to make them as gender-inclusive as possible. If you can, leave some free texts for people to be able to self-identify and if you can’t, then be inclusive with those terms. Ask about someone’s sex assigned at birth and also ask them for their gender. Ask them for their preferred name, not their legal name, or both. Ask them what their pronouns are. So that would be one thing that I think is important. And like Max said, many of these things, it doesn’t make a big difference to folks who are straight and cisgender. We get this question a lot: “Oh gosh but how is this seventy-two-year-old farmer from Kalona gonna feel about that?” You know, they’re not actually going to notice, but those folks who identify as LGBTQ, they are on the lookout for the smallest sign that might convey to them that this is a welcoming and safe place. The other thing would be to really think about any of your single-stall bathrooms. There is no need to have a gendered single-stall bathroom. If you have a single-stall bathroom, it should be a restroom that is available to folks of all genders. I think that, again, that is a small thing that it seemingly doesn’t make a big difference to many people, but it can make a huge difference to folks who identify as transgender or non-binary.

Those are some really good concrete, direct suggestions of things people could do and it really strikes me that they’re all about creating a welcoming, affirming, inclusive environment, so thank you. With that, I think that brings us to the end of our discussion. I want to thank you both for taking the time to chat with me today. We’ve covered a lot of ground. There’s a lot more, but in our limited time here of our episode, we’ve covered who we’re talking about, what we mean, what the health concerns are, and a lot of really good concrete things that we could do to promote better health for our LGBTQ community members, so thank you.

Katie Imborek Thank you so much for having me.

Max Mowitz Thank you.

Hannah Shultz Thank you for joining us today. Special thanks to Rima Afifi, Anne Crotty, Alejandra Escoto, Paul Gilbert, Kaci Ginn, Mike Hoenig, Kathleen May, Felicia Pieper, Melissa Richlen, Hannah Shultz, and Laurie Walkner. Theme music for Share Public Health is composed by Dave Hoing and Roger Hileman. Funding for this webinar is provided by the Health Resources and Services Administration. Please see the podcast notes for an evaluation and transcript.