We’re hitting the end of June and I am yet to talk about LGBTQ issues in PT. I know that I harp on this a lot throughout the year, but I thought now would be a good time to reemphasize it, especially as Pride Month winds down and many of us are tired of everyone arguing about rainbows. I know that I probably over-cover these issues relative to others in PT, but they’re very important to me and I’m the guy who writes this, so that’s what you get. Proper care of LGBTQ+ individuals is important for many reasons, especially considering that about 24 million Americans identify as “non-heterosexual”. And as a bisexual queer PT, I’m one of those 24 million.
I think it’s particularly important to point out here that compassionate care of LGBTQ+ people is not just about them, it’s about everyone. Inclusive choices make things easier for everyone. Out in life, we see and talk about this all the time with reference to ramps, kneeling buses, smooth sidewalks, handicapped doors, and more. In PT, being more inclusive for LGBTQ people makes clinics and practice better for everyone.
Also, if you’re tired of this content, no worries. Next week we’re talking spondy.
But for now, let’s dive in!
The Gist - We open with a type of piece that I cover about once per quarter here in PT Crab, the Editorial. This one is from PTJ in 2022 and is written by Gail M. Jensen, a PT and professor at Creighton University in Omaha (where LSU just won the men’s college World Series, go Tigers!). Gail writes the editorial in response to a paper we’ve covered in the Crab before, “An Exploration of the Experiences of Physical Therapists Who Identify as LGBTQIA+: Navigating Sexual Orientation and Gender Identity in Clinical, Academic, or Professional Roles” by Ross et al. It’s a great reference piece and available open access. The reason I’m looking into the editorial, rather than the piece, is that it breaks down complex topics in just 3 pages and gives actionable information and advice on how to address these issues in your own life and practice.
The piece, and this editorial, break the challenges of LGBTQ+ PTs down into three main topics, normativity, stress and labor, and professionalism. Normativity is about the language that frames out lives. According to the editorial, “Understanding the term heteronormativity is foundational to gaining insight into the lived experiences of our community” because of how it permeates culture and our personal assumptions, often “othering” those who fall outside norms. Simple assumptions like gender, a partner’s gender, the alignment between gender and gender assignment at birth, all of these are viewed in a heteronormative world and the expression of them can lead others to “turn their light down” and be less authentic versions of themselves. As anecdata, this has certainly been a factor in my life that has changed in the last few years even through simple things like embracing purple as my favorite color, as it always has been, rather than blue as purple wasn’t “manly enough” to me when I was younger. I know it’s simple, but it’s important to me and being in a more supportive environment in life has helped me express that.
I’m rambling, so let’s go to the next section.
Tell Me More - The next discussion is on Stress and Labor, which Jensen discusses as our work environment and I think can be broadened beyond just PTs, to our patients as well. According to the Ross paper, “there is a toll arising from the fear people experience when they consider sharing their true identity,” and I’m sure patients go through the same. According to Jensen, “Fearless organizations create workplaces where human capacities can flourish in an environment that provides psychological safety. These environments facilitate a sense of trust and respect as all members of the team are free to speak up without the fear of embarrassment or rejection.” This type of organization is helpful for those with non-heterosexual identities but also, in an industry where 47% of therapists experience inappropriate patient sexual behavior each year, this sense of trust and respect in a workplace could help curtail that. There is an innate tension in PT, according to Jensen, where “there is the expectation that (1) we care for all patients, regardless of their behavior, and (2) this caring overrides everything,” potentially even the clinician’s right to be treated with dignity and respect. It shouldn’t but in some workplaces it does, leading to burnout, stress, “feelings of powerlessness, discrimination, and invisibility.”
Lastly, professionalism, which “Ross et al argue… is the pervasiveness of cis/heteronormativity, along with other white middle-class norms that can lead to the perception of being “deviant” and not conforming to what is perceived as professional.” Jensen argues that “for far too long, we have assumed that the conceptions of a profession— developed and shaped by how we see traditional (historically white, male-dominated) professions—are not to be questioned or shaped by other professions, including female-dominated professions.” In Jensen’s understanding, “the ability of our colleagues to bring their diverse characteristics into the workplace is important in connecting better with patients and fostering inclusive workplaces for others.”
I know that none of the above actually gives an actionable step you can take in clinic today to make your practice better. But I hope that it leads you to question the priors and norms inherent in your care and clinic and that you turn up the light of your individualism and help create a safe space for others to do the same.
Paper? Got it.
How Can I Learn More?
I’m glad I forced you to ask that question. The National LGBTQIA+ Health Education Center has an incredible collection of free resources to learn more about how to be a more inclusive clinician and person, how to build supportive environments, and just what the heck all of these new words mean.
They recommend you start with their two intro modules, on the foundations of LGBTQIA+ Health. Here’s part 1, for all. And Part 2 for clinicians. And if you like it and want staff to take it, there are also parts for non-clinical staff and administrators.
Outside of those, I particularly like this one on Sensitive and Affirming Communication, one on Sexual and Gender Minority Terms and Concepts, another on Healthcare for LGBTQIA+ Older Adults, and Healthcare for Transgender and Gender Diverse People.
Again, they’re all free, you just need an account. If you have the time, please do learn more. They are eligible for CME credit, but whether or not that means they count as Con-Ed in your state is up to your state, so they’ll have to look into it.
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The Gist - This piece, a short dissertation on LGBTQ+ patient experiences in physical therapy in Washington state takes the other side from the above, looking into what it’s like to be a patient and how to improve things from their perspective. Because it’s a dissertation, it’s 93 pages long. So I’m going to skip to the recommendations section to give us some actionable stuff. This was qualitative research done via interviews with 19 participants. Results-wise, the broad strokes were that an “inclusive organizational environment, establishing trust, and being involved in the bigger picture as it relates to health and physical therapy services,” where key areas the participants indicated.
The inclusive organizational environment recommendation comes with some more specifics, as well, including trauma-informed care practices, demonstrations of organizational authenticity, having care options that are inclusive of privacy needs throughout the process, and having a choice of providers. Changing providers to one you’re more comfortable with is often a challenge in PT, both because it can be awkward as a patient and because schedules are often quite full, but it can make patient experiences much better, the paper points out.
Tell Me More - In reference to establishing trust and trauma-informed care practices, the patients had some interesting ideas about how to help patients discuss this.
I think it would've been great if somewhere on that form there had been a thing that was sort of like if you have a history of physical trauma and would like to discuss that with your physical therapist, please check here and then we will have a private discussion about that. Or an area that said something like, ‘are there any areas where you do not like to be touched?’ You could imagine that that might be ... I think that because queer and trans folks have higher rates of experiences of violence it's a perfectly reasonable thing. The thing that's so great about asking a question like this is it's not just for queer and trans folks, right?
Relatedly, one person in the study had an idea about how to tweak intake forms to make them more inclusive with one simple question, “Is there anything you think is important for us to know?”. In their words, this question lets them discuss their gender and sexuality, their history of trauma, or anything not covered on the form, and it doesn’t just apply to LGBTQ+ people. I for example, have a hypersensitive area of skin along my inguinal canal, bilaterally. I can’t stand to have it touched. But if someone is working on my hip, they often do, and I often forget to tell them until they have and I’ve nearly jumped off the table. So things like that.
There’s a lot more in this paper (did I mention it’s 93 pages long?) so if this is an area in which you’re interested, I highly recommend checking it out. But it is long (93 pages). I’m going to leave it there because this Crab is long.
Paper? It’s here if you want it. Did I say, it’s 93 pages long? Well it is.
And that’s our week! Thanks for getting into these issues with me and do indeed check out the resources above. They’re an amazing set of guides. Next week, spondy.
Here’s this week’s bibliography, along with a few other papers on the topic:
- Charles, D., Clay, R., Moroney, B., Stewart, A., & Ramsey, C. (2022). The Lack of LGBTQIA Cultural Competency in Physical Therapy Education. Journal of Allied Health, 51(1), 47–51.
- Glick, J. C., Leamy, C., Hewlett Molsberry, A., & Kerfeld, C. I. (2020). Moving Toward Equitable Health Care for Lesbian, Gay, Bisexual, Transgender, and Queer Patients: Education and Training in Physical Therapy Education. Journal of Physical Therapy Education, 34(3), 192. https://doi.org/10.1097/JTE.0000000000000140
- Jensen, G. M. (2022). Time to Shine the Light. Physical Therapy, 102(3), pzab257. https://doi.org/10.1093/ptj/pzab257
- LGBTQ+ Considerations Related to Physical Therapy: A Qualitative Study in Washington State - ProQuest. (n.d.). Retrieved June 22, 2023, from https://www.proquest.com/openview/c548a3d4bab8a062cd74eab9eabc3032/1?pq-origsite=gscholar&cbl=18750&diss=y
- Morton, R. C., Ge, W., Kerns, L., & Rasey, J. (2021). Addressing Lesbian, Gay, Bisexual, Transgender, and Queer Health in Physical Therapy Education. Journal of Physical Therapy Education, 35(4), 307. https://doi.org/10.1097/JTE.0000000000000198
- Ravi, R., Cheng, S., Hutter, J., Ibbitson, A., Ljubojevich, E., Chan, Z., Beavers, L., & Nixon, S. (2022). A Call to Disrupt Heteronormativity and Cisnormativity in Physical Therapy: Perspectives of 2SLGBTQIPA+ Participants on Future Directions for PT Curricula. Physiotherapy Canada, e20220019. https://doi.org/10.3138/ptc-2022-0019
- Ross, M. H., Hammond, J., Bezner, J., Brown, D., Wright, A., Chipchase, L., Miciak, M., Whittaker, J. L., & Setchell, J. (2022). An Exploration of the Experiences of Physical Therapists Who Identify as LGBTQIA+: Navigating Sexual Orientation and Gender Identity in Clinical, Academic, and Professional Roles. Physical Therapy, 102(3), pzab280. https://doi.org/10.1093/ptj/pzab280