1. What the heck is genderqueer
What the heck is genderqueer? Inclusivity requires more than a policy change.
David Kappel, MD, FACS
Valerie Satkoske, PhD, MSW
Annual Medical Ethics Update Conference
Center for Bioethics and Health Law
University of Pittsburgh
March 31, 2017

2. CMS Requirements CMS COP Patient Rights 482.13 Non-Discrimination
Hospital establishes explicit requirements not to discriminate on the basis of race, color, national origin, sex (including gender identity), age, or disability
Hospital establishes and implements a written policy prohibiting discrimination on the basis of race, color, national origin, sex (including gender identity), age, or disability
Hospital establishes requirements not  to discriminate on the basis of religion or sexual orientation and establishes and implements a written policy prohibiting discrimination on the basis of religion or sexual orientation

3. Ethics Committee Took up voluntarily Formed subcommittee Researched
Looked at existing policy (nondiscrimination, patients’ rights…)
Mapped every bathroom in the hospital
Looked for Catholic statements
Participated on Catholic Health Associate (CHA) conference call
(closed invitation only call)

4. Resources we found helpful
IOM, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding (2011)
Lambda Legal, Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Affirming Hospital Policies (2016)
Oregon Health & Science University-Transgender Health Program
The Joint Commission, Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide (2011)
UCSF, Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, 2nd edition (2016)
VHA Directive ,Providing Health Care For Transgender And Intersex Veterans ( )

5. What we found… A mountain of information on: Terminology and framing
Clinical considerations
Rooming and bathroom considerations
Training and Educational Materials
History LGBTQ interaction with medical community
Need to create a warm and inclusive environment

8. Joint Commission
Integrate unique LGBT patient needs into new policies or modify existing policies:
Nondiscrimination policies
Visitation policies
Policies which define “family”
Room assignment policies
Employment policies

9. VA Policies (p A-7)
“Cultural awareness and sensitivity education for field staff was developed and implemented in fiscal year The VA standard of zero tolerance for discrimination, harassment, or abuse of Veterans applies to VHA treatment of transgender and intersex Veterans.”
“Transgender Veterans who presently self-identify as female are allowed to use bathrooms for women. Likewise, those who presently self-identify as males are allowed to use bathrooms for men. This is irrespective of the Veteran’s appearance or whether the Veteran has had sex reassignment surgery. The privacy needs of other patients must also be considered; availability of “unisex” bathrooms (for men and women) throughout facilities is a practical approach to this issue and is common practice in some facilities.”

10. Clinical Considerations
Labs, labeling, and interpretation
Birth sex specific health concerns
Hormone therapy
Transition specific behaviors (breast binding, penis tucking, free silicone, …)
Emotional response / resistance to birth sex health screenings in the transgender patient (pelvic exams can be especially traumatic)

11. Providing Quality Care to Lesbian, Gay, Bisexual, and Transgender Patients: An Introduction for Staff Training
Welcome to the learning module: Providing Quality Care to Lesbian, Gay, Bisexual, and Transgender Patients. In this module, you will learn ways to provide affirming and inclusive health care for lesbian, gay, bisexual, and transgender, or LGBT, patients.
Learning Module

13. Assessing Receptiveness
Resistance within our own committee
Cautioned by some doctors to proceed slowly
Decided upon minimal language changes within existing policy and education for internal community (for nondiscrimination policy)
Culture changes slowly…so small incremental change

14. Multiple committees approval
Patient care committee—education provided and committee in agreement to accept and pass to med / exec…
Last minute question regarding Catholic position (A member of medical leadership)
Med / Exec passed to Board for final approval
Ended up in administration for approval..which it was

15. Moral Distress
We now had all of this information on this underserved community of people…but didn’t feel we could successfully be change agents And then….

16. Meaningful Use: Stage 3

17. Meaningful Use and registration
Micro fields…called ethics for physician offices
Education for managers, registration staff
Form designed for patient to complete and registration to input (multiple iterations…)

18. Joint Commission
Identify a process to collect data at registration/admitting
Identify a process to document self-reported sexual orientation and gender identity information in the medical record
Ensure that the disclosure of sexual orientation and gender identity information is voluntary

19. Why a form and registration?
Decreased need for framing (scripting…reduce nonverbal messaging)
Lack of privacy at “the window”
Completing a form may be more comfortable on multiple levels
Written definitions, voluntary in nature, literacy levels, option to opt out, option to discuss with doc….all agree clinician best to ask question….but many docs resistant, uncomfortable

20. Constructive feedback
Peds---hadn’t considered and decided may put minors at risk so will leave to clinicians to ask as they see appropriate
What to do with paper form after info put in EHR
Providing option of discussing with doctor
Concerns over info populating face sheet or banner in EHR
Literacy levels

21. Not so constructive feedback….
I don’t see the clinical implication for it.
I don’t even want to talk about it.
I will not listen to this or talk about it—it violates my religious beliefs.
Do we HAVE to do this?
This is offensive. Patients will be offended. I am offended by this discussion.

24. Catholic Health Association
Currently no official position
Good clinical care
Is gender affirming surgery “medically necessary?”
Tops and bottoms
NCBC article
Cooperation
Dignity, respect, nondiscrimination
**People will try to hide behind religion without understanding church teaching