Hello, and welcome to our webinar: Exploring Culture in CLAS: Sexual Orientation and Gender Identity. My name is Darci Graves, and I serve at the Senior Health Education and Policy Specialists with the Health Determinants and Disparities Practice at SRA International, where we work to support the HHS Office of Minority Health Think Cultural Health and National CLAS Standards initiative. Today.s webinar, Exploring Culture in CLAS: Sexual Orientation and Gender Identity, is part of a larger series on Exploring Culture in CLAS. Where we dove deeper into the various aspects of culture within culturally and linguistically appropriate services.

First, let me introduce you to the HHS Office of Minority Health. At OMH, we work to improve the health of diverse populations through the development of health policies and programs that will eliminate health and health care disparities. As you may know, there is a significant body of research that documents the persistent and widespread disparities experienced by many communities in our nation.

The OMH established the Center for Linguistic and Cultural Competency in Health Care (what we commonly refer to as the .CLCCHC.) to address the health needs of populations who speak limited English. Its mission is to collaborate with federal agencies and other public and private entities to enhance the ability of the health care system to effectively deliver culturally and linguistically appropriate health care. The CLCCHC is considered a "center without walls," encompassing all existing and new policy, partnership, communications, service demonstrations, and evaluation activities related to cultural and linguistic competency.

Among its goals are to: Facilitate access and the exchange of information on literature, research and programs for removing language and cultural barriers to health care for limited English-speaking populations. It also includes in its goals to provide technical assistance to health care providers to enhance their ability to deliver linguistically appropriate and competent health care to diverse minority populations. Think Cultural Health and the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care are two of the key initiatives born out of these goals, and I will talk more about each of these initiatives at the conclusion of this webinar.

What is CLAS? CLAS is an acronym that stands for culturally and linguistically appropriate services. CLAS is defined as services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs. CLAS should be employed by all members of an organization, regardless of its size, at every point of contact. Implementing CLAS helps health and human services professionals treat individuals with respect and be mindful of their culture and language.

CLAS helps a health and health care providers better respect and consider a client.s cultural background, from the diagnostic interview to the formulation and implementation of a treatment plan to which the client can adhere. This respect and consideration lays the foundation for a trusting relationship, which is vital for the success of any treatment. CLAS also helps create a system for recognizing communication barriers and taking steps to reduce those barriers. For example, a mental health system that implements CLAS will collect data on language needs and preferences at intake, and then ensure that clients who have limited English proficiency have trained and qualified interpreters to facilitate communication at every point of contact.

To assist organizations in providing CLAS, the Office of Minority Health has developed a framework for operationalizing it. We call it, The National CLAS Standards or the National Standards for Culturally and Linguistically appropriate services in he. The Standards are an important tool for promoting and implementing culturally and linguistically appropriate services. The National CLAS Standards were first developed by the HHS Office of Minority Health in 2000. In 2010, the Office of Minority Health launched an initiative to update the Standards, which incorporated public comment, a literature review, and ongoing consultations with an advisory committee comprised of 36 experts representing a variety of disciplines and organizations.

In April of 2013, we were very excited to released the enhanced National CLAS Standards at a series of events. There are now 15 Standards, each of which is an action step that guides professionals and organizations in their implementation of culturally and linguistically appropriate services. Now, let.s walk through some of the concepts that underpin the National CLAS Standards.

The enhanced National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities. The Standards establish a blueprint for health and health care organizations to implement and provide culturally and linguistically appropriate services.

The definition of .health. used by the National CLAS Standards, includes physical, mental, social, and spiritual well-being. This definition of health reflects the fact that many aspects of health influence an individuals well-being.

Thus, this definition encompasses medicine, behavioral health, mental health, public health, social work, community health centers, emergency health services, and more. Because of this, the audience of the Standards is considered to be any .health and health care organizations,. which includes any public or private institutions addressing individual or community health and well-being.

Now to bring into focus why we are here today, lets talk about culture and all that culture includes. Within the Standards .culture. encompasses race, ethnicity, and linguistics, as well as geographical, religious and spiritual, biological, and sociological characteristics. Culture is defined as the integrated pattern of thoughts, communications, actions, customs, beliefs, values, and institutions associated, wholly or partially, with racial, ethnic, or linguistic groups, as well as with religious, spiritual, biological, geographical, or sociological characteristics. Culture is dynamic in nature, and individuals may identify with multiple cultures over the course of their lifetimes. This definition attempts to reflect the complex nature of culture, as well as the various ways in which culture has been defined and studied across multiple disciplines.

It is also why we use this Venn Diagram so that we can illustrate the intersections and the overlay of the various aspects of culture including age, race, ethnicity, socioeconomic status, spirituality, gender identity, and sexual orientation because we all have all of these pieces, and they all interact and inform each other. Today we are going to talk more about sexual orientation and gender identity.

Pulling from the NCS blueprint, we have these definitions of sexual orientation which encompasses attraction, behavior, and identity. Most researchers studying sexual orientation have defined it operationally in terms of one or more of the following components.

Defined in terms of behavior, sexual orientation refers to an enduring pattern of sexual or romantic activity with men, women, or both sexes.

Defined in terms of attraction (or desire), it denotes an enduring pattern of experiencing sexual or romantic feelings for men, women, or both sexes. Identity encompasses both personal identity as well as social identity.

Defined in terms of personal identity, sexual orientation refers to a conception of the self-based on one.s enduring pattern of sexual and romantic attractions and behaviors toward men, women, or both sexes.

Defined in terms of social (or collective) identity, it refers to a sense of membership in a social group based on a shared sexual orientation and a linkage of one.s self-esteem to that group.

The terms lesbian, gay, and bisexual relate to an individuals sexual orientation.

Whereas the term transgender refers to an individuals gender identity, which is one.s basic sense of being a man, woman, or other gender, regardless of what gender one who born at birth. It is important to note that terminology around sexual orientation and gender identity is not limited to what we commonly refer to as LGBT or lesbian, gay, bisexual, and transgender. These are just currently the most common terms used when talking about this community. Sexual orientations and gender identities that do not fall within the perceived norm can create barriers in accessing and receiving culturally and linguistically appropriate care. The LGBT community faces numerous health and health care disparities.

LGB youth are at increased risk for suicidal ideation and attempts as well as depression. Small studies suggest the same may be true for transgender youth. Rates of smoking, alcohol consumption, and substance use may be higher among LGB than heterosexual youth. Almost no research has examined substance use among transgender youth. LGBT youth report experiencing elevated levels of violence, victimization, and harassment compared with heterosexual and non-gender-variant youth.

As we move across the lifespan and we enter early and middle adulthood, we see that LGBT people are frequently the target of stigma, discrimination, and violence because of their sexual and or gender minority status. And as a group, LGB adults appear to experience more mood and anxiety disorders, more depression, and an elevated risk for suicidal ideation and attempts compared with heterosexual adults.

And finally, in later adulthood, geriatric populations and LGBT elders, frequently experience stigma, discrimination, and violence across the life course. The use of all of this information in these statistics come from the Institute of Medicine in a report on LGBT health which I will talk about a little bit later, and only touch the surface of health and health care disparities experienced by the LGBT community. The next two slides come from .real life. legal cases in which sexual orientation and gender identity played a critical role in how the individuals received care and services.

This case illustrates how policy and implementation guidance can be changed to become more culturally and linguistically appropriate. The Department of Public Health and Environment, Women.s Wellness Connection Collaboration had the following case cited against it. The Complainant, who is a transgender woman, alleged that WWC discriminatorily denied her funding for her breast examination and mammogram based on her sex in March 2013. The Department stated that its actions and decisions relating to Complainant were due to its status as a grantee of the Centers for Disease Control and Prevention (CDC), which had issued guidance stating that grant funds could only be used to cover women who are genetically female.

In December 2013, the CDC issued guidance to its grantees stating that grant funds can now be used to provide services to transgender women (male-to-female transgender individuals) who have taken or are taking hormones to increase their screenings for mammograms and other preventative services.

Discrimination can manifest itself in many points along the continuum of care

Having policies is not sufficient to providing culturally and linguistically competent services; policies must also be monitored and enforced. This case involves Jenny and Jessica who met in 2008 and fell in love while serving in Iraq. They legally wed on October 8, 2010, and remain in the Army Reserves. After planning a family together, Jessica became pregnant via in vitro fertilization and an anonymous donor. On October 21, 2011, Jessica gave birth to Brayden, at 30 weeks. gestation. He died in utero prior to labor after his umbilical cord became wound around his neck. On the fetal death certificate form, Jessica filled out the boxes for .mother. and Jenny filled out the boxes marked .father,. which were the only option on the form for a second parent.

On January 12, 2012, Department of Public Health (IDPH) issued them a death certificate on which someone erased Jenny.s name and identifying information. This cruel display of insensitivity disregards State law, which dictates that the spousal presumption of parentage applies to children born to same-sex spouses in the same manner it applies to children of different-sex spouses. A different-sex married couple grieving a similar loss would receive a two-parent death certificate with no questions asked. Death certificates and other vital records like birth certificates document legal parentage, and not biology. And this case comes from Lambda legal website, which has other cases that highlight discrimination faced by LGBT individuals.

The following slides talk about ways to, or illustrate ways in which you can add open ended questions to your intake forms that will allow a patient, or client, to identify themselves, as well as illustrating your openness to serving members of the LGBT community. By asking questions such as those that appear on this screen, allowing individuals to identify as male or female, as well as transgender, or not wanting to affiliate, are all viable options that give you insight into a patients gender or gender identity. The same goes for sexual orientation. As you can see here that the sexual orientation question includes Heterosexual, Bisexual, Gay, Lesbian, Questioning, or Self-identified orientation. The last two are two options that I kind of referred or eluted to earlier in this presentation when we are talking about LGBT not being the only terminology related to sexual orientation.

Here are some additional examples of a way that you can elicited history information in a very open ended and nonjudgmental fashion. So, inquiring if the patient or client is sexually active, and if they are whether they.re having sex with men, women, or both and then determining the behavior that is associated with those sexual encounters.

Here is another option on how individuals may identify and how you may be able to include, as the slide says, respectful, non-judgmental, and inclusive language on your intake forms. You may also see that this form identifies LGBTTTIQ , so again including queer, questioning, intersex, all of these other terminologies that you may want to also become familiar with. So, here are some following examples of inclusive questions: What is your current gender identity? And allowing the patient or client to check all that apply; male, female, transgender, genderqueer, intersex, etc. How do you identify your sexual orientation? Again, allowing individuals to check all that apply; straight or heterosexual, lesbian, gay, bisexual, queer, transsexual, questioning, other, and prefer not to answer. And then, going a step further and inferring about what kind of pronoun the individual prefers. All of these things allow you to understand more about your patients identity, your patients perspective, and to create that rapport that is so necessary in order to properly treat a patient.

When you are interviewing the patient, after you.ve had these inclusive forms created, history taking techniques, making sure that you are not assuming heterosexuality in the questions that you.re asking. Questions such as, .Are you married or single?. Or asking a male or female patient .Do you have a boyfriend?. Or asking a male patient, .When did you first become interested in girls?. are all hetero-normative questions and make an assumption about the person sitting in front of you. Some examples of inclusive questions, which may not create as many barriers, or which would not create the barriers that the previous questions would create are, .Are you dating anybody? Are you currently in an intimate relationship? And What is your level of commitment to your partner?.

So, some additional examples instead of asking .Are you married?. Try .Are currently dating, sexually active, or in a relationship?. Instead of asking, .Are you the mother or the father?. Inquiring, .Are you the parent or the guardian?. And instead of asking, .What form of birth control do you use?. Inquiring about, .Do you use birth control, and if so what kind?. These are just some of the tools available related to sexual orientation and gender identity. There are a number of centers and institutes around the country, focusing on this topic, including the Finway Institute in Boston and the University of California San Francisco Center for LGBTs out in San Francisco, Ca. For more information on integrating sexual orientation and gender identity into your broader culturally and linguistically competent efforts, please visit Think Cultural Health.

I know I.ve gone through quite a bit of information but there is so much more information to go through, but we want to honor your time here today so, where can you find more information? As I mentioned, there are a number of organizations out there producing literature, producing resources, to assist in the care and treatment of LGBT individuals. The joint commission and California published a field guide entitled, Advancing Effective Communication, Cultural Competence, and Patient- and Family- Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community. That field guide is available on their website to download for free.

In addition, the Institute of Medicine released a report on The Health of Lesbian, Gay, Bisexual, and Transgender Individuals. Building a foundation for better understanding, and that is also available on their website and provides a lot of great information about the health disparities, how to overcome them, strategies, resources, and the like. As I mentioned, because sexual orientation and gender identity is part of the broader aspects of culture that Think Cultural Health and the National CLAS Standards stand for, or represent.

We want to make sure that you are aware of the additional resources available on Think Cultural Health which can help you provide an all inclusive culturally and linguistically appropriate approach. You can find the National CLAS Standards and other resources on the Think Cultural Health website. As I mentioned earlier, Think Cultural Health is an initiative of the OMH Center for Linguistic and Cultural Competence in Health Care. The goal of Think Cultural Health is to Advance Health Equity at Every Point of Contact through the development and promotion of culturally and linguistically appropriate services.

Think Cultural Health houses the National CLAS Standards and its implementation guide, A Blueprint for Advancing and Sustaining CLAS Policy and Practice . simply referred to as The Blueprint. Think Cultural Health is the only place to find both the PDF and the web-based versions of the content.The Blueprint outlines the Case for CLAS and explains the concepts that the Standards are grounded in, such as those that I talked about earlier with the OMH definitions for culture and health. Then, The Blueprint offers one chapter per Standard that explains the Standard.s purpose and provides strategies for implementation. Each chapter also provides a list of additional resources for more information.

Think Cultural Health also houses a suite of free e-learning programs are based on the National CLAS Standards and therefore this expanded definition of culture and health and these e-learning programs have over, to date, have over 250,000 registrants and we.ve awarded over 900,000 credits. Program include, for providers, include ones for: Physician.s, Nurses, Disaster Personnel, Oral Health Professionals, Promotores de Salud, and many other health professionals.

Think Cultural Health also offers communication tools, including a communication and language assistance guide for administrators as well as health providers. In the next few weeks, we will be publishing an updated version of this valuable resource. The Guide is a tool to help organizations provide effective communication and language assistance services to diverse individuals receiving care and services. It includes strategies for communicating in a way that considers the cultural, health literacy and language needs of clients and patients, thus increasing their access to health care. The knowledge and skills gained through reading the Guide will help you and your organization provide effective communication at all points of contact within an organization.

The CLAS Clearinghouse is a compilation of online resources, tools, and publications on health equity and CLAS, which is searchable by keyword.

And finally, there is Join the CLCCHC , again CLCCHC represents the OMH.s Center for Linguistic and Cultural Competence in Health Care. Which is an initiative at Think Cultural Health for health and health care professionals. Registering will give you access to a quarterly e-newsletter and specialty educational units. There is also an .Ask the Expert. feature, in which you can contact our team to ask a question about cultural and linguistic competency. It is likely that you found this webinar within the join the CLCCHC webinar catalog , which houses on-demand webinars (narrated PowerPoint presentations) on various topics related to CLAS, including:

Why CLAS matters

communication and language assistance

CLAS in mental health

And an overview of Think Cultural Health

As well as this new series on Exploring culture in CLAS.

I invite you to visit www.ThinkCulturalHealth.hhs.gov. You will find a variety of resources that can support and inform you and your organization.s efforts to implement CLAS and the National CLAS Standards.

I would like to take a moment to acknowledge the contributions of all those who have worked on this project including our technical team at Astute Technology. You can see our partners at the HHS Office of Minority Health, as well as my colleagues at the Health Determinants & Disparities Practice at SRA International.

I encourage you to send questions, ideas and your stories of implementation to AdvancingCLAS@ThinkCulturalHealth.hhs.gov. Successful implementation of the National CLAS Standards and culturally and linguistically appropriate services in general, is dependent upon you! We look forward to collaborating with you to promote, implement, and assess all of these important initiatives.

Thank you.