Section 4. Ongoing training for all staff in SGM cultural competency, including use of supportive language

Training in SGM healthcare competencies, terminology, and health disparities is essential to creating a supportive environment. At a fundamental level, SGM people experience the same frustrations with health care as non-SGM people. They deal with the same issues related to not having reliable health insurance, lack of understanding of their coverage, difficulties expressing their health concerns, and not knowing how to manage their care. However, some SGM patients are guarded when they seek health care due to past experiences feeling discriminated against, providers who were insensitive to their needs, or mistreatment. In addition, insensitive comments or signs in the clinic may elicit negative emotional reactions from patients. For these reasons, all staff (e.g., janitors, receptionists, medical clerks, and providers) will benefit from cultural sensitivity training focusing on the SGM population. Ongoing training regarding inclusive and supportive SGM language is a key in establishing successful provider-patient relationships and facilitating positive patient-centered healthcare experiences! 

Training should first occur in the new staff orientation process. Evaluation of training activities should be ongoing and include questions and concerns of staff and national trends in serving SGM patients in a clinical setting to improve the quality of their health care. Continuing SGM training should occur as needed but at least annually for all staff. The clinic’s governance body and executive team should be required to participate. A commitment of the governance body and executive staff to provide and take part in this training will enhance a successfully implemented SGM culture in the clinic. 

Topics to cover in a staff training program should include:

• Basic SGM terminology (e.g., sex designated at birth, gender identity, gender expression, sexual orientation).
• Language usage when referring to patients, their significant others, and their families.
• Health disparities impacting SGM people and their causes.
• Identifying and challenging internalized discriminatory beliefs about SGM people.
• Avoiding assumptions about a patient’s body, behaviors, sexual activities, or family situation.
• Trauma-Informed Care.
• Becoming familiar with SGM health issues (e.g., impacts of discrimination and harassment; mental health; substance use; reproductive health; and HIV/STDs).
• Making referrals to SGM-affirmative health and social service providers.

The clinic does not need to be burdened by creating cultural competency training from scratch. Several resources can be accessed at low or no cost to the clinic. Furthermore, there may be SGM organizations and other resources in the area, such as academic medical centers, that will provide education and training for staff. Training on LGBTQ health and health care topics in and around the community should be advertised to staff at the clinic. Staff should be encouraged and supported to attend through compensation for their time and travel. In addition, the Implementation Team may need to add “clinic specific” policy and procedures to such training. In addition, there are national organizations that offer online training related to SGM health care, including the National LGBT Health Education Center and the Human Rights Campaign. Table 9.2 includes links to their websites. Online training can be a valuable supplement to classroom training and can be integrated into the orientation process for new staff. While all staff will not require clinical training to deliver SGM health care, all staff will benefit from sensitivity training in SGM cultural competency.

Encouraging inclusive and supportive language

The use of inclusive and supportive language is a powerful way to create a welcoming environment for SGM patients and improve the overall quality of care. It may diffuse those feelings of unease or wariness for patients who have experienced past mistreatment when coming to a clinic. Inclusive and supportive language should be used throughout the clinic and regardless of whether a patient is present or not. Using SGM culturally sensitive language with other non-SGM people normalizes the language. Below are some communication basics from GLMA that all staff should consider.²    

• Never assume gender identity or sexual orientation based on a person’s name, how they look or sound, or any other differentiating characteristics. When addressing patients for the first time, avoid using pronouns or other terms that imply gender. Instead of “How may I help you, sir?” simply say, “How may I help you?” The same practice should inform how staff speak to each other about a patient. Instead of “She’s here to see you,” use “Your patient is here to see you.”
• In the place of the gender pronouns “he” or “she,” “they” is an acceptable substitute. Some patients may use “they” as their pronoun. For example, instead of “He is here for his appointment,” use “They are here for their appointment.” Do use a patient’s gender pronouns if you are sure of which ones to use.
• Never refer to a person as “it.”
• Use the terms that people use to describe themselves and their relationships. It is okay if you feel awkward at first. Using language reflective of how patients see themselves and their relationships will produce a much more comfortable experience for them and improve their overall care experience. Just to be clear, if a patient refers to themselves as “gay,” use that term rather than “homosexual.” If a patient refers to their “partner” or “wife,” use “partner” or “wife” when referring to that person.
• When taking histories or speaking with patients, do not assume that they have a partner, that their partner is of the opposite sex, or that they have two opposite-sex parents. Instead of inquiring about a boyfriend or girlfriend, ask if they are currently in a relationship. Instead of asking for their mother’s and father’s name, ask for the name of their parent or parents.
• Never ask what someone’s “real” name is. If you believe someone’s name to be a nickname, ask specifically about that instead: “Is that short for something?” Otherwise, asking for someone’s “real” name may imply that you do not acknowledge their chosen name as their real name.
• Do not use disrespectful language or slurs, stare, or express surprise at someone’s appearance or gossip about a patient.

It is impossible to altogether avoid mistakes. When one happens, simply apologize. A simple acknowledgment of the mistake and apology can go a long way to help undo the damage and to re-establish trust. Encouraging staff to help and correct each other when mistakes are made promotes a supportive environment of learning while at the same time ensuring that inclusive and supportive language is being used. Table 9.3 includes further examples of simple language changes that can make a big difference. Printouts with information like that in Table 9.3 can be posted for staff to view as a reminder, especially in the beginning stages of learning.³

Potential steps to include in action plans to train all staff in SGM cultural competency and using supportive language 

• Use organizational assessment results to inform the selection of training topics and formats (e.g., in-person and online) that will work best for the clinic.
• Develop a proposal that aligns training topics and formats to types of staff.
• Once the clinic approves the proposal, collaborate with administrators to schedule training(s) and invite staff to participate. Inform staff that the training(s) will prepare them to support all patients in the community in getting safe and supportive services at the clinic.
• Arrange for participants in the training(s) to receive Continuing Medical Education (CME) credits, Continuing Education Units (CEUs), or Certificate(s) of Completion.
• Obtain evaluation feedback from trainers and participants on both process and outcomes. When obtaining this feedback, prompt trainers and participants to ask questions, express concerns, and share their ideas for future training opportunities.
• Revise training(s) as needed based on evaluation feedback.
• Check-in with staff regularly (every three to six months, for example) to ensure they apply what they learned from the training and identify the need for additional support.
• Provide ongoing training (e.g., annual) and support to participants, so they are fully prepared to integrate what they have learned into practice.