Sexual orientation and gender identity advocacy in emergency medicine

Murdoch Leeies  · Michael Kruse  · Brock Weston  · Sheila Smith  · Robert Primavesi  · Ben Klassen  · Chris Draenos  · Nadia Primiani

Introduction

The ED care of SOGI-diverse patients has been identified as a priority area for improvement by the Canadian Association of Emergency Physicians (CAEP) SOGI committee. SOGIdiverse persons make up 2.3–8% of the North American population. Transgender and gender diverse (TGD) persons, specifically, make up 0.3–0.6% of the adult population with adolescent TGD populations estimated at 1.2–4.1% [1–6]. SOGI-diverse persons are less likely than cisgender, heterosexual persons to have a family doctor in North America and more likely to use EDs to access healthcare.1 The extant literature reports that even though TGD persons may use EDs more than cisgender persons, they also have significant ED avoidance. This has been attributed to previous experiences of, or fears of discrimination in the ED [1].

Literature has shown that health inequities for subgroups of SOGI-diverse populations exist. These include higher lifetime risks for substance use disorders [9, 10], breast and anal cancers [11], as well as sexually transmitted infections [11–13]. TGD persons have also been shown to suffer disproportionately from intimate partner violence [7]. The recent global outbreak of Mpox, disproportionately impacting SOGI communities, served as a cogent reminder of the unique health issues that SOGI-diverse persons continue to face [8].

The inequities that SOGI-diverse persons face are further amplified for individuals with intersecting identities from other systemically marginalized groups (e.g., based on race, socioeconomic status, etc.) with disproportionately fewer programs or interventions to address intersecting social determinants of health [14, 15]. Both patients and emergency medicine (EM) healthcare worker (HCW) professional societies have identified a need for enhanced SOGI-specific cultural humility training [16, 17]. A survey of Canadian ED physicians found that 83% of respondents endorsed a need for further training in SOGI-specific healthcare [18]. Population-specific crisis services have been identified by SOGI patients as being desired due to their affirming nature [19]. EDs represent a unique interface between community-based and hospital-based health services where there is an opportunity to address SOGI-specific inequities through enhanced SOGI-focused healthcare.

Current Recommendations

A recent scoping review on the care of sexual and gender minority persons in EDs identified several gaps in EM care for SOGI populations as actionable targets for improvement [1]. CAEP undertook a national Canadian engagement and consensus process leading to published recommendations for SOGI-specific education in Canadian EM residency programs [17]. These recommendations identified a need for enhanced education for healthcare workers on SOGI-specific healthcare. Recommendations to enhance the care of systemically marginalized and oppressed populations in EDs through the collection of sociodemographic data were generated from a systematic review and qualitative evidence synthesis 20. This review found the presence of an SOGI-specific advocacy position was a facilitator of safe disclosure of SOGI-related personal information in the ED. Intersectional recommendations on anti-racism and de-colonization published by CAEP similarly call for the recruitment and integration of population-specific patient advocates in EDs [21].

Knowledge to Action

Having identified SOGI-specific health inequities and gaps in care, action is needed to close these divides and promote equitable access and outcomes for SOGI-diverse persons in EM.

Proposed Intervention

A multi-disciplinary ED SOGI Advocacy Program that aims to:

1. Provide patient-centred advocacy and support.

2. Enhance the delivery of clinical services related to SOGI-specific needs.

3. Facilitate linkages between ED patients and community-based resources.

4. Provide education to clinical and non-clinical frontline staff and trainees.

Position Statement

To ensure that SOGI-diverse persons receive equitable care in EDs across Canada, the following high-level concepts are supported. We recommend these concepts be incorporated into “SOGI Advocacy Programs” developed by each Canadian EM healthcare service delivery organization (SDO).

EM SOGI advocacy programs should:

1. Be flexible in composition (depending on available resources) and where possible should include:
   

   • Clinical leadership with SOGI-health expertise who oversee(s) training, service provision, and program development for the advocacy program.

   • An embedded or on-call clinical SOGI advocate (e.g., physician assistant, specialized nurse, allied health practitioner, and/or peer-support worker).

   • This advocate would support patients in-person while in the ED. This clinical advocate will have expanded-scope training that should include:

     – Gender-affirming medical and/or surgical considerations in the ED – SOGI-specific mental health care

     –  SOGI-specific sexual and reproductive health care – SOGI-specific sociodemographic variable collection and health information privacy.

   • Transparent patient complaints processes with anonymous and non-anonymous reporting options.

   • Local physician, nurse, and allied health champions

   • Who would have additional cultural humility training and who are formally recognized by the SOGI advocacy service.

   • On-call SOGI advocates.

   • Where an in-person on-call advocate is not possible (e.g., rural/remote settings), then on-call SOGI-specific advocates should be available via tele-health or video-conferencing platforms. These services should be recognized and integrated as legitimate consultants in the SDO even when remote.

   • Defined SOGI-specific community-based healthcare partners including SOGI specialty clinics and community-based social services.
     

2. Have defined SOGI-specific educational deliverables for clinical and non-clinical (e.g., clerical, registration, and security) staff, medical trainees, and volunteers working in the department
   

3. Publicize services available in EDs, and actively offer them universally to all patients from the time of registration.
   

4. Include rigorous quality assurance processes.

   
   

5. Engage SOGI-diverse persons and communities, including those with intersecting experiences of oppression or marginalization, from the outset of program design to ensure their lived experiences are respected and needs are addressed.

   
   

6. Develop relationships with, and maintain links to, nonmedical community service organizations. This would allow for direct referral from the ED for ongoing community and social support.
   

7. Approach inequities through an intersectional lens and explicitly recognize that intersecting identities result in unique social advantages and disadvantages. SOGI advocacy programs should formally interface with intersecting social-identity based health services.

Conclusion

We recognize that emergency medicine is facing unprecedented challenges regarding capacity, quality of service delivery, and burnout across Canada. We feel that given these challenges, it is more important now than ever to develop strategies to promote health for equity-deserving populations. Through advocacy and action, we hope not just to help our patients, but to help heal ourselves.

Glossary

Declarations

Conflict of interest - On behalf of all authors, the corresponding author states that there is no conflict of interest.