LGBTQ cultural competence for pharmacists

Abstract

Limited access to inclusive, affirming health care and exposure to stigmatizing and discriminatory experiences have resulted in multiple health disparities for lesbian, gay, bisexual, transgender and queer (LGBTQ) people.1.Ard KL and Makadon HJ. Improving the health care of lesbian, gay, bisexual and transgender people: Understanding and eliminating health disparities. The Fenway Institute. Accessed June 7, 2020.Google Scholar As key members of the clinical team, pharmacists are uniquely positioned to improve medication treatment outcomes, and as a result, facilitate achievement of optimal health for their LGBTQ patients. To provide high-quality, personalized care, pharmacists must be able to 1) identify LGBTQ-specific health needs and disparities; 2) examine their own cultural worldview, values, beliefs, behaviors, and biases; 3) utilize clinical skills consistent with cultural competence and cultural humility; and 4) recognize key elements of an inclusive, welcoming work environment. As the demographic landscape of the United States continues to evolve, LGBTQ-specific cultural competence training for pharmacists has become increasingly more important. An estimated 3.5% (approximately 12 million)2.Gates G.J. How many people are lesbian, gay, bisexual, and transgender? The Williams Institute.2011Google Scholar of adults in the United States identify as LGB and 0.39% (approximately 1 million) as gender diverse,3.Meerwijk E.L. Sevelius J.M. Transgender population size in the United States: A meta regression of population-based probability samples.Am J Public Health. 2017; 107: e1-e8Crossref PubMed Scopus (283) Google Scholar and over 600,000 households are composed of same-sex couples.4.O’Connell M. Feliz S. Same-sex couple household statistics from the 2010 census.U.S. Bureau of the Census. 2011; Google Scholar Furthermore, approximately 8.2% (19 million) adults report having engaged in same-sex sexual behavior and 11.0% (25.6 million) report having at least some same-sex sexual attraction.2.Gates G.J. How many people are lesbian, gay, bisexual, and transgender? The Williams Institute.2011Google Scholar Given that health disparities are differentially distributed in the LGBTQ population,1.Ard KL and Makadon HJ. Improving the health care of lesbian, gay, bisexual and transgender people: Understanding and eliminating health disparities. The Fenway Institute. Accessed June 7, 2020.Google Scholar and that more than one-half of all Americans live with at least one chronic disease,5.Manolakis P.G. Skelton J.B. Pharmacists contributions to primary care in the United States collaborating to address unmet patient care needs: The emerging role for pharmacists to address the shortage of primary care providers.Am J Pharm Educ. 2010; 74: S7Crossref PubMed Scopus (91) Google Scholar the safe and effective use of medications is critical to disease management and health promotion. Accreditation informationProvider: APhATarget audience: Pharmacists and pharmacy techniciansRelease date: 9/1/2020Expiration date: 9/1/2023Learning level: 1APhA is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education (CPE). The ACPE Universal Activity Number assigned to this activity by the accredited provider is 0202-0000-20-242-H04-P/T.Advisory board: Juan Carlos Venis, MD, MPH, assistant professor of clinical family medicine, department of family medicine, Indiana University School of Medicine, IndianapolisDisclosures: Rhonda Schwindt, DNP, RN, PMHNP-BC, Juan Carlos Venis, MD, MPH, and APhA’s editorial staff declare no conflicts of interest or financial interests in any product or service mentioned in this activity, including grants, employment, gifts, stock holdings, and honoraria. For complete staff disclosures, please see the Education and Accreditation Information section at www.pharmacist.com/apha-disclosures.Development: This home-study CPE activity was developed by APhA.ACPE Universal Activity Number: 0202-0000-20-242-H04-P/TCPE credit: 2 hours (0.2 CEUs)Fee: There is no fee associated with this activity for members of the American Pharmacists Association. There is a $25 fee for nonmembers. Learning objectives■Explain health disparities among the LGBTQ population.■Define cultural competence and cultural humility.■Use inclusive and affirming language when interacting with LGBTQ patients.■Describe the role of the pharmacist in the care of LGBTQ patients.■List three characteristics of an inclusive and welcoming environment for LGBTQ patients. Provider: APhA Target audience: Pharmacists and pharmacy technicians Release date: 9/1/2020 Expiration date: 9/1/2023 Learning level: 1 APhA is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education (CPE). The ACPE Universal Activity Number assigned to this activity by the accredited provider is 0202-0000-20-242-H04-P/T. Advisory board: Juan Carlos Venis, MD, MPH, assistant professor of clinical family medicine, department of family medicine, Indiana University School of Medicine, Indianapolis Disclosures: Rhonda Schwindt, DNP, RN, PMHNP-BC, Juan Carlos Venis, MD, MPH, and APhA’s editorial staff declare no conflicts of interest or financial interests in any product or service mentioned in this activity, including grants, employment, gifts, stock holdings, and honoraria. For complete staff disclosures, please see the Education and Accreditation Information section at www.pharmacist.com/apha-disclosures. Development: This home-study CPE activity was developed by APhA. ACPE Universal Activity Number: 0202-0000-20-242-H04-P/T CPE credit: 2 hours (0.2 CEUs) Fee: There is no fee associated with this activity for members of the American Pharmacists Association. There is a $25 fee for nonmembers. ■Explain health disparities among the LGBTQ population.■Define cultural competence and cultural humility.■Use inclusive and affirming language when interacting with LGBTQ patients.■Describe the role of the pharmacist in the care of LGBTQ patients.■List three characteristics of an inclusive and welcoming environment for LGBTQ patients. Preassessment questions1.Cultural competence is defined asa.Behavioral responses acquired over time that include implicit and explicit beliefs, attitudes, and values.b.An understanding of the dynamics of cultural interactions.c.A set of congruent behaviors, knowledge, attitudes, and policies that enable effective work in cross-cultural situations.d.A set of absolute cultural truths that apply to different ethnic groups.2.Lesbian, gay, bisexual, transgender, and queer (LGBTQ) health disparitiesa.Are higher only among LGBTQ people who live in rural areas where there is a shortage of health care providers.b.Do not impact LGBTQ people negatively since there are special programs and health care clinics designated for this population of patients.c.Are closely linked to discrimination and bias based on a person’s sexual orientation and/or gender identity.d.Are similar to those found in the general population.3.Pharmacists can help create an inclusive and welcoming environment for LGBTQ patients bya.Using chosen name and pronouns.b.Correcting staff members for using a patient’s chosen name because it does not match insurance documents.c.Asking transgender or nonbinary persons if they have had any gender affirmation surgeries.d.Avoiding questions about a patient’s sexual orientation or gender identity. 1.Cultural competence is defined asa.Behavioral responses acquired over time that include implicit and explicit beliefs, attitudes, and values.b.An understanding of the dynamics of cultural interactions.c.A set of congruent behaviors, knowledge, attitudes, and policies that enable effective work in cross-cultural situations.d.A set of absolute cultural truths that apply to different ethnic groups.2.Lesbian, gay, bisexual, transgender, and queer (LGBTQ) health disparitiesa.Are higher only among LGBTQ people who live in rural areas where there is a shortage of health care providers.b.Do not impact LGBTQ people negatively since there are special programs and health care clinics designated for this population of patients.c.Are closely linked to discrimination and bias based on a person’s sexual orientation and/or gender identity.d.Are similar to those found in the general population.3.Pharmacists can help create an inclusive and welcoming environment for LGBTQ patients bya.Using chosen name and pronouns.b.Correcting staff members for using a patient’s chosen name because it does not match insurance documents.c.Asking transgender or nonbinary persons if they have had any gender affirmation surgeries.d.Avoiding questions about a patient’s sexual orientation or gender identity. Culture describes a shared identity that influences the behavior of a specific group of people.6.Purnell L. The Purnell model for cultural competence.J Transcult Nurs. 2002; 13: 193-201Crossref PubMed Scopus (141) Google Scholar, 7.Leung A.K. Lee S. Chiu C. Meta-knowledge of culture promotes cultural competence.J Cross Cultl Psychol. 2013; 44: 992-1006Crossref Scopus (23) Google Scholar A multitude of dimensions are used to identify cultural groups including race, ethnicity, religious practices, sexual orientation, gender, gender identity, age, disability, and socioeconomic status.8.Cross T. Bazron B. Dennis K. Isaacs M. Towards a culturally competent system of care. Georgetown University Child Development Center, CASSP Technical Assistance Center, Washington, DC1989Google Scholar Culturally competent providers are those who have acquired the knowledge, behavior, skills, and attitudes to effectively engage with people from cultures different than their own.6.Purnell L. The Purnell model for cultural competence.J Transcult Nurs. 2002; 13: 193-201Crossref PubMed Scopus (141) Google Scholar, 7.Leung A.K. Lee S. Chiu C. Meta-knowledge of culture promotes cultural competence.J Cross Cultl Psychol. 2013; 44: 992-1006Crossref Scopus (23) Google Scholar, 8.Cross T. Bazron B. Dennis K. Isaacs M. Towards a culturally competent system of care. Georgetown University Child Development Center, CASSP Technical Assistance Center, Washington, DC1989Google Scholar However, cultural norms are constantly evolving, and individual characteristics within groups vary considerably. To fully appreciate the complexity of culture and its impact on all aspects of behavior, it is beneficial to consider the role of cultural humility in the provision of inclusive, affirming care. Cultural humility is an interpersonal approach that relies less on knowledge acquisition and skill application and more on lifelong learning, self-reflection, power imbalances, and social justice.9.Hook J.N. Davis D.E. Owen J. et al.Cultural humility: Measuring openness to culturally diverse clients.J Couns Psychol. 2015; 60: 353-366Crossref Scopus (384) Google Scholar Though cultural humility has been suggested as an alternative to cultural competence, the two are not mutually exclusive, and thus, can synergistically enhance clinical care. In its simplest form, cultural humility encourages providers to recognize that learning does not involve a discernable end point; patients’ lived experiences shape the health care encounter; and partnering with others to exact systemic change for minority populations is a vital, albeit often overlooked, aspect of inclusive, affirmative care.9.Hook J.N. Davis D.E. Owen J. et al.Cultural humility: Measuring openness to culturally diverse clients.J Couns Psychol. 2015; 60: 353-366Crossref Scopus (384) Google Scholar Pharmacists need to acquire foundational knowledge about key concepts and terminologies relevant to the LGBTQ population. To provide care consistent with cultural competence and humility, pharmacists must also be aware of the diversity between and within different segments of the LGBTQ community, and the intersectionality of multiple identities (e.g., race, ethnicity, socioeconomic status, etc.) that shape a person’s life experiences. Furthermore, it is important to note that while various identities such as gender, sexual orientation, and gender identity intersect, one is not predictive of the other. For example, a person’s gender identity does not determine their sexual orientation and the biological sex designated at birth does not define their gender identity.11.National LGBT Health Education Center. Ready, set, go! Guidelines and tips for collecting patient data on sexual orientation and gender identity. A program of the Fenway Institute; 2018. Accessed May 27, 2020.Google Scholar Sexual orientation is a person’s emotional, romantic, sexual attraction, or non-attraction to other people and is composed of three separate dimensions: behavior, identity, and desire. Some people may engage in same-sex sexual behavior but not identify as lesbian, gay, or bisexual. Similarly, a person may be sexually, romantically, or emotionally attracted to members of the same sex and choose not to be sexually active with same-sex partners. For research purposes, the terms “men who have sex with men” (MSM) and “women who have sex with women” (WSW) are often used to describe a person’s sexual behavior regardless of their identity.10.Killerman S. A Guide to Gender: The Social Justice Advocate’s Handbook.2nd Edition. Impetus Books, Austin, TX2017Google Scholar, 11.National LGBT Health Education Center. Ready, set, go! Guidelines and tips for collecting patient data on sexual orientation and gender identity. A program of the Fenway Institute; 2018. Accessed May 27, 2020.Google Scholar Sex refers to a set of biological attributes primarily related to physical and physiological features. The phrase “sex assigned at birth” (SAAB) or “designated sex at birth” (DSAB) is used to describe a person’s biological sex, most often, but not exclusively, based on the external appearance of genitalia at birth. Gender is a socially constructed concept used to characterize the behaviors, actions, and qualities of women and men or girls and boys. The critical flaw of an exclusive binary paradigm is that it does not account for the inherent diversity of human gender. A more expansive conceptualization of gender recognizes that each person possesses a wide range of characteristics that may or may not be consistent with the gender binary, represent a combination of male and female, or fall somewhere in between the two.10.Killerman S. A Guide to Gender: The Social Justice Advocate’s Handbook.2nd Edition. Impetus Books, Austin, TX2017Google Scholar, 11.National LGBT Health Education Center. Ready, set, go! Guidelines and tips for collecting patient data on sexual orientation and gender identity. A program of the Fenway Institute; 2018. Accessed May 27, 2020.Google Scholar Gender identity is a person’s inner sense of their gender. For some people, their gender identity may not be congruent with the one typically expected based on their SAAB/DSAB. They may describe themselves in a variety of ways including, but not limited to, transgender, male, female, gender fluid/genderqueer, nonbinary, agender, or as another gender. Decisions to change gender expression and/or physical appearance to be more consistent with their gender identity through medical (e.g., hormone replacement therapy), nonmedical (e.g., voice therapy, choosing an affirming name, etc.), and/or surgical options (e.g. gender affirmation/confirmation surgery) is wholly determined by the individual10.Killerman S. A Guide to Gender: The Social Justice Advocate’s Handbook.2nd Edition. Impetus Books, Austin, TX2017Google Scholar, 11.National LGBT Health Education Center. Ready, set, go! Guidelines and tips for collecting patient data on sexual orientation and gender identity. A program of the Fenway Institute; 2018. Accessed May 27, 2020.Google Scholar (Table 1).Table 1LGBTQ terms and definitionsSource: Killerman, S. 2017. A Guide to Gender: The Social Justice Advocate’s Handbook, 2nd Edition. Impetus Books: Austin, TX.TermDefinitionBisexualHaving the capacity to be emotionally, romantically, sexually and/or affectionally attracted to some men and women or some people of one’s gender or another gender.CisgenderA person whose gender identity is congruent with their sex assigned at birth or designated sex at birth.GayA person who is emotionally, romantically, sexually, and/or affectionally attracted to members of the same sex and/or gender.GenderA socially constructed concept used to classify a person as a man, woman, or some other gender.Gender diverseA person whose gender identity does not support the binary understanding of gender. Often used as an umbrella term.Gender expressionHow a person expresses their gender in terms of dress, behavior, hairstyle, etc.Gender fluid or Gender queerA person whose gender identification and expression shifts, whether within or outside of societal, gender-based expectations.Gender identityA person’s inner sense of their gender. It is solely determined by the individual based on their appraisal of how much they do or do not align with the socially constructed expectations of gender.IntersexAn umbrella term to describe a wide range of natural body variations that do not fit into conventional definitions of male or female. Intersex variations may include, but are not limited to, variations in chromosome compositions, hormone concentrations, and external and internal characteristics.LesbianWomen who are emotionally, romantically, sexually, and/or affectionally attracted to other women.MSMAn abbreviation for men who have sex with men.NonbinaryA gender identity and experience that embraces a full spectrum of expressions and ways of being that resonate for an individual, moving beyond the male/female gender binary.QueerPeople whose gender, gender identity, gender expression and/or sexuality do not conform to dominant expectations. The term is often considered hateful when used by those who do not identify as LGBTQ.SexA medically constructed categorization often assigned based on the appearance of the genitalia, either in ultrasound or at birth.Sexual orientationAn enduring emotional, romantic, sexual, or affectional attraction or nonattraction to other people.TransgenderA person whose gender identity is not congruent with their sex assigned at birth or designated sex at birth.Transgender/trans manA person who was assigned female at birth and who identifies as maleTransgender/trans womanA person who was assigned male at birth who identifies as femaleWSWAn abbreviation for women who have sex with women. Open table in a new tab Pharmacists can incorporate several communication strategies into their clinical practice to enhance their relationship with LGBTQ patients. While some people may choose to legally change their name and/or their gender markers, it is not unusual for many to have insurance and identity documents (i.e., license, passport, etc.) that do not accurately reflect their authentic gender identity or chosen name. For pharmacists who do not have access to an electronic medical record which allows for the documentation of sexual orientation and gender identity (SO/GI) data, the information can be collected using a three-step process.10.Killerman S. A Guide to Gender: The Social Justice Advocate’s Handbook.2nd Edition. Impetus Books, Austin, TX2017Google Scholar In addition to SO/GI data, requesting a person’s chosen name and pronouns used is highly recommended. Pharmacists can avoid confusion and prevent mistakes by asking every patient “What name and pronouns do you use?”10.Killerman S. A Guide to Gender: The Social Justice Advocate’s Handbook.2nd Edition. Impetus Books, Austin, TX2017Google Scholar, 12.GLAAD Media Reference Guide. 10th Edition. 2016. Accessed June 29, 2020.Google Scholar The use of gender-neutral pronouns is an additional strategy that pharmacists can implement. The singular pronoun (“they/them”) can be substituted for binary-gendered pronouns (“he/him” or “she/her”) when documenting or discussing relevant patient information (e.g., “They are requesting a refill.” vs. “He/she is requesting a refill.”). Likewise, replacing expressions that assume a person’s or a group of people’s gender identity such as “Hello, sir/ma’am” or “Hello, ladies/guys” with a more generalizable option such as “Hello, how may I help you today?” reflects an inclusive and culturally sensitive approach. During conversations that refer to LGBTQ persons, it is equally important for pharmacists to use adjectives instead of nouns and to choose words and phrases that do not label or stereotype groups of people (Table 2). For example, “Mary is a transgender woman” is preferable to “Mary is a transgender.” Respectful and affirming conversations between a pharmacist and their patients also include sincere apologies for inadvertent mistakes and asking only for information that is relevant to the care being provided.10.Killerman S. A Guide to Gender: The Social Justice Advocate’s Handbook.2nd Edition. Impetus Books, Austin, TX2017Google Scholar, 11.National LGBT Health Education Center. Ready, set, go! Guidelines and tips for collecting patient data on sexual orientation and gender identity. A program of the Fenway Institute; 2018. Accessed May 27, 2020.Google Scholar, 12.GLAAD Media Reference Guide. 10th Edition. 2016. Accessed June 29, 2020.Google ScholarTable 2Communication best practicesSource: GLAAD Media Reference Guide. 10th Edition. 2016. Accessed June 29, 2020.Not acceptableAcceptableReasoningBiologically male or biologically femaleSex assigned at birth or designated sex at birthA person’s external genitaliaat birth does not determine their gender or gender identity. Gender is a complex concept that is not based solely on biology or genetics.HomosexualLesbian, gay, bisexual, queer, or a gay person/peopleThe label homosexual has been used to dehumanize people who are not heterosexual or ascribe to societally constructed norms which do not reflect the full range of sexual orientations.Openly gayOutUsing the phrase “openly gay” implies that a person’s sexual orientation is something to hide and must be publicly acknowledged.Sex reassignment surgery or sex changeGender affirmation or gender confirmation surgeryFor many people, their gender identity is the one they have always had and thus, they do not need to transition from one gender identity to another. People do not need to have surgery to affirm their identity.Sexual preferenceSexual orientationThe term sexual preference implies that a person chooses to be attracted to certain people or genders and thus, they can be changed or “cured.”Transgenders or a transgender or gaysTransgender people or a transgender personTransgender should be used as an adjective and not a noun.TransgenderedTransgenderThe adjective transgender should not have an “-ed” added to the end of the word. It suggests there is an endpoint to a person’s gender identity.TransgenderismBeing transgenderThe word transgenderism has been used to dehumanize transgender people and label gender diversity as a condition or “-ism” Open table in a new tab Health disparities are differences in mental and physical health affecting groups of people who have experienced greater social, economic, and environmental disadvantage.11.National LGBT Health Education Center. Ready, set, go! Guidelines and tips for collecting patient data on sexual orientation and gender identity. A program of the Fenway Institute; 2018. Accessed May 27, 2020.Google Scholar Several diseases and conditions are disproportionately distributed based on sexual orientation and gender identity.12.GLAAD Media Reference Guide. 10th Edition. 2016. Accessed June 29, 2020.Google Scholar Exposure to minority stress, a lack of culturally competent health care providers, and a history of anti-LGBTQ bias are the most significant contributors to health disparities in the LGBTQ population.12.GLAAD Media Reference Guide. 10th Edition. 2016. Accessed June 29, 2020.Google Scholar, 13.CDC. Healthy People 2020. https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities. Published December 2010. Accessed May 27, 2020.Google Scholar, 14.Institute of Medicine The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. National Academies Press, Washington, DC2011Google Scholar, 15.Hendricks M. Testa R.A. A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model.Prof Psychol Res P. 2012; 43: 460-467Crossref Scopus (759) Google Scholar, 16.Meyer I.H. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations.Psychol Bull. 2003; 129: 674-697Crossref PubMed Scopus (6025) Google Scholar Exposure to stressors unique to minority groups—discrimination, internalized stigma (shame and self-devaluation), enacted stigma (experienced discrimination and unfair treatment), and felt stigma (anticipation and expectation of discrimination)— negatively impacts LGBTQ persons’ health-seeking and health-related behaviors and are associated with increased risk for some mental and physical illnesses. LGBTQ persons who are members of more than one minority group face additional challenges. The intersectionality of minority stress based on sexual orientation and gender identity with those linked to race, ethnicity, and socioeconomic class can result in compounded stigma and discrimination.15.Hendricks M. Testa R.A. A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model.Prof Psychol Res P. 2012; 43: 460-467Crossref Scopus (759) Google Scholar, 16.Meyer I.H. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations.Psychol Bull. 2003; 129: 674-697Crossref PubMed Scopus (6025) Google Scholar Access to care is a persistent and pervasive challenge for the LGBTQ population and a well-documented contributor to poor health outcomes. Men and women in same-sex relationships are more likely than their heterosexual counterparts to report unmet health care needs and to be under- or uninsured. Sexual minority women are less likely to have had a checkup in the past year or a recent mammogram or Papanicolaou test,17.Buchmueller T. Carpenter C.S. Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000–2007.Am J Public Health. 2010; 100: 489-495Crossref PubMed Scopus (212) Google Scholar and gay and bisexual men are less likely to have received recommended vaccinations.18.Conron Kerith J. Mimiaga Matthew J. Landers Stewart J. A population-based study of sexual orientation identity and gender differences in adult health.Am J Public Health. 2010; 100: 1953-1960Crossref PubMed Scopus (568) Google Scholar The gender diverse community faces similar challenges. The Transgender National Health Survey revealed that 33% of respondents (N = 27,715) who sought care in the prior year reported being mistreated by a health care provider, including verbal harassment or refusal of treatment, and 23% did not seek care due to fear of mistreatment.19.James S.E. Herman J.L. Rankin S. et al.The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, Washington, DC2016Google Scholar A comprehensive discrimination study using a nationally representative sample of gender diverse persons (N = 7,000) yielded similar findings. Twenty-eight percent of participants reported harassment and violence in medical settings, 19% were refused care due to their gender identity, and 28% postponed medical care because of discrimination or inability to pay (48%).20.Grant J.M. Mottet L.A. Tanis J. et al.National transgender discrimination survey report on health and health care. National Center for Transgender Equality and the National Gay and Lesbian Task Force, Washington, DC2010Google Scholar The marginalization and stigmatization of the LGBTQ population has resulted in further barriers to care. Health care providers, individually and collectively, have a long history of pathologizing diverse sexual orientations and gender identities based largely on religious, medical, social, and legal stigmas.21.Drescher J. Queer Diagnoses: Parallels and contrasts in the history of homosexuality, gender variance, and the Diagnostic and Statistical Manual.Arch Sex Beh. 2009; 39: 427-460Crossref Scopus (214) Google Scholar For example, in the Diagnostic and Statistical Manual of Mental Disorders (DSM), homosexuality was categorized as a mental illness until 1973. Clinicians used DSM criteria to diagnose gender diverse persons with a disorder of identity (i.e., gender identity disorder) rather than with gender dysphoria—distress and disruption caused by the incongruence between SAAB and gender identity—until 2013.22.American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. American Psychiatric Association, Washington, DC2000Google Scholar Additionally, some members of the LGBTQ community endured “reparative” therapies (e.g., electroconvulsive therapy, castration, and conversion therapy) in an attempt to change their sexual orientation, gender identity, and/or gender expression.23.Turban J.L. Beckwith N. Reisner S.L. Keuroghlian A.S. Association between recalled exposure to gender identity conversion efforts and psychological distress and suicide attempts among transgender adults.JAMA. 2020; 77: 68-76Google Scholar, 24.Haldeman D. The practice and ethics of sexual orientation conversion therapy.J Consult Clin Psychol. 1994; 62: 221-227Crossref Scopus (194) Google Scholar Though most clinicians and pro