We initiated the MAPP process by developing an expert team of PHMDC staff who were interested in the topic area. This team consisted of cross-divisional staff with a range of professional experience. We engaged with Public Health Nurses, an Epidemiologist, a Health & Racial Equity Coordinator, Program Specialists, and Public Health Coordinators. Forming this team with intention allowed us to approach the topic of LGBTQ+ health equity with a wide lens. As a team, we developed a weekly meeting schedule and a feasible timeline for data collection, writing the profile, crafting recommendations, and implementing the recommendations. We aimed to complete the profile within a 9 month period, and develop recommendations shortly thereafter. It was difficult to schedule past the recommendation development stage because we weren't sure how complex the recommendations would be to implement. Since implementation began in late 2017, we have been working strategically through the recommendations that exist within PHMDC. We are reconvening as a group in January 2020 to map out the rest of the recommendations, and will likely develop a 3-5 year plan for our department, which will also include accountability metrics and consistent communication.
We began the process by pulling preliminary data on the health and well-being of LGBTQ+ people across the country. Relying on sources such as Fenway Health, Gay Lesbian Straight Education Network (GLSEN), Center for Disease Control and Prevention (CDC), and the National Center for Transgender Equality, we were able to identify high level persistent health disparities. Using these disparities as a foundation for our work, we then acknowledged relevant stakeholders in the Dane County community who would be key informants to our assessment, and mapped out an engagement strategy that spanned a variety of industries. We included school district staff, non-profit organizations, health care systems, media outlets, mental health care providers, LGBTQ+ focused organizations, state legislature, academic partners, and state level advocates. We planned to conduct the assessment, identify strategic issues, and formulate goals to tackle these issues, and then receive comments from our partners and update our recommendations based on their feedback. A detailed description of how we prioritized our stakeholder and subsequent partnerships is below.
Understanding the critical role that health systems play in either hindering or supporting LGBTQ+ health, we prioritized working with specialists in the fields of transgender health, and LGBTQ+ health promotion. We interviewed a family doctor who has extensive experience in hormonal therapy for gender transition, fertility options for queer families, puberty blocking for appropriate adolescents, and other sexual health related services. Her story is one that highlights the deficits of mainstream medicine, and provided great insight into the ways that medical systems are ill-equipped to deal with the complex medical needs of LGBTQ+ patients. Speaking with her highlighted many potential projects to engage with, including increased LGBTQ+ provider training for medical and nursing students, the imperative relationship between specialty clinics and comprehensive insurance, the importance of using correct language to instill patient trust, and the need for holistic treatment that includes mental health screening and treatment. Connecting with mental health providers was paramount to our profile, and elucidated the vast mental health needs of our LGBTQ+ community and the dearth of affordable and specialized options available to them.
Given that Madison is home to multiple esteemed academic institutions, we felt it was important to connect with local research experts. This perspective was crucial to capture because many of our faculty and staff at University of Wisconsin-Madison are engaging in excellent and emergent strategies to address the pressing needs of our LGBTQ+ communities, especially those that live in rural areas with fewer resources. We interviewed an Assistant Professor from the Department of Counseling Psychology, and one from the Department of Communication Arts. Through these interviews, we spoke extensively about the role of intersectionality and LGBTQ+ health, which cannot be untangled. Given the rural nature of Dane County, our recommendations therefore needed to directly address strategies to reach and provide care to these vulnerable populations.
Conversations centering intersectionality encouraged us to develop deeper relationships with LGBTQ+ professionals of color. We connected with and interviewed the director of an organization committed to ending violence against people of color, women, and those that non-traditionally gender identify. This interview led to a long-term partnership that concentrated PHMDC's community health education focus, and expanded our reach to include youth of color who we would not have otherwise connected to. Additionally, this process introduced us to an incredibly impactful mental health provider who works with Latinx youth who are questioning their gender identity and or sexual orientation. Due to the religious-based nature of many Latin American cultures (and specifically, the lack of support for LGBTQ+ people in the Catholic Church), we found that youth in these families were experiencing additional hardships and feelings of isolation. Madison is home to an after-school program that provides a safe and supportive space for Latinx youth to express themselves and explore their identity. Interviewing this program's LGBTQ+ identified Latinx director provided us greater knowledge into the cultural needs of Latinx youth and the potential for family engagement to shift these narratives. We incorporated lessons gleaned from this conversation into the recommendations we made to school districts, especially related to working with Latinx families and communities.
Youth who identify as LGBTQ+ have distinct and prevailing needs associated with school safety and familial/social support. In order to best capture these stories and opportunities, we connected with school district officials, school staff, and also statewide workers who provide supportive services to school districts. Madison's school district boasts a LGBTQ+ coordinator position, who we interviewed for this project. She gave us incredible insight into the great work the district is already participating in to promote LGBTQ+ safety, but highlighted the need for additional teacher training and systems level change as it relates to name and pronoun acknowledgement during a youth's transition. Our interview with state-level Department of Public Instruction staff clarified the regulations around the standardized human growth and development curricula, and a high level overview of the ways districts institutionalize health equity into their curricula, or not. For a more thorough understanding of what happens to LGBTQ+ youth who leave the educational system, we interviewed a number of staff from the local youth service organization, which includes a runaway shelter. These conversations were heartbreaking, and illuminated harrowing stories of youth who escape their homes for fear of their own safety. While we are grateful that these shelters exist, there needs to be greater emphasis on acceptance in families, and more common language for youth to express their feelings around questioning their gender identity. We produced 5 recommendations from these conversations all that relate to school level policies, more inclusive curriculum development, training and education for staff, and cultivating a culture of acceptance.
The media is an incredibly powerful influence on how LGBTQ+ people are represented in mainstream cultures. In Dane County, we have one LGBTQ+ monthly magazine, and a LGBTQ+ non-profit organization that sends out news blasts with relevant happenings and upcoming events. Interviews with reporters has since led to a more robust communication strategy for PHMDC, and keeps us looped in to community events that promote and support LGBTQ+ health. Furthermore, Dane County is home to a number of LGBTQ+ advocacy groups, and engaging them in the profile work both afforded us the opportunity to understand the local landscape and politics surrounding LGBTQ+ health in Dane County, but also allowed PHMDC to become a visible ally to this population.
Once we conducted all of our qualitative interviews, we came together as a core team and identified the major themes and strategic issues. Our epidemiologist was integral in ground-truthing the narrative stories and the themes that were emerging with data analysis. With both local anecdotes and national statistics, we were able to develop a profile that was representative of the Dane County community, but also supported by external advocates.
As the recommendations emerged, we confirmed our findings with stakeholders we had interviewed to make sure that the ideas were relevant and feasible to our partners in this work. We received some valuable feedback during this time. For example, our senior care specialist working at a non-profit LGBTQ+ organization, made the point that in our recommendations to expand data collection”, we had no formal question about age, which would leave out elder adults. In an effort to better advocate for this often overlooked population, we added a section on this in our profile, and have since connected with the senior center and other geriatric service providers to ensure that our efforts are reaching this age group. Ultimately, we sent out the data profile brief to all of our interviewees, and invited them to continue engaging with the process as we worked to implement the recommendations.
Deciding on what recommendations to tackle was also a calculated, collaborative, and community-informed process. We focused on health care access for transgender patients within our SRH clinic, government trainings, and city-wide policy development because they operated within our direct locus of control. Now that these efforts have been in existence for two years, we are expanding outwards to work with Dane County's healthcare systems. In fact, we conducted an 11-week systems thinking process with Dane County health care systems to better understand scope and capacity for this type of project. We developed a mind map that emphasized five inherent flaws within our current medical model for LGBTQ+ patients seeking care. This effort showcased our ability to network effectively with decision makers in health care systems, and our facilitation skills in shepherding a strategic mapping process among them.
The transgender health training came to fruition directly out of the recommendations put forth by the LGBTQ+ profile. Profile data revealed harrowing health inequities experienced in the LGBTQ+ population, and our SRH clinic was not treating many transgender patients. As a public health clinic, part of our mandate is to reach people with no other access to care. As the profile states, transgender people are less likely to have health insurance, or to have negative health care experiences. We realized that in order to reach a more diverse audience, our clinic staff required additional training on the knowledge, attitudes, and skills needed to be excellent stewards of health for our transgender patients. To fill this gap, we sought trainings that focused on the basics of transgender inclusion in health care settings, but could not find adequate resources related to the sexual practices of transgender people, or the language to talk about the experience of transitioning and its impact on reproductive health care needs. We had personal connections to the Wisconsin Transgender Coalition, and worked directly with them to develop a comprehensive training that covered our needs. With supervisorial support, PHMDC's Community Health Division budget funded this effort.
Developing the LGBTQ+ Health Equity trainings was a deeply cooperative process. We worked with three partners from the LGBTQ+ community who emerged from our profile interviews – a transgender mental health provider, a non-binary executive director, and a lesbian state worker. Using data and the MAPP process to identify priorities, we developed a training curriculum that both celebrated the resilience of Dane County's LGBTQ+ population, but also highlighted the harrowing health disparities and systems of oppression that need reform. We focused the training on concrete steps that government agencies and other organizations could take to transform their practices, policies, and environments to be more inclusive and welcoming to our LGBTQ+ clients and residents. Our outreach for the training began within government agencies, but quickly expanded to include all of the high priority populations that had been identified through the profile process. Because these trainings filled to capacity and received such glowing recommendations, we developed a secondary training with the same staff with more explicit planning towards taking transformative action through policy revision, environmental scans, and trainings.
The city of Madison is in the process of expanding its policies related to LGBTQ+ inclusivity, which is a direct result of the PHMDC-coordinated LGBTQ+ trainings. Many government officials that participated in the trainings recognized the need to transform their systems and are starting to advocate explicitly for LGBTQ+ rights. In the fall of 2019, the City of Madison made an official statement supporting its LGBTQ+ employees, and we are currently writing a policy to support transitioning employees on the job. It is PHMDC's goal to play an integral role in the subsequent training development that comes with these policies, as we have extensive experience in successfully implementing a training schedule that remains relevant and wanted. It will be important to focus on financial sustainability as we build out our training capacity and city-wide goals.
The MAPP process did not cost PHMDC any additional funding. However, we prioritized paying our Health Equity trainers handsomely, and each training cost $3,000 to host. The transgender inclusion training, which came out of the Community Health budget was $3,600. We are currently in the process of identifying ways to make these efforts more financially sustainable, while still providing a fair and just wage to our partners who are critical in the success of this work.