Welcome back to the Healing Pain Podcast with Melissa Hofmann, PT, PhD, Karla A. Bell, PT, DPT, PhD(c), Chris Condran, PT, DPT, EdD

In my profession of physical therapy, the lack of gay, lesbian, bisexual, transgender and queer-specific education has given rise to deficiencies in our cultural competence and our humility. When deficiencies exist in a profession’s educational system, as well as its continued education system, it can create a climate of discrimination and disparity. This ultimately leads to decreased access to health and effective healthcare.

In the context of chronic pain, which is what we discuss on this show, LGBTQ+ people are more likely to suffer from a long-term chronic pain condition than heterosexuals. To begin this episode, I would like to share with you a couple of reasons why this community or this population of people experience more pain before we meet our expert guests.

The first reason is that a larger portion of the LGBTQ+ community lacks access to health insurance or lives in poverty, more so than their heterosexual counterparts. They’re more likely to delay medical care or, at times, just forgo it completely because they can’t afford it or they simply just don’t have access to quality healthcare.

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The Time Is Now – Changing LGBTQ+ Discourse In Physical Therapy With Melissa Hofmann, PT, PhD, Karla A. Bell, PT, DPT, PhD(c), Chris Condran, PT, DPT, EdD

The next are psycho-social issues. We talk about anxiety, depression, and the link between anxiety and depression and chronic pain oftentimes on this show. We know that the rates of depression and anxiety are higher in the LGBTQ+ community than in heterosexual populations. The reason why is because they’re more likely to experience injustice, prejudice, social stress, exclusion, hatred and even violence which can contribute to this increased incidence of depression and anxiety.

How about physical activity? Investigations have demonstrated that only 42% of LGBTQ+ people meet the level of physical activity required for good health compared to 60% of people in the general population. We know that participating in exercise and regular physical activity is a fantastic way to prevent or delay the development of chronic pain.

We also know that certain people in institutions still have a negative attitude toward LGBTQ+ people. It’s these attitudes that can lead to social isolation from friends, family, employers, and even society at large. People who are socially isolated are more likely to develop chronic pain than those who are not.

There’s also childhood trauma. We know that childhood trauma primes the nervous system and creates more pain as people move into adulthood. All of you have access to PubMed. If you want to see some concerning statistics, look at the incidents of child abuse, sexual abuse, and physical assault that exist for LGBTQ+ children and adolescents.

Finally, there’s substance use disorder. LGBTQ+ people have a higher incidence of substance use disorder. Consider for a moment living in a world where you are stigmatized, socially isolated, lack access to proper healthcare or don’t have any access to healthcare at all, where you’ve been rejected. You feel worthless and have feelings of self-hatred. Fear of rejection is around almost every corner.

What happens, in that case, is that people develop challenging emotions. They try to mute these emotions so they don’t feel emotional and physical pain. They turn to substances because certain substances provide a sense of euphoria or relief. However, we know that early or long-term use of certain substances such as opioids leads to decreased pain tolerance and increased sensitivity to pain. At times, living as an LGBTQ+ person in this society hurts unless you find the proper network and support that accepts who you are and who you want to become.

Joining us today are three physical therapists, Dr. Melissa Hofmann, Dr. Chris Condran and Dr. Karla Bell, who are leading advocacy efforts for the LGBTQ+ community within the physical therapy profession. All three are physical therapists and physical therapy educators. They work in a DPT program. All three have conducted research in the area of LGBTQ+ disparities within the physical therapy profession.

In this episode, we’ll discuss the main issues that impact the LGBTQ+ community when accessing healthcare, as well as advocacy efforts at the level of physical therapy education, and the American Physical Therapy Association. With further ado, let’s begin and let’s meet Dr. Melissa Hofmann, Dr. Chris Condran, and Dr. Karla Bell.

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Chris, Melissa and Karla, welcome to the show. It’s awesome to have the three of you here.

Thanks for having us.

Every year in June, I do at least one, sometimes two, episodes on LGBTQ+ issues and physical therapy. That extends to chronic pain, physical health, mental well-being, and lots of different overlaps there. Chris, you’ve been on before. Karla, you’ve been on. Melissa, it’s your first time here. We welcome you.

The three of you, collectively as well as individually, are constantly working on this important topic at the American Physical Therapy Association level. We appreciate their input and their assistance on this topic. You’re all working on it in your respective universities because you all teach at DBT programs. You individually have projects and evidence-based research that I want to talk to you about.

I started PT school in 1995. I’ve been a PT for a long time. I am a member of this community. I identify as a gay male. This is an important topic to me, which did not exist in 1995. I’m not even sure how much of it even exists now. I’m not pointing fingers at any one person or group, but as a profession, we’re a tiny bit late in bringing affirmative action or practice in this area to the profession and our colleagues.

For example, organizations like the American Psychological Association have had statements, training, and massive amounts of information. Why are we a little bit late? What should we be doing? It’s a big question to start off but people who identify like us and our straight peers who support us want to have the same question answered.

The structure and operation of professional organizations have some limitations with moving into the social justice advocacy realms of health. You mentioned APA and AMA, and you’re right. There are a lot of professional organizations that have stepped up a bit, at least with public advocacy statements, and physical therapy professional organizations have not. We do need to shift our sails a little bit on our sailboat as professional organizations in health. Now more than ever, the systemic inequities for vulnerable populations, historically traumatized populations, and marginalized populations are having a measurable impact on the health and well-being of people.

Any health professional organization, in its mission values and core values, has an obligation to stand up for equity and health equity. That looks different now than it used to look. I dare say of paramount concern is the political determinants of health for these communities. In 2021 and 2022, it has been historical. When I talk about the political determinants of health, that means how politics legislate the lives of people. Their legislation implemented into public policy has impacted all the way down with the structural inequities that exist for these communities.

The profession at large is moving in the right direction. I agree with Karla’s and Joe’s sentiments that we are late to the game. If you look at the historical context of our profession, Gail Jensen put out a great editorial in 2022 for PTJ, where she commented on her own personal experience and perspectives about Ross et al’s paper that was published in December 2021. It was looking at the experiences of LGBTQ+ practitioners or people in academia and what their experience was as LGBTQ+ people within those fields and going back in time. The editorial was to the effect of “time will tell” or something like that.

Looking back at the discrimination, even not so much outright policy, it wasn’t talked about. There weren’t DEI initiatives that were happening at that time. I agree with Karla. That is fostered and facilitated by current social politics and where society has come to in the last 20 to 30 years. Everybody, read that editorial if you get a chance. It’s a great read. Gail Jensen is one of the best educational researchers out there. She has quite a bit of experience and shared her personal journey in that realm.

I want to go into a little bit talking about our professional organizations. Our professional organization has demonstrated advocacy in context through their commitment outlined in their policies to be accepting of all communities regardless of race, gender, sexual identity, disability, etc. The most powerful advocacy is to not only say that you support something but to demonstrate through action that you do.

It’s more powerful to have a national or state organization provide support against a specific policy that is discriminatory, especially when it involves the community that is part of their own organization. What would this potentially look like? Maybe public support behind policy initiatives that are set forth by state delegations. For instance, to advocate for the LGBTQ+ communities, public display of discontent or disapproval of policy that overtly discriminates such communities, and maybe even public collaboration with organizations for events that support the community. The key word here is being more public.

I’m going to build off of that a little bit. I see this more as looking inward at our profession as a whole. When we look at examples of professions like social work, psych or even medicine, we see professions that have created clinical practice guidelines for these populations. They specifically look at identifying the disparities that are happening, addressing them specifically through educating our students and our clinicians in continuing education, and creating those clinical practice guidelines that would drive a high-quality inclusive practice rather than a practice that is willy-nilly and not driven by the evidence.

As clinicians, we have a responsibility to deliver evidence-based practice. In the physical therapy realm, there isn’t a lot of evidence-based practice going on, particularly when addressing the specific needs of trans people. We know from recent studies that students are only getting around an hour to, potentially at the greatest, three hours on this topic in most academic programs, particularly in doctoral programs and for physical therapy. To me, that is alarming.

For example, in a lot of states, physical therapists are direct access clinicians. We treat patients without a referral from a physician. If we don’t create an inclusive environment that allows for patients to feel comfortable disclosing their medical status, whether it’s what types of medications they’re on or what types of procedures they’ve had, we could harm them with our treatment. When it falls back on trans folks, in particular, most clinicians have no idea what gender-affirming care looks like, whether it’s hormone blockers that are being received by someone or gender-affirming hormone therapy.

Some gender-affirming hormone therapy carries specific health risks or issues that can potentially be lifelong that we should be screening for before providing care. That’s why clinical practice guidelines would be essential in creating and establishing a process for treating these patients in an inappropriate way. For me, it comes back to what we are doing at the professional level.

In addition to the advocacy, we need to acknowledge that LGBTQ+ people have a specific set of needs that are not being met because our clinicians are not being educated, whether it’s in academic settings or in continuing ed. It’s falling back to that funnel of creating clinical practice guidelines that would address those situations, along with addressing the specific health disparities that are happening with access to quality of care, and with providing top-level quality of care for these patients.

Karla said something that made me perk up a little bit. We have clinical practice guidelines for things like chronic low back pain, osteoarthritis, and every condition that we see as physical therapists. Is there a clinical practice guideline in the works for affirmative practice in this area? Has anyone started to pursue that? What has the feedback been about that? Where are we going with that?

In the physical therapy realm, no. Other professions have clinical practice guidelines for LGBTQ+ folks, but we do not have them here in physical therapy. When I first started my transition, this was something I was talking about and bringing into the spotlight then. It has still not been mentioned much. When I attended the clinical practice guidelines workshop, I was addressed in a way that said there isn’t enough evidence for us to have clinical practice guidelines in physical therapy for this. This was a few years ago.

Over the last few years, there has been a huge surge in the amount of evidence that we have, particularly around the trans community in gender affirmation. Whether it’s gender affirmation surgeries or gender affirmation hormone therapy, we have so much more information. At this point, I feel we should have these from a differential diagnosis standpoint and direct access care standpoint. We could potentially be missing lots and lots of things from nerve damage from laying on the table for long periods of time from surgery.

Therapists aren’t thinking about those things because they’ve never had the experience of being trans. They haven’t had those experiences of being on hormone therapy or gender affirmation surgeries. They may not even have a friend or an acquaintance who has had those experiences. It’s the ignorance piece that has globally given us this space where people don’t know about these things. They’re not thinking that way because they haven’t had those experiences or shared those experiences with a loved one, a friend or an acquaintance.

Having gone through some of them myself and having a lot of acquaintances and friends who have, it has changed my perspective. I am direct access licensed therapist. I work in outpatient orthopedics settings. It has shaped how I see why these clinical practice guidelines are so important and why we should have them and try to drive the change to create them.

You’re in this atmosphere. You’re interacting with your peers in a public arena. Someone says to you, “There’s not enough evidence.” You know of evidence way more than I do and I would say, “We need more LGBTQ+ evidence in physical therapy specifically.” As licensed health professionals, why can’t we pull from the evidence that does exist in the other professions, medicine, psychology, social work, etc. and use that?

For example, the therapeutic alliance is one of the most important factors in any type of condition that we see as health professionals. A lot of the affirmative guidelines that the American Psychological Association put out for LGBTQ+ practice are along those lines. How do you foster a therapeutic alliance with a population that you may not have ever had any experience with?

That’s okay, but why can’t we start to pull from that? If we at least had that, where we know how to treat people, human beings that deserve care, why can’t we start with that? We can then figure out if you’re treating. We can then get into the lower back pain for this population in physical therapy or those specific things. That doesn’t resonate with me anymore.

You bring an interesting point to that. It’s the recognition of this being an issue. That is a place where our profession has been in denial for a long time and that we can treat everyone the same. That is part of what we’ve done in our research. All three of us are in research groups together. I ran a pilot study as part of my dissertation. I had 130 respondents and almost unanimous support for the creation of clinical practice guidelines and for this content to be CAPTE-accredited in DPT programs.

I’m assuming there’s nothing in the CAPTE accreditation guidelines that mentions LGBTQ+ individuals and care. That’s a problem.

There’s not. My understanding is those are being updated. I don’t have any idea what those look like. I’m told that DEI is heavily being integrated, but I don’t know what that means.

Those guidelines aren’t updated every year. It’s run every five years or something like that. Does that sound about right?

One of the biggest issues with CAPTE at this point is individuals can’t publicly identify as they truly identify within the CAPTE framework. If you go to PTCAS, one of the big challenges for folks for a lot of academic institutions, as far as admissions go, is they don’t know who identifies as what because there are no options within the CAPTE framework or the PTCAS network for them to identify as such. It makes it challenging when you’re trying to diversify your student body and you’re not getting that important information from PTCAS, which is essentially sponsored by CAPTE.

That same experience is going on in HR departments across academia as well. They’re not collecting any gender-related information from an application standpoint other than male and female. If you are non-binary, there is no place for you to put your true identity. Academic programs have no idea who they’re recruiting, whether it’s a diverse hire or not unless you’re known to them outside of that.

I was reading some information on Generation Z, which is the upcoming generation, on how they’re much more diverse in this area. They identify much differently than probably all of us did. We didn’t have this language. We didn’t have these constructs to help explain what our lived experience is like for people.

As you look at these younger generations, even though we don’t necessarily have the policies in place either on the APA level, state level, legislative level or politics, they’re leading. They’re starting to come into PT school already with this vernacular. We’re not necessarily able to meet them, which is interesting for us to think about.

Karla, you mentioned political determinants, which is probably somewhat of a new word on this show. We heard about personal determinants of health. We’ve heard about social determinants of health. When you mentioned political determines, you’re talking about jurisdictional and legislative changes, which are important.

As a licensed healthcare professional, if your state were to pass anti -LGBTQ+ legislation that you see could potentially impact the health of individuals, communities and populations, do we have a responsibility to become active in that, raise our voice and say, “This could potentially impact not only the health of populations?” When health is impacted in the United States of America, finances and economics are also impacted. When you talk about political determinants, where do we go with that as a profession?

The bottom line is pretty simple when you break it down to health equity. Our core values and mission, and even our public policy priorities revolve around advocacy efforts for social determinants of health and health equity. When we look at it through that lens, the political determinants of health are front and center for these communities for the past few years, at least if not forever.

As health professionals, we have an absolute obligation to understand what is going on for communities related to public policy efforts and legislation because the implications then are numerous. I can think of a number of examples. There are many states now where gender-affirming care is illegal. Some of them have stipulations related to health professionals providing care. Some of them have mandatory reporting parts to them too.

Can you give us an example of what that looks like?

As health professionals, if we have a minor that comes into us for physical therapy and they disclose their identity to us, there is some legislation out there that says we have to tell the parent. That is completely unsafe. We have no obligation under HIPAA or anything to provide that identity to the parent or guardian. It’s only what is the plan of care related to why they’re coming to us and their health needs.

That’s not just specific to physical therapy. That could be any licensed health provider in the state. For an individual, if an adolescent is in therapy with a psychologist or a mental health professional and they’re working through their identity, that professional is supposed to then finish the session up and disclose to the parents what’s happening behind closed doors in a private session.

That’s correct. I don’t have time to go into the horrific statistics related to the safety of our youth, but 40% of homeless youth are LGBTQ+. That statistic has not changed for decades, and the suicide rate for that population. These laws are endangering. As health professionals, it goes back to health equity and what that looks like. It goes back to cultural competency and what that looks like. We are not doing our job as physical therapists with these communities in those realms.

There’s so much policy out there that is discriminatory against all of our communities. You can’t just pick one. There are probably over 200 bills that are out there. It’s incredible. When you look at the way that PT Proud that our advocacy committee is organizing, this is looking at what are our core values as a profession, what are our ethics, and what do these policies look like in coordination with our core values and ethics?

To give you a few examples, when we think about it, accountability is a huge one for the profession. There is no ordinance in place for non-discrimination within religious organizations or discrimination against employing LGBTQ+ people. It’s still legal in some of those spaces to be discriminatory. When we look at inclusion, there are policies out there like Oklahoma SB 1100 limiting the biological sex designation on the certificate of birth to male or female and prohibiting nonbinary designation. Minnesota HF 3843, a person’s sex is either male or female as biologically defined.

We look at things like social responsibility. That’s one of the core values of our profession. There is a policy that goes against that core value as well, like Arizona SB 1138, irreversible gender reassignment surgery. It prohibits physicians from providing any irreversible gender reassignment to individuals under the age of eighteen, including all gender-affirming surgeries, things like phalloplasty and vaginoplasty. It’s exhausting in some ways to think about all this policy. Where do you start to fix that problem?

You brought up PT Proud. I want to thank you for bringing that up. It’s a good place for us to pause here in the center. A lot of people tuning in to this episode will be physical therapists or other health professionals. Tell us about the resources that we have for physical therapists and others at our national level that they can access to learn more. We’re going to go more into this topic, but let’s point them to some resources that they can start to educate themselves early on here.

First and foremost, PT Proud has grown in the last few years. We started out as a simple catalyst group in the Health Policy Administration, which is now the Academy of Leadership and Innovation. We have moved from a catalyst group to a committee. We hope to move to a special interest group. Chris and I were talking earlier. We think that moving to a special interest group is going to give us some more leverage to start to stand up to the national organization or other organizations to make sure that we can advocate for these communities.

One of the most important things is for folks to understand how you can get involved. If you’re interested in getting involved, we have multiple subcommittees within PT Proud. We have a membership committee, webinars, podcasts, and social media advocacy which has been busy. We can always use more help on the advocacy committee. Our website has also moved to the Academy of Leadership and Innovations homepage. If you go to HPA The Catalyst and go under Engage, you can find PT Proud. We do have resources there.

Chris worked hard over the last few years collaborating with OutCare so that we can add to our network of providers. People can find providers that are inclusive of our communities. We also have educational resources. We post all of our podcasts and our webinars also on the website. We do have recommendations for different organizations where you can get additional information about our communities.

Chris, there are PT educators tuning in to this and they’re learning you talk about those stats. Maybe there are two hours of this in the PT program. What would your advice be to educators who want to learn more about this topic and how they can start to insert it into the DPT curriculum?

Karla and I both feel that the only way to make this successful is to immerse this in all PT content. When you’re presenting content on orthopedics, your cases are inclusive cases. When you’re presenting content on inpatient acute care settings, maybe you are having cases of a patient that’s had phalloplasty and you’re mobilizing someone after phalloplasty. What does that look like? We have patients that have had top surgery. We’re talking about how to provide lean care do a graph site. How do we do wound massage on someone who’s had top surgery and wants to reduce the appearance of their incisions? What’s the evidence behind that?

If we don’t start integrating that piece into all that we do, I feel as though we’re doing our students and our community a disservice. In addition to that, it’s essential that those of us that are out-licensed and practicing pursue continuing ed. Every year at CSM, we provide Brave Space Training. Most of us are doing our own educational sessions on these topics.

It’s continuing to pursue those types of education so that you can take them back to your home university and be able to provide that. Overall, it needs to come also from the administration at universities where we’re providing inclusive excellence training for all of our academics and looking at how to utilize pronouns. We know that affirming people’s identities using pronouns, having chosen names, policies, and gender-inclusive bathrooms. There are so many things we can do in the academic setting to make that happen.

In addition to that, on all of my syllabi, I taught Labs. My students had to be in a special type of attire where we could access body parts and whatnot. We’re making sure that language is inclusive and respectful of anybody’s identity. We oftentimes have gendered dress codes and gender-neutral dress codes on our syllabus. There are so many things that we could do. That’s skimming the top of the iceberg there. I’m going to leave it to Karla to chime in here if I missed anything that she’s doing because this is a big part of her research.

Thanks, Chris. Yes to all of that. To tag on what the research says about what we need in entry-level health professional curriculum, not necessarily specific to physical therapy, but there’s a literature in the medical literature that suggests that these one-offs are maybe even worse than not doing it at all. They’re suggesting we need 35 hours or more of this specific content in our educational programs for our emerging professionals. What that means is every faculty is responsible. Every faculty has to get involved, just like Chris says, threading through cases and running through whatever.

What that ultimately means is we have a faculty base that has no idea what they’re doing in this realm. Professional development is important. There are not a lot of programs out there. I could speak about one of the research studies that I’m part of here at Thomas Jefferson University. It is a professional development program called Sexual and Gender Minority Education and Training. It is an interdisciplinary and interprofessional program that is aimed at faculty, staff and clinicians alike.

It is a comprehensive program that addresses cultural competency through the lens of knowledge being important for historical reasons of what’s going on with these communities, then all the way up to inclusive practices and practicing inclusive practices, and then action planning. You leave the program with a written action plan of what you are going to change in the next six months, what you teach or how you practice. Those programs are important because our faculty can’t teach our students until they know what they’re doing.

That’s your work, Karla, as part of your PhD?

It’s a research study aside from my PhD. My PhD work is more on population health. I’m going to be doing measurement development and creating a measurement tool to look at the likelihood of providers using inclusive practices.

Chris, you finished up your EdD. Why don’t you give us a snapshot of what your research entailed with that? It was along the lines of a lot that we’re talking about here.

I took what I’ve been doing for the last several years, guest lecturing around the country at different universities, and created a two-hour module where I recorded myself doing an asynchronous type of instructional. I enrolled 130 participants that were already licensed clinicians. They had to go through the Twoo app. They took a pretest. I used a validated survey to look at cultural competency.

The way that we see cultural competency is typically you acquire this knowledge and have this skillset. You have reached this start to finish. Rather than what Karla is talking about with competent ability, it’s about pursuing this throughout our lives as clinicians and examining our own internal biases, what’s going on for us, how we interact with our patients, and how that impacts how we provide care.

The next step is for me to go in that direction. This was a very basic two-hour asynchronous course. Pretty much everyone’s scores improved. I had 30 clinicians that finished the study. Part of that was a set of questionnaires that looked at whether or not individuals supported CAPTE accreditation, whether they supported this content being in academic programs in general, and also whether there was going to be support for clinical practice guidelines. That was pretty much unanimous across the board as well.

It can be done. Even in a two-hour lecture course where you’re listening to the content, people’s scores significantly increased in that study. The people that finished had higher scores, to begin with, than those individuals that never engaged in the study course. Overall, there’s low-hanging fruit on this because we come from a society and in a profession where there is little training for folks in general. If we can create this type of content in a continuing ed way, a method, and in our classrooms, there’s a significant impact that we can make for our patients in particular and the type of quality care that we provide.

It is low-hanging fruit because there is little on this. Hopefully, WPATH standards of care will be coming out soon. This will help drive more content for the trans side of things that are evidence-based. That’s typically where most health professions get their trans-related content. They’re pretty much the leader of the standards there. I’m looking forward to that coming out soon so that we have more driving that as well. Fingers crossed that we can continue to make changes and publish more research on this stuff. Mel, you should chime in here on all the stuff that we’re doing with our studies since you’re the PI on that.

There are lots of great stuff happening. We’re right about publication for the clinical phase of our study. It was a national multiple-phase study using mixed methods, so qualitative and quantitative research methods. The clinician arm of the study was the first phase. The writing is nearly complete. We’re hoping to present it to PTJ. Look out for that publication. The second part of that publication was the quantitative part. We took themes regarding barriers to LGBTQ+ cultural competency from a clinician perspective and created a cultural competency survey tool that is specific to physical therapy.

We did a pilot study. We had about 180 subjects that participated. We’re going to publish it as a pilot. We are collaborating with Heidi Jannenga, who is the co-owner of WebPT. We will be putting our survey out on a much larger platform to validate that survey. We are continuing to talk to faculty and students about their perceptions of the barriers to cultural competence in these communities. We just started talking to patients. There are lots of great information to come out.

I’m also involved in some other workaround gender-affirmation surgery. We have a paper in the process of republication with transgender health. It’s looking at the implementation of pelvic floor physical therapy, the rehab for individuals that have had vaginoplasty. We are working with the University of Colorado Health Anschutz and Denver Health. Both of which have gender affirmation surgery programs.

I’m working with a pelvic health therapist, Krystyna Holland, to develop another research project looking at the outcomes and status of post-gender affirmation surgery after providing pre-surgical educational sessions for patients. Lots of research to come out. The multi-phase national study that we’re doing is almost a needs assessment for a much larger project that all of us are going to be involved in, which is developing standards and competencies that are specific to the curriculum of DPT and all rehab sciences programs. We feel it’s important to be inclusive of all rehab professions in that regard. Some great things are happening.

The pelvic health therapists have been wonderful allies in all this, haven’t they?

They sure have. At this point in time, they are the most knowledgeable about our specific communities and the care that we provide.

We want to thank them. Who do we need to win over in our profession? Pelvic health is already there. They see these populations in practice. They’ve been treating them for years and have started to develop some of this in their practice. Who do we need to start to educate more in our communities within the physical therapy profession?

The interesting part there is saying that the pelvic health therapists have been the ones that have been treating us. Everyone has been treating LGBTQ+ people. The issue is that we do not recognize that those folks have specific needs that should be met in a different way than cisgender heterosexual people. In order to win everyone over, we need to address all clinicians. We need to get people to acknowledge this and realize that you are engaging these people every day. You just don’t know it because your environment is likely not inclusive and we’re not disclosing and outing ourselves because we don’t feel safe to do so.

With this current legislation that’s happening with anti-trans athlete bills, gender-affirmation medicine, and bills that are criminalizing parents that provide gender-affirming care to their children, we’re mandated to report those. If you work in the state of Texas, the new law says that if a patient comes to you and they’re a minor, and they disclose that they’re getting gender-affirmed care, you’re mandated to report that with the new policy that has been passed.

It’s recognizing that this is happening across the country and that we exist in many different facets. Most of the time, unless we out ourselves, you don’t know that we are part of this community. It’s winning over everyone from acute care to outpatient to inpatient rehab settings, this is something that impacts everyone’s practice. This isn’t something that you can pick and choose. Thank goodness for the folks who all have been driving the change and saying, “This community deserves recognition and its own special set of quality practice.” Thank you all for that.

This is relevant to everyone. That’s the part that people in our clinical practice and our profession have not quite wrapped their heads around. Many of us have experienced where our colleagues in academia and clinical practice don’t acknowledge that we have a unique set of experiences that make us different from other people. That drives the quality of care that we could be potentially providing to our patients that’s part of this community.

Chris, you bring up some great points. I would also add that semantics matter for a professional organization. When we have DEI initiatives that are put on the top of what we’re supposed to be doing and supposedly implemented and prioritized moving forward, but you are not inclusive with what you mean by diversity, equity and inclusion, semantics matter.

For example, when you are talking about DEI initiatives, but you are specifically talking about race and ethnicity, then say that. Don’t say diversity equity and inclusion initiatives because they are not all-inclusive. We need to be specific about what we’re addressing. If we do that as professional organizations, you will find that we are invisible in those initiatives. That is also a priority that we need to address. These communities and populations continue to be invisible in health. The health needs that they have is a travesty.

To round out the conversation, in our research, we do ask folks, “How do we reach people? Where do we start? How do we make changes in this area?” One of the most critical things or recommendations that we get is back to education. It has got to start at the educational level. Our entry-level therapists need to go out prepared to treat these communities. Can we make changes for individuals that have been out for 30 years? Maybe and maybe not, but we can make changes with the folks that are going out now. Hopefully, that change will translate over time. That is one of the most critical places that we need to start as a profession.

We’ve talked about politics and policy. You’ve talked about competency standards within the profession. They pointed people to some resources where they can access within our profession specifically. There are going to be people who read this or maybe see this topic come up in other venues and areas. They might say, “I was raised with good values. I treat everyone the same. I treat everyone like a good person. I don’t see why we need this, why I need this, why our profession needs this, or why we should put energy, resources and money toward this.”

I’m wondering if the three of you, either individually or collectively, have a case study or a case example, without mentioning names, of how that hasn’t worked and how that’s failed for a particular individual. What we’re talking about here is validating people and their experiences, but then how that translates to their care as human beings.

A lot of what we do as professionals are build resilience in people. When people approach it like, “My parents raised me with good values,” I don’t think they understand the resilience opportunity that they have to work with this particular population to increase their resiliency even more by having an affirmative practice agenda in their practice or as part of their stance as a professional.

I have a direct case here that I can speak to from our research. I can’t say a lot about it, but it’s from our patient research. We did have a younger individual, early twenties, that identifies as non-binary. One of the things that we talked about in the research is the fact of whether they know an institution, an organization or a clinic is inclusive of our communities.

This individual spoke of their experience and said that they went to a clinic that was recommended to them. They were excited because they felt like they were going to a clinic that was highly inclusive. The intake paperwork was inclusive of their gender and sexual identity, their preferred name, and things like that.

At the intake portion of their session, they were pleased with what looked like an inclusive climate. The problem happened when they went back and saw the physical therapist. There was a breakdown. This clinic is promoting itself to be an inclusive clinic, yet its providers don’t have any knowledge of the inclusive practice. For this individual, it became a challenge. They were assuming that this individual was knowledgeable and that they knew of the mechanisms to treat them effectively and they did not. The role reversal happens.

The question for this individual was, “Do I take the time to educate this person which is exhausting, challenging, and makes me more vulnerable because I didn’t think I would have to do that in this context? Do I let it go and not come back to this clinic ever again?” That is a travesty in itself. The problem in all these clinics is that they want to become inclusive and promote that climate, but we need to make sure that the clinics are prepared to treat this clientele as well. That’s an example.

I can speak a little bit to that question too and put out a shout-out to your upcoming book on lifestyle medicine and physical therapy. The chapter that we all contributed to gives some illustrative points of the impact on these communities of our behaviors, the inequities that exist, and facilitators and barriers. There’s a great table in that book as well. I think of some literature out there, and there’s not a lot. When you look at Ross and Setchell’s 2019 study looking at the experiences of patients who are LGBTQ+ and what they highly recommended we do as a profession, that’s a great article that talks about some of the experiences.

Calzo et al. put out an article on physical activity and the differences in sexual minority youth. As professionals and PTs, why should we care? I’m going to go back to the legislation. What we’re doing is a travesty to physical activity in gender minorities in this country. We know all the goodness that goes along with promoting physical activity and sports. That is being taken away from these communities in some states.

Calzo et al.’s article specifically talk about the significant differences in vigorous physical activity among sexual minority youth versus non-sexual minority youth. We know that we would love to have more research to denote what some of these other things are. People don’t do this kind of research and we don’t collect these demographics. We have to go with what we have.

There is some robust information out there in the little literature that we have that points to the fact that physical therapists have the main role in needing to know these communities and their health needs and to intervene and help provide the interventions from an educational and clinical perspective to help them promote their healthy lifestyles.

I want to give you an opportunity to talk to your peers because you’re all educators. You have peers on the university level. You’re doing research. What’s the one thing you want them to take away from this conversation, from the work you’re doing, and how you want their support on this important topic? We can go with Chris, Karla, and then Melissa.

One of the biggest things is acknowledging that there is a problem. From what we’ve all seen, part of the reason why there isn’t a lot of research on this is because no one has seen it as something to investigate in the past. We need to acknowledge that there is a problem in our profession. There are a unique set of needs and health disparities experienced by these populations that require us to change how we practice, teach, educate, and how we move forward as a profession.

The only way for that to happen is for us to gain more support across the professional organizations of our profession. The only way that that’s going to happen is if people that don’t look like us and talk like us start singing the same chant that we’re singing. This is an important issue. It’s happening. There are lots of research to suggest that there are significant experiences, whether they’re driven politically or otherwise, that there is a serious problem here for the LGBTQ+ populations. Other professions have seen it. Other professions are singing the same chant we’re singing. We need the rest of you to do the same.

Thank you for that. I echo every single thing that you said. I’m begging people to understand the urgency of what’s going on in our country for our populations. We are being erased at many levels or trying to be erased. We will never be erased. Let me stipulate that. I have to be honest. This starts with people who don’t look like us and identify like us speaking up. As a community, we don’t have the power. It comes back to power, privilege, and speaking your truth when you have that privilege.

We need people in our profession, educational programs, and clinics to speak up and be public about the fact that the inclusion of our populations in our profession is important. They need to understand why. They need to further their education. Our curriculum committees and our educational programs need to step up their game. They need to bring this conversation to the table. I’m still waiting for that to happen in many of the programs I know. When it’s brought up, it’s immediately put under the table. That’s a travesty in itself too, because we can’t continue to perpetuate this invisibility in our health professions.

Thanks, Chris and Karla, for both of your sentiments. I agree with every last word that both of you have said. The way that I want to round out, what you’ve said is to make a plea to our profession to keep an open mind and maintain that curiosity and that wonderment in your educational practices. It’s important to be able to have sometimes difficult conversations and discussions. If you keep an open mind, that helps to move the practice and research along.

We don’t want to halt right where we are. We want to keep moving. We need you to help with that. There are individuals that have fear in some areas of the country to bring this content back. What you could do is collaborate with somebody like us who is knowledgeable and bring us into your institution. Let us do the work for you. Collaboration is a big piece and having an open mind to that possibility or opportunity is one of the first steps.

I want to thank Melissa, Karla, and Chris for joining me on this episode. It’s an important episode that I always enjoy doing once a year. Even as I look at this, I’m like, “Why am I doing this once a year?” This needs to be done more than once a year. I do it in other, probably smaller ways. Speaking with you has helped me reflect on my behavior and what I’m doing. If I’m saying this is important, that needs to be more than I do as an individual than just in June for Gay Pride Week. I want to thank you for opening my eyes to this topic. It’s important for all of us individually and important for our profession.

If you want to reach out to Melissa, Karla, and Chris and learn more about the work that they are doing or the educational resources they have on this topic, that will be on the website at the IntegrativePainScienceInstitute.com. You can go to that website, scroll over to podcasts, and then scroll all the way down to the bottom.

You’ll find all their information, as well as other information about the great work they’re doing. Share this episode with your friends, family, and colleagues who are interested in this topic and those who maybe are not interested. We need to raise awareness around this. Happy pride and we’ll see you next time.

Important Links

• PubMed
• Dr. Melissa Hofmann – LinkedIn
• Dr. Chris Condran – LinkedIn
• Dr. Karla Bell – LinkedIn
• American Physical Therapy Association
• American Psychological Association
• PTJ
• An Exploration of the Experiences of Physical Therapists Who Identify as LGBTQIA+
• CAPTE
• PTCAS
• HIPAA
• PT Proud
• OutCare
• Brave Space Training
• WPATH
• WebPT
• Krystyna Holland
• Physical Activity Disparities in Heterosexual and Sexual Minority Youth Ages 12-22 Years Old
• https://Twitter.com/PTProudAPTA
• https://www.Facebook.com/PTProud/

About Melissa Hofmann

Melissa C. Hofmann: Melissa Hofmann, MSPT, PhD, is an Assistant Professor of Physical Therapy at Regis University. She teaches in areas of Evidence Based Practice and Research and Management of Applied Physiology. Dr. Hofmann’s educational background includes a BS/MS in Physical Therapy (D’Youville College, 2000) and a PhD in Research Methods and Statistics (University of Denver, 2016). She has 22 years of clinical experience and continues to practice as a Senior Physical Therapist at the University of Colorado Health. As a member of the APTA, she is active in the Academy of Leadership and Innovation, Neurologic, Research, and Education sections. Dr. Hofmann serves as Chair to the board for the LGBTQ+ PT Proud Committee through the Academy of Leadership and Innovation of the APTA and Co-Chair of the APTA CO Chapter Diversity, Equity and Inclusion (DEI) Committee.

Additionally, she is a member of the Diversity Council, the Queer Resource Alliance (QRA) and the Anti-Hate Campaign Committee at Regis University through the office of Diversity and Inclusivity that supports efforts for marginalized communities and specifically LGBTQ+ issues/events. She has completed Brave Space Training at institutional and national levels to increase awareness and dialogue about sexuality and gender specific to the LGBTQIA+ community. Dr. Hofmann is active in research and scholarship. She serves on the Regis University Research and Scholarship Committee as a grant reviewer. Currently, Dr. Hofmann is engaged in a SGM (Sexual and Gender Minority) National Mixed Methods Study examining barriers to LGBTQ+ cultural competence from clinical, academic and patient levels. In addition to SGM research, Dr. Hofmann has presented and facilitated discussion of research centered around Trauma Advocacy for Practitioners/Patients, Traumatic Brain Injury, and Stroke at local, state, and national levels.

About Chris Condran

Chris Condran is an outpatient orthopedic physical therapist with 9 years of clinical experience. He is a visiting faculty assistant professor at Lebanon Valley College in the Doctorate of Physical Therapy Program. Dr. Condran’s educational background includes a BS in Exercise Science (East Stroudsburg University, 2006) MS in Exercise Physiology (West Chester University, 2009) MBA in Business Administration (Widener University, 2014) DPT in Physical Therapy (Widener University, 2013) and is currently enrolled in an EdD in Kinesiology (University of North Carolina Greensboro). He also holds certificates in Healthcare Management (Widener University, since 2013) as Certified Exercise Physiologist (American College of Sports Medicine, since 2006) and as Certified Conditioning Specialist (National Strength Professionals Association, since 2004).

Chris’s research and advocacy interests are centered in providing inclusive clinical environments for all patients, transgender health issues and the intersections of PT clinical practice, eliminating health disparities in the LGBTQIA+ populations, and establishing curriculum for LGBTQIA+ cultural competency in the classroom and beyond. Chris has found an outlet for these interests as a board member of PT Proud the LGBTQIA+ Catalyst Group/Committee of the Health Policy & Administration Section of the American Physical Therapy Association, where he serves as the treasurer and webinar subcommittee leader.

About Karla Bell

Karla A. Bell, PT, DPT, PhD(c) is an Associate Professor and Co- Director of Clinical Education at Thomas Jefferson University Physical Therapy.
Dr. Bell has 24+ years in the profession and is a co-founder and past Co-Chair of PT Proud, the LGBTQ+ committee under the Academy of Leadership and Innovation and serves on the APTA DEI committee. She is a candidate for a PhD in Population Health from Thomas Jefferson University with a focus on looking at provider behavior interventions to help mitigate healthcare disparities experienced with SGD populations. She is currently part of three active educational research projects around sexual and gender minority education, professional development, and student/patient experience in the healthcare professions. One of these is a sexual and gender minority education and training program for faculty, staff, and clinicians that is open to participants nationally.