Cultural Competency OSCE scenario

A brief clinical scenario and why it requires cultural awareness/humility

A 14 y/o female presents to pediatric ER accompanied by father with a complaint of shortness of breath for the past 2 years. Father demonstrates medical records indicating full workup by three different providers with no abnormal findings. Cardiac/Endocrine/Infectious disease workup in the ER fails to demonstrate physiologic cause for patient’s shortness of breath. During the private part of the interview the PA student learns that patient has had difficulties coping with the discovery of her sexual identity and orientation as, coming from a traditional  background, she is concerned her family and community would not understand. Lack of needed support and feelings of alienation caused her a lot of anxiety and she admits to having anxiety attacks which coincide with her shortness of breath.

Sexual minorities routinely report discrimination, bias, and lack of trained providers when attempting to use the health care system, leading some to avoid health care altogether. In a 2005 survey, 22 percent of lesbians reported prior bad experience(s) with health care, 18 percent reported feeling afraid or embarrassed to talk about health issues, and 15 percent had specific concerns regarding discrimination. Studies note that health professionals report a lack of access to training that would help them meet the needs of LGBT clients and, even when training is available, it may not be mandatory.

Sexual and gender minority men and women who disclose their sexual orientation have significantly fewer psychiatric symptoms than those who do not. In addition, negative reactions from others to the disclosure of sexual orientation have been linked to current and subsequent use of substances (e.g., alcohol, cigarettes, marijuana) and to other health risks.

In addition, the field still lacks an agreed-upon clear vision for guidelines to define cultural competence for working with sexual and gender minorities.

The cultural factors that need to be considered

When youth come out they are more likely to experience not only peer victimization, but also victimization at home. In contemporary Western societies, adolescents are typically emotionally and economically dependent on their parents. In previous cohorts, LGB people would come out when they were financially, legally, and socially independent from their primary caregivers. The declining age of coming out therefore makes contemporary cohorts of LGB youth particularly susceptible to family regulation and rejection, victimization, pushout, and homelessness which reflect several pathways to compromised health. Further, even when families are accepting or affirming of sexual minority youth’s identities, there is little empirical evidence to show that support from families can buffer the negative influence of peer discrimination or victimization.

Relatedly, after years of human developmental research documenting the ways that family rejection undermines the well-being of LGB youth, studies now identify accepting and supportive families, and show that family acceptance is strongly linked to the wellbeing of LGB and transgender youth. Importantly, amid changing social acceptance, parental attitudes towards LGB children have also shifted. One new report shows that in large-scale surveys, 89% of U.S. adults in 1985 reported that they would be upset if they “had a child who told you he or she was gay or lesbian”; by 2015 the proportion who would be upset dropped by 50% (to 39%), with 57% reporting that they would not be upset. However, school victimization and bullying remain the focal point in studies on minority-specific stressors.

Any beliefs that might be different from western medicine beliefs or unique considerations that care of this patient might require

For the mental health and wellbeing of sexual and gender minority youth, the developments in social acceptance are encouraging, and should certainly be linked to positive mental health and other forms of adjustment. Yet inequalities, prejudice, and discrimination are vexingly persistent. The civil rights and feminist movements in the United States more than a half a century ago resulted in a number of legal and political changes that ended racial and sex discrimination that had long been legal and institutionalized. Yet the emergence of the Black Lives Matter and Me Too movements, now 50 years later, dramatically underscores the persistence of institutional cultural racism, sexism, and white male supremacy. Despite unequivocal social and legal changes, including changes in public opinion and attitudes, there is no question that racism and sexism remain embedded in Western cultures. Further, they remain central organizing principles in the lives of adolescents, and are evident in persistent racial and gender disparities across multiple domains of adolescent well-being.

Engaging in sexual identity exploration also goes hand in hand with other prevailing characteristics of emerging adulthood. The distinctive features of emerging adulthood include negotiating experiences of instability, feelings of transition, heightened self-focus, and identity exploration. Exploring identity options and maintaining flexible commitments in identity domains, such as education, work, politics, and religion, is commonplace in emerging adulthood.

Adolescence is a unique time in life of every individual that shapes the way one sees the world and establishing a trusting patient-provider relationship is crucial to how they will perceive healthcare for the remainders of their lives. This relationship can prevent many comorbidities in future thus easing physical, emotional and financial burden not only for the patient, but the healthcare system altogether.

Areas where conflict might develop (e.g. for a Jehovah’s Witness patient or for someone who has strong beliefs about the healing value of prayer or traditional herbs)

For sexual minority adolescents, fear of stigma, rejection, and other sequelae related to their sexual minority stature can lead to defensive compartmentalization and the perceived need to protect and hide this aspect of their identity. This may result in behavioral changes that get misdiagnosed as mood or personality disorders and possible mistreatment that could have been easily avoided had the patient been provided with a safe environment for sharing and building trust. These matters may be challenging to navigate, especially in a setting of a pediatric patient since often the family members inherently participate in care. Maintaining strict patient confidentiality is crucial for building trust with the patient but transparency is necessary for the family to feel the patient is getting the best care possible. Therefore, additional training may prove being of great use for any provider.

What would be expected of the student in demonstrating Cultural Competence/Humility – what things would the student be expected to say/do/avoid/suggest/consider in this scenario (these may not all be relevant).  These would be the elements on which the student taking the OSCE would be graded

Cultural competence with sexual and gender minority groups involves:

(a) awareness of one’s own beliefs, biases, and attitudes regarding LGBT populations;

(b) knowledge and understanding of LGBT populations, including expectations for the counseling relationship and how one’s own sexual orientation and gender identity come into play; and

(c) skills and tools to provide culturally-sensitive interventions for LGBT populations. Training programs should increase LGBT-specific knowledge both of theories of identity formation, minority stress, and the current state of the literature (which changes at rapid pace) about LGBT-specific concerns and health disparities.

Clinicians should attempt to understand if a presenting problem is LGBT-specific or if it is another individual difference factor in understanding a case and formulating a treatment plan, but not central to treatment. For example, a PA student must not jump to assumptions that patient’s anxiety is caused exclusively by concealing her sexual orientation and that there may be other factors involved that may also need to be addressed.

Any patient counseling or education that would be required in the situation.

  • Provide time and space for confidential conversations
  • Assess and build upon the youth’s strengths
  • Approach sensitive topics respectfully; instead of lecturing, engage the youth in conversation (ask open ended questions)
  • Aim to foster healthy psychosexual development, integrated identity formation, and adaptive functioning
  • Avoid assumptions (adolescents may not view themselves as lesbian, gay, or bisexual even though they are having sex with same-sex partners)

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