Why equity and inclusion matter
When ACEM’s Barb West (Lead, Equity and Inclusion) shared her presentation, Pride and Prejudice, at ACEM’s Annual Scientific Meeting (ASM) last week, it was the first time that ACEM had a dedicated paper aimed at educating its members and broader community about the unique identities and needs of the LGBTQIA+ISB community.
Pride and Prejudice was one of four talks that made up a broader Equity and Inclusion session. While West’s session focused specifically on sharing a deeper understanding of what LGBTQI+ISB is, FACEM Dr Bhushan Joshi presented a talk to explore how unconscious bias can show up in medicine, while FACEM Dr Eve Foreman spoke on the Utopian ED and what that looks like in terms of gender equity. The session closed with FACEM Dr Jean-Yves Kanyamibwa presenting the findings from ACEM’s Diversity Survey as well as the Governance and Leadership Diversity Report before all four presenters engaged in a panel discussion, featuring ACEM President FACEM Dr Stephen Gourley.
(Pictured above, L-R: FACEM Dr Jean-Yves Kanyamibwa , FACEM Dr Bhushan Joshi, FACEM Dr Eve Foreman and Barb West with session facilitator FACEM Dr Andrew Perry.)
“‘Don’t treat people like you want to be treated. Treat them the way they want to be treated.’”
West said she was motivated to co-deliver the presentation by Dr Joshi.
‘‘Bhushan was one of the people who planned this session, and I am honoured that he was willing to let me deliver this first ACEM paper on the topic,’ West said. ‘Our joint idea was to run through the alphabet of identities and define each one and then give information about each one.’
She said that presenting the information for the first time in the setting of the annual ASM came with a certain sense of ‘weight’.
The reason it’s so important for emergency medicine professionals and other health service workers to get it right, West said, is because ‘you want to engage with people and treat them with respect and dignity’.
‘There’s the feeling that you need to cover a lot of territory. But what we mainly want to get across is an explanation of the different identities that make up the broader LGBTQIA+ISB community and how gaining a deeper understanding of those identities helps create better health outcomes in emergency departments (EDs).’
Ask respectful questions
“‘You want to engage with people and treat them with respect and dignity.’”
As far as ED presentations go, West said it’s important emergency physicians acknowledge that, while sexuality and gender identity can have some bearing on some ailments and should be approached with the respect accorded to all patients, it has absolutely no impact on other health conditions.
‘When you present to emergency with a sprained ankle, it makes no difference what your gender identity or sexuality is,’ she said. ‘There’s no such thing, for example, as a “lesbian knee”. So, it’s important for emergency medicine physicians to understand that and refrain from asking questions that are intrusive and irrelevant to the necessary treatment.
FACEM DR Bhushan Joshi and Barb West, Lead, Equity and Inclusion, ACEM.
‘At the same time, asking respectful questions does matter,’ she said. ‘Asking about preferred names and pronouns, for example, can be central to creating a safe and inclusive environment for some patients. The key is to stick to the platinum rule, not the golden rule. Don’t treat people like you want to be treated. Treat them the way they want to be treated.’
By understanding some simple inclusion guidelines – and that means inclusion for everyone – West said the safety and security of each unique individual is genuinely valued and protected, no matter what community they are part of.
Championing equity and inclusion in the ED – and beyond
Dr Joshi works in Royal Darwin Hospital, as well as Palmerston Hospital, in the Northern Territory. He is also a proud member of ACEM’s Inclusion Committee. Outside of ACEM, he is the Advocacy Officer of Darwin Pride and is the chair of GLADD, an association for doctors and dentists within the LGBTQIA+ISB community, as well as chair of the NT Health LGBTQIASB+ working group.
‘So, both inside and outside of work I sit on various committees which aim to champion equity and inclusion,” Dr Joshi said.
“‘I think it should matter to everybody. Inclusion for everybody – beyond the LBTQIA+ISB community – matters.’”
Delivering the panel presentation at the ASM, he said, was another positive step by ACEM to enhance inclusion for both ED staff and their patients.
‘Part of the commitment is to be as inclusive as possible to all our Fellows, patients, trainees and everyone connected to the College and the EDs in which we work,’ he said.
‘One of the goals (ACEM’s Inclusion Committee) had was to get equity and inclusion into ACEM education and ACEM activities, so doing this panel at the ASM is a way to do that.’
When asked why fostering greater inclusion is so important, his answer is clear.
‘I think it should matter to everybody. Inclusion for everybody – beyond the LBTQIA+ISB community – matters. A nice quote to illustrate that is, “we’re not free until we’re all free”. We know that, in society, there are different levels of privilege, and they come with levels of unconscious bias and that impacts every level of how we live and function within a society.
‘In the health care spectrum, LGBTQIA+ISB people often have less access to care, are more fearful of accessing health services, (have) increased mental health issues, poorer health outcomes and they often have poorer connections with their health care community.
‘That affects people working in emergency medicine, because we are the front door of medicine.
‘It affects the way patients share their medical background with us, whether they feel comfortable talking to us, and that affects our ability to deliver quality patient care.’
Dr Joshi said that the issue of inclusion also affects ‘the way we carry ourselves in the workplace’.
‘For colleagues who identify as being in the LGBTQIA+ISB community, they have a daily conundrum,’ he said. ‘Do they tell their colleagues? Do they not?’
Pivotal to that internal debate is acknowledging whether they feel a genuine fear of being discriminated against at work or, he said, ‘being seen in a less favourable light’.
‘If our ultimate goal is to have patient-centred care and make everyone feel welcome and improve health outcomes, inclusion should matter to everybody.’
Dr Joshi said that, for inclusion to be authentic and sustainable, ‘we need to not just talk it, but to be genuinely behaving in that manner as well’.
‘We need to shift our behaviour and attitudes so that we are truly welcoming and inclusive – of everybody.’
“‘When I was younger, I felt like I couldn’t really come out in the medical community. It’s very different now – but there is still more to do.’”
He’s seen ACEM already take many meaningful steps toward creating an inclusive environment for its members, as well as the way those members manage patients in EDs across the country.
‘I’m very proud of our College,’ he said.
And although he said, ‘I think we can definitely do a lot more’, Dr Joshi said ACEM is already one of the very few medical colleges currently that has an Inclusion Committee – ‘and that’s an incredible achievement’.
Dr Joshi said some of the other key achievements ACEM has achieved include ‘unconscious bias training for its staff, inclusive recruitment strategies for staff and members to College entities and committees, a yearly equity and inclusion report for College entities and committees, support for GLADD at World Pride 2023 and, of course, Queer EM – a new social event which was first held at the 2023 ASM’.
‘And not forgetting the Diversity Survey (a first for any specialist college, carried out in 2022),’ he said.
‘From my own experience working in emergency medicine since when I was a trainee, I feel like the general public and our medical community are much more receptive to talking about LGBTQIA+ISB issues and how we can improve their health outcomes. I feel there is a willingness to understand about the populations that make up the LGBTQIA+ISB community and I feel like that change is happening within broader society. After all, LGBTQIA+ISB people have been around since the beginning of every culture known to humanity.
‘When I was younger, I felt like I couldn’t really come out in the medical community. It’s very different now – but there is still more to do.’
“‘Greater education leads to greater cultural change.’”
For emergency physicians, Dr Joshi said ‘I think we should be including better education around the LGBTQIA+ISB community in our curriculum’.
‘I feel that things that are taught early and taught well will help it just become part of our practice as emergency physicians.’
When it comes to helping patients entering EDs feel like they are being welcomed into an inclusive space, Dr Joshi said ‘having welcoming signs in the emergency departments, with progress flags, are all easy wins’.
Beyond fostering greater inclusivity for the LGBTQIA+ISB community, he said this kind of welcoming approach, with signs in different languages and other shows of multicultural inclusion would also be positive.
‘Greater education leads to greater cultural change,’ he said.
Helping deliver the panel discussion to the ASM, he said, helped highlight the importance of creating greater inclusion for members of the LGBTQIA+ISB community – and he is hopeful that it will ultimately lead to better patient care and better workplace culture in hospitals across the country.
‘It’s been a long time coming. It’s very much something that our community needs and has been asking about for a while,’ he said.
‘We all know that a safe workplace culture makes a big difference and we’ve all been in departments that do not have that.
‘If people don’t feel comfortable to be who they are in their own workplace, it can have negative consequences. Championing inclusion for everyone means everyone thrives. Everyone benefits – and the way we share that positivity with our colleagues and patients multiplies.’
He believes that amplified positivity can lead to improved workplace happiness, greater staff retention and enhanced workplace performance.
The alternative approach, he said, means risking isolating Fellows and trainees who identify as part of the LGBTQIA+ISB community.
‘The risks of not focusing on better inclusion leads to a poor work culture, which we know leads to poor outcomes for staff and the patients they treat. And that can lead to people leaving emergency medicine.’
For patients, Dr Joshi said, the risk is ‘we will miss diagnoses’.
‘We will make patients feel unwelcome, we may contribute to increased issues around mental health, and we’ll help create a greater distrust of doctors.’
He said when people are in crisis, ‘that’s when they need us the most’.
‘That’s when they need people working in EDs to put our own beliefs, attitudes and cultural values aside and just hold space for them. Just hold them for whom they are and give them what they need. It’s not difficult. And it makes a dramatic difference.’
If you are interested in consulting on ACEM's next Equity and Inclusion Action Plan, please contact Barb West at Barb.west@acem.org.au. All comments will remain anonymous.
Understanding the LBTQIA+ISB alphabet and its components
This complex identity group is made up of three different subcategories of identity markers: sex, gender and sexuality, noting the important differences among these terms (despite pop culture references that often conflate them, especially sex and gender).
Sex refers to chromosomal, genetic, hormonal and cellular traits leading to bodies that present as female, male or intersex.
Gender is the system of cultural categories (identities, presentations, systems) that organise ‘masculinity’ and ‘femininity’ and can include women, men, trans, Hijra, sistergirl and many, many more across the globe.
Sexuality is the complex sexual, emotional and/or physical feelings, attractions, thoughts and/or behaviours we have towards other people.
Lesbian:
Same sex-attracted females, often women but not always.
Gay:
Same sex-attracted males, often men but not always.
Bisexual:
Individuals who are attracted to both males and females or to people of both the same gender and another one.
Transgender:
No universal definition but generally someone whose gender identity differs from that typically associated with the sex they were assigned at birth. May also identify as ‘transsexual’ if they desire medical assistance to change secondary sex characteristics, but this is more often people who transitioned prior to the 21st century. Some who are non-binary in gender or gender-queer also identify as trans. The opposite of trans is ‘cis-gender’, which implies sex and gender identities that are congruent according to the person’s dominant culture’s gender framework (e.g. female-born person who identifies as a woman).
Queer:
Queer is often used as the umbrella term for people of all non-dominant sexualities and gender identities, often those who are younger than 45 or who have come out in the past 15 or 20 years. People may also feel they identify as Queer if they do not associate typically with the hetero-normative (cis-gender, opposite sex-attracted) culture. Q can also stand for Questioning.
Intersex:
Person born with physical, hormonal or genetic features that do not fit the typical expectations for male or female bodies; there are about 40 different variations. Many of these folks do not identify as a member of the LGBTQIA+ISB community. They can have any gender and any sexual orientation. Many people do not even know their own intersex status until puberty, until they attempt to have a child or even ever. Surgery in infancy to ‘create’ a more standard male or, more commonly, female body, remains legal in Australia, despite significant intersex activism to end the practice of non-consensual surgical alterations.
Asexual or aromantic:
Person who feels little or no sexual attraction or desire. Can be a person of any sex and gender. That said, sexual and romantic attraction are on a spectrum, and these are mutually exclusive. People who are aromantic can feel sexual attraction and vice versa. Commonly known as Ace and Aro, these identities can emerge during puberty or even much later in life (often distressingly due to self and societal judgement). This is not to say AA people do not have relationships; they just may not be of the traditional sexual or romantic variety people in our culture are used to.
+:
Pansexual = sexual, romantic or emotional attraction to people of all genders, regardless of their sex or gender identity. Pansexual people may refer to themselves as gender blind, asserting that gender and sex are not determining factors in their sexual and/or romantic attraction.
Polyamorous = a form of ethical or consensual, non-monogamy that involves having romantic and/or heterosexual, homosexual and/or bisexual relationships with multiple partners at the same time.
Allies = supporters of people in the LGBTQIA+ISB community. This does NOT include sexual criminals, such as paedophiles.
Irawhiti:
Umbrella term in Aotearoa New Zealand for Māori and Pasifika binary trans person, non-binary, transsexual, agender, tāhine, irahuri, whakawāhine, tangata ira tāne, fa'afāfine, fa’atama fakaleiti, leiti, akava’ine, genderqueer and others who identify as outside the gender binary.
Sistergirl:
Aboriginal and/or Torres Strait Islander trans category for people who are born male but identify as a gender other than man. Non-trans but non-conforming Aboriginal and/or Torres Strait Islander males may also use this term. Sistergirls have a female spirit and take on women’s roles in their communities, including looking after children and family. Many sistergirls live a traditional lifestyle and have strong cultural backgrounds.
Brotherboy:
Aboriginal and/or Torres Strait Islander trans gender for people born female but identify as a category other than woman. Non-trans but non-conforming Aboriginal and/or Torres Strait Islander females may also use this term. Brotherboys have a male spirit and take on men’s roles in their communities. Many brotherboys have a strong sense of their cultural identity.
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