A Facilitator’s Guide for training health care providers to deliver optimal care to Lesbian, Gay, Bisexual and Transgend...

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Material Information

Title:
A Facilitator’s Guide for training health care providers to deliver optimal care to Lesbian, Gay, Bisexual and Transgender Persons
Physical Description:
103p; digital original
Language:
English
Creator:
Derek Springer
Publisher:
Ministry of Health
Place of Publication:
Guyana
Publication Date:

Subjects

Subjects / Keywords:
Caribbean, guyana, health, hiv, lgbt   ( lcsh )

Notes

Abstract:
his facilitator‘s guide outlines the key activities and background information needed for the training of clinical and non clinical health care providers responsible for delivering youth friendly services to sub-populations including lesbian, gay, bisexual, and transgendered people. The guide is laid out in four chapters; 1. Exploring Values and Diversity; 2. Exploring the Complexity of Sexual Orientation; 3. Communication Skills for Optimal Health Care; and 4. Theory to Practice The facilitator‘s guide provides training activities design to guide the facilitator on how to stimulate critical thinking and encourage interaction among the participants. The activities will lead the facilitator and participants to examine their deeply held views about sexual orientation and sexual behaviour. The facilitator will engage participants in a process of defining sexual orientation and examining its complexities. Participants will develop and in some cases deepen their understanding of the terms ―lesbian,gay, bisexual and transgender. By engaging in the activities participants will appreciate that assumptions can lead to stereotypes and unfair judgements about individuals and groups and how stereotypes and biases affect our lives. They will be introduced to gender neutral language required for communicating with LGBT people seeking health care services and will have an opportunity to practice using gender sensitive language during role play. To ensure realism it is recommended that as much as possible members of the GLBT community should be recruited to play themselves during the role play activity. As implied this document is a guide and facilitators must feel free to adapt the content through the use of other relevant activities. This facilitator‘s guide is a working document which should be revised as needs and contexts change.
Funding:
Support for the development of the technical infrastructure and partner training provided by the United States Department of Education TICFIA program.
Publication Status:
The Facilitator's Guide was produced by the <a href="http://www.moh.gov.gy"> Ministry of Health, Guyana </a> in April 2008. It was revised in December 2010 to include a chapter on "Sexual Health of Men Who Have Sex with Men and Gay Men" and to add time frames for the activities.

Record Information

Source Institution:
Caribbean IRN
Holding Location:
Caribbean IRN
Rights Management:
All rights reserved by the source institution.
System ID:
AA00000019:00001


This item is only available as the following downloads:


Full Text







Youth Friendly Services
Training Manual


A Facilitator's Guide
for training health care providers to deliver
optimal care to Lesbian, Gay, Bisexual and
Transgendered Persons






Youth Friendly Services
Adolescent and Young Adult Health & Wellness
Unit
Ministry of Health
Guyana

Revised December 2010

Ministry of Health in collaboration with the United States
Agency for International Development (USAIb)











Content


Acknowledgements

Acronyms

Introduction

About this Guide

About this Training

Training Outline

Workshop Evaluation


Chapter 1





Chapter 2

26


Exploring Values and Diversity
Identifying our Values
Exploring Diversity
Respecting Diversity

Exploring the Complexity of Sexual Orientation
Straight Talk


The Fish Bowl
Respecting Others' Sexual Orientation


Chapter 3 Communication Skills for Optimal Health Care
Communication Skills
Sharpening our Vocabulary
Guide to Taking a Sexual History


Chapter 4: Sexual Health of Men Who Have Sex with Men and Gay Men 48
What is Sexual Health? 49
Transmission of STIs and HIV 51
Brainstorming Knowledge of STIs 52
Prevention of STIs and HIV 53
Vulnerability and Risk Taking 56
Reducing Vulnerability to STIs and HIV 60









Chapter 5 Theory to Practice 62
Health Care Concerns of LGBT People 63
Guidelines for Coming Out 66
Recognising Signs of Depression and Suicide Risks 69
Guidelines for dealing with Male Rape or Sexual Assault 71
Referral Guidelines 74
Role Plays in Triads 76
Sources 79

Appendices: Participants' Handouts 81













I would especially like to thank the Ministry of Health Adolescent, Youth
Health and Wellness Unit Youth Friendly Services Department for
commissioning me to compile this facilitator's guide. This assignment
provided me with much useful insight into the issues surrounding sexuality
and sexual orientation.

Special thanks are extended to the following Ministry of Health staff for
their excellent support:

Ms. Yumiko Texidor, Coordinator, Adolescent Health Unit, MoH
Ms Reyana Mckenzie, Co-Coordinator, Adolescent Health Unit, MoH

I would like to acknowledge the significant contribution of representatives
of the Society Against Sexual Orientation Discrimination, SASOD, and the
Guyana Rainbow Association (Guybow) for participating in the focus group
discussion. The focus group offered an opportunity to validate themes
emerging from the literature review and identify health care concerns, and
barriers and facilitators for accessing health care among members of the
LGBT community in Guyana.


Dereck Springer, MPH
Consultant











Acronyms


Acquired Immune Deficiency Syndrome
Antiretroviral
Biological Behavioural Surveillance Survey
Female Sex Workers
Guyana Rainbow Association
Human Immuno-deficiency Virus
Lesbian, Gay, Bisexual, Transgendered
Men who have sex with men
Ministry of Health
People Living with HIV
Society Against Sexual Orientation Discrimination
Sexually Transmitted Infections
Voluntary Counselling & Testing
Women who have sex with woman


AIDS
ARV
BBSS
FSW
GUYBOW
HIV
LGBT
MSM
MoH
PLHIV
SASOD
STI
VCT
WSM













In Guyana there are a growing number of men who has sex with men (MSM),
women who have sex with women (WSW) and individuals who engage in sex
with both men and women and some reported cases of transgendered people.
A review of the literature suggests that there is a paucity of data in
relation to the health of lesbian, gay, bisexual and transgendered (LGBT)
people in Guyana. Significantly, the review also found the there has been no
specific study done to determine the health needs of lesbian, gay, bisexual
and transgendered people in Guyana.

The 2005 Biological Behavioural Surveillance Survey (BBSS) provided data
on the sexual health of gay men but was limited both in scope and
geographical representation. The survey reported an HIV prevalence of 21.2
percent among MSM in the capital city, Georgetown. The Terborg (2006)
study, which sought to determine the 'Perceptions and Behaviour Regarding
HIV and AIDS Prevention and Care among Female Sex Workers (FSW) and
Men who have Sex with Men (MSM), was limited to MSM and had an HIV and
STI bias. The Terborg study found that while MSM have access to STI and
HIV related services such as knowledge, condoms, early treatment of STI,
and HIV testing, there were many who complained about the quality of the
services, particularly public health services. Long and inconvenient waiting
hours, lack of confidentiality, limited pre-test counselling and inadequate
post-test counselling, lack of informed consent, the prejudiced attitude of
health workers and their lack of adequate communication skills, were some
of the issues listed. MSM living with HIV stressed the double burden of
stigma and discrimination. First they suffer stigma and discrimination based
on their sexual lifestyles and second because they are HIV positive.

Sub-populations forced to keep their behavior and identities secret because
of personal prejudice, stigma and discrimination are less likely to access
vital health care, including lifesaving information about HIV and STI
prevention. The Terborg study observed that community health care
workers are not sensitive to the needs of MSM thus exposing them to
further ridicule and humiliation. The Society Against Sexual Orientation
Discrimination (SASOD), a Guyanese-based NGO which is committed to
eradicating discrimination on the grounds of sexual orientation, in its March








8, 2008 online response to the UNGASS Guyana Country Progress Report
2006-2007 expounded on the observations highlighted in the Terborg study.
SASOD opined that the approach to health promotion targeting vulnerable
sub-populations of gay, bisexual and other men who have sex with men
(MSM) is still based on narrow, technical public-health strategies of
outreach and referral to "friendly" services. SASOD recommended that the
programmatic response needs to be holistic by improving the quality of
client services across the board through training to mitigate same-gender
and HIV-related stigma by addressing homophobia among health care
workers. SASOD posited that once services become and are know to be
client-friendly, there will be less need to invest in "targeting MSM" as Gay,
Lesbian, Bisexual and Transgendered (GLBT) communities in Guyana would
gain confidence that the public health system does not house homophobic
prejudices and allow discriminatory practices.

Although the findings of the Terborg study are limited to the MSM
population, there is anecdotal evidence that LGBT people in Guyana
experience discrimination when seeking health care. In light of the
prevailing situation the Ministry of Health's Youth Friendly Services,
identified as a priority, the development of a manual for the training of
health care providers to ensure that they provide optimal clinical and non-
clinical services in a non stigmatized and non discriminatory manner to
lesbian gay, bisexual, and transgendered people seeking services at their
youth friendly centres and beyond.














This facilitator's guide outlines the key activities and background
information needed for the training of clinical and non clinical health care
providers responsible for delivering youth friendly services to sub-
populations including lesbian, gay, bisexual, and transgendered people. The
guide is laid out in four chapters;
1. Exploring Values and Diversity;
2. Exploring the Complexity of Sexual Orientation;
3. Communication Skills for Optimal Health Care;
4. Sexual Health of Men Who Have Sex with Men and Gay Men
5. Theory to Practice

The facilitator's guide provides training activities design to guide the
facilitator on how to stimulate critical thinking and encourage interaction
among the participants. The activities will lead the facilitator and
participants to examine their deeply held views about sexual orientation and
sexual behaviour. The facilitator will engage participants in a process of
defining sexual orientation and examining its complexities.

Participants will develop and in some cases deepen their understanding of
the terms "lesbian", 'gay", "bisexual", and transgenderr". By engaging in the
activities participants will appreciate that assumptions can lead to
stereotypes and unfair judgments about individuals and groups and how
stereotypes and biases affect our lives. Participants will explore sexual
health of gay men and other men who have sex with men. They will be
introduced to gender neutral language required for communicating with
LGBT people seeking health care services and will have an opportunity to
practice using gender sensitive language during role play. To ensure realism
it is recommended that as much as possible members of the GLBT
community should be recruited to play themselves during the role play
activity.

As implied this document is a guide and facilitators must feel free to adapt
the content through the use of other relevant activities. This facilitator's









guide is a working document which should be revised as needs and contexts
change.





Duration
The training is designed to take place over five days.

Organisation of the Training
The training guide is comprised of 21 activities which build upon each other,
therefore it is recommended that the sequence be maintained as much as
possible.

Learning objectives, suggested materials, facilitator's instructions, and
where applicable relevant background reading materials comprise each
activity. Additionally participants' handouts are provided in the appendix
section.

Each activity is structured and presented in the following manner:

Learning Objectives

Suggested Materials

Facilitator's Instructions

Background Reading Materials (where relevant)














TangO6ulin


08:30 Hours

09:00 Hours

09:05 Hours

09:15 Hours

09:20 Hours

09:30 Hours

10:30 Hours

10:45 Hours

12:00 Hours

13:00 Hours

14:30 Hours

14:45 Hours


16:00 Hours


Day 1

Registration

Welcome

Introductions

Overview of Training Objectives

Ground Rules

Identifying our Values

BREAK

Exploring Diversity

LUNCH

Respecting Diversity

BREAK

Exploring the Complexity of Sexual
Orientation Straight Talk

Departure















Day 2

09:00 Hours Reflection

09:30 Hours Exploring the Complexity of Sexual
Orientation The Fish Bowl

10:30 Hours BREAK

10:45 Hours Exploring the Complexity of Sexual
Orientation The Fish Bowl Cont'd

12:00 Hours LUNCH

13:00 Hours Respecting Others' Sexual Orientation

14:30 Hours BREAK

14:45 Hours Communication Skills

16:00 Hours Departure















Day 3

09:00 Hours Reflection

09:30 Hours Communication Skills Sharpening our
Vocabulary

10:30 Hours BREAK

10:45 Hours Guide to Taking Sexual History

12:00 Hours LUNCH

13:00 Hours Recognising Depression and Risks for Suicide

13:45 Hours Guidelines for Coming Out

14:30 Hours BREAK

14:45 Hours Theory to Practice
Health Care Concerns of LGBT People (Group Work)

Guidelines for Dealing with Male Rape or Sexual Assault

16:00 Hours Departure

















08:30 Hours

09:00 Hours

09:45 Hours

10:45 Hours

11:00 Hours

12:00 Hours

13:00 Hours

14:30 Hours

14:45 Hours

16:15 Hours


Day 4

What is Sexual Health?

Transmission of STIs and HIV

Brainstorming Knowledge of STIS

BREAK

Prevention of STIs and HIV

LUNCH

Vulnerability and Risk Taking

BREAK

Reducing Vulnerability to STIs and HIV

Departure


















09:00

09:30


Hours

Hours


10:30 Hours

10:45 Hours

12:00 Hours

13:00 Hours

14:30 Hours

14:45 Hours
Members of the LGBT

15: 30 Hours

15:50 Hours

16:00 Hours


Day 5

Reflection

Theory to Practice
Role Play in triads

BREAK

Role Play in triads

LUNCH

Role Play in triads

BREAK

Questions and Answers
community field questions from participants

Workshop Evaluation

Closing Remarks

Departure


















1. Please rate the workshop as a whole by circling your answer.
Po o r.......................................................... ...................................E x ce lle nt
1 2 3 4 5 6 7 8 9 10

2. Please rate the following items by circling your answer.
Course content:
Poo r......................................... ............................. .. ... E x ce lle nt
1 2 3 4 5 6 7 8 9 10

Quality of Instruction:
Poor........................... ... ... ....................... Excellent
1 2 3 4 5 6 7 8 9 10

Group Work /Activity during Sessions:
Po o r............................................................................. .. ... E x ce lle nt
1 2 3 4 5 6 7 8 9 10

Achievement of Workshop Objectives:
Poor ...................... ... .. .......................Excellent
1 2 3 4 5 6 7 8 9 10

Overall Level of Satisfaction:
Poor........................... ... ... ........................Excellent
1 2 3 4 5 6 7 8 9 10

3. What other topics should be included in future workshops subject?








4. Which concepts or ideas presented in the workshop did you find
particularly useful or helpful?


5. Has the workshop inspired you to change or think differently in relation
to LGBT people? Please explain.


6. Which sessions were most relevant to your work? Why?


7. On which topics would you have preferred additional time?


8. Who would benefit most from this training?


9. Action Plan: Please list three things you plan to do in the next 6 months to
apply the knowledge and skills gained from this workshop








Thank you for your feedback.


Exploring Values and Diversity


"Live by your personal code of values to get the most out of life. Life is
fulfilling and free of stress when we live in accordance to our own personal
values"
Jerry Lopper

This chapter aims to:
Enable participants to identify and express their values;
Increase participants' understanding of how values represent
themselves in everyday life;
Facilitate participants' understanding of and respect for diversity.


I frI














Activity 1: Identifying our Values


Times: 60
Minutes
Objectives
Define values;
Help participants understand where they learn their values;
Enable participants to identify their values.

Materials
Flip chart
Markers
Masking Tape

Facilitator's Instructions

Step 1 Facilitator first divides a flip chart into three columns. He/she
begins discussion by asking participants to define values. Facilitator records
participants responses in column one.

Step 2 Asks participants to identify where they learn their values who
teaches them values? Record their responses in column two.

Step 3 Finally, asks participants to identify specific values they hold.
Record their responses in column three.

What are values? Where do you learn What values do you
your values? hold?
Values are deeply held We accumulate our Record values stated
beliefs about what is values from childhood
good, right, and based on teachings and
appropriate. Values are observations of our
deep-seated and remain parents, teachers, and
constant over time. religious leaders, other

















Facilitator's Instructions Cont'd

Facilitator concludes the activity with some summary thoughts and
impresses on the participants the idea that when an individual acts in
accordance with his/her values, he/she is becoming a person of character,
irrespective of who he/she is.


influential and powerful
people and culture.

















Activity 2: Exploring Diversity


Time: 75 Minutes
Objectives
Enable participants to explore the diversity of the group;
Allow participants to begin to break down some of the stereotypes
and assumptions they hold.

Materials
Activity Guide only


Facilitator's Instructions

Facilitator says that it is important to start this activity by establishing common
ground for the activity. We live in a diverse world. In this activity we will explore
the diversity among us by thinking about our values, our backgrounds, our
teachers, and our experiences. We might even discover that this group that might
seem alike is much more diverse than any of you would assume.

This activity will involve labeling and personalizing some of this diversity. This
personalization (relating to self) might prove uncomfortable at times. Eventually,
however, it might empower us to break down some of the stereotypes and
assumptions that we, as a product of our cultures, experience, and life, hold.

This exercise is fairly simple. I will ask that all of you gather on one side of the
room and face towards its center. I will call out specific categories/labels/
descriptions, and ask that all of those to whom this applies, walk to the other side
of the room. For example, I might request that anyone with glasses please cross
the room. If this describes you and you feel comfortable acknowledging it, you
would walk to this side of the room (indicate).










Once there you would turn and face the crowd you just left. Get in touch with
your feelings and think about those people on both sides of the room then
return to the side you started from. After a few seconds, I will continue with a
new category. A number of categories will be called out. Remember, cross the
room if the category applies.

Remember, there is no pressure to cross the room if you don't feel comfortable
doing so. You will need to make that decision.

At the conclusion of the activity, we will discuss what we felt and what we
learned. There may be times when this activity makes you feel slightly
uncomfortable. I would urge you to lean into that discomfort since it may mean
that you are about to gain an important learning or insight.

However, if the discomfort becomes intense, you may stop participating at any
time. No questions will be asked and we will respect your decision. We would,
however, encourage you to remain in the room as an observer.


The facilitator begins the activity by asking questions from the
following list:

Anyone who has visited another country .cross the room
Anyone who has never flown...
Anyone who owns your own car...

Anyone who does not believe in God...
Anyone who is a person of mixed race...
Anyone who feels that he/she knows very little about his/her cultural
heritage...

Remember, walk across the room only if you feel comfortable
identifying yourself this way.

Anyone who is the oldest in the family...
Anyone who is the youngest in the family ...
Anyone who is an only child...
Anyone who is adopted...










Anyone who sometimes has low self-confidence...
Anyone who sometimes feels lonely...
Anyone whose natural parents have divorced...
Anyone who has had a parent who passed away...

Anyone who believes it is alright for someone to have a date of the
same gender at a social event...
Anyone who has a family member who is gay, lesbian, bisexual, or
transgendered...
Anyone who is choosing to abstain from sex until marriage...
Anyone who has experienced the effects of alcoholism in the family..

Anyone who has experienced the effects of drug addiction in the
family...
Anyone who has a friend or relative who attempted suicide...
Anyone who has not yet crossed the line...

Facilitator invites participants to form a circle

Facilitator leads a discussion about the activity; as much as possible focus on
values.
What did you learn?
What kind of feelings did you have as you participated?
How did you feel when there were very few of you on one side of the
room?
Did you find yourself making judgments of others?
Through this activity, intentionally or not, did you share your values?
Through this activity, intentionally or not, do you think that you
learned about the values of others?

If this activity is about values, then how do we use this experience to
remove the stereotype (label)?
How do values represent themselves in everyday life?
Are there times in life when values are ignored?
What is the result when values are ignored, forgotten or trashed
about?











"We are not our label"'
Eckhart Tolle A New Earth


Activity 3: Respecting Diversity

Time: 90 Minutes
Objectives
Help participants become aware of the many ways in which individuals
show both respect and disrespect towards each other;
Enable participants to adopt a value for treating people respectfully;
Help participants to learn to appreciate people's differences rather
than fear them.

Materials
Flip Chart
Markers
Masking tape

Facilitator's instructions

Facilitator asks participants to respond to the following questions:

1. Agree or disagree: It's okay to insult or make fun of people as long as
they don't hear it.

2. What are some common signs of disrespect that you see in your place of
work? How do you feel about that?

3. What do you dislike most about the way people treat each other at your
place of work? Why do you feel that way?

4. Is there a difference between a put-down and an insult? What's the
difference?









5. Do you have to like a person in order to be respectful, or can you be
respectful to someone even if you don't particularly care for him or her?

6. Do you think there is discrimination at your place of work? How is it
expressed? How does that make you feel?

7. Have you, personally, ever experienced discrimination or some other type
of prejudice? What happened? How did it make you feel?

8. Do you think people are afraid of differences sometimes? Can you give
some examples? Why do you think that's true?

9. Is it harder to respect someone who is very different from us? Why?

10. What are the benefits of having friends who are different from us?

11. Have you ever learned something new about a different culture from a
friend?

12. Is it ever okay to treat another person with disrespect?

13. What are the benefits of treating people with respect?

At the end of the exercise the facilitator emphasizes that everyone wants
to be treated with respect. You and everyone in your life want to be
accepted, considered as individuals, treated politely, allowed some privacy,
and judged on their own merits. Respect is earned and deserved when you
learn how to respect others.

To be respectful, you must recognize and understand other people's beliefs,
and accept individual differences without prejudice. Don't insist that
everyone like you, simply treat others as they wish to be treated and expect
them to do the same for you. When you are respectful, you value and
encourage others. You must help other people find value in themselves. You
will become respected when you act with respect towards others. Respect is
never demanded.


"If you judge people you have no time to love them"








Mother Teresa


Exploring the Complexity of Sexual Orientation

"Truly straight people do not cannot make a choice about their sexual
orientation, just as gay people don't, and can't, choose. People who are
comfortable in their own sexual persona are not threatened by the way the
sexuality of others is expressed"

Jon Ponder

This chapter aims to:
Illustrate the difficulty in defining rigid and consistent categories of
sexual orientation;
Fill the information gap that exists regarding sexual orientation in
recognition of the lack of knowledge in this area;
Uncover misconceptions and stereotypes in relation to sexual
orientation.
Enable participants to explore their own feelings, beliefs, and values
regarding sexual orientation.
Expose participants to other people's points of view, attitudes, and
values.


I IWSV



















Activity 4: "Straight Talk"


Time: 75 Minutes
Objective
Enable participants to explore heterosexuality.

Materials
Activity Guide only

Facilitator's Instructions

Facilitator asks participants the following questions:
1. What is heterosexuality? (Define)
2. How can you tell if someone is heterosexual ('straight')?
3. What causes heterosexuality?
4. Is it possible that heterosexuality stems from neurotic fear of others of
the same sex?
5. The media seems to portray straights as preoccupied with (genital) sex.
Do you think this is so?

6. Do you think straights flaunt their sexuality? If so, why?
7 Do you believe it is sinful for straights to engage in sexual behavior other
than vaginal/penile intercourse for procreation?
8. In a straight couple, who takes the dominant role and who takes the
passive role?
9. If 50% of married couples get divorced, why is it so difficult for
straights to stay in long-term relationships?
10. Considering the consequences of overpopulation, is it feasible that the
human race could survive if everyone were heterosexual?









11. Since 99% of reported rapists are heterosexual, why are straights so
sexually aggressive?
12. A disproportionate majority of child molesters are heterosexual.
Therefore, do you consider it safe to expose children to heterosexual
teachers, scout leaders, coaches, etc?
13. What would you do if a straight person of the other sex tried to force
him/herself on you?
14. When did you choose your sexual orientation?
15. Did one of your teachers have a significant influence on your sexual
orientation?
16. How easy would it be for you to change your sexual orientation starting
right now?
17. Techniques have been developed which might enable you to change your
sexual orientation if you wished to. Would you consider intensive
psychotherapy?
18. What have been your reactions to answering these questions? What
feelings have you experienced? Why?




"What do we live for if not to make life less difficult for each other?"
George Eliot



















Activity 5: The Fish Bowl


Time: 90 Minutes
Objectives
Enable participants to address issues of rights related to sexuality,
including sexual orientation;
Help participants develop self-confidence to express their own opinion
on these issues;
Promote tolerance and empathy.

Materials
3 chairs
2 facilitators
Space for participants to move about
Flip charts and markers
Small slips of papers and pens
A small box or a hat
Copies of Handout 1: Exploring Sexual Orientations, for participants

Preparation

Facilitator please note that the aim of this activity is to allow participants
to reflect on their own sexuality and the norms of their society and to
encourage them to have the self-confidence to express their own point of
view while being tolerant of people who hold different views. The aim is not
to convince people of one point of view or another, nor to come to a
consensus decision.

Before running the activity it is important to reflect on your own values and
beliefs about what is right for yourself, your families and for others and to
remember that these values will be reflected in everything you do and say,








and what you don't do or say. It is crucial that you acknowledge your own
values and prejudice and understand the origins of those values in order
that the participants may also develop insights into the origins of their own
values.

It is a good idea to start off with two facilitators as conversationalists. for
example, one of you may start by saying, "Have you heard, about the
pregnant man?" The other might reply, "Yes. I saw him speaking about it on
Oprah". In this way you imply that the conversation is about a real person
and not a theoretical debate. It also helps open up a discussion about what
people know about other sexual orientations and their attitudes to those.

Facilitator's Instructions

Facilitator hand out slips of paper and asks participants to write down any
questions they have about sexual orientation in general, and to put their
papers in the hat/box. The questions should be anonymous.

Facilitator explains that this activity is about exploring attitudes to
sexuality and in particular to sexual orientation. Everyone is free to express
opinions that may be conventional or unconventional, controversial or which
challenge the norms of their society. People may present points of view with
which they agree, or with which they disagree with without fear of ridicule
or contempt. Offensive or hurtful comments, which are directed at
individuals in the group, are not allowed.

Participants are given a few minutes to write their questions on the slips of
paper. Facilitator passes around the hat or small box and asks participants
to place their questions into it.

Facilitator then places three chairs in a half-circle in front of the group,
these are for the three conversationalists who are in the "fish-bowl"; one
facilitator and two participants. The rest of the group are observers.

Facilitator invites two volunteers to join him/her in a conversation in the
"fish bowl". Facilitator then explains that if at any point someone else would
like to join the conversation then they may do so, but as there is only room
for three fish in the bowl at any one time, someone will have to step out.
Someone who wishes to join the conversation should come forward and









gently tap one of the "conversationalists" on the shoulder. These two people
exchange seats and the original "conversationalist becomes an observer.

Facilitator then asks a volunteer to pick up a question from the box/hat and
start discussing it. Let the discussion run until people have exhausted the
topic and points are being repeated. Facilitator leaves the conversation.
Hopefully one of the observers will quickly replace you, thus enabling you to
leave the discussion to the participants. However, you should continue to
participate as an observer so that you maintain the possibility of taking
another turn as a conversationalist. This leaves open the possibility for you
to discretely manipulate the discussion either to open up different avenues
of debate or to tactfully remove a participant who is not keeping to the
rules.

If you wish to, you can introduce a rule that any particular point of view can
only be raised once. This prevents the discussion focusing on only a few
aspects of the topic and helps to discourage repetition of popular
prejudices.

Facilitator asks for three volunteers to discuss another question and start
another round of conversations under the same rules as before.

Participants discuss as many questions as possible within the time allotted.
Before you finally go on to the debriefing and evaluation, take a short break
to allow time for people to come out of the "fish-bowl". This is especially
important if the discussion has been heated and controversial.

Debriefing and Evaluation of Activity

*Start with a brief review of how people felt being both inside and
outside the "fish-bowl". Then talk about the different views that
were expressed, and finally discuss what people learnt from the
activity:
* Was anyone shocked or surprised by some points of view expressed?
Which ones? Why?
* In your community, how open-minded are people generally about
sexuality?
* Are some groups more open than others? Why?
* What forces mould how our sexuality develops?








* Where do people get their values about sexuality from?
* Do participants' attitudes about sexuality differ from those of their
parents and grandparents?
* If so, in what ways do they differ? Why?



It is recommended that you prepare yourselves by reading the background
information below. Some frequently asked questions and issues include:

* What is homosexuality?
* What are the differences between heterosexual, gay, lesbian,
bisexual and transgendered people?
* Is homosexuality (same-sex attracted) an illness?
* How do people become gay or lesbian?
* In some countries (e.g., Sweden same-sex attracted relationship is
accepted and persons with different sexual orientations can get married
while in others it is punishable by death.

Sexual orientation is one of the four components of sexuality and is
distinguished by an emotional, romantic, sexual or affectionate attraction to
individuals of a particular sex.

The three other components of sexuality are biological sex (whether we are
born as a male or female), gender identity (the psychological sense of being
male or female) and social gender role (the extent to which people conform
to what is regarded in our society as feminine and masculine behaviour).

Three sexual orientations are commonly recognized:

Heterosexual, attraction to individuals of the other sex;

Homosexual, attraction to individuals of one's own sex (same-sex attracted);
Women with a same sex orientation are usually referred to as lesbian and
men with a same sex orientation are usually referred to as gay;

Bisexual is used to describe the capacity for emotional, romantic and/or
physical attraction to more than one gender. That capacity for attraction
may or may not manifest itself in terms of sexual interaction; or








Transgender is the state of one's "gender identity" (self-identification as
male, female, both or neither) not matching one's "assigned gender"
(identification by others as male or female based on physical/genetic sex).
"Transgender" does not imply any specific form of sexual orientation;
transgender people may identify as heterosexual, homosexual, bisexual.
"Transgendered" refers to the individual. For example, "I am a male
transgendered person who chooses to present female".

"Drag Queen" in the local culture refers to a male who, by and large,
identifies as his birth-designated sex, but who plays at or performs as the
opposite gender. He is a cross dresser who periodically adorns himself in
women's clothes and appears boldly on the streets mainly at nights. He is
seen as an entertainer.

What causes a person to have a particular sexual orientation?
How a particular sexual orientation develops in any individual is not well
understood by scientists. Various theories provide different explanations
for what determines a person's sexual orientation, including genetic and
biological factors and life experiences during early childhood. Despite much
research there is no proven explanation of how sexual orientation is
determined. However, many scientists share the view that for most people
sexual orientation is shaped during the first few years of life through
complex interactions of genetic, biological, psychological and social factors.

Despite what some people claim, there is no evidence that society's greater
acceptance of homosexuality results in more people having a homosexual
sexual orientation. The greater numbers of people identifying as homosexual
are a result of fewer people fighting their homosexual feelings while
attempting to live heterosexual lives.

Is Sexual Orientation a Choice?

No. For most people, sexual orientation emerges in early childhood or
adolescence without any prior sexual experience. Some people report trying
very hard over many years to change their sexual orientation from
homosexual to heterosexual, with no success. For these reasons,
psychologists do not consider sexual orientation for most people to be a
conscious choice that can be voluntarily changed. People don't choose their








sexual orientation; they can of course choose the kind of a life they want to
live.

"If God, as they say, is homophobic, I wouldn't worship that God,"
Archbishop Desmond Tutu


Activity 6: Respecting Others' Sexual Orientation

Time: 90
Minutes

Objective

*To enable participants to examine their feelings, thoughts and actions
in relation to people who are lesbians, gays, bisexuals, and
transgendered.

Materials
Activity Guide only

Facilitator's Instructions

Facilitator says let's examine our likely reaction to the situations below.
Facilitator then asks participants the following questions:

a) How would you react if you learnt that your child is lesbian, gay, or
bisexual or transgendered?

b) How would you react if you learnt that your co-worker is lesbian, gay, or
bisexual or transgendered?

c) How would you react if you believed that the person you are counseling is
lesbian, gay, bisexual or transgendered?

d) How would you react if you learnt during the session that the person you
are counseling is lesbian, gay, bisexual or transgendered?









e) How would you react if you believed that the person you are attending to
is lesbian, gay, bisexual transgendered?

f) How would you react if you learnt while attending to someone that he/she
is lesbian, gay, bisexual or transgendered?

g) How would you react if you learnt that your best friend with a lesbian,
gay, bisexual or transgendered person?

h) How would you react if you learnt that an influential person in your life is
lesbian, gay, bisexual or a transgendered person?

i) How would you react if you learnt that the person you are in a relationship
with reveals he/she was a lesbian, gay, bisexual or transgendered person?

At the end of the activity the facilitator asks the following questions to
help participants clarify their values in relation to others.

A) What have you learnt about yourself as a result of this activity?

b) Have your feelings and thoughts regarding sexual orientation changed as
a result of this exercise? Please give reasons for your answers.

c) Would you like people to respect your values in relation to sexual
orientation? If yes, how would you like them to demonstrate that they
respect your values?

d) Do you respect the right of other persons to express their sexual
orientation if it is different to yours? If yes, how can you demonstrate that
you respect theirs.

In closing the facilitator shares that as participants are entitled to their
values and to be respected for their sexual orientation so do others. This is
especially important in their capacity as health care providers since they
are expected to provide optimal care in a non judgmental and non
discriminatory manner to patients/clients with different values and
lifestyles.








Participants must therefore learn to deal with their own areas of
discomfort, lest they communicate negative messages to their
patients/clients without realizing it.


"I believe that it takes a lot of courage no matter where you are to come
out and say you are gay"
Oprah Winfrey


Communication Skills for Optimal Health Care

"The basic building block of good communications is the feeling that every
human being is unique and of value"

Unknown Author

This chapter aims to:

Create an awareness that good communication skills are necessary for
delivering optimal care;
Facilitate participants' awareness of the verbal and non verbal
communication that act as barriers to individuals' access to health
care;
Reduce the heterosexual bias in language when referring to lesbian,
gay, bisexual and transgendered people;
Provide participants with knowledge and skills to conduct
patient/client interviews and take sexual histories of LGBT people.

Effective communication offers more than just good manners or being nice.


I ITH^









Effective communication enables us to be better heath care providers.

Effective communication improves patient care and disease outcome.


Activity 7: Communication Skills

Time: 75 Minutes


Objectives


* Help participants identify the four basic parts in the communication
process;
* Facilitate participants' understanding of the two basic modes of
communication;
* Enable participants to recognize the barriers to effective
communication.


Materials
Flip chart
Markers
Masking Tape


Facilitator's Instructions

Facilitator begins by saying to participants that the human communication
process consists of four basic parts. Facilitator then asks participants to
identify the four parts. Facilitator notes the responses and summarized as
follows:









The human communication process consists of four basic parts:

1. The sender of the message; the sender starts the process;

2. The message; the message is the body of information the sender wishes
to transmit to the receiver,

3. The receiver of the message: the receiver is the individual intended to
receive the message;

4. Feedback, feedback is the response given by the receiver to the message.
Feedback, at times, is used to validate whether effective communication has
taken place.





Facilitator's Instructions Cont'd

Facilitator asks participants to identify the two basic modes of
communication.

Facilitator acknowledges responses and states that:

Verbal communication involves the use of words.

He/she then asks participants to explain their understanding of non verbal
communication and provide examples of the various forms.

Facilitators notes participants' responses and summarises. Nonverbal
communication, on the other hand, does not involve the use of words. For
example:

Dress, Gestures, Facial expressions, Eye contact, Tone of voice, Pauses
and Silence

Facilitator points out that even though there are two forms of
communication, both the verbal and the nonverbal are
inseparable in the total communication process.









Conscious awareness of this fact
your professional effectiveness is
communication.


is extremely important because
highly dependent upon successful


Facilitator's Instructions

Facilitator says now let us examine barriers to effective communication
Ineffective communication occurs when obstacles or barriers are present.

Facilitator asks participants to brainstorm the various barriers to effective
communication and records their responses on flip chart.

The facilitator then works with participants to group the responses under
three main categories on a flip chart.

Physiological Barriers Physical Barriers Psychosocial Barriers
Result from some kind Consist of elements in Are usually the result
of sensory dysfunction the environment (such of one's inaccurate
on the part of either as noise) that perception of self or
the sender or the contribute to the others; the presence
receiver. Such things as development of of some defense
hearing impairments, physiological barriers mechanism employed to
speech defects, and (such as the inability to cope with some form of
even vision problems hear). threatening anxiety; or
influence the the existence of
effectiveness of factors such as age,
communication. education, culture,
language, nationality, or
a combination of
socioeconomic factors.


Facilitator's Instructions

Facilitator encourages a discussion around the barriers identified and
highlights the following:









Psychosocial barriers are the most difficult to identify and the most
common cause of communication failure or breakdown. A person's true
feelings are often communicated more accurately through nonverbal
communication than through verbal communication.

Facilitator ends the discussion by emphasizing that participants who are
aware of their verbal and non verbal communication and the impact that
these have on their patients/clients are more likely to improve the quality
of health care they provide to them.





Activity 8: Sharpening our Vocabulary

Time: 90
Minutes

Objectives

Expose participants to the preferred vocabulary when referring to
lesbians, gays, bisexuals and transgendered people and their sexual
behaviours.
Reduce the heterosexual bias in language when referring to lesbian,
gay, bisexual and transgendered people.

Materials
Flip chart
Markers
Masking Tape
Copies of Handout 3: Problematic versus Preferred Examples, for
participants

Facilitator's Instructions

Facilitator informs participants that the next activity is about word
association. Facilitator explains that he/she will write a word related to
sexual orientation and sexual behavior and participants are invited to share









what words come to mind. A few words are provided here for the
facilitator's use however, the facilitators should feel free to include others.

1) Homosexual
2) Heterosexual
3) Lesbian
4) Gay
5) Oral Sex
6) Anal sex

Facilitator records participants' responses to each of the words he/she
provides.

Facilitator then explains that it is important when referring to lesbian, gay,
bisexual and transgendered persons that participants use gender neutral
language such as partner rather than husband, wife, boyfriend, girlfriend
since these words suggest that the health care provider has made an
assumption that the patient/client is heterosexual. When such assumptions
are made it is difficult for a lesbian, gay, bisexual or transgendered person
to share their sexual orientations with the provider, thus, receive the most
accurate and optimal care.

Additionally, the use of words such as homosexuality has been associated in
the past with deviance, mental illness and criminal behavior, and these
negative stereotypes may be perpetuated by bias.

The Committee on Lesbian and Gay Concerns American Psychological
Association, points out that problem occur in language concerning lesbians,
gay men, and bisexual and transgendered people when language is too vague
or concepts are poorly defined.

The Committee also believes that there is need to reduce heterosexual bias
and increase the visibility of lesbians, gay men, bisexual, and transgendered
people since they often feel ignored by the general media which take the
heterosexual orientation of their readers for granted. It is within this
context that the Committee offers a guide (below) to aid us in improving our
vocabulary in relation to sexual orientation and sexual behaviour.









Facilitator shares the problematic for each of the sections below and
request participants to suggest the preferred terms. Facilitator shares the
comment for each of the sections and encourages a discussion around the
issues identified.


Issues of Designation: Ambiguity of Referent

1. PROBLEMATIC: Sexual preference
PREFERRED: Sexual orientation

Comment: Avoids the implication of voluntary choice that may not be
appropriate.

2. PROBLEMATIC: The sample consisted of 200 adolescent
homosexuals
PREFERRED: The sample consisted of 200 gay male adolescents
The sample consisted of 100 gay male and 100 lesbian adolescents

Comment: Avoids use of "homosexual" and specifies gender of subjects.

3. PROBLEMATIC: None of the subjects were homosexual or bisexual.
PREFERRED: None of the subjects were lesbians, gay men, or
bisexual people
All of the subjects were heterosexual








Comment: Avoids use of "homosexual" and increases the visibility of
lesbians, gay men or bisexual people.

4. PROBLEMATIC: Manuscript title: "Gay relationships in the 1990s"
PREFERRED: Manuscript title: "Gay male relationships in the 1990s"

Comment: Specifies gender of gay persons before the term gay is used to
describe women and men; avoids invisibility of lesbians.

5. PROBLEMATIC: Subjects were asked about their homosexuality.
PREFERRED: Subjects were asked about the experience of being a
lesbian or a gay man.

Comment: Changes sentence construction to avoid use of the term
"homosexuality".

6. PROBLEMATIC: The women reported lesbian sexual fantasies.
PREFERRED: The women reported female-female sexual fantasies.

Comment: Avoids confusion of lesbian orientation and specifies sexual
behaviors.

7. PROBLEMATIC: The two bisexual subjects had engaged in both gay
and heterosexual sexual encounters in the past year.
PREFERRED: The two bisexual subjects had engaged in both male-
male and male-female sexual encounters in the past year.

Comment: Avoids confusing sexual orientation (bisexual) with specific sexual
behaviors.

8. PROBLEMATIC: The male dogs were bisexual.
PREFERRED: The male dogs were observed to engage in both male-
male and male-female sexual behavior.

Comment: Increases specificity; does not use sexual orientation terms with
animal species.

9. PROBLEMATIC: It was the subjects' sex, not their sexual
orientation that affected number of friendships.








PREFERRED: It was subjects' gender, not their sexual orientation
that affected number of friendships.

Comment: Avoids confusing gender with sexual activity.


Problems of Designation: Stereotyping

10. PROBLEMATIC: Homosexual abuse of children.
PREFERRED: Sexual abuse of male children by adult men.

Comment: Does not imply sexual orientation of participants; does not imply
that gay men are rapists.





Problems of Evaluation: Ambiguity of Reference

11. PROBLEMATIC: Questionnaire item: Have you ever engaged in sexual
intercourse?
PREFERRED: Questionnaire item: Have you ever engaged in
penile/vaginal intercourse?

Comment: States precisely if penile/vaginal intercourse is the purpose of
the item.

PREFERRED: Have you ever engaged in sexual activity?

Comment: Avoids assumption of heterosexual orientation if sexual activity is
the purpose of the item.

Problems of Evaluation: Stereotyping

12 ROBLEMATIC: AIDS education must extend beyond the gay male
population into the general population.
PREFERRED: AIDS education must not focus only on selected groups.

Comment: Does not refer to gay men as set apart from the general
population.








13. PROBLEMATIC: Psychologists who work with special populations (e.g.,
lesbians, drug abusers, survivors of sexual abuse) need extra
training.
PREFERRED: Psychologists who work with minority populations (e.g.,
Latinos, lesbians, Black women, older women) need extra training.

Comment: Avoids equating lesbians with pathology.

14. PROBLEMATIC: Women's sexual partners should use condoms.
PREFERRED: Women's male sexual partners should use condoms.

Comment: Avoids assumption of heterosexuality





Activity 9: Guide to Taking a Sexual History

Time: 75 Minutes

Objectives
Facilitate participants' understanding of the importance of creating a
safe atmosphere when taking a sexual history;
Help participants understand the importance of confidentiality in
taking a sexual history;
Explore how a health care provider's use of language can either
facilitate or hinder the taking of a sexual history;
Indentify common stereotypes to avoid making when taking a sexual
history with LGBT patients/clients.

Materials
Copies of the Handout 3: Issues to Consider When Taking a Sexual
History, for participants

Facilitator's Instructions

Facilitator explains to participants that any person who walks into their
clinic/centre could self-identify as gay, lesbian, or bisexual and/or have a
history of relationships with members of the same sex.









Similarly, they may have been born another gender to the one they now
adopt. You have better chance to create trust with the LGBT patient/client
during the initial interview.Ensure that questions you ask are open-ended
and apply to all patients/clients.

Facilitator reviews with participants the guide to history taking below.

Summary Points; Issues to consider when taking a sexual history

Create a Welcoming and safe atmosphere
Confidentiality
Use inclusive language
Evaluate sexual risk
Identify the patient's/client's concerns
Common Assumptions Not to Make in Taking a Sexual History



Creating a Welcoming and Safe Atmosphere

In general, creating a safe environment for taking a sexual history is similar
in LGBT and heterosexual patients/clients. In all such situations, the health
care provider strives to be open minded, nonjudgmental, patient, tactful,
respectful and provides assurances that privacy and confidentiality will be
maintained.

It is useful, however, to keep in mind that many LGBT people may approach a
health care provider interview with greater anxiety and guardedness than
their heterosexual counterparts. Their anxieties may stem from past
experiences with providers who were critically judgmental or they may
anticipate a critical or judgmental response by projecting their own
"internalized homophobia" or transphobia (discrimination transgendered
people). These patients/clients may need additional time and encouragement
to reveal their true concerns.

As with any patient/client, the provider's non-judgmental attitude will help
bring out honest and relevant information. Such an attitude is conveyed to
the patient/client both verbally and non-verbally through body posture and
room set up. A relaxed stance and not conducting an interview from behind a








desk can be beneficial. Techniques such as open-ended questions, verbal
mirroring of the patient's/client's own language, use of non-judgmental
language, attention to heterosexist assumptions and avoidance of
stereotyping can all lead to greater success in obtaining a more accurate
sexual history.

Confidentiality

Confidentiality is the cornerstone of all provider-patient/client relationships
and assurances of confidentiality are crucial to taking a sexual history. This
is done by assuring a patient/client that any information provided will not be
shared with others. In cases where complete confidentiality cannot be
assured, a provider should clarify the limits of confidentiality from the
onset and respect the patient's/client's decision as to how much sexual
history he/she is willing to reveal.

Special caution needs to be taken when working with children, adolescents
and young adults who may not have shared their concerns about sexual
orientation or gender identity with their parents. Children and adolescents
are particularly unlikely to share their intimate feelings with providers
unless their wishes and sensitivities are recognized.

Use of Inclusive Language

When taking a sexual history, the provider's task is aided by using inclusive
terms and language. Inclusive language should not make assumptions about a
patient's/client's sexual identity or sexual behavior, particularly in
situations where patients/clients do not volunteer such information. One way
to do this is to have intake forms and questionnaires that do not make
heterosexual assumptions.

Such inclusive language also conveys to the LGBT patient/client that the
provider is potentially open to hearing about his or her sexual identity and
relationships. The accuracy and completeness of the details requested will
reflect the patient's/client's level of comfort with the process.

Evaluatina Sexual Risk








Sexual history should explore the patient's/client's knowledge of both high
risk and safer sex behaviors. The following are important to keep in mind:

Anti-homosexual attitudes and stigma can contribute to a
patient's/client's lack of information about what constitutes risky
sexual behavior and may contribute to a patient's/client's inability or
unwillingness to use safer sex practices. For example, internalized
homophobia has been found to be associated with increased
problematic substance use and riskier sexual practices (Meyer 2003).
Depression, anxiety, psychosis (irrational or disturbed thinking),
mental retardation and other psychiatric disorders can contribute to
inconsistent use or even complete neglect of safer sex precautions.
A patient/client may lack or have inaccurate knowledge about HIV and
other sexually transmitted infections. Providing a patient/client with
up-to-date information about STI can be a useful part of taking a
sexual history.
In general, giving advice or telling patients/clients what they should
or should not do may not lead to behavioral change. Exploring the
motivations behind patient/clients choices, the accuracy of their
information, and their capacity for self-care can help patients/clients
think through risk-benefit scenarios.

Identifying the Patient's/Client's Concerns

When taking a sexual history, it is important to assess its relevance to the
patient's/client's presenting complaint (i.e., an LGBT patient/client being
seen for congestive heart failure) or whether some aspect of the
patient's /client's sexual activity or identity represents a source of concern
to the patient and therefore warrants clinical attention. In both situations,
the information gathered may be critical to the development of a reasonable
treatment plan. Avoid the appearance that you are 'minding the
patient/client's business".

However, the patient's/client's major focus of concern should always be
uppermost in the provider's mind and guide how the interview proceeds and
how much detail is required in the sexual history.

Common Assumptions Not to Make in Taking a Sexual History








* Don't assume patients/clients are heterosexual just because they
haven't said otherwise.
* Don't assume LGBT patients/clients do not have children.
* Don't assume that self-identified gay men do not have sex with
women or that lesbians never have sex with men.
* Don't assume that early same-sex erotic feelings are merely a passing
phase, and therefore not to be taken seriously.
* Avoid conceptualizing gender identity confusion as an immediate need
to establish a male or female gender identity.
* Avoid common stereotypes: that all gay men are promiscuous or that
all lesbian couples experience "bed death" (likened to heterosexuals
who stop having sex after being in a relationship for a long time) -
individuals are unique in their sexual behavior.
* Don't assume that domestic violence does not occur in LGBT couples.


Sexual Health of Gay Men and Other Men
Who Have Sex with Men

Health is a state of complete physical, mental and social well-being, and not
merely the absence of disease or infirmity. ~World Health Organization,
1948



This chapter aims to:

Introduce participants to the health care concerns of lesbian, gay,
bisexual and transgendered people;
Help participants understand the issue of 'coming out';
Help participants to identify the signs of depression and suicide risks;
Provide participants with guidelines for referral;
Provide participants with the opportunity to practice effective
provider-patient/client communication through role play.


ISW I





























Activity 10: What is Sexual Health


Time: 30 Minutes

Objective
To ensure that participants have an understanding that sexual
health includes physical, emotional, intellectual and social aspects
of well-being.

Materials
Flip chart
Markers

Facilitator's Instructions
1. Ask the participants to think about what sexual health means to them
personally. Write the response on flip chart paper. For example:

- healthy ways of having sex
- healthy functioning of sexual organs
- not having sexually transmitted infections (STIs)
- knowledge and practice of safer sex
- knowledge of sexual organs









- experiencing sexual pleasure
- mental peace about sex and sexuality
- positive attitude about sexuality

2) Ask the group how they would define sexual health?

3) Record participants' responses and facilitate a discussion.

4) Share with participants that WHO defines sexual health as the
integration of physical, emotional, intellectual and social aspects of sexuality
in a way that positively enriches and promotes personality, communication
and love.

5) Conclude by telling participants that sexual health is important to men
because research has shown that men generally seek health services late or
not at all and this can have serious consequences for their sexual health.

Notes for Facilitator:
Facilitator should have a good understanding of the various aspects of
sexual health and how these might impact on vulnerability to STIs and HIV.































Activity 11: Transmission of STIs and HIV


Time: 45 Minutes
Objective
To ensure that participants understand the major means of transmission
of STIs and HIV.

Materials
Flip chart
Markers

Facilitator's Instructions

1) Ask the whole group to brainstorm all of the sexual acts performed among
gay men and other MSM. Make a list on flip chart.

2) Ask participants to identify all the sexual acts between two men that can
lead to HIV and STI transmission. In addition to the exchange of body









fluids ensure that the group includes different types of direct contact with
the skin, sore or parasite.

3) Facilitate a discussion about the level of risk associated with each sexual
act. Include which MSM sexual partner is at greater risk for infection.

3) Invite questions for clarification. How big is the gap between the
"reality" of risk and people's "perceptions" of risk? Where do we get our
information from? How can we improve access to accurate, appropriate and
timely sexual health information? What factors affect the level of risk?
What can we learn from this about the factors that might increase
vulnerability?

4) Conclude by summarising the basic facts about HIV transmission.

Notes for Facilitator:
Discussion should be generated in a way that is sex positive. During the
brainstorm, you may need to add any suggestions of your own, if you think
that important risk behaviours have been missed by the group.



Activity 12: Brainstorming Knowledge of STI

Time: 60 Minutes

Objective
To review participants' knowledge of STIs including HIV.


Material!

*


Flip chart
Markers


Facilitator's Instructions

1) Having just discussed the sexual routes of transmission of HIV and STIs
with the group, ask them now to identify the names of STIs they are aware
of. Guide discussion to which STIs are common amongst MSM and gay men









and ensure that discussion refers to anal and oral sex. What STIs are
associated with which sexual behaviours?

2) Beforehand prepare two sets of cards or flip charts. One set will have
the name of the STI on it. The other will have the symptoms of the STI.
Arrange the cards or flip charts with the names of the STIs on it so that all
the participants can clearly see them. It might be helpful to stick them on
the wall. Ensure that there is adequate space beside them so that
participants can match up the symptoms for each STI.

3) Ask each participant to take one or more cards or flip charts with a list
of symptoms and match it with the appropriate STI. The card or flip chart
with the symptoms on it should be placed to the right of the card or flip
chart with the STI name on it. The facilitator should provide clarification
where necessary ensure that the difference between HIV and AIDS is
understood.

Notes for Facilitator
See list of STIs and their signs and symptoms in Handout.. in the Appendix.







Activity 13: Prevention of STIs and HIV

Time: 60 Minutes

Objective
To ensure that participants understand the major means of prevention of
STIs
and HIV.

Materials
Flip chart
Markers
Male condoms
Lubricants








Dildo
Flip chart flip chart of different sexual acts from Activity 11.
Blindfold

Facilitator's Instructions
Prevention

1) Refer back to the different sexual acts between MSM and ask
participants to list ways of preventing the transmission of HIV and STIs.

2) Explore issues about non-penetrative sex, use of condoms, reducing
numbers of partners, HIV testing as a prevention tool and not having sex
(e.g. how realistic is it to ask people not to have sex?). What other sexual
practices are considered safer sex?

3) What is the role of the condom in safer sex? Invite one person to
demonstrate correct use of a condom using dildo or substitute.

4) Repeat the above exercise with one person blindfolded.

5) Discuss ways in which to ensure the condom will remain effective.
* Avoid tearing the package with your teeth or a sharp object
* Check the date of expiry
* Do not keep condoms in the back pocket where they risk being damaged
from being sat on regularly

6) Discuss use of water-based lubricant as a part of efficient condom use
especially for anal sex.


Notes for Facilitator
Discussion should be generated in a way that is sex positive. This activity
usually brings up a lot of questions and concerns that people have about how
HIV and STIs are prevented. Make sure that you are comfortable with the
basic facts of transmission and prevention. Remember that there is still a
lot of research being carried out on HIV and that there is still much that we
do not know. It is OK to say that you do not know an answer to a particular
question as long as you make a commitment to try to find out.










Ensure that there is identification of
* non-penetrative sex -
* use of condoms note need for lubricants for anal sex

Generate discussion about the possibility of achieving these forms of safer
sex
* the extent to which negotiating safe sex is realistic and what it means
- negotiated safety

In discussion of reduction of number of partners be sure to be clear that
this only reduces risk in a mathematical sense it does not remove risk -
only sex where there is no exchange of bodily fluids removes risk.

In discussion of abstinence be sure to discuss realism of this choice and
reinforce sex positive message.








Activity 14: Vulnerability and Risk Taking

Time: 90 Minutes

Objectives
1. To explore the vulnerability of MSM and gay men to STIs and HIV as it
relates to a number of economic and social issues.
2. To explore risk taking as it pertains to particular sexual behaviours and
raises issue of vulnerability of female partners of men who have sex with
men and gay men.

Materials
Flip chart
Markers
Scenarios (provided below)








Facilitator's Instructions

1) Ask the participants to break into three small groups. Each group will
receive a different role-play scenario related to vulnerability and risk taking
among MSM and gay men. Ask each group to consider the scenario they are
given. Make sure all scenarios are used. The group should discuss the
dynamics of the situation and the vulnerability and/or risk taking of the
characters related to STIs and HIV transmission.

Note: A copy of these role play scenarios appears in the Appendix. It can be
photocopied and then cut in three for distribution to the three groups.

2) Ask each group to prepare to act out the scenario with two members
playing the roles. They should provide an ending which results in unsafe sex.
Inform the groups that they only have 10 minutes to present the role play.
They should keep their preparations general to enact the situation
described. The dialogue should be simple. Avoid having the groups spend too
long scripting dialogue. Monitor the groups to ensure that the instructions
and time frame are understood.

3) Participants return to the large group and the scenarios are briefly
enacted. Ensure that participants stick to the time frame.

4) Facilitate discussion about the issues involved and the probability of the
outcomes. What were some of the factors affecting the character's
vulnerability? Which of these were examples of individual factors (referring
to aspects of an individual's life) and which are social factors (referring to
aspects of family, institutions, etc)? What was the relative importance of
individual factors as compared to social causes of vulnerability? What
examples were there of risk taking?

Note:
The "risk taking" will he determined by the participants in how they choose
to enact the unsafe sexual encounters.

Examples of individual contexts affecting vulnerability:
* Levels of knowledge about safer sex
* Perceptions of personal risk









* Attitudes about oneself (sense of self worth/self esteem)
* Power
* History of sexual abuse

Examples of social contexts affecting vulnerability:
* Norms about relations between men and women (and how this can be
projected onto male partners)
* Social attitudes towards sexuality and MSM/gay men (homophobia)
* Economic conditions (unemployment, poverty)
* Racism
* Accessibility of HIV and STI prevention education and relevant services
* Lack of safe spaces where safer sex can be practiced
* Political and legal climate

5) Ask participants to consider the notion of risk taking. How do they
understand the term? How is it different from vulnerability? How is it
related?

Generally speaking, risk taking is associated with personal choice regarding
sexual behaviour.

Vulnerability is associated with social conditions, institutional structures
or personal experiences/histories that may affect sexual behaviour. It is
not always clear that risk taking can be easily differentiated from
vulnerability. People have, based on their experiences and social situation,
different perceptions about what choices they can make about sexual
behaviour. Social and individual factors limit choices available to people or
reduce people's ability or willingness to make safe choices. Understanding
the range of factors that affect people's vulnerability to becoming infected
with HIV or a STI is vital in order to design effective HIV prevention
services.

Role Play Scenarios:

Scenario 1
Gavin is 19, and male sex worker who works mainly on the streets at night.
He is not very proud of his work but feels he has no choice because he has
no other professional skill or training. He is completely out of money this








day. Cedric is 37, a businessman who is married but sometimes looks for sex
with men and will pay for it when he has to. Cedric is not very comfortable
with his sexuality and can be rough. Gavin is not physically very strong.
Cedric knows about STIs and HIV but assumes this does not really relate to
him. He doesn't enjoy using condoms. Tonight he is a bit unhappy. Cedric
visits the street and meets Gavin he wants him badly.

Scenario 2
Anthony and Imtiaz are in their early twenties, graduating from university
and in love. Anthony is happy with his sexuality but is very private about it.
Imitaz is very confused. Recently the pressure has increased from Imitaz's
family for him to marry. In a fight with his father he told him he thought
that he was a homosexual and his father threw him out of the house. Imitaz
went and had a few drinks and now has gone to Anthony's house. He is in his
room and wants to have sex to wash away the fight with his father. He
doesn't want to use a condom because he wants Anthony to prove his love
for him. He gets a bit noisy from time to time and Anthony is worried about
his family hearing what is going on.

Scenario 3.
Andy and Sheema are newly married. Andy prefers sex with men but he likes
and respects Sheema and is happy to marry and raise a family. Soon after
the marriage he learns that an old partner of his has tested HIV positive.
Andy has never had an HIV test. He knows he may have been exposed to
HIV. Sheema is very keen to start a family and enjoy her new married life.
Sex had been going well since the marriage but suddenly has stopped. She is
very strong willed and determined that things should get moving again!


Notes for Facilitator:
Issues that the facilitator should ensure are raised include the link
between:
* economic status and vulnerability and risk, (Scenarios 1 & 3) violence and
vulnerability and risk, (Scenarios 1 & 2)
* confusion about sexual identity and emotional security and vulnerability
and risk (Scenarios 1, 2 & 3)
* impact of family pressure, expectations and vulnerability and risk
(Scenarios 2 & 3)








* the vulnerability of female partners of men who have sex with men
(Scenario 1 & 3)

























Activity 15: Reducing Vulnerability to STIs and HIV

Time: 60 Minutes

Objectives
1. To ensure that MSM and gay issues are appropriately integrated into
programmes that promote sexual health through awareness raising, provision
of information and education, encouraging safer sexual behaviour and
condom promotion.


Materials
Flip chart
Markers
Scenarios from Activity 14









Facilitator's Instructions

1) Put the following two questions on flip chart paper. Ask the participants
to get up and put their responses on different pieces of flip chart paper.

* What do MSM need to help them to reduce vulnerability and risk taking in
relation to STIs and HIV?

Discuss: Referring to the previous exercise, what were the needs of the
different MSM/gay male characters? What did they need to know about
their bodies, HIV/STI transmission, etc.?
* How do you deliver these services?

Discuss: What strategies could be used? How can we increase access to
services? What limitations are there to various strategies/services? What
are the limitations of the NGO's role? Where else can MSM/gay men go for
assistance?

2) Ask the group as a whole to brainstorm two lists one that lists as many
possible components of effective programmes that help people reduce their
vulnerability to HIV/STIs and risk taking (see list below) and another list of
activities/approaches which are often used but which we know are
ineffective in really helping people reduce vulnerability and risk (see list
below). The groups should also identify if any of the elements listed are of
particular relevance or importance in relation to sexual health of MSM and
gay men. Have the group refer back to the flip charts from Activity 14 to
ensure that different strategies are identified to address all the causes of
vulnerability and risk taking identified. Emphasise how the NGO's and health
workers involvement and services can assist in decreasing vulnerability and
risk taking?

Facilitate a guided discussion on any issues with increasing focus on issues
particularly relevant to sexual health of MSM and gay men. Encourage the
group to draw their own conclusions.

Optional, if time permits:









4) Reintroduce the role plays from Activity 14. Ask five participants to
volunteer to represent the MSM/gay male characters in Activity 14. Ask
five additional participants to volunteer to portray NGO workers who would
then identify and act out different ways of addressing the situation with
one of the MSM/gay men resulting in a positive outcome (e.g. telephone
counselling, community outreach, one-on-one counselling, education campaign,
etc.).

Ensure that a diversity of different strategies and services are addressed.
You should address:
* building negotiation skills to talk about sex and safety (all scenarios)
* where realistic and possible, building capacity to say no (all scenarios)

5) Ask the groups to quickly enact the role plays with different NGO
interventions.

6) Facilitate a discussion about the following:
* What does this suggest about the kinds of strategies that might be
effective in responding to vulnerability? How can NGO's services (education,
etc.) assist in decreasing vulnerability and risk taking? To what extent do
people have "choice" about behaviour?

Notes for Facilitator:
The discussion should be introducing general issues and not trying to
produce a detailed design for programmes.

Effective approaches should be including things like:
* provision of explicit sex positive information about behaviour, transmission
and prevention-that includes information relevant to MSM and gay men
* counselling
* non-discriminatory statements about sex, sexual preference and gender.
* a mix of public information, inter-personal activities, counselling, high
quality STI care, availability and accessibility of good quality condoms &
lubricant
* inclusion of people affected by STI and HIV in developing responses
* addressing issues related to gender inequality, poverty & mobility
* sensitive and strong policy leadership from government
* partnership between government, community,








* building skills in negotiating sex when possible
* working on specific issues concerning young gay men and their self esteem.
* peer based approaches where appropriate
* incorporating a component of training and income generation

Ineffective programming could include:
* using primarily fear based approaches without any context
* blaming anyone
* dictating behaviour saying "no" "don't"
* concentrating only on an individual responsibility to change behavior
without paying attention to factors that limit choice or capacity to do this
* promoting condoms but not having good quality condoms available,
affordable and accessible
* speaking in generalities about sexual behaviour not being explicit and
direct
* advocating sexual abstinence/no sex
* not involving MSM and gay men


Theory to Practice

"Civility in health care begins with effective communication, driven by
respect and empathy for the patient,"

Dr. Michael Woods

This chapter aims to:


I Inj~









Introduce participants to the health care concerns of lesbian, gay,
bisexual and transgendered people;
Help participants understand the issue of 'coming out';
Help participants to identify the signs of depression and suicide risks;
Provide participants with guidelines for referral;
Provide participants with the opportunity to practice effective
provider-patient/client communication through role play.

Additionally, through role play participants will demonstrate being
respectful, valuing the diversity of patients/clients, offering services in
their language and in a culturally competent manner, and acknowledging the
unique barriers to accessing services experienced by members of the LGBT
community.

















Activity 16: Health Care Concerns of LGBT People

Time: 60 Minutes
Objective
Identify health care concerns of LGBT People.


Materials
F
1
/


:lip chart
Markers
Masking tape


Facilitator's Instructions









Facilitator divides participants into the four groups below.
Group 1: Health care concerns of lesbians
Group 2: Health care concerns of gay men
Group 3: Health care concerns of bisexual people
Group 4: Health care concerns of transgendered people

Facilitator requests that each group selects a facilitator to lead the
brainstorm session, a scribe and a presenter and informs them that 15
minutes are allotted for discussion.

Facilitator calls time up and invites groups to present. Facilitator adds any
missing needs to the lists.

Facilitator makes reference to the concerns identified for each of the four
groups and points out that while there are some similarities, there are
noticeable differences.

Facilitator advises that health care providers must take these differences
into consideration when dealing with individuals from the LGBT community.

In ending the activity the facilitator reminds participants that while we all
belong to groups where we have a number of things in common, as individuals
we have different concerns.

The implication is that LGBT must not be lumped into one group when their
health care concerns are being addressed.

Lesbians' Health Care Concerns

Research found that many professionals within the health care system
maintain a position that lesbian health is synonymous with women's health,
secure in their belief that it is unnecessary to identify women as lesbian or
bisexual within a consultation. Discussions with lesbians in Guyana suggest
that they are concerned with issues related to:

Safe sexual practices, including cervical cytology screening;
Reproductive health and parenting;








Psychological support to deal with alcoholism, drug abuse, and tobacco
use, cope in the face of stigma and discrimination and with suicidal
thoughts and actions;
Empowerment to disclose to significant others in their lives;
Ageing in relation to issues such as menopause.

Gay Men's Health Care Concerns

There is increasing evidence that gay men demonstrate distinctive health
needs besides HIV since findings suggest greater vulnerability for poor
health among gay men in many areas.

Discussions with gay men in Guyana suggest that they are concerned with
issues related to:

Psychological support to deal with their identity, denial of their true
sexuality, depression, alcoholism and drug abuse; cope in the face of
stigma and discrimination and with suicidal thoughts and actions;
Sexual health, including anal and oral sex, hygiene, HIV and STI;
Relationship dynamics as it relates to domestic violence, stress
involving issues/pressures to fulfill heterosexual expectations of
marriage and fatherhood.

Bisexual Men and Women's Health Care Concerns
Research shows that many bisexuals have negative experiences with health
care providers whether it is because they are afraid to come out to their
providers, or because their providers give them improper or incomplete
information. Discussions with the LGBT people in Guyana suggest that
bisexual men and women are concerned with issues relating to:

Psychological support to deal with their identity, denial of their true
sexuality, depression, alcoholism and drug abuse; cope in the face of
stigma and discrimination and with suicidal thoughts and actions;
Conflict with identity leading to violence;
Sexual health, including anal and oral sex, hygiene, HIV and STI;
Relationship dynamics as it relates to being in a relationship with
someone with multiple partners;
Risks associated with STI transmission;








How to present themselves to the health care facility to have their
health needs addressed;
Eliminating barriers to accessing health care.

Transgendered People's Health Care Concerns

Transgendered people's health issues are beginning to come to the attention
of many health practitioners and researchers. Discussions with
transgendered people in Guyana suggest that they are concerned with issues
relating to:

Barriers accessing healthcare in a non-discriminatory environment;
Communicating their health care needs to providers;
Building the capacity of health care provider to recognize the present
needs of those who are transitioning from one identity to another or
those who are already in the preferred identity.
HIV and STI
Hormone issues
Alcohol abuse
Drug abuse













Activity 17: Coming Out

Time: 45
Minutes
Objective
Enable participants to understand the issues around 'coming out'.








Materials
Copies of Handout 4: Guidelines for Coming Out, for participants.

Facilitator's Instructions

Facilitator explains that the term coming out is used to describe the
process of understanding, accepting, and disclosing one's sexual identity.
The process is very personal and can happen in different ways for each
person.

Facilitator asks participants to share their understanding of the challenges
faced by LGBT people who wish to 'come out' Facilitator notes the
responses and discusses the following:

Coming out to one self

Some people acknowledge their sexual identity during their childhood or
teenage years, while others continue to explore their sexual identity much
later in life.

One of the first steps in the process of coming out is acknowledging one's
own sexual identity. During this process, it can help to think of sexual
orientation as a continuum from exclusive attraction to the same sex to
exclusive attraction to the opposite sex. People of many sexual orientations
have questions about their physical and emotional attractions to others.

It is normal to have questions about one's attractions. Simply exploring
these questions does not determine if one is gay, lesbian, bisexual,
transgendered, or straight. Many persons are confused about their sexual
identity. You are not alone.

Coming Out to Other Lesbians and Gay Men

Often, after spending some time getting in touch with one's own feelings,
the next step is to come out to others.

It is usually advisable to come out first to those who are most likely
to be supportive.








LGBT people are a potential natural support system because they have
all experienced at least some of the steps in the process of coming
out.
Sharing experiences about being gay, lesbian, bisexual or transgender
can help oneself decrease feelings of isolation and shame.
Furthermore, coming out to other LGBT people can help oneself build
a community of people who can then support and assist in coming out
to others.
Many LGBT groups offer a number of helpful resources, including local
coming out groups, switchboards, social outlets, and political and
cultural activities and organizations.
Coming out to other LGBT people does not need to happen quickly.
Also, choosing to do so does not mean that one must conform to real
or presumed expectations of the LGBT community.
What is most important is that he/she seeks his/her own path
through the coming out process and that he/she attends to his/her
unique, personal timetable.
One should not allow oneself to be pressured into anything he/she is
not ready for or don't want to do.
It is important to proceed at his/her own pace, being honest with
oneself and taking time to discover who she/he really is.

Coming out to heterosexuals

Perhaps the most difficult step in coming out will be to reveal yourself to
heterosexuals. It is at this step that one may feel most likely to encounter
negative consequences. Thus it is particularly important to go into this part
of the coming out process with open eyes. For example, it will help to
understand that some heterosexuals will be shocked or confused initially,
and that they may need some time to get used to the idea that you are
LGBT. Also, it is possible that some heterosexual family members or friends
may reject him/her initially. However, do not consider them as hopeless;
many people come around in their own time.

In coming out to others, you must counsel the client to consider the
following:

Think about what he/she wants to say and choose the time and place
carefully.








Be aware of what the other person is going through. The best time
you believe for you might not be the best time for someone else.
One should present him/herself honestly and remind the other person
that he/she is the same individual he/she was yesterday.
Be prepared for an initially negative reaction from some people. Do
not forget that it took time for you to come to terms with your
sexuality, and that it is important to give others the time they need.
Have friends lined up to talk with you later about what happened.
Don't give up hope if you don't initially get the reaction you wanted.
Due to inculcated societal prejudices mentioned earlier, some people
need more time than others to come to terms with what they have
heard.

However, LGBT individuals must consider these issues because of the very
real presence of heterosexism, homophobia, and discrimination.

Some people feel more comfortable disclosing their sexual identity to LGBT
people or others who will be supportive before they decide to disclose their
identities on a broader basis.

Often, people choose to disclose to close friends and family members,
depending on their comfort levels.

Some people choose to come out in very public forums. Regardless of the
circumstances, the choices surrounding coming out to others require courage
and deserve respect.








Activity 18: Recognising Signs of Depression and Suicide
Risks

Time: 45 Minutes
Objective
Enable participants to recognize signs of depression and suicide risks.

Materials
Copies of Handout 5: Recognising Signs of Depression and Suicide Risk, for
participants.

Facilitator's Instructions
Facilitator explains that many LGBT people experience depression and some
even contemplate or commit suicide. These can result from internal conflicts
they have experienced while trying to determine who they are. Society's
perception of people whose sexual orientations are not heterosexual, as well
as the discrimination they experience also contribute to feelings of
depression and thoughts of suicide.

It is therefore vital that you know how to recognize signs of depression and
suicide risks. Some of you might have the skills to apply this knowledge to
counsel the client. Others might need to refer.

Facilitator then leads a discussion about the common signs of depression and
suicide risk.

Common signs of depression and suicide risks are:

change in personality: sad, withdrawn, irritable, anxious, tired,
indecisive,
apathetic (lack of concern/interest)
change in behaviour: can't concentrate on school, work, routine tasks
change in sleep pattern: oversleeping, insomnia sleeplessness),
sometimes with early waking
change in eating habits: loss of appetite and weight, or overeating
loss of interest in friends, sex, hobbies, activities previously enjoyed
worry about money, illness (real or imaginary)
fear of losing control, going crazy, harming self or others








* feeling helpless, worthless, "nobody cares", "everyone would be better
off without me"
* feeling of overwhelming guilt, shame, self-hatred
* no hope for the future, "it will never get better, I will always feel this
way"
* drug or alcohol abuse
* recent loss: through death, divorce, separation, broken relationship,
or loss off health, job, money, status, self- confidence, self-esteem
* loss of religious faith
* nightmares
* suicidal impulses, statements, plans, giving away favourite things,
previous
* suicide attempts or gestures
* agitation, hyperactivity, restlessness may indicate masked depression








Activityl9: Guidelines for Dealing with Male Rape/Sexual
Assault

Time: 45
Minutes
Objective
Enable participants to acknowledge and deal with male rape/sexual assault.

Materials
Copies of Handout 8: Guidelines for Dealing with Male Rape/Sexual Assault,
for participants.

Facilitator's Instructions

Facilitator explains that male rape is a reality and that men who are raped
or sexually assaulted will help to deal with their health and emotional needs.
Facilitator engages in an interactive discussion with participants to bring out
the following:

What is male sexual assault?
Sexual assault is any unwanted sexual contact. It can be committed by the
use of threats or force or when someone takes advantage of circumstances
that render a person incapable of giving consent, such as intoxication.

Male sexual assault can include unwanted touching, fondling, or groping of a
male's body including the penis, scrotum or buttocks, even through his
clothes.

Male rape is any kind of sexual assault that involves forced oral or anal sex,
including any amount of penetration of the anus or mouth with a body part or
any other object.

Some of the feelings a male survivor may experience

Any survivor of sexual assault may experience the following feelings, but
male survivors may experience these feelings in a different way:

SGuilt as though he is somehow at fault for not preventing the assault
because our society promotes the misconception those men should be
able to protect themselves at all times.









Shame as though being assaulted makes him "dirty," "weak," or less
of a "real man."
Fear that he may be blamed, judged, laughed at, or not believed.
Denial because it is upsetting, he may try not to think about it or
talk about it; he may try to hide from his feelings behind alcohol,
drugs, and other self-destructive habits.
Anger about what happened; this anger may sometimes be
misdirected and generalized to target people who remind him of the
perpetrator.
Sadness feeling depressed, worthless, powerless; withdrawing from
friends, family, and usual activities; some victims even consider
suicide.

If a male victim became sexually aroused, had an erection, or ejaculated
during the sexual assault, he may not believe that he was raped. These are
involuntary physiological reactions. They do not mean that the victim wanted
to be sexually assaulted, or that the survivor enjoyed the traumatic
experience. Just as with women, a sexual response does not mean there was
consent.

The experience of sexual assault may affect gay and heterosexual men
differently. Counsellors have found that gay men have difficulties in their
sexual and emotional relationships with other men and think that the assault
occurred because they are gay.

What you should do as a Health Care Provider
If you are unsure, you should:
Ask the patient when no one else is in the examining room.
Make direct eye contact and actively listen to the response.
Ask direct questions in a non-judgmental way
Avoid technical or medical language.

Begin by first normalizing the topic. For example:
"I need to ask you some personal questions. Let me explain why."
Asking these questions can help me care for you better."
"Since I am your health care provider, we need to have a good
partnership."
I can better understand your health if you would answer some
questions about your sexual history."










Next ask the patient/client directly:
Have you ever been touched sexually against your will or
without your consent?
Have you ever been forced or pressured to have sex?
Do you feel that you have control over your sexual relationships
and will be listened to if you say "no" to having sex?

What if your patient/client says yes?

Validate your patient's/client's response.
"Thank you for telling me about such a difficult experience."
"I'm sure that was hard for you to tell me. It is good that you
told me."
"Rape is devastating in many ways. Let's talk about some of the
ways you need support."

If your patient/client says "yes"
Medical Needs
Discuss any injury or trauma the patient/client might have experience
Conduct examination with patient's/client's permission, if qualified to
do so, or refer for evaluation.
Evaluation of potential sexually transmitted infections
and treatment.
Discussion of HIV counseling and testing.

Emotional Needs
Support counseling to deal with clients feelings
Referral for appropriate follow-up counseling, if you are unable to
provide. Help & Shelter NGO can provide such assistance.

If your patient/client says "no"
Offer education and prevention information and provide follow-up
at next visit.

If your patient/client is "not sure"
Evaluate the experiences) with the patient and provide.
Education about violence and consent.












Activity 20: Referral Guidelines

Time: 45 Minutes
Objective

*Provide guidance to providers on when and how to refer
patients/clients and what information to provide to the referral
agency.

Materials
Flip chart
Markers
Masking tape
Copies of Activity 13: Referral Guidelines, for participants


Facilitator's Instructions

Facilitator asks participants to share how they make referrals and what
informs their decision to refer. Facilitator records responses.

Facilitator reminds participants that referral of patients/clients from
primary care (health centres) to secondary care (hospitals and NGOs) is an
indispensable part of health care practice.

As a provider you must have an awareness and recognition of your limitations
and must know when to refer. This means that you must be aware of your
knowledge, skills and experience and must be able to determine when what is
being required of you by the patient/client is beyond your expertise and
experience.

You must take responsibility for finding out the qualification and experience
of the person or agency to whom/which you are referring the patient/client.
The client will expect you to refer him/her to a reputable person or agency.
You must never fail the client in this regard.









It is important that you first seek agreement from the patient/client
before you make the necessary referral. You must also inform the client
that you will be including personal information about his/her condition and
medical history in the referral and seek his/her permission before doing so.

The following are included in the referral:

Date of referral
Name, address and phone number of referring provider
Name, address and Date of Birth of patient/client
Reason for referral (counselling and/or treatment requested)
Key details of problem
Medical history and treatment given
Relevant social and family history
Indication of urgency of referral
Signature and printed name of referring provider
Must be addressed to the referral agency (Name, designation,
Agency, Address, telephone Number

Facilitator's Instructions Cont'd

You can still refer a patient/client who does not give permission to disclose
his/her condition and medical history. In this case you should provide the
patient/client with the name, designation, agency, address and telephone
number of the referral agent or agency.












Activity21: Role Play in Triads


Time: 120 Minutes

Objective

Provide participants with the opportunity to practice effective
provider-patient/client communication through role play.

Materials
Copies of Care Guidelines for each participant
Scenario for each participant playing the role of client
Representatives of the LGBT community; a lesbian, a gay man, a
bisexual man or woman and a transgendered person.

Facilitator's Instructions

Facilitator shares with participants that during this section of the training
they will spend time working in groups of three (triads). Using health care
scenarios, they will role-play provider-patient/client and observe the
interaction. The key to this experience is to create an atmosphere where
making mistakes is alright and, in fact, desirable. It is best for participants
to learn during a role-play. Participants will have an opportunity to combine
new knowledge and skills crucial for providing optimal care to LGBT people.

Learning from this experience can reduce ineffective communication during
real provider-patient/client interactions. By the end of this activity each
participant will have the opportunity to be in the role of provider. (minimum
12 participants)

Participants and facilitator will provide feedback to the provider at the end
of each 15-minute session. Participants will provide feedback in plenary to
the 'provider' using the C. A.R. E. Guidelines below:

C.A.R.E. Guidelines









C-Communicate immediately, both verbally and nonverbally, to set
the tone of the encounter; show openness, genuine concern, and
positive regard for the patient/client.
A-Use Appropriate communication behaviors for the
patient's/client's age, gender, social position in the family and
community, language use and comprehension, and degree of discomfort
or distress.
R-Recognize the patient's/client's experience, efforts, and emotions
in an honest, straightforward manner, using statements of concern
and empathy, indicating you care about the patient/client and his or
her problem.
E-Express support and partnership by letting patients/clients know
you will work with them to help them get better.

Facilitator's Instructions

Facilitator recommends that participants provide feedback by first
identifying what they liked about the provider-patient/client interaction
and then stating what they wished the provider could have done differently.

Providing feedback in this manner allows for the provider to receive the
feedback without feeling judged.

Example 1: "I liked the way you used statements of concern and empathy"

Example 2, "I wished that you would have done more to express your
support by letting the patient/client know you would work with him/her to
help him/her get better"



Role Play Scenarios

Scenario 1: Lesbian seeking services

Sheila, 21, presents at the Youth Friendly Centre in her community
complaining of feeling depress. She is withdrawn. After some probing she
tells you that she believes that she is different. You continue to probe.










Scenario 2: Gay teenage male seeking services
David, 17, presents at the Youth Friendly Centre in his community and tells
you that he believes that he is overweight. He says that his desire is to look
like a model. You probe.
Scenario 3: Male who have sex with women and men seeking services
Brad, 30, presents at the Health Centre in his community and tells you that
he is abusing alcohol. He also tells you that he is married but is having sex
with someone else. You probe.

Scenario 4: Female who have sex with men and women seeking services
Brandy, 24, presents at the Health Centre in her community and tells you
that she is having irregular periods. She also tells you that she is having sex
with someone other than her boyfriend. You probe.

Scenario 5: Female transgendered person seeking services
Shirls, 24, presents at the Youth Friendly Centre in her community and tells
you that she is in an abusive relationship. You probe.

Scenario 6: Gay male seeking VCT services
Patrick, 27, presents at the VCT Centre in his community and informs you
that he would like to have an HI V test. You begin the history taking.

Scenario 7: Gay male recently raped seeking services
Phil, 16 presents at the Health Centre in his community. He seems
distressed, but is hesitant to speak. You begin to probe. He finally shares
that he was forced to have sex.

These are only suggested scenarios. The facilitator should feel free to
include other scenarios.

"It is the same with sexual orientation. It is a given. I could not have fought
against the discrimination of apartheid and not also fight against the
discrimination that homosexuals endure, even in our churches and faith
groups."
Archbishop Desmond Tutu



















CLERMONT, C., SIOUI-DURAND, G., Government of Quebec, Department
Orientations, Adapting Health and Social Services to Homosexuals,

Committee on Lesbian and Gay Concerns, American Psychological Association,
2007 Available at: http://apastyle.apa.org/sexuality.html, April 7, 2008

Lopper, Jerry, A Personal Code of Values, March 10, 2007

Makadon, Harvey, J. Improving Health Care for the Lesbian and Gay
Communities, The New England Journal of Medicine, Volume 354:895-897,
March 2, 2006

National Health Service, Reducing Health Inequalities for LGBT, Briefing 1

Quality Assurance Project, Improving Interpersonal Communication
Between Healthcare Providers and Clients, Instructor Manual, January 1999.
Available at: http://64.233.167.104/search?q=cache:j3FC4-
U4ujcJ:www.gapro ject.org/training/ipc/instl.pdf+provider/patient+communi
cation+tips&hl=en&ct=clnk&cd=9&gl=gy, April 7, 2008

Roberts, Matthew, J. Patient-Provider Communication. Available at
www.mjrc.info/Images/Provider-PatientCommunication.pdf, April 5, 2008

SASOD, SASOD 's Comments on UNGASS Country Progress Report for
Guyana, March 8, 2008. Available at:
http://sasod.blogspot.com/2008/03/sasods-comments-on-ungass-
country.htm/, April 2, 2008

Terborg. Julia, Perceptions and Behaviour Regarding HIV and AIDS
Prevention and Care of FSW and MSM' December 15, 2006. Available at:








http://www.hiv.gov.gy/news sn 15dec06 studymarps.php?
PHPSESSID=c9a49798a41a01ce2da66b64ace636e6. March 4, 2008

The Australian Psychological Society Ltd, Sexual orientation and
homosexuality. Available at:
http://www.psychology.org.au/publications/tip sheets/orientation/, April 3,
2008

The Journal of American Medical Association, Health Care Needs of Gay
Men and Lesbians in the United States, Volume 275(17) 1 May 1996 pp 1354-
1359

The University of Texas at Dallas, Self-Help: Sexual Identity and
Orientation Coming Out, Available at:
http://www.utdallas.edu/counselina/selfhelp/sexual-identitv.html




















Sexual Orientation: The physical and emotional attraction of someone to
persons of the opposite sex, same sex, or both sexes a state of being
attracted to anybody. Three forms of sexual orientation are labeled
heterosexual, gay/lesbian, and bisexual.

Sexual Behaviour: How someone expresses himself or herself sexually.

Sexual Identity: How an individual presents to the world, i.e. heterosexual
identity, gay/lesbian, bisexual identity.

Gender Identity: Someone's sense of being male or female.

Gender Role: Refers to characteristics attached to culturally defined
notions of femininity and masculinity.

Heterosexual: Someone who is physically and emotionally attracted to
people of the opposite sex.

Homosexual: Someone who is physically and emotionally attracted to people
of the same sex. Because the term is associated historically with a medical
model of homosexuality, most homosexual people encourage the use of the
terms lesbian, gay and bisexual.

Gay: A term for "homosexual". This can refer to both males and females,
but is increasingly used to refer to men only.

Lesbian: A female who have sex with other females.








Bisexual: Someone who is attracted physically and emotionally to persons of
the same and opposite sex.

Transsexual/Transgendered: Someone whose gender identity is different
from her or his biological sex. For example, a biological male who would
describe himself as a woman trapped in a man's body.

Cross Dressing: The practice of wearing clothes of the opposite sex which
is for erotic enjoyment. Many transvestites are heterosexual men who are
often referred to as transvestism (noun, transvestite).

brag Queen/King: Someone who dresses up in clothing of the opposite
gender for fun and entertainment. For example, a gay man who dresses up
as a woman to attend a social function is called a "Drag Queen", a woman
would be a "Drag King".

Female Impersonator: A man who dresses as a woman to perform
professionally in public.

Heterosexism: The belief that heterosexuality is superior to any other
form of sexual orientation, the idea of inherent superiority; the assumption
that everyone is heterosexual unless otherwise indicated.

Homophobia: Fear and hatred of lesbians, gays and bisexuals (homosexuals),
often exhibited as prejudice, discrimination, harassment, and acts of
violence.

Internalized Homophobia: The inner feelings of fear or shame felt by
lesbian, gay or bisexual people about their sexuality; these are often caused
by negative attitudes and/or personal prejudices.

Coming Out:
1. The developmental process through which lesbian, gay and bisexual people
recognize their sexual orientation and integrate this knowledge into their
personal and social lives.
2. It may also be used to mean disclosure to another person. For example, "I
just came out to my parents".








What causes a person to have a particular sexual orientation?
How a particular sexual orientation develops in any individual is not well
understood by scientists. Various theories provide different explanations
for what determines a person's sexual orientation, including genetic and
biological factors and life experiences during early childhood. Despite much
research there is no proven explanation of how sexual orientation is
determined. However, many scientists share the view that for most people
sexual orientation is shaped during the first few years of life through
complex interactions of genetic, biological, psychological and social factors.

Despite what some people claim, there is no evidence that society's greater
acceptance of homosexuality results in more people having a homosexual
sexual orientation. The greater numbers of people identifying as homosexual
are a result of fewer people fighting their homosexual feelings while
attempting to live heterosexual lives.

Is Sexual Orientation a Choice?

No. For most people, sexual orientation emerges in early adolescence
without any prior sexual experience. Some people report trying very hard
over many years to change their sexual orientation from homosexual to
heterosexual, with no success. For these reasons, psychologists do not
consider sexual orientation for most people to be a conscious choice that
can be voluntarily changed. People don't choose their sexual orientation;
they can of course choose the kind of a life they want to live.



















1. PROBLEMATIC: Sexual preference
PREFERRED: Sexual orientation

Comment: Avoids the implication of voluntary choice that may not be
appropriate.

2. PROBLEMATIC: The sample consisted of 200 adolescent homosexuals
PREFERRED: The sample consisted of 200 gay male adolescents
The sample consisted of 100 gay male and 100 lesbian adolescents

Comment: Avoids use of "homosexual" and specifies gender of subjects.

3. PROBLEMATIC: None of the subjects were homosexual or bisexual.
PREFERRED: None of the subjects were lesbians, gay men, or bisexual
persons
All of the subjects were heterosexual

Comment: Avoids use of "homosexual" and increases the visibility of
lesbians, gay men or bisexual persons.

4. PROBLEMATIC: Manuscript title: "Gay relationships in the 1990s"
PREFERRED: Manuscript title: "Gay male relationships in the 1990s"

Comment: Specifies gender of gay persons before the term gay is used to
describe women and men; avoids invisibility of lesbians.

5. PROBLEMATIC: Subjects were asked about their homosexuality.
PREFERRED: Subjects were asked about the experience of being a lesbian
or a gay man.








Comment: Changes sentence construction to avoid use of the term
"homosexuality".

6. PROBLEMATIC: The women reported lesbian sexual fantasies.
PREFERRED: The women reported female-female sexual fantasies.

Comment: Avoids confusion of lesbian orientation and specifies sexual
behaviors.

7. PROBLEMATIC: The two bisexual subjects had engaged in both gay and
heterosexual sexual encounters in the past year.
PREFERRED: The two bisexual subjects had engaged in both male-male and
male-female sexual encounters in the past year.

Comment: Avoids confusing sexual orientation (bisexual) with specific sexual
behaviors.

8. PROBLEMATIC: The male dogs were bisexual.
PREFERRED: The male dogs were observed to engage in both male-male and
male-female sexual behavior.

Comment: Increases specificity; does not use sexual orientation terms with
animal species.

9. PROBLEMATIC: It was the subjects' sex, not their sexual orientation
that affected number of friendships.
PREFERRED: It was subjects' gender, not their sexual orientation that
affected number of friendships.

Comment: Avoids confusing gender with sexual activity.

Problems of Designation: Stereotyping

11. PROBLEMATIC: Homosexual abuse of children.
PREFERRED: Sexual abuse of male children by adult men.

Comment: Does not imply sexual orientation of participants; does not imply
that gay men are rapists.

Problems of Evaluation: Ambiguity of Reference








12. PROBLEMATIC: Questionnaire item: Have you ever engaged in sexual
intercourse?
PREFERRED: Questionnaire item: Have you ever engaged in
penile/vaginal intercourse?

Comment: States precisely if penile/vaginal intercourse is the purpose of
the item.

PREFERRED: Have you ever engaged in sexual activity?

Comment: Avoids assumption of heterosexual orientation if sexual activity is
the purpose of the item.

Problems of Evaluation: Stereotyping

13 ROBLEMATIC: AIDS education must extend beyond the gay male
population into the general population.
PREFERRED: AIDS education must not focus only on selected groups.

Comment: Does not refer to gay men as set apart from the general
population.

14. PROBLEMATIC: Psychologists who work with special populations (e.g.,
lesbians, drug abusers, survivors of sexual abuse) need extra training.
PREFERRED: Psychologists who work with minority populations (e.g., Latinos,
lesbians, Black women, older women) need extra training.

Comment: Avoids equating lesbians with pathology.

15. PROBLEMATIC: Women's sexual partners should use condoms.
PREFERRED: Women's male sexual partners should use condoms.

Comment: Avoids assumption of heterosexuality
















Summary Points

Create a Welcoming and safe atmosphere
Confidentiality
Use inclusive language
Evaluate sexual risk
Identify the patient's/client's concerns
Common Assumptions Not to Make in Taking a Sexual History

Creating a Welcoming and Safe Atmosphere

In general, creating a safe environment for taking a sexual history is similar
in LGBT and heterosexual patients/clients. In all such situations, the health
care provider strives to be open minded, nonjudgmental, patient, tactful,
respectful and provides assurances that privacy and confidentiality will be
maintained.

It is useful, however, to keep in mind that many LGBT individuals may
approach a health care provider interview with greater anxiety and
guardedness than their heterosexual counterparts. Their anxieties may
stem from past experiences with providers who were critically judgmental
or they may anticipate a critical or judgmental response by projecting their
own "internalized homophobia" or transphobia (discrimination towards
transgendered people). These patients/clients may need additional time and
encouragement to reveal their true concerns.

As with any patient/client, the provider's non-judgmental attitude will help
bring out honest and relevant information. Such an attitude is conveyed to
the patient/client both verbally and non-verbally through body posture and
room set up. A relaxed stance and not conducting an interview from behind a
desk can be beneficial. Techniques such as open-ended questions, verbal
mirroring of the patient's/client's own language, use of non-judgmental








language, attention to heterosexist assumptions and avoidance of
stereotyping can all lead to greater success in obtaining a more accurate
sexual history.



Confidentiality

Confidentiality is the cornerstone of all provider-patient/client relationships
and assurances of confidentiality are crucial to taking a sexual history. This
is done by assuring a patient/client that any information provided will not be
shared with others. In cases where complete confidentiality cannot be
assured, a provider should clarify the limits of confidentiality from the
onset and respect the patient's/client's decision as to how much sexual
history he/she is willing to reveal.

Special caution needs to be taken when working with children, adolescents
and young adults who may not have shared their concerns about sexual
orientation or gender identity with their parents. Children and adolescents
are particularly unlikely to share their intimate feelings with providers
unless their wishes and sensitivities are recognized.

Use of Inclusive Language

When taking a sexual history, the provider's task is aided by using inclusive
terms and language. Inclusive language should not make assumptions about a
patient's/client's sexual identity or sexual behavior, particularly in
situations where patients/clients do not volunteer such information. One way
to do this is to have intake forms and questionnaires that do not make
heterosexual assumptions.

Such inclusive language also conveys to the LGBT patient/client that the
interviewer is potentially open to hearing about his or her sexual identity
and relationships. The accuracy and completeness of the details requested
will reflect the patient's/client's level of comfort with the process.

Evaluating Sexual Risk

Sexual history should explore the patient's knowledge of both high risk and
safer sex behaviors. The following are important to keep in mind:








Anti-homosexual attitudes and stigma can contribute to a
patient's/client's lack of information about what constitutes risky
sexual behavior and may contribute to a patient's/client's inability or
unwillingness to use safer sex practices. For example, internalized
homophobia has been found to be associated with increased
problematic substance use and riskier sexual practices (Meyer 2003).
Depression, anxiety, psychosis, mental retardation and other
psychiatric disorders can contribute to inconsistent use or even
complete neglect of safer sex precautions.
A patient/client may lack or have inaccurate knowledge about HIV and
other sexually transmitted infections. Providing a patient/client with
up-to-date information about STI can be a useful part of taking a
sexual history.
In general, giving advice or telling patients/clients what they should
or should not do may not lead to behavioral change. Exploring the
motivations behind patient/clients choices, the accuracy of their
information, and their capacity for self-care can help patients/clients
think through risk-benefit scenarios.

Identifying the Patient's/Client's Concerns

When taking a sexual history, it is important to assess its relevance to the
patient's/client's presenting complaint (i.e., an LGBT patient/client being
seen for congestive heart failure) or whether some aspect of the
patient's /client's sexual activity or identity represents a source of concern
to the patient and therefore warrants clinical attention. In both situations,
the information gathered may be critical to the development of a reasonable
treatment plan. Avoid the appearance that you are 'minding the
patient/client's business'.

However, the patient's/client's major focus of concern should always be
uppermost in the provider's mind and guide how the interview proceeds and
how much detail is required in the sexual history.

Common Assumptions Not to Make in Taking a Sexual History

Don't assume patients/clients are heterosexual just because they
haven't said otherwise.
Don't assume LGBT patients/clients do not have children.








* Don't assume that self-identified gay men do not have sex with
women or that lesbians never have sex with men.
* Don't assume that early same-sex erotic feelings are merely a passing
phase, and therefore not to be taken seriously.
* Avoid conceptualizing gender identity confusion as an immediate need
to establish a male or female gender identity.
* Avoid common stereotypes: that all gay men are promiscuous or that
all lesbian couples experience "bed death" (likened to heterosexuals
who stop having sex after being in a relationship for a long time) -
individuals are unique in their sexual behavior.
* Don't assume that domestic violence does not occur in LGBT couples.















Lesbians' Health Care Concerns

Research found that many professionals within the health care system
maintain a position that lesbian health is synonymous with women's health,
secure in their belief that it is unnecessary to identify women as lesbian or
bisexual within a consultation. Discussions with lesbians in Guyana suggest
that they are concerned with issues related to:

Safe sexual practices, including cervical cytology screening;
Reproductive health and parenting;
Psychological support to deal with alcoholism, drug abuse, and tobacco
use, cope in the face of stigma and discrimination and with suicidal
thoughts and actions;
Empowerment to disclose to significant others in their lives;
Ageing in relation to issues such as menopause.

Gay Men's Health Care Concerns

There is increasing evidence that gay men demonstrate distinctive health
needs besides HIV. Since findings suggest greater vulnerability for poor
health among gay men in many areas.

Discussions with gay men in Guyana suggest that they are concerned with
issues related to:

Psychological support to deal their identity, denial of their true
sexuality, depression, alcoholism and drug abuse; cope in the face of
stigma and discrimination and with suicidal thoughts and actions;
Sexual health, including anal and oral sex, hygiene, HIV and STI;
Relationship dynamics as it relates to domestic violence, stress
involving issues/pressures to fulfill heterosexual expectations of
marriage and fatherhood.

Bisexual Men and Women's Health Care Concerns








Research shows that many bisexuals have negative experiences with health
care providers whether it is because they are afraid to come out to their
providers, or because their providers give them improper or incomplete
information. Discussions with the LGBT people in Guyana suggest that
bisexual men and women are concerned with issues relating to:

Psychological support to deal with their identity, denial of their true
sexuality, depression, alcoholism and drug abuse; cope in the face of
stigma and discrimination and with suicidal thoughts and actions;
Conflict with identity leading to violence;
Sexual health, including anal and oral sex, hygiene, HIV and STI;
Relationship dynamics as it relates to being in a relationship with
someone with multiple partners;
Risks associated with STI transmission;
How to present themselves to the health care facility to have their
health needs addressed;
Eliminating barriers to accessing health care.

Transgendered People's Health Care Concerns

Transgendered people's health issues are beginning to come to the attention
of many health practitioners and researchers. Discussions with
transgendered people in Guyana suggest that they are concerned with issues
relating to:

Eliminating barriers to accessing health care;
Accessing services in a non discriminatory environment;
Communicating their health care needs to providers;
Training of providers to deliver appropriate services to them;
Building the capacity of health care provider to recognize the present
needs of those who are transitioning from one identity to another or
those who are already in the preferred identity.
HIV and STI
Hormone issues
Alcohol abuse
Drug abuse

















Coming Out to Other Lesbians and Gay Men

Often, after spending some time getting in touch with one's own feelings,
the next step is to come out to others.

It is usually advisable to come out first to those who are most likely
to be supportive.
LGBT people are a potential natural support system because they have
all experienced at least some of the steps in the process of coming
out.
Sharing experiences about being gay, lesbian, bisexual or transgender
can help oneself decrease feelings of isolation and shame.
Furthermore, coming out to other LGBT people can help oneself build
a community of people who can then support and assist in coming out
to others.
Many LGBT groups offer a number of helpful resources, including local
coming out groups, switchboards, social outlets, and political and
cultural activities and organizations.
Coming out to other LGBT people does not need to happen quickly.
Also, choosing to do so does not mean that one must conform to real
or presumed expectations of the LGBT community.
What is most important is that he/she seek his/her own path through
the coming out process and that he/she attend to his/her unique,
personal timetable.
One should not allow oneself to be pressured into anything he/she is
not ready for or don't want to do.
It is important to proceed at his/her own pace, being honest with
oneself and taking time to discover who she/he really is.

Coming out to heterosexuals








Perhaps the most difficult step in coming out will be to reveal yourself to
heterosexuals. It is at this step that one may feel most likely to encounter
negative consequences. Thus it is particularly important to go into this part
of the coming out process with open eyes. For example, it will help to
understand that some heterosexuals will be shocked or confused initially,
and that they may need some time to get used to the idea that you are
LGBT. Also, it is possible that some heterosexual family members or friends
may reject him/her initially. However, do not consider them as hopeless;
many people come around in their own time.

In coming out to others, you must counsel the client to consider the
following:

Think about what he/she wants to say and choose the time and place
carefully.
Be aware of what the other person is going through. The best time
you believe for you might not be the best time for someone else.
One should present him/herself honestly and remind the other person
that he/she is the same individual he/she was yesterday.
Be prepared for an initially negative reaction from some people. Do
not forget that it took time for you to come to terms with your
sexuality, and that it is important to give others the time they need.
Have friends lined up to talk with you later about what happened.
Don't give up hope if you don't initially get the reaction you wanted.
Due to inculcated societal prejudices mentioned earlier, some people
need more time than others to come to terms with what they have
heard.

However, LGBT individuals must consider these issues because of the very
real presence of heterosexism, homophobia, and discrimination.

Some people feel more comfortable disclosing their sexual identity to LGBT
people or others who will be supportive before they decide to disclose their
identities on a broader basis.

Often, people choose to disclose to close friends and family members,
depending on their comfort levels.









Some people choose to come out in very public forums. Regardless of the
circumstances, the choices surrounding coming out to others require courage
and deserve respect.


The following are common signs of depression patients/clients at risk for
suicide:
change in personality: sad, withdrawn, irritable, anxious, tired,
indecisive,
apathetic (loss of interest/concern
change in behaviour: can't concentrate on school, work, routine tasks
change in sleep pattern: oversleeping, insomnia (sleeplessness),
sometimes with early waking
change in eating habits: loss of appetite and weight, or overeating
loss of interest in friends, sex, hobbies, activities previously enjoyed
worry about money, illness (real or imaginary)
fear of losing control, going crazy, harming self or others
feeling helpless, worthless, "nobody care", "everyone would be better
off
without me"
feeling of overwhelming guilt, shame, self-hatred
no hope for the future, "it will never get better, I will always feel this
way"
drug or alcohol abuse
recent loss: through death, divorce, separation, broken relationship,
or loss off health, job, money, status, self- confidence, self-esteem
loss of religious faith
nightmares
suicidal impulses, statements, plans, giving away favourite things,
previous
suicide attempts or gestures
agitation, hyperactivity, restlessness may indicate masked depression


















Handout 7: C.A. Guidelines


C.A.R.E. Guidelines


* C-Communicate immediately, both verbally and nonverbally, to set
the tone of the encounter; show openness, genuine concern, and
positive regard for the patient/client.
* A-Use Appropriate communication behaviors for the
patient's/client's age, gender, social position in the family and
community, language use and comprehension, and degree of discomfort
or distress.
* R-Recognize the patient's/client's experience, efforts, and emotions
in an honest, straightforward manner, using statements of concern
and empathy, indicating you care about the patient/client and his or
her problem.
* E-Express support and partnership by letting patients/clients know
you will work with them to help them get better.























What is male sexual assault?
Sexual assault is any unwanted sexual contact. It can be committed by the
use of threats or force or when someone takes advantage of circumstances
that render a person incapable of giving consent, such as intoxication.

Male sexual assault can include unwanted touching, fondling, or groping of a
male's body including the penis, scrotum or buttocks, even through his
clothes.

Male rape is any kind of sexual assault that involves forced oral or anal sex,
including any amount of penetration of the anus or mouth with a body part or
any other object.

Some of the feelings a male survivor may experience

Any survivor of sexual assault may experience the following feelings, but
male survivors may experience these feelings in a different way:

Guilt as though he is somehow at fault for not preventing the assault
because our society promotes the misconception those men should be
able to protect themselves at all times.
Shame as though being assaulted makes him "dirty," "weak," or less
of a "real man."
Fear that he may be blamed, judged, laughed at, or not believed.









Denial because it is upsetting, he may try not to think about it or
talk about it; he may try to hide from his feelings behind alcohol,
drugs, and other self-destructive habits.
Anger about what happened; this anger may sometimes be
misdirected and generalized to target people who remind him of the
perpetrator.
Sadness feeling depressed, worthless, powerless; withdrawing from
friends, family, and usual activities; some victims even consider
suicide.

If a male victim became sexually aroused, had an erection, or ejaculated
during the sexual assault, he may not believe that he was raped. These are
involuntary physiological reactions. They do not mean that the victim wanted
to be sexually assaulted, or that the survivor enjoyed the traumatic
experience. Just as with women, a sexual response does not mean there was
consent.

The experience of sexual assault may affect gay and heterosexual men
differently. Counsellors have found that gay men have difficulties in their
sexual and emotional relationships with other men and think that the assault
occurred because they are gay.

Heterosexual men often begin to question their sexual identity and are more
disturbed by the sexual aspect of the assault than any violence involved.

What you should do as a Health Care Provider
If you are unsure, you should:
Ask the patient when no one else is in the examining room.
Make direct eye contact and actively listen to the response.
Ask direct questions in a non-judgmental way
Avoid technical or medical language.

Begin by first normalizing the topic. For example:
"I need to ask you some personal questions. Let me explain why."
"Asking these questions can help me care for you better."
"Since I am your health care provider, we need to have a good
partnership."
I can better understand your health if you would answer some
questions about your sexual history."










Next ask the patient/client directly:
Have you ever been touched sexually against your will or
without your consent?
Have you ever been forced or pressured to have sex?
Do you feel that you have control over your sexual relationships
and will be listened to if you say "no" to having sex?

What if your patient/client says yes?

Validate your patient's/client's response.
"Thank you for telling me about such a difficult experience."
"I'm sure that was hard for you to tell me. It is good that you
told me."
"Rape is devastating in many ways. Let's talk about some of the
ways you need support."

If your patient/client says "yes"
Medical Needs
Discuss any injury or trauma the patient/client might have
experience.
Conduct examination with patient's/client's permission, if qualified to
do so, or refer for evaluation.
Evaluation of potential sexually transmitted infections
and treatment.
Discussion of HIV counseling and testing.

Emotional Needs
Support counseling to deal with clients feelings.
Referral for appropriate follow-up counseling, if you are unable to
provide. Help & Shelter NGO can provide such assistance.

If your patient/client says "no"
Offer education and prevention information and provide follow-up
at next visit.

If your patient/client is "not sure"
Evaluate the experiences) with the patient and provide.
Education about violence and consent.




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