Pillars of Service

Health inequities are widespread and persistent; the root causes are social, political and economic as opposed to exclusively behavioral or genetic. A barrier to transformative change is the tendency to frame these inequities as unfair consequences of social structures that result in disadvantage, without also considering how these same structures give unearned advantage, or privilege, to others. (Nixon, 2021)

Anti-oppressive care is an essential starting point to address the health inequity emergency in the US. As a healthcare provider in a position of power, I practice critical allyship (Nixon, 2021) to consistently strive toward providing anti-oppressive care. Practicing critical allyship allows me to understand my positions of privilege, and use my understanding of approach care from a place of solidarity and collective action on systems of oppression, rather than as a savior for underserved people. My practice of critical allyship and anti-oppressive care are supported by my pillars of service.

Pillars of Service

Multicultural Humility

2SLGBTQIA+ Affirmative Care

Multicultural Humility

Sex-Positive Care

2SLGBTQIA+ Affirmative Care

Multicultural Humility

2SLGBTQIA+ Affirmative Care

Trauma-Informed Care

Body Liberation & Weight-Neutrality

2SLGBTQIA+ Affirmative Care

Access-Centered Care

Body Liberation & Weight-Neutrality

Multicultural humility involves a provider reflecting on their own cultural identity, and how it impacts their interactions with others (other providers, organizations, general public and clients).

The Tenets of Multicultural Humility

The tenets of multicultural humility include the following: Lifelong learning, mitigating power imbalances, and institutional accountability.

Lifelong learning is the process of self-reflection, self-critique, commitment to understanding and respecting differing points of view, and engaging with others humbly (from a place of learning).

(Tervalon & Murray-Garcia, 1998)

Mitigating power imbalances involves the desire to fix power imbalances where none ought to exist. This also involves recognition that each person brings something different to the proverbial table of life helps us see the value of each person. When providers work with clients, the client is the expert on their own experiences. The provider holds a body of knowledge unavailable to the client, and the client has a lived-understanding unavailable to the provider. (Tervalon & Murray-Garcia, 1998)

Institutional accountability includes working to develop partnerships with advocacy efforts. This allows providers to practice interdependence: The intentional, meaningful collaboration between two or more partners that assumes connection and cooperation are not just beneficial, but essential for progress. While individual providers can create some positive change, individual providers working together within the larger systems creates positive change on a systemic level. (Tervalon & Murray-Garcia, 1998)

both Competence & Humility Matter

The concept of multicultural competence gained widespread attention in public health and medicine in the 1980s and 1990s, where it became integrated into health promotion and health education practices.

(Greene-Moton & Minkler, 2019)

However, the word “competence” is described as problematic, as it implies a top-down approach, with one person (often privileged members of any given group) deciding what is and is not considered relevant and beneficial in treatment. Cultural competence also is described by some as too binary a construct, implying that if one can never be fully multiculturally competent, as they will always have implicit bias to unpack.

(Greene-Moton & Minkler, 2019)

Multicultural humility is an outlook, not an achievement. Practicing humility unpacks assumed "right ways" of doing, communicating, and thinking, and steps back to make room for alternatives (Nixon, 2021).

However, multicultural humility may not encompass the provider's responsibility in their privileged position to receive education and training outside of client-care to use within client-care.

(Greene-Moton & Minkler, 2019)

While there has been controversy that creates an "either/or" dynamic between them, both multicultural competency and multicultural humility are focused on building understanding and bridging cultural differences while encouraging self-reflection with respect to privileged and marginalized communities. Both concepts also stress the need to challenge the systems in which we live to bring about collective action. Providers can step out of the "either/or" dynamic and approach care through a “both/and” lens.

(Greene-Moton & Minkler, 2019)

Sex-positive care is thorough, comprehensive, emphasizes the pleasurable, rewarding, and nonprocreative aspects of sex. Sex-positive care recognizes the significant cultural diversity in sexual practices, while also acknowledging substantial variation in personal meanings and interests. Sex-positive care recognizes sexuality as a valid human need, that exists across the lifespan. Sex-positive care believes sexual wellbeing, sexual health, and sexual justice are essential determinants of sexual experience over the lifespan. Sex-positive care believes sexual pleasure has both clinical and public health implications for addressing the pleasant, unpleasant and ambiguous diversity of sexual experiences. Sex-positive care believes concepts of sexual justice (including sexual rights and sexual citizenship) identify the social, cultural, and legal structures that continuously shape and define the sexual experience. Sex-positive care is trauma-informed, interconnecting sexual justice, pleasure, wellbeing, and health.

(Fava & Fortenberry, 2021)

Let's Talk about Sex

Since human sexuality and its expression are so diverse, it is important that the topic of sexuality is discussed in an open, informed, respectful, and nonjudgmental manner. Discussions around sexuality are not substantially different from any other topic. When sexuality feels like a taboo topic, it limits the focus we can give to human diversity, contributing to marginalization and othering. Sex-positive care also emphasizes the importance in accepting of individual differences related to sexuality and sexual behavior and allows for a wide range of sexual expression.

Similar to the approach with other systemic issues, healthcare providers need to participate and contribute to respectful, honest and safe discussions of sexuality to prevent and resolve substantial social problems. (Harden, 2014)

The Critical Need for Sex Education

Sex-positive care is a stark contrast from the predominant 'risk' perspective circulated in erotophobic

(sex-negative) societies. Erotophobic societies encourage sexual asceticism, and present sex as a risky, problematic, and flagrant past-time. Erotophobia is linked to prejudices of sexual practices and identities, but also to the systemic oppression of other marginalized identities. Erotophobic societies expect members of "vulnerable" communities (teenagers, older adults, disabled people, gender-diverse people, etc.) will abstain from sexual activities. However, this is not a realistic expectation; individuals in all of these communities engage in sexual activities⁠—they just have less access to representation, celebration, education and sexual healthcare than more privileged communities. (Harden, 2014)

It’s important that individuals have access to information on their bodies—denying knowledge is a way of denying autonomy, which increases likelihood of harm. In the US, only 26 states require both sex education and STI/HIV education in schools, and only 13 states require that sex education and STI/HIV education be medically and scientifically accurate. (Guttmacher Institute, 2022)

Although exorbitant federal funding goes into abstinence-only programs, meta-analytic research shows that these programs don't have a significant effect on sexual behavior. Abstinence-only programs do succeed in reinforcing social inequities (race, class, gender, sexuality, ability, etc.). More directly, abstinence-only programs are rooted in the moral values of the dominant culture (white, middle-class, heterosexual, monogamous, and reproductive-focused cisgender men). (Harden, 2014)

Sex-positive programs, which encourage both abstinence and contraceptive use as forms of birth control, have effectively delayed the onset of sexual activity in adolescents and increased contraceptive use.

However, Sex-positive programs do not solely promote engaging in sexual activity as the takeaway from sex education. Sex-positive programs emphasis the importance of choice, consent, expression, health and development. Furthermore, sex-positive programs provide communities with a safe space to ask questions and learn and receive available resources. (Harden, 2014)

Sexuality ≠ Allosexuality

Sex-positive care does not assume everyone's sexuality is the same. Sex-positive care encompasses a variety of sexual behaviors, sexual identities, and gender identities that have been historically stigmatized, medicalized and minimized. Sex-positive honors diversity in sexual expression and sexuality across the lifespan. Sex-positive care uplifts asexual identities (asexual, gray-ace, demi-sexual, etc.), as well as genderless identities (agender, non-gender, neutrois, gender-neutral, demi-gender, demi-flux, etc.).

2SLGBTQIA+ affirmative care refers to a range of models that serve to create safe and supportive health care environments in which individuals can express their identity. 2SLGBTQIA+ affirmative care assumes sexuality and gender diversity were normal aspects of human diversity, and recognizes the importance and affirming identity in helping individuals integrate their identity with the rest of their lived experience. 2SLGBTQIA+ affirmative care is a means to celebrate and honor the individual, given the myriad ways in which an individual exists within a culture, even when their experience includes being oppressed and stigmatized. (Mendoza et. al., 2020)

Affirmative care is life-saving care

2SLGBTQIA+ affirmative care blends the micro, mezzo, and macro by supporting 2SLGBTQIA+ individuals while actively speaking out when individuals, groups, institutions, and communities treat them with less than the full dignity they deserve. (Gates & Kelly, 2018)

2SLGBTQIA+ individuals experience disproportionately high rates of stress-sensitive mental health conditions resulting from stigma-related challenges across the lifespan. 2SLGBTQIA+ individuals are also more likely to seek mental health treatment than individuals in the general population. Despite higher rates of treatment use, 2SLGBTQIA+ individuals still experience large unmet treatment needs and significant barriers, such as: Lack of available 2SLGBTQIA+ affirmative providers, shame about emotional challenges and stigma-related stress that interferes with treatment access, compounded marginalized identities that also experience disproportionate poverty and financial barriers (race, class, nationality, ability, etc.), and mistrust of mental health services due to current heterosexism and cisgenderism in healthcare as well as historical stigma, oppression and medicalization of 2SLGBTQIA+ individuals. (Pachankis et. al., 2021)

These experiences of discrimination and oppression are also reflected in mental health trends among transgender people. Disproportionate rates of suicide ideations and attempts as well as violence and hate crimes are reported. A better understanding of affirming care could help healthcare professionals interact with these individuals in a meaningful and patient-centered way as well as increase the healthcare system’s ability to identify individuals who may be in crisis and connect them to protective resources. (Shearer-Cantrell & Daniels, 2020)

2SLGBTQIA+ affirmative care understanding and empathizing with discrimination, microaggressions, and victimization experienced by 2SLGBTQIA+ clients. 2SLGBTQIA+ affirmative care contextualizes identity and develops safe, supportive, and identity-affirming networks. (Gates & Kelly, 2018)

Far & Few Between

historical stigma, oppression and medicalization of 2SLGBTQIA+ individuals. (Pachankis et. al., 2021)

While 2SLGBTQIA+ community centers provide frontline, essential healthcare and support services, the existing needs outweigh their resources. Furthermore, most of the 2SLGBTQIA+ community centers in the US are located in cities and coastal states characterized by low anti-2SLGBTQIA+ structural stigma defined as the societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and well-being of the stigmatized. 13 states do not have 2SLGBTQIA+ community centers, posing access barriers to SGMs living in many high-stigma, rural areas. Additionally, little is known about these services. 2SLBGTQIA+ community center treatment capacity, format of services, type of services, and perceptions of community mental health needs across centers remain relatively unknown.

(Pachankis et. al., 2021)

To Infinity & Beyond (2SLGBTQIA+)

2SLGBTQIA+ affirmative care isn't simply learning more about the identities of 2SLBTQIA+ clients. It is not enough to acknowledge a client’s cultural experience. 2SLGBTQIA+ affirmative care is both active celebration and activism. Providers are called on to affirm client experiences through validation, cultural celebration and active involvement of forces outside the individual to play a role in their care. Ultimately, providers must be dedicated students of the clients they serve while respecting the lived-experience and autonomy of their clients. (Mendoza et. al., 2020)

Trauma-informed care is an approach to treatment with any client and client-system, regardless of background and circumstance. Trauma-informed care equips providers with a thorough understanding of traumatic events, experiences and effects to use in the context of general care.

Principles of Trauma-Informed Care

Have you ever spoken with a professional about a sensitive topic, and their responses or behaviors during the conversation left you feeling dismissed, triggered, isolated and powerless?

Trauma is often an unspoken presence in the background of our lives, that may step forward unannounced. This is also known as being triggered. We can track trauma responses and predict when they're likely to show up, but we are not in control of the actions of others that can be triggering.

The world can be triggering enough⁠—treatment should never be a place where you are made to feel triggered without help, consent or support. Trauma-informed care creates space for providers to interact with clients in a way that will avoid re-traumatizing the clients. Trauma-informed care is grounded in the principles of safety, the power of choice, collaboration, trustworthiness and empowerment in session.

Trauma-Informed Care & Trauma-Focused Care

While both forms of care require a rudimentary and holistic understanding of trauma, trauma-informed care and trauma-focused care are not the same—they are forms of care with different approaches, focuses and treatments.

Trauma-focused therapy is a group of specific approaches to treatment that primarily focus on trauma recovery. In trauma-focused therapy, clients learn about trauma, work to re-establish safety, identify what their triggers are, develop coping skills to use in triggering moments, and practice trauma processing and integration. Trauma-focused therapy aims to reduce trauma symptoms and increase a sense of personal empowerment.

Trauma-informed care does not necessarily focus on the impacts of trauma in treatment. Trauma-informed care is an approach that recognizes the nature of trauma and how to honor a client's experience with trauma while focusing on other aspects of their life in treatment.

Access-centered care is an approach to care that believes access is an ongoing practice. Access-centered care recognizes that everyone has access needs that deserve to be met. Access is more than just Disability, but also related to other marginalized identities. Centering access is a starting point—not the end goal.

Accessible Care —Vs— Access-Centered Care

"Accessible care" is a term that assumes the provider is fully prepared to meet the access needs of all potential clients. This is impossible. There is no such thing as universal access because everybody has different needs. Access-centered care is an ongoing practice that takes time and commitment. Skilled providers focus on being access-centered, which means they are centering and prioritizing access for everyone. (BADT, 2021)

Disability Justice

While everyone has access needs that will change over the lifespan, disabled folks have been shut out of spaces, events, and resources for generations. Disability Justice centers the disproportionately marginalized communities within disabled communities (Black, Indigenous and other People of Color; BADT, 2021).

Disability justice (DJ) is a framework created by disabled, queer women of color that analyzes the intersection of disability and ableism with other forms of oppression and marginalized identities. Operating through a DJ lens helps to dismantle ableism in all its forms, as well as its support of the larger systems of white supremacy.

Body liberation is the freedom from social and political systems of oppression that designate certain bodies as more worthy, healthy, and desirable than others. Body liberation believes all bodies are worthy and all bodies deserve respect. (UVM, 2022)

Weight-neutrality is an approach to well-being that decenters the BMI, size, weight, and shape of bodies. Weight-neutrality believes the following: A person's health status, risk level, or quality of life cannot be assumed based solely on a number on a scale; a person's weight, size and shape are not as directly and linearly related to higher quality of life and reduced risk of disease as is commonly thought; bodies have always come in a variety of shapes and sizes, and it is not reasonable to expect that the majority of people can attain and maintain a bodyweight in a relatively small range; and all individuals (regardless of weight) can benefit from interventions that help them take charge of their thoughts, feelings, and decisions, which can lead to improved well-being. Weight neutrality offers an alternative with demonstrable positive and sustainable health outcomes without negative consequences. It also engages individuals in meaningful and compassionate efforts to improve health and quality of life, regardless of size. (Johnson, 2015)

Combatting Body Terrorism

Fatphobia is the implicit and explicit bias of individuals in larger bodies that is rooted in presumed moral failing. Fatphobia is intrinsically linked to other systems of oppression (anti-blackness, racism, classism, sexism, cisgenderism, ableism, ageism, etc.). (Glossary for Cultural Transformation, 2021)

Healthism is the belief-system that sees health as the responsibility of the individual and ranks the personal pursuit of health above all else; healthism measures individual worth by their health. Healthism ignores the impacts of genetic, social, political and environmental factors that are out of an individual's control. Healthism supports white supremacy, leading to placing blame an responsibility on marginalized bodies and privilege, widening health inequalities, and perpetuating interpersonal discrimination. (Goldberg, 2018)

Fatphobia and healthism are body-shame and body-based forms of oppression that terrorize our relationships with our bodies, also known as body terrorism. Fatphobia and healthism frame size, weight and fatness as the individual failures of self-control, discipline, intelligence, etc. Furthermore, the medical industrial complex (MIC) has fatphobia and healthism built-in, so generations of healthcare providers have been taught to blame weight, size and poor choices for ailments that people of all sizes experience. Challenging fatphobia and healthism involves constantly combatting deeply embedded cultural messages, values and laws circulating throughout society. (Taylor, 2018)

Radical Reflection: Take a moment to consider how body terrorism has impacted your life and the lives of people you love. Imagine what might be possible in a world without it. (Taylor, 2018)

Body-Positivity & Fat Positivity

Body positivity believes all individuals deserve to have a positive body image, regardless of how society defines the ideal body. (Cherry, 2020).

While body positivity is a place to start for self-acceptance work, the movement fails to acknowledge the privilege of thin or "straight" bodied individuals and the marginalization of individuals in larger bodies. Body positivity promotes self-love, but it's difficult to maintain unwavering self-love in a culture that marginalizes bodies on a regular basis. Practicing self-love and combating systemic oppression may be connected, they are not the same. Fat positivity and acceptance centers and celebrates the bodies that are not culturally accepted now. (Severson, 2019)

Anti-Oppressive Care