Curriculum
It is critical to emphasize that health care system encounters should be centered on the individual and family, avoiding assumptions and stereotypes.
Cultural competence trainings of healthcare providers and staff should aim to improve learners’ knowledge, attitudes, skills, and behaviors. The specific content of a training or program will vary depending on the amount of time allotted, the professional backgrounds of learners, and their job description relative to providing healthcare or related services. Moreover, cultural competence trainings will differ based on the specific goals and issues faced by the organization or health care practice.
- provide essential information about concepts and terminology, culture, discrimination, and health disparities;
- provide information on health-promotion strategies for people that address institutional and interpersonal catalysts of resilience as well as barriers to health;
- promote awareness of how people may differ in their needs and concerns, based on race, ethnicity, income and resources, cultural background, and other identities and life experiences;
- promote self-awareness of the learner’s assumptions and implicit biases along with tools and resources for addressing them; and
- facilitate the development of skills that will allow providers and staff to provide patient-and family-centered care that is discerning, respectful, and non-judgmental by eliciting each patient’s specific needs, history, and concerns, and facilitating shared decision-making of patient and provider.
It is critical to emphasize that health care system encounters should be centered on the individual and family, avoiding assumptions and stereotypes. Providers and staff must be attentive to and respectful of the diversity of many individuals’ identities (e.g., race, ethnicity and cultural backgrounds as well as sexual orientation, gender identity and expression, or the presence of intersex traits). It is critical to emphasize strength-based strategies for building resilience for individual patients and their families and communities. These strategies include, but are not limited to, trauma-informed care, affirmative treatment and assessment approaches, shared decision making, person-centered planning, informed consent, and non-medicalized psycho-social supports.
Ideally, a cultural competence training or program will include the following topics:
Basic concepts of sexual orientation, gender identity and expression; sex development and variatiosn in sex characteristics including basic facts about intersex people; and essential terminology.
Healthcare disparities – both between and non- persons, and within communities – and their relationship to stigma, discrimination, minority stress, and reasons for distrust of health care providers. It is useful to include local as well as national data when available, to summarize the particular challenges and disparities experienced by subpopulations. In addition, it is recommended to tailor the presentation of disparities to the particular work of the learner audience – e.g., family medicine, mental health provider, executive leadership, geriatric nursing, pediatric care, facility security. Where relevant, it may also be helpful to illustrate how stigma and discrimination can affect the health of people over a lifetime – e.g., the long-term implications of discrimination and stigma on young people; and the particular challenges faced by elders who may have lived with stigma and discrimination for decades, including potentially in health care settings.
Applicable nondiscrimination requirements of federal, state, and local laws, professional and ethical standards of care, and institutional policies.
How sexual orientation, gender identity and expression, and variations in sex characteristics intersect with race, ethnicity, immigration status, and other stigmatized or marginalized identities in the relevant population (e.g. Washington DC’s large community of transgender immigrants) or service area (e.g., gender-queer youth in white rural communities; people who inject drugs and are living with or at risk for HIV). It is very important that discussion of intersectionality not be limited to the simple point that most people have multiple identities. Discussion of intersectionality should focus on the multiple ways in which individuals with different identities experience oppression and are situated differently in power relationships.
Implicit bias and microaggressions; self-awareness and self-reflection. Awareness of how certain privileges may “blind” service providers to the realities that confront oppressed minorities, for example, heterosexual privilege, white privilege, male privilege, cisgender privilege, and gender-conforming privilege. Further, that many in the medical community may have been trained under modes of treatment that do not center patient autonomy. These forms of oppression may be exacerbated by the power dynamics that frequently exist between providers and patients.
Effective communication skills; building affirming environments; how to acknowledge and recover from mistakes, for example when a patient is misgendered.
How to ask questions about sexual orientation, gender identity and expression, and sex characteristics in a respectful manner, and how to meaningfully utilize this information for safe, affirming, non-judgmental care.
How to avoid disrespectful and clinically inappropriate questions – for instance, questions about a patient’s intersex traits which are not relevant to the health issues the patient is presenting.
How stigmas impacting sexual, gender and sex development (intersex) minorities (and other stigmatized or marginalized identities) creates barriers to high-quality healthcare and can cause or exacerbate poor health.
How to appreciate and communicate respect for a patient’s sexual orientation, gender identity or expression, and/or intersex traits/sex characteristics, and to appreciate ways in which the patient’s minority status, and the related obstacles they have encountered, may have stimulated resilience and strengths. In this regard, it is important to emphasize ways in which a health care provider or staff person can either contribute to, or help alleviate, strong feelings of isolation and internalized stigma that many individuals and families experience. It is also recommended to provide examples of how past misunderstanding or mistreatment experienced by individuals and families may have led them to mistrust providers and to withhold information.
Trainings will ideally help participants to discern ways in which their institution creates a welcoming or unwelcoming environment for individuals and families, and ways in which the institution’s policies and procedures encourage or discourage such persons to seek care and to be forthcoming about their lives and sexual practices. The goal is to educate and empower participants to assess opportunities for institutional change as well as improve their personal encounters with individuals and families.
Although the focus of cultural competence training is different from trainings specific to particular clinical services (and cultural competence trainers may not be qualified to address specific issues of clinical care), it is highly recommended that the content of a training session illustrate particular points with examples or scenarios that are likely to arise for the audience in question (e.g., an ER, or a skilled nursing or assisted living facility, or a post-surgical care unit, or a primary care physician’s office, or in a therapy session)
Time constraints may require particular topics to be omitted or covered only briefly in a specific training session. When tailoring a session with time constraints in mind, it is important to emphasize communication skills, and awareness of the learner’s own implicit as well as explicit biases and how those may limit the provider-patient relationship. Basic concepts of sex development, sexual orientation, and gender identity and expression should be covered, along with terminology that is essential for respectful communication (including an individual’s partner, chosen name and pronouns). However, detailed discussions of terminology may be less critical than fostering communication skills and open attitudes. There must be an awareness of and openness to patients with intersecting marginalized identities such as trangender people or people of color.
The curriculum should align with the learning objectives. For shorter and single-session trainings, most of the learning objectives focus on increasing the learners’ knowledge and awareness. Changing attitudes takes time and is unlikely to happen in a single training. Likewise, skills-building may take multiple sessions. However, even if time is limited, there should be at least one exercise or reflection that focuses on empathy.
Trainers should keep in mind that health care providers may be habitually predisposed to emphasize “hard” knowledge (a specific set of facts or conceptual categories or rules of thumb for a patient encounter) over “soft” skills of respectful listening and communication, and reflective awareness of one’s own assumptions and emotional responses. Such a predisposition should be expressly acknowledged and addressed by emphasizing the importance of listening and communication skills, and an open, respectful attitude, to good patient care.
Trainers should specifically name what is and what is not being addressed (or being addressed only superficially) in a specific training. For instance, trainers should explicitly note if a training session is addressing lesbian, gay, and bisexual, people but not transgender and gender non-binary individuals. Another example is stating directly to the participants if the experiences of individuals who speak languages other than English or recent immigrants are not addressed.
Similarly, given the diversity of people, it is very important that the audience not assume that the experiences of the trainers are representative of the entire community. Therefore, consider the intersectional identities of the trainers and how this might impact the session content or how participants interpret it. For example, if all of the trainers are white and primarily have experience with white patients, these gaps should be explicitly acknowledged. When this happens, figure out ways to bring in absent voices, for example, through videos or a guest speaker.
Although most cultural competence trainings will not focus on clinical issues, issues of barriers to culturally competent care should, when appropriate, be integrated into clinical trainings. For instance, in educational sessions on cancer screening or cancer care, the importance of regular screenings for gay and bisexual men, individuals with intersex traits, lesbians and bisexual women, transgender men and women should be included. Continuing education and health professions school courses that include case studies should include individuals and their partners and families. Even when a clinical issue may not be related to the patient’s sexual orientation or gender idenetity and expression, introducing, e.g., a bisexual, lesbian, or transgender male patient into a case study, can reinforce the provider’s understanding of the diversity of the patients they encounter.