#47 - LGBTQ+ and Healthcare: What you Need to Know With Phillipa Oakley, Part 1

FAKTR, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents. Serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to consume. to digest with actionable information that you can implement into practice right away. Let's get started. Hi guys, welcome to The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thanks for listening. Today's episode features a new training titled LGBTQ+ and Healthcare: What You Need to Know with Philippa Oakley. If I were to ask most any healthcare provider if they offer the same level of care across the board to their patients, Most would answer with a resounding yes, being offended that I even asked the question. Well, today we'll learn why providing the same great care to all of your patients may still leave your LGBTQ+ patients needing a bit more. In this 2-part training, we will discuss some of the key barriers that prevent members of the LGBTQ+ community from accessing equitable and affirming healthcare. We will also cover some of the often overlooked practicalities of providing hands-on care to patients. Such as differential diagnoses, impact of hormone therapies, and the role chiropractors can play in supporting LGBTQ+ patients at every step of their journey. Our guest speaker is Philippa Oakley, the Clinical Director of Acorn Health, an award-winning interdisciplinary clinic based in the United Kingdom. Through Oakley Coaching, Philippa enjoys working with practitioners to help them develop their soft skills and improve their outcomes from care with coaching and motivational interviewing. Philippa graduated from the Welsh Institute of Chiropractic and was awarded the RCC's prize for best research project for her work into how thoughts and feelings surrounding back pain can impact a patient's response to care. She began her career working for a group of private clinics with an NHS AQP contract, completing a postgraduate certification in professional development and chiropractic with the AECC, and received the Graham Heale Award for outstanding postgraduate training. Philippa holds an SFEDI Level 5 Diploma in Personal Performance Coaching, is a professional member of the European Mentoring and Coaching Council, and is a coach and mentor with NHS Leadership Academy. Let's cue the intro music and get started.

Thank you. Well, thank you, Jessica, and thank you very much for having me. It's always a privilege to be invited along to talk about this topic. It's something I feel incredibly strongly about, both as a member of the LGBTQ+ community myself, but also as a clinician working in direct patient-facing contact roles. As Jessica, as you highlighted there, I think this is something that's enormously important for clinicians. I think it's important in terms of humanity as well. And of course, we have the legal aspects that we need to consider to ensure that we are providing the best practice care that we possibly can. So, to introduce myself again, my name is Philippa Oakley. I use she and her pronouns. A little bit of background to me, I am a qualified chiropractor. I graduated 10 years ago, and since then I've been running my own clinic, and I also run Oakley Coaching alongside my wonderful wife, Rhiannon, and we focus on communication skills, on clinical and non-clinical LGBTQ+ inclusivity, and interpersonal skills development and EDI. I'm also the LGBT Development Officer for the NHS Rainbow Badges programme, which is working very closely with NHS Trusts, so the way that the NHS is structured over in the UK, is they have individual trusts that are based on geographic locations. And my role is to work with them to improve the care that they provide to the LGBTQ+ community by reviewing policies and processes and making sure that they are doing what they should do and identifying areas for improvement. So, I'd like to think that this is a topic that I will hopefully be able to add some insight and some value for you all. I'm here predominantly to talk about how this is relevant to chiropractors and what we as clinicians need to know about caring for the LGBTQ+ community. When we talk about this, we quite often hear people say, well, LGBTQ+ people's bodies are exactly the same as ours. We don't need to know anything. We don't need to know anything in particular about the specifics of healthcare. We actually know that thinking along those lines actually goes in the face of science. And hopefully what I'm going to do today is to share some insight into that and give you some clinical pearls and some knowledge to take away, should you ever need it in the future. So, for example, when we talk about LGBTQ+ specific healthcare, we know that transgender patients have really high levels of physical pain. And it's thought that this is due to gender dysphoria. So the emotional distress that comes from living in a body that doesn't match who you feel you are inside, and that can cause underlying mental health issues. The repercussion of that, the long-term impact of that, is that often LGBTQ+ people, but transgender people in particular, feel very unsafe going to practitioners. It is incredibly powerful as a healthcare provider when you can provide somebody with what is often their first ever inclusive healthcare examination. I will never forget treating my first HIV-positive patient who came into clinic and was physically shaking with anxiety. He was sweating, he was almost in tears. He was so anxious about needing to see a healthcare provider, and so apologetic about his needs and the fact that he was HIV-positive. And to be able to alleviate his concerns, to be able to get a smile from him, and for him to visibly and physically relax and enjoy being in the caring hands of a practitioner. It was an incredibly powerful experience. It still gives me goosebumps when I think about it. So we can make an enormous impact, not only on the healthcare trajectories of LGBTQ+ people, but the way they feel about themselves and their lives going on when we provide inclusive care. Now, because of established health inequalities, because of fear of discrimination, LGBTQ+ patients are more likely to present to us with more advanced pathology. So we do have this bigger question to ask about preventative care and the impact that this could have on overall health trajectories. If we were able to create more inclusive spaces, would we encourage LGBTQ+ people to seek care earlier? And there's that big question there that I think needs exploring, but that's probably far too much to get into in the time that we have today. But that's definitely where I'd like to see some more information. Now, I think it's really important just to mention that all the statistics, any references that are quoted in this seminar, we have available in a document which we can send out to you after the seminar. And also to give a trigger warning, because this seminar does involve discussing homophobia, transphobia, trauma, self-harm, and suicidal ideation. And I know that those can be very triggering topics, so there are support links that are available to you. And I also wanted to familiarise you all, all attendees, with some terminology. So, In this talk, I interchangeably use the terms LGBTQ+ or LGBT, and I mean that as an umbrella term for anybody who identifies within the LGBTQ+ community. And I use the term transgender again as an umbrella term for anyone who falls within that bracket, and cisgender to denote someone who was born into a body that matches their sex that they were assigned at birth. It's really important to remember as well as we go through that gender identity is a spectrum. The process is unique for each person. So, just because you have somebody who presents to your clinic and says that they are transgender, it doesn't mean that they have undergone surgery. We know, in fact, 85% of transgender women, so people who were assigned male at birth and have transitioned to female, they do not undergo surgery. Now, that's really important to remember. We're going to talk about the clinical information and why that matters later on in the seminar. And again, to reiterate about Jessica's comments about posting in the chat, I really welcome questions. I think some of the challenges that we have with inclusivity is that we've become so worried about causing offense that it puts people off asking questions or feeling like they're in a safe space to ask questions. So I would ask anybody, I will put my personal email in the chat, but I know also with this platform that you are able to send questions when you're watching the replay. And I would urge you, if you have questions or you'd like to ask them, but you don't feel confident asking them live or in this kind of forum, then please do feel free to reach out to me afterwards. I just ask that if we're having a conversation that we keep the tone respectful in the chat, because obviously We don't know who's going to be listening and who's affected by what we're talking about today. Moving on, what do we mean by health inequalities when we talk about health inequalities for LGBTQ+ people? Now, the biggest survey that we have to look at for drawing data down from the UK is the National LGBT Survey, and we have about 108,000 responses, which for the UK is pretty good going. What that has told us is that LGBT people within the UK and within the world, actually, we know that the issues that they have are fairly standard across the world. LGBT people face widespread discrimination. They face a lack of understanding or meeting of their health needs. They have generally poorer experiences with healthcare, major concerns about accessing healthcare, not just accessing inclusive providers and accessing practitioners who are skilled and aware of LGBT health needs, but geographical challenges with accessing healthcare as well. And it's a generally accepted statistic that 2 in 5 trans people report that healthcare practitioners have a gross lack of understanding of trans-specific health needs. In terms of the scale of the problem, it is really difficult to assess the scale, particularly here in the UK, because up until the most recent census, which we are waiting for the data to be published later on this year, we don't know how many people in the UK identify as transgender. That data just hasn't been collected. We haven't asked that question. In the US, as I know many of you tuning in today will be from the US, around 1 in 6 adults identify as being members of the LGBT community. And around 1.4 million people identify as transgender. And looking in terms of the geographic layout of where those transgender people report as living, we're looking at Hawaii, Georgia, California, and New Mexico as being the states with the highest percentage of transgender people. And then we've got North Dakota, Iowa, Wyoming, Montana, and South Dakota with the smallest populations. It's really interesting to me when we talk about health inequalities, we recognize as practitioners, we recognize that people in the geriatric population have specific healthcare needs. We know that someone's socioeconomic background can influence their healthcare needs. We know that certain conditions are more prevalent in Black and ethnic minority communities, for example, sickle cell anaemia. And you only have to look at what's happening in the media over here in the UK when we talk about racial disparities in maternal mortality rates. That's been receiving an awful lot of attention in the media. So we know that different demographics of people have different health needs. But there is a real reluctance sometimes to engage with the fact that LGBTQ+ people have health inequalities, and these are globally recognized and globally established. There are specific health challenges that we need to consider for LGBT people. We know that there are higher rates of HIV and other STIs, especially amongst young Black men who sleep with men. This is not due to unsafe sex and sexual behavior, but it's due to decreased access to antiretroviral therapy in comparison to white communities. That statistics comes from data in America. So we know that that is the case for young Black men in America. And I think it's really important to mention here that when I say young Black men who sleep with men, I don't necessarily mean men who would identify as gay. So that's something that's often overlooked in practice. Some studies have shown that less than 50% of men and women who have had intercourse with members of the same sex would identify as gay, lesbian, bisexual, or homosexual. So sometimes as a practitioner, we need to be aware of the fact that whether people self-disclose as being a member of the LGBTQ community, It doesn't necessarily mean that they're not at risk of other health behaviors that are associated with the LGBTQ+ community.

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Other health inequalities that we see, higher rates of substance abuse, and a major, major problem within the LGBT community is really low uptake of cancer screening. So mammography, cervical smear screening, and prostate exams, for example, in gay men. This is because around 36% of LGB, so lesbian, gay, and bisexual women, have been told by healthcare providers That they do not need to have cervical smear tests because they are not sleeping with men. Most of us get very excited at the thought of that, of thinking, yay, no more smear tests. But unfortunately, that's not the case. It's one of those medical myths that serves to perpetuate the health inequalities and the health challenges experienced by LGBT people. We know there are higher rates of unhealthy weight control or weight perception, and a significantly higher rate of mental health disorders, most likely due to internalized social stress, due to stigma, and the impact of overt and covert trauma of growing up in an LGBTQ+ unwelcoming environment, or being exposed to bullying at school, or hearing derogatory remarks being made about the LGBTQ+ community by friends, family, social peers, for example. There are also higher rates of smoking in the LGBTQ+ community, higher rates of depression and anxiety, and significantly higher rates of violence victimization. So we know that around 50% of lesbian women, for example, have been victims of sexual violence. When we are looking after LGBTQ+ people in clinic, hopefully you're beginning to realise that actually, there are certain conditions that we need to be more aware of. There are certain risk factors that we need to be more aware of when we are caring for LGBTQ+ people in our clinics. So, I want to show you a little video here of what life is like for a transmasculine patient within the UK. This is Ray. He is a 50-year-old female-to-male transgender person, and he has very kindly shared his insight into his experiences with the NHS here in the UK. Ray has a very strong Irish accent and speaks very fast, but I hope that we'll be able to keep track of what Ray is saying here. So I'm going to start the video now.

But you're going to get one. So I started on gels, and that has nothing to do with the NHS except that my doctor, lovely man, is happy to work with Gender GP to move things along. He's very understanding. But like I said, if it's not from him specifically, the others don't know what the hell's going on, right? So he's been brilliant. It has been hard to get them to read the prescriptions properly, and it's like almost like you're being— as far as they're concerned, you're being rationed. So if anybody asks questions, fine, but nobody does. They're, they're too busy to care. They just want to— they just want to get the form right.

So would you say that that's something— talking to other friends and any other people in similar situations— is that something that you think is quite universal, that people are really having kind of advocate for themselves and really fight for—

100%. Yeah, you have to educate everybody. They're like, I don't know what to do with this. So you have to educate them.

Right. Which requires you learning and upskilling yourself in terms of the hormone therapy.

Yeah, you need to come prepared. You need to come prepared.

They haven't a clue.

But what a lot of other people are saying, it's not my experience, a lot of other people, that doctors are just like, no, unless the NHS has given us a letter, we're not doing it.

So hopefully that has given you some insight into what life is like for a transmasculine patient here in the UK. I think the things that Ray is talking about as being challenging, getting people to read prescriptions properly, getting people to be willing to look at referral letters for him, experiencing a lack of care of people who are just too busy to care, that was really impactful to me to think that actually, this is basic healthcare that we're talking about, reading prescriptions. It's not transgender-specific. And yet, in the context of the wider challenges that LGBTQ+ people experience, That can significantly contribute to the stress and anxiety that surrounds the transitioning experience for somebody who's just starting to use testosterone gels. So I want to talk a little bit about the stigma that is fueled by myth of LGBTQ+ healthcare. And we keep encountering a similar type of comment from healthcare professionals that LGBTQ+ people's bodies are exactly the same as anybody else's, and they don't need specialist care. And it's very interesting. I was talking to somebody recently who was working in dementia care, and we were discussing the fact that actually Now we know that the, for example, homosexuality was decriminalized here in the UK in 1967. And it was declassified from the DSM, so declassified as being a mental illness in 1973. That is well within living memory. And talking to this person who runs a care home in the UK, they were saying, well, we've got an aging population now of LGBTQ+ people who are living with dementia. And unfortunately, one of the impacts of dementia is that it causes people to live in the past. So they are experiencing a number of their patients in care homes who are living at a time where they could be arrested, or even imprisoned for being homosexual, and how difficult that is to deal with as a practitioner, how challenging that it is for their families, and the real practical aspects of how do you honour the choices for somebody who's living with dementia that perhaps is really struggling with the social impact of being LGBTQ+. And so, There are so many different things that we simply need to draw the connection between what we know in the cisgender community and what we know about the LGBTQ+ community and take the data that's available to us and say, well, actually, we need to be able to provide specific care to LGBTQ+ people. I think PTSD is a really interesting one to look at as well. We know that in veterans, for example, they have significantly higher rates of PTSD, and those links have been really well explored. And we know that people with PTSD, for example, firemen with PTSD, have a significantly increased likelihood of developing back pain or developing other MSK conditions. And so we've drawn that link between PTSD, veterans, and back pain, but we haven't drawn the link between the fact that the LGBTQ+ community are significantly more likely to develop PTSD. And therefore, are the LGBTQ+ community also by extension at increased risk of developing lower back pain? So it's really interesting to me when I consider the question of whether we need to know specifics of caring for LGBTQ+ people, because actually, it goes in the face of what we know about the biopsychosocial models in healthcare. And this is despite all of the studies that we have available to us that say that the biopsychosocial model is something that is multifaceted, and that we need to be aware of when caring for any patient. So actually, it does somewhat go in the face of science to ignore the fact that LGBTQ+ people do have specific health needs. So when we talk about the key obstacles with getting professionals to a point where they can provide inclusive care, one of the main challenges is stigma. And this is reflected in studies with key contributing factors which influence the poor health trajectories of trans people. And it is literally one of the 3rd biggest contributors to poor health trajectories in trans people in the UK. And the 2 other biggest contributing factors were lack of awareness and information erasure. So where somebody's transgender status isn't reflected appropriately in their notes, for example. And one of the issues that we see with cervical screening, for example, is the fact that cervical screening results are marked as being male, and they are therefore rejected from the lab because they are marked as a male sample. And that is a simple fact that the technology systems, for example, in the UK are not set up to cope with transgender people, for example. So we can see how multifaceted this challenge is when we're talking about LGBT healthcare. So, when we talk as well about health inequalities, I'm sure that most of us are probably familiar with this conversation. We talk about equality, equity, and we talk about liberation. This proves that when we provide equal or the same care to a patient with pre-existing disadvantages, we aren't actually levelling the playing field for them. We're perpetuating further inequality. And as a practitioner, it can be quite upsetting when we say that we have health inequalities in some of our patients that we aren't addressing. And people will often say back to me, but I treat all of my patients the same. I treat everybody the same. I welcome everybody to my clinic. And that's never in question. Absolutely never in question. We know that, practitioners. We know that you're all out there providing the very best care that you can to your patients. But if we've got a patient with an existing disadvantage, then we know from this example that if we provide that patient with exactly the same care that we would provide to somebody who does not have that disadvantage, that actually the inequality is still going to exist. Treating everybody the same doesn't recognise an individual's health needs or recognise how an entire demographic of people can have shared experiences of health issues. And speaking to LGBTQ+ patients, we have this challenge with the fact that many of them would not seek care from practitioners who aren't appropriately trained in LGBTQ+ care. So again, when we think that perhaps you might be sitting there thinking, well, this is really interesting, but I don't treat transgender people. You potentially do, or you might well be missing out on this demographic because they simply don't feel confident coming into your practice. And we're going to talk about visual signposting and about practical steps towards inclusivity that you can do slightly later on in the talk. Now, it's very, very interesting to me as well because one of the statistics that shocked me when I was producing some research for our course is the fact that 31% of transgender people in the USA do not have a single primary care provider who is aware of their transgender status. 31% of transgender people. So that, to me, it's worrying. We know that hormones are readily available on the black market. We know that there are many transgender people who are out there microdosing, so they're providing themselves with hormone therapies and they're self-administering those without the care of an endocrinologist, for example, overseeing their care. So that's desperately worrying. So we do need to think about the impact of not signposting ourselves and not practicing active inclusivity, and whether this is, again, perpetuating the health inequalities that we might experience. What is the impact of these health inequalities? Now, going back to the National LGBT Survey and the information as well that we have from America, we know that negative experiences of healthcare are a huge, huge issue. We know that there is a struggle that people are not able to access care that they need when they need it. And that, that is an enormous challenge for LGBT people. But almost 40% of survey responders had had a negative experience with a healthcare provider because of their gender identity. 40% of people. And 50% of survey responders struggled with access to mental health services, saying that the waits were too long, saying that the waiting list for gender identity clinics was too long. Now, Jessica and I were talking about this just before we came on air, but over here in the UK, the largest gender identity clinic that we have Is currently accepting referrals that was made to it in 2017. They are currently offering first appointments for referrals that were made in 2017. So that's a 5-year waitlist, and that's the shortest waitlist that we've currently got. And it's really important to bear in mind as well that that's the first appointment. That's just to get in and talk to somebody. That's not to start hormone treatment. So for some people like Ray, for example, when he was presented with the fact that he could have a 5-year waitlist just to get that initial appointment, And then you have another year after that before you can potentially start on hormone therapies. That's 6 years. And as he says in the rest of the interview, which I haven't shared with you because it's a 45-minute-long interview, but he says at 50, that would have him as 56 before he was able to live authentically as himself. So he has actually traveled over to the US to have surgery over there. Why are LGBTQ+ people experiencing health inequalities? And what is the impact on us as clinicians? That one of the biggest challenges, particularly over here in the UK to talk about that, is that there is no required training on transgender-specific care for GPs in the UK. They do not have to study it at any level. And that in itself is an enormous factor. I think the Royal College of General Practitioners is trying to address that and is trying to introduce it at an undergraduate level here in the UK. But we're also compounded by the fact that there's a massive lack of awareness of the need for training. And unfortunately, it tends to only be people who are Either actively involved in caring for the transgender community, or who recognise that there is this gap in the knowledge, who then seek out the training. So we are finding that people who are engaging in the training are perhaps not the people who need the training the most, which is unfortunate and is something that I really hope becomes addressed, whether we produce standardised training or whether it is introduced as a prerequisite in training over here. That would be wonderful. We also know that there's a challenge with whether the training is specific enough. So we know that, for example, LGBT training, if it is included in any other healthcare care programmes over here, that it tends to be included as part of a wider equality, diversity, and inclusivity package, and it's simply not specific enough. It's really important to note that the things that I'm talking about here, whilst I talk about the situation in the UK, I know some of you who are joining us live or who are watching the replay will be from the UK. Some of you might be from Australia, some of you might be from other countries around the world. The issues that we experience, that the LGBTQ+ community experience, tends to be fairly standardized around the globe. That tends to be a common feature that we see. So we know, for example, that in Canada, they have very similar challenges. We know that the main gender identity clinics are located in places like Toronto and Quebec. And if you live in a rural environment, that's going to present enormous challenges to you for trying to actually geographically access the clinic. So this is something that we can extrapolate this information, and we can gather that this is going to be a similar challenge for LGBTQ+ people around the world. Bearing in mind as well that there are still a worrying amount of countries in the world where it is illegal to be homosexual, to be a member of the LGBTQ+ community, and the impact that that must have on someone's trauma experiences and long-term health trajectories of growing up gay, we can only but see. It's considered now— we used to think that growing up in a homophobic environment was traumatic, but actually we now know that it is traumatic, that it has the same influence on the brain as any kind of childhood trauma. So that is something to really consider with LGBTQ+ patients who might come into your clinic, that their mental health needs are going to be significantly more prevalent, that they're going to have a significantly increased likelihood of having underlying mental health concerns that need to be supported. And again, the mental health involvement, the psychosocial concerns with lower back pain, and what I hope is fairly standard term to call them yellow flags, Those are well established as being factors in terms of predicting outcomes from care in low back pain cohorts. So this information is, I hope, is coming across. While we do not have the data to back this up, unfortunately, because we do not have enough research to draw upon, we have to draw upon a lot of data from a global environment from across the world, because we simply do not have enough studies into LGBTQ+ specific healthcare. And these more niche areas like LGBTQ+ low back pain, for example. But hopefully we can look at the data that is available and draw hypothetical conclusions that are hopefully going to be proven correct when we are able to produce more research into this as a global community. So let's share another video of Libby. Now, Libby is a gay single parent living in Brighton in the UK. I will let her video speak for herself, but it's another video that is enormously impactful to me to highlight the, some of the insensitivities that the LGBTQ+ community face. The reason why I share this is because I hope it gives an overview of why LGBTQ+ people, for example, might present with higher levels of anxiety, why they might have more emotional reactions when they come into clinic. And unfortunately, It's because the experience of microaggressions, of insensitivity, is such a common occurrence in the LGBTQ+ community that many people do not even note it as being part of the complaint, for example. So, a lot of the work that I do with the NHS, they say, we don't have these challenges. Being LGBTQ+ people, it doesn't form part of a patient's complaint. So we aren't discriminating against LGBTQ+ people. They aren't having a worse health experience. They are. When we actually look at data that has been collected by external groups, Stonewall, for example, who are a leading LGBTQ+ rights charity in the UK, we know that people are experiencing terrible experiences with healthcare here in the UK. But the NHS is saying that no problem exists. And it's simply because LGBTQ+ people do not believe that enough will be done. And they do not think that there is any point in challenging these microaggressions, because it's become such a commonplace occurrence for them. So let's have a listen to Libby.

And it's— I've got a couple, one of them's trans and the other one's queer, and they look like a heterosexual couple. So when they've been to sort of appointments and things, it's like, oh, husband and wife. And, and it's like they said, it's really difficult because there's an assumption all the time, isn't there?

Yep.

And when I've been to different— to the doctors and to appointments, and it's like it's on the system. I've said so many times that I'm gay, so many times that I'm solo, they don't go on the system. And with another example, my friend was heavily pregnant, getting really bad palpitations. Her wife, because of COVID couldn't go in, so she stayed in the car park. Said, right, go in. I'll wait out here, any problems call. So she's gone in and the doctor's like, right, sit down, tell me what's going on. She said, look, pregnant, getting really bad palpitations, my wife's in the car. She went, your wife?

How are you pregnant then?

She just was just distraught, very emotional, as you can imagine, and devastated by this comment. And then it just made her even worse.

Yeah.

I mean, the wife wanted to get out and kind of have a chat with this doctor, but it didn't happen. But the feedback, again, it's like you go in to trust these practitioners and you're getting—

So Libby's experiences of healthcare within the UK, as you can see, it wasn't something particularly catastrophic that was said to her friends. It wasn't an overtly homophobic, transphobic comment. It was simply insensitive. It was simply an insensitive comment that was made that had such a significant impact on her friend's experience of healthcare. And when we think about the impact of that, if you think as a patient, if you're walking into a clinic and you experience that, and that is your experience within that clinic, how that would make you feel about that clinic, how trusting you would feel of the practitioners within it.

That's it for today's episode. Be sure to tune in for episode 48, where we finish up part 2 of this training on LGBTQ+ and healthcare. In our next episode, we dive deep into the issues and intersectional challenges behind the health inequalities that LGBTQ+ patients experience. We'll gain a solid understanding regarding the key considerations that practitioners need to be aware of when providing hands-on care to LGBTQ+ people and learn practical steps to create an actively inclusive business. You won't wanna miss it. Episode 48 drops in 2 weeks. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Give us a 5-star rating to help us grow the show. Every little bit helps. You can also subscribe to our Patreon channel for special discounts and member perks on Factor products, live trainings, and online course offerings. To learn more, visit the Patreon link in our show notes. You'll also always find a link to download the PDF presentation from the training featured in each episode, along with a link to view the full video webinar recording if you're a visual learner. So please be sure to always check the show notes for additional details. And last but certainly not least, we invite you to join us for a live hands-on factor training in a city near you. Next month, we will be in Mesa, Arizona on March 11th and 12th, and in Bayamón, Puerto Rico on March 25th and 26th. Please be sure to visit factoreducation.com— that's F-A-K-T-R education dot com— to view the full course schedule, including our international course dates, and take advantage of any special discounts and offers. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R hyphen store dot com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word. to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.