Taking Action Summit: At a Crossroads: How Place, Data, and Identity Impact Suicide Prevention for Sexual and Gender Minority Communities
The site prevention for sexual and gender minority communities. Your presenter today is John R. Blosnich. He's the assistant professor at the Suzanne Dworak-Peck School of Social Work and director of the Center for LGBTQ+ Health Equity at the University of Southern California, where his work focuses on social determinants of health and suicide risk.
Working with the US Department of Veterans, VA, for 10 years, his pioneered research about LGBT veterans, and recipient of several VA, and National Institute of Health, NIH Awards. In 2021, Dr. Blosnich received an NIH director New Innovator Award, which supports his research on expanding suicide prevention into non-clinical sectors, targeting adverse social factors and acute life crises for upstream prevention. Dr.
Blosnich, the floor is yours.
- Great, thank you. I hope everyone can hear me, and possibly see me. This is new to me to be able to do the in-person and virtual at the same time. I'm gonna start sharing my slide deck.
And so I wanna thank everybody, first at the University of Rochester for inviting me to come talk, and for making the time. I was hoping to touch on sort of this crossroads about data links and how that impacts suicide prevention for LGBT communities. And I was gonna start this a little bit unconventionally. And this picture in the background is a picture of my hometown in Pennsylvania, right.
The person taking the photograph is standing on the road that I live on. That's over. So before we get into all that, I just wanna go over quickly, you know, the three things I hope to cover today for everyone to give you some information and just to say that I, you know, the disclosures, these opinions are mine. They do not necessarily reflect those of the funders for the institutions that I'm affiliated with.
So with that, who is this guy? So this is a picture, so you see in the map over here that that marker is where the town of Rices Landing is in Pennsylvania. And that's where I grew up, so in this photograph you can see the Monongahela River in the background. The two brown brick buildings are old lock and dam houses, so there was a night master and a day master for the locks.
And the building with the curved roof over on the right is an old bank building. Unfortunately, it's- (microphone glitches) In the foreground, that grass in the middle, actually the department store that used to be there when Rices Landing was in its heyday, probably in the, you know, 30s, 40s. So, my town has probably about 436 people in it. My high school, my public school, my class had about 80 people who graduated from it.
So really... isolated small area that I grew up in. But it's not unlike a lot of other rural areas in Appalachia. So Rice's Landing, where I'm from, is situated in Greene County, Pennsylvania. And so unsurprisingly, Greene County is 93% white.
About 18% of people have a college degree and we're a little bit older than the general population, coming in at a median age of about 42. And like many other rural areas where I'm from, this is when I was a kid, we had about 42,000 people in the entire county. And that has gone down. So we've lost about almost 20% of our population over the ensuing 40 some years, almost 40 years since then.
So not unlike a lot of other rural areas in Appalachia. So my kind of unique place in all of this is not only did I grow up gay in Appalachia, that was a part I could hide, in order to kind of, in my mind, survive to get out. But I'm also biracial, so my mother is from Vietnam. And so that was the part I couldn't get away from.
Growing up in a place that had 93% folks who were white. And so my growing up in the rural area, you know, I tell people very honestly and very candidly, you know, my childhood was great, my adolescence not so much. So, you know, it's when I was asked to talk about stigma and the intersection of morality and the LGBT identities, it actually was pretty personal. So I thought what better way to start this off than just from the jump.
Being personal and telling you about how I grew up a country mouse who became a city mouse. I'm currently in Los Angeles at the University of Southern California. But yeah, deep in the heart of Appalachia is where I came. In the last part, and this sort of dovetails a lot with the issues of being biracial and being gay in a very rural place, is that again, not unlike other rural areas in this country, Greene County has become increasingly politically partisan.
You can see here in this graph that in 2000, it was roughly maybe 45, 55, a little bit over 40% Republican Democrats split. And now we have about a 70-30 Republican split in Greene County. So that's about me, but you didn't come to hear about me. So let's talk a bit more about the LGBT population.
And so to start off, for folks in the room, who may be contemporaries or maybe a little bit older, these symbols here probably mean something. For folks who are younger they're probably like put the ball on these things. So when I was growing up, it was GI Joes and Barbies were sort of the quintessential demarcations of gender. But we know that sex and gender are much more complex than simply the toys that you play with.
But it is omnipresent, gender is omnipresent for sure. So I talk about sex, this is something that is assigned to somebody in birth or increasingly in utero that's based on genitals or chromosomes. Gender is a social construction. So its the thing that society has created and these assumptions about how different sexes should look, how they should think, how they should behave.
Now your gender identity is your internal sense of self. So you define yourself as masculine or feminine, a little bit of both, maybe neither, or you have some other identity. And lastly, your gender expression, which is how you show your gender identity to the world. So that could be how you choose to dress, how you choose to style your hair.
Now again, this just shows that gender is omnipresent. So people have quite actually set fields on fire trying to announce the gender of their soon to be baby. We know that there's a very real, very persistent gender wage gap in this country. And then lastly, that gender has become much, much more politicized, especially for individuals who identify as transgender or non-binary or convert globally, gender minority.
So in terms of gender minority. So transgender is more of umbrella term. So it really speaks to folks who have a gender identity, expressions, or behaviors that are different from those that are traditionally associated with the sex that they were assigned at birth. Some common terms, a transgender woman, so this would be someone who's assigned male sex at birth and identifies as a woman or as feminine.
Transgender man is someone who was assigned female sex at birth and identifies as a man or masculine. Now all that to say, there are lots of identities out there. And so these are data from the USTS, stands for the US Transgender Survey. And you can see that when you give folks the opportunity to tell you about their gender identity, we get a whole lot of answers, a lot of different answers.
So you can see folks who identify as genderqueer, non-binary, gender fluid, androgynous. And these are not small numbers. The USTS had about 20... over 25,000 respondents who either were transgender or gender nonconforming. And the last thing I wanna say is that gender identity does not depend on medical interventions.
So it does not depend on hormones or affirming surgeries. Your gender identity is your own. Now, sexual orientation is related but distinct from gender identity. And this becomes... it's a really important point because we always sort of say LGBT and LGBTQ plus and we sort of lump everyone together in one abbreviation, but sexual orientation is distinct from gender identity.
And when we think about sexual orientation, we really kind of think about it in three different constructs. So again, your identity, how you choose to describe or identify yourself in terms of your sexual identity, sexual attraction, and, of course, sexual behavior. So those three things sort of compiling what we think of as this construct of sexual orientation. Now I just wanna emphasize the point of the distinction between these two.
So you can see here on the left side that this is a sample of folks. So there's folks who identify as transgender and then folks who are identified as cisgender. And so cisgender, meaning these are individuals who, their gender identity, their current gender identity aligns with the sex they were assigned at birth. But these folks also answer questions about their sexual orientation.
And so you can see for the folks who are transgender in this sample, that the majority of them, almost 63% of them, describe their sexual orientation as heterosexual. So it does not mean that because you are transgender or because you identify as being transgender or non-binary, that you are automatically gay, lesbian or bisexual. That is not the case. So just wanna hit that home with folks that, you know, sexual orientation and gender identity, related but distinct.
And so the other question I always get is how many LGBT people are there in the US? So Gallup has added questions to their poll, their national poll. And so they've been doing this for quite some time, quite a few years. And so they're kind of giving us what we think is a really good indicator about how many people in the US would identify themselves as LGBT.
So right up there, I'll just tell you how distinct they are. The question is actually, do you identify as LGBT? So kind lumping everyone back together. But the most recent data from Gallup in 2022 shows about 7% would identify as LGBT.
And so you translate that into people, you know? What does 7% actually mean? That's about almost 20 million people, 18.3 million people.
So it's not a small group of people because my background's in public health, we kind of reduce some social math and kind of give these big numbers some conceptualization. So it could be the fifth most populous state in the country. And that's more people than there are in the state of Pennsylvania. So this is not an insignificant population in the US despite being a minority population in the US.
And so the other thing that Gallup did was divide the population, the sample by generations. And so you can see here how much more prevalent having an LGBT identity is among younger generations, which is not necessarily a surprise. But you can see here for baby boomers, Gen X, millennials, and then the current generation, generation Z, there's a cadence of an increasing prevalence of people who are willing to disclose that they identify as LGBT in this country. And so this, I show you all this map cause I'm sure people are joining from everywhere across the country.
We can imagine that there are probably some patterns for where LGBT people may live. But this map just shows you they are everywhere. So I did most of, for instance, I did most of my training, my education in West Virginia. Pretty rural state.
I lived there for 12 years. You can see about 4% of the state of...
There are 4% of people in West Virginia who identify as LGBT. Wyoming, another pretty rural state, 3.3%. So this just goes to show that, you know, LGBT people are everywhere. They're not just in enclaves in cities, they're literally across the United States in all areas.
So not only this grounding in the demographic, what we're talking about in terms of who the population is, let's think about some of the research we know that's talked about health risk and disparities in the population cause there are a lot. So one really important health risk exposure is adverse childhood experiences. So you can see here in this graph that the orange line and the blue line...
The orange line is for gay and lesbian respondents. The blue line for bisexual respondents, and the gray line at the bottom are heterosexual respondents. The by-large LGB, or sexual minority individuals, are much more likely to report a vast array of adverse childhood experiences. Unfortunately, these data do not include or didn't include folks who identify as a gender minority.
But there's a lot of research evolving now because we've been having success in getting measures of sexual orientation and gender identity into federal health surveillance surveys that have revealed a lot of other health risk disparities in this population. So for instance, we know that LGBT populations are much more likely to smoke than their non-LGBT peers. Chronic stress, being victims of assault. They're more likely to use opioids, and they're much more likely to have a lifetime of suicide attempts and to report suicide ideation at some point in time in their life.
So just to hit that home, this study is a meta analysis. So what this means is it just, it went out and found every study that, you know, measured suicide attempts, lifetime suicide attempts. (audio cuts out) (silence) - [Woman in Striped Shirt]
We really appreciate that today. It's very enlightening. We'll also open the floor to our audience here in person if anyone would like to come up and ask the doctor any questions or if you had any thoughts or ideas that you wanted to share today. But I'll go ahead and start with our first question for you.
And what are some of the main healthcare challenges that sexual and gender minority people face in rural communities compared to urban or metropolitan communities?
- I'm sorry, you said the healthcare challenges?
- [Woman in Striped Shirt]
- Yeah, so I mean, I guess there's probably two things. One is sort of unique to living in a rural area that affects everybody in that rural community. So closure of rural hospitals is a very real problem in this country and it affects everybody in that community, not just sexual and gender minority people. So, there's the sort of general overlay of the challenge and resources that happens in excess, that happens generally in rural areas.
But then there's also sort of that unique piece, right, of you know, say you did have access to services, how welcoming do you feel going into those spaces? And so, you know, partially what I tell people is my own experience, when I walk into an area like any small signifier can set someone at ease. So it could be the smallest rainbow symbol. I always joke that like a lot of LGBT people have hawk eyes for some stuff.
Like it could be a rainbow pin sitting on someone's desk like in the back of the room, but somehow, you just hone in on it. And so you find these small signifiers of what is welcome there, right? And these, and not just overt things like, you know, small... like I said like small stickers or you know, things like that. But even in health reforms.
(microphone glitches) How healthcare reforms are designed, or how the healthcare interaction goes where, you know, the assumption would be if I walked in and didn't say anything and just they didn't know me. You know, someone's saying, you know, are you married? What's your wife's name? Or the assumption that you know, people are in heterosexual relationships and more to general ways you can approach the clinical encounter that wouldn't be sort of awkward for the patient to have to sort of pivot with the provider, you know, even down to to pronoun usage.
So there would be these small things that can happen for LGBT people within a clinical study that can really, you know, set their tone for it either... yeah. Everyone's bars are up when they go into healthcare settings anyway. It's not a good place to be. You're not really coming in there when you're feeling great.
So it's sort of, I think an interplay of those two things. So the way that student is both kind of overtly but also really not covert, very unintentionally, that sort of part of the healthcare experience that can really speak to that LGBT part, then also this overlay of just generally the rural area.
- [Woman in Striped Shirt]
Thank you so much for that. It's one of those things that I think I don't think about is like you mentioned, just simply having the rainbow flag there or having those welcoming little mementos in that space to let somebody know that they are accepted. So given that this is a taking action summit, it feels like you gave somebody a little piece that they can go into their rural community and advocate and educate and help the healthcare system and their community allow people to feel more accepting.
- It doesn't have to be, you know...
(chuckles) This is again my own opinion. It is incremental. Especially, I mean, if I were to single out Greene County, I'm not gonna go in and demand that the healthcare center drive to Pittsburgh for the pride parade, have their own float. They have...
It is an incremental thing to find where you can make those small inroads because it's not... for a lot of places I imagine it's not gonna be this, you know, pride parade, everybody's on board sort of deal, and this heavy handedness of, we're all gonna do this, we're all gonna have these giant things out. You know, to signify might not be the best way, especially for a rural area to go. So we have to think really specifically about how do we find the footholds, right? We're not gonna just sprint to the top of the mountain.
There's gotta be sort of footholds along the way that we can make small progress against small victories along the way.
- [Woman in Striped Shirt]
Thank you for that. So in thinking about data, then, how can the rural communities use their data to educate and advocate?
- You know, that is a great question. You know, I think first off, you gotta collect it, that's for sure a stepping stone. But even before that, you know, especially in healthcare, there's been a lot of research about we wanted to be able to include this and electronic health records or Benthos, teach providers about how to integrate this into the conversations with patients right? If it comes up in sexual health history or you know, somehow within that clinical encounter.
And there's some resistance, you know, providers say, Well I don't really need to know that for like a diabetes follow up or something, why would I bring that up, it feels uncomfortable, feels intrusive, you know, those sorts of things. Personally, I don't think that...
I mean its healthcare. I mean intrusive and personal is the first thing that comes to mind when I think about going into healthcare and having some conversations sometimes. But I think we need folks to feel both from the provider and the patient side. So the provider to be able to just briefly and very clearly explain why they might be asking this information or why it comes up and to not belabor the point.
If that, when you sort of start wavering it is where might sort of detour into, you know, well, are you just prying? Like, why you would need to know this about me? In that we treat this information just as confidentially as we would any other piece of health information that we get from a patient, right? And from the patients side, there's gonna be better patient education around why this would be important to the healthcare visit and some reckoning that there are folks, especially in the LGBT community who are frankly very cautious and very suspect of our systems, and will not and do not feel comfortable doing this.
It's not just this idea that you're going... if you ask this question, cisgender, heterosexual people are gonna be really mad at who asked it. Just asking a question could also put people in the LGBT community on guard cause they don't...
You know, why are you asking me this? Why do you need to know this? Speaking again to the whole hypervisionist aspect. So I think that there's communication that needs to happen on both sides that kind of meet in the middle to really get this infrastructure of data to be made complete.
So I don't run into the problem where it's like, oh yeah, we added this thing to our EHR and nobody answers it because providers are afraid to ask it and patients are afraid to answer it. So it's not just simply building something they're... you know, in a system, it's really cultivating that environment, that atmosphere, that culture that recognizes why this is important and can communicate that to all parties involved.
- [Woman in Striped Shirt]
So, and this may be a little broad stretch, but are there any organizations or any information out there for providers who are wanting to start that data collection and that conversation to educate themselves on how to do that?
- Oh yeah, absolutely. So the first thing that comes to my mind is the Fenway Institute. For years they have, you know, documents, they have training modules about how to implement sexual orientation, gender identity into clinical systems. So I would definitely, you know, direct folks to the Fenway Institute in Boston.
They've done a lot of not just research but actual implementation studies of how this works on the ground. It's not just, you know, research is in an ivory tower, somewhere in a university crunching numbers. I mean these are folks who run a healthcare center and help to train other folks and sort of get better iterations of this one more time. So we can think about, you know, all of the nuances that may happen in healthcare and how best to train people, and how best to have your system ready for implementing this kind of data direction.
- [Woman in Striped Shirt]
So, once a rural community collects all the data and they start doing all the processes that you've been speaking to us about today, so now they have it, how do they then convince their community and their role community of the importance of this and what's that next first step to put it into action?
- So I think, you know... if I had my druthers, it would be really partnering the health system, so the healthcare provision part of it, with departments of public health, with sort of the community health advocates who can actually sort of do the community outreach part. The healthcare system's gonna be collecting the information cause it's, you know, business as usual. We're collecting this for billing, we're collecting this for patient information, but how we mobilize healthcare information to, you know, grow legs and go into the community to help people understand what's happening. I
think that becomes, you know, the arena for the county health system to figure that out. You have public health cause that's...
Prevention is part of...
Healthcare is kind of on prevention, but they're so busy (laughs) having to do care provision on the prevention side often get short trimmed. That's a general critique of healthcare in this country. So I would say that healthcare systems, whether it be the federal qualified healthcare systems or healthcare centers, or independent hospitals, they sort of, bond together. And that's the other sort of thing is that rural areas...
There's not a lot people. Town of 436, I mean you have to get a county seat to get to the hospital. But to be able to aggregate data to look at population patterns would be important I think too. So the ability for healthcare systems across the county or across the region to be able to talk to them to get these patterns together and maybe the county public health infrastructure is the hub where those data go.
For analysis or you know, thinking about dissemination, and including community partners. Like how do we communicate to the community these findings. That's the only thing that researchers like me admittedly do really poorly on. I can go the Cisco model and I can interpret things, but when it comes down to what does a community wanna hear about it, they need to tell me that I need to ask them that.
You know, what resounds to them? What makes sense to them from these data? And that's sort of the extra charge that folks working in research, working in public health or community health and prevention at the accounting level really need to do. Cause again, we can build all these models, we get all these data, but if you're not resonating with people that we need to reach, that's on us and we gotta find better ways to get that out in the world.
- [Woman in Striped Shirt]
Thank you for that. And I know we are about to wrap up, so if we can cap off with one more quick question, specifically about SUD, you mentioned the lack of program and services. So if an SUD treatment program did not have services, what would be the first thing you would like to see implemented to support the LGBTQ community?
- You know, that's a really good question too. You know, I'm not a technician, but I've also been thinking about the, you know, especially all of us having been through and surviving through this era of COVID, you know, the very quick build of telehealth in this country and how we could really leverage that for individuals who are, you know, not in a place where they can find treatment that speaks to them, but could actually benefit from treatment from somewhere else. And that now distance is maybe not so much of an issue or it's something that, you know, it could be partnered with, sort of an additive to, the in-person care that need to get.
There's some way that we could really harmonize places that do really well, could find ways to, you know, partner with areas that are maybe struggling, just don't have that suite of services for their diverse patient base.
- [Woman in Striped Shirt]
Thank you for that, and thank you for all of your insight and your research and your service and passion for this cause. We appreciate that.
- Yeah, absolutely. Thanks again, and feel free to reach out, I think my email is...
Yeah, right there on the screen. Hopefully you're seeing the screen and not my gigantic talking face.
- [Woman in Striped Shirt]
Well we won't tell you that we are. (both laughing) But yes, they have access to all that information.
- Awesome. Cool. And just thank you everyone for making the time.
- [Woman in Striped Shirt]
John Blosnich, PhD, MPH
Assistant Professor & Director of the Center for LGBTQ+ Health Equity, Suzanne Dworak-Peck School of Social Work, University of Southern California