NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population
Individuals that identify within the Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) population have been shown to be at a greater risk for increased health disparities (WPATH, 2019). About 3.5% Americans identify themselves as lesbian, gay, or bisexual while 0.3% identify themselves as transgender (Hafeez, Zeshan, Tahir, Jahan, & Naveed, 2017). The LGBT community consists of almost every race, ethnicity, religion, age, and socioeconomic group in the United States (Hafeez et al., 2017). The purpose of this paper is to research the effectiveness of specialized training regarding the LGBT population of patients. By approaching this topic with a way to reduce discrimination will also assist in decreasing health disparities in the LGBT population within the healthcare settings.
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The Spirit of Inquiry Ignited
The topic of LBGT in the healthcare setting has transpired over the years and has become more prevalent than ever today. Discrimination among this population is often felt at various places and within the healthcare arena (Martos, Wilson, & Meyer, 2017). The LGB population report that 56% of them experience discrimination while 73% of the transgender patients felt like they face discrimination in the health care setting (Hanneman, 2014). Evidence-based practice (EBP) has shown that with the implementation of specialized education and special training for employees and clinicians regarding the LGBT population, these interventions can be successful at decreasing feelings of discrimination and increasing healthcare delivery. NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population. With the use of EBP and a team approach, such an implementation of specialized training can be successfully implemented and done for all clinical and non-clinical employees that communicate or come in contact with any LGBT patient within the healthcare setting.NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population
The PICOT Question Formulated
PICOT: In the LGBT population of patients (P), would specialized training designed towards this population (I) as compared to traditional diversity training (C) decrease the rate of discrimination for this population in the healthcare arena (O)? NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population.
Search Strategy Conducted
South University Library was accessed with the objective of finding supportive data for the PICOT. Databases accessed within SU Library included the Cochrane Database of Systematic Reviews, CINAHL, JAMA, and PubMed. Articles showed that EBP data was found to support the PICOT. Both level I and II studies were found when searching the studies and researching the process. The key terms used were LGBTQ, LGBT, healthcare discrimination, and LGBT competent.
Critical Appraisal of the Evidence Performed
An evaluation table was used to evaluate validity, reliability, and applicability to practice (See Appendix). The table analyzed five different studies by population, comparison, outcomes, and time frames. The evidence from each of the studies suggests that this is a change that needs to be implemented in the health care setting and high-level reviews also show this. One study implied and revealed that knowledge gaps about the LBGT population within the healthcare arena is very prevalent (Butler, Schwer, Burgess, Call, Przedworski, Rosser, Larson, Allen, Fu, & Kane, 2017). Specialized competency training that focuses on the LGBT population can definitely aid providers to understand the need to inquire about the patients’ gender identity and sexual orientation (Kenya, Lebron, & Carrasquillo, 2017). The LGBT patient population are at an increased rate for health disparities and feelings of discrimination (Kenya et al., 2017). Another study revealed that interventions are being taken into consideration regarding this population in healthcare arenas everywhere to help decrease both the feelings of discrimination as well as the health disparities that are prevalent (Lunn, Wanjun, Zack, Thompson, Blank, & Yehia, 2017). NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population.
A positive impact of implementing LGBT specialized healthcare training versus traditional cultural and diversity training has been shown to improve the ability of health care professionals to provide more effective healthcare to this patient population thus reducing disparities and feelings of discrimination (Kenya et al., 2017). These specialized competencies that are being offered have been found to provide a significant benefit to the provider as well as making the patient feel more comfortable (Shetty, Lancaster, Wilson, Quinn, & Schabath, 2016). The specialized training also was shown to promote providers and other employees in the health care setting to understand the need to inquire about the patients’ gender identity and sexual orientation thus making them feel more comfortable (Kenya et al., 2017). When the LGBT patients were surveyed about their experience after the implementation of this specialized training, it revealed they rated they care they received an overall score of 9/10 in the 105 LGBT participants with 10 being the most excellent service possible (Shetty et al., 2016). It is a step by step process to get such interventions implemented but studies have shown it is well worth it in order to prove the best quality care possible for this population within health care (Kenya et al., 2017).
Evidence Integrated with Clinical Expertise & Patient Preferences to Inform a Decision & Practice Change Implemented
The plan for this project is based on the EBP researched. There is various evidence of research as well as clinical expertise on this subject that will have a positive impact on this patient population and reducing overall feelings of discrimination within the healthcare setting. Specialized competency training will be done for all employees; both clinical and non-clinical that communicate and come in contact with these patients. It is important to provide the specialized training competencies and other programs that are live, online and done annually at competencies (Margolies, Joo, & McDavid, 2012). This training will be mandatory for all employees. The practice change will be implemented utilizing a team approach using the IOWA Model. The problem focused triggers is identifying the clinical problem. Researching internal and external data must be done as well (Brown, 2014). Process improvement data, and risk management data are all part of the focused triggers. Getting buy in, organizing and planning is all an important part of the implementation to do a Pilot. NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population.
New research, clinical guidelines, organization standards and guidelines, philosophies of care, and last but not least questions from Institutional Standards Committees will all be reviewed for the project. Other known knowledge focused triggers should be considered as well. This topic is a priority for the organization and for the LGBT population of patients to not be discriminated or feel like they are being discriminated against in the health care setting. A team approach must be formed and relevant research and related literature as well as critique and synthesis research for using in practice has to be conducted. There has to be enough sufficient research which there is for this topic (Brown, 2014). All clinical and non-clinical employees and staff will have to attend live face to face specialized training sessions focusing on the care of the LGBT population. This competency will also become part of the annual competency requirements. The change will be piloted for 90 days and then data collected and analyzed about how the LGBT patients felt about their visits. NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population.
Outcome Evaluated
The evaluation plan includes four important steps that must be implemented and followed in order to have a successful project with successful outcomes. The first step includes clarifying objectives/goals. This step will help identify which major program components should be evaluated. One way to do this is to make a table or chart of program components and elements to share with the team. This will be done in staff meetings as well as email reminders. Step two includes developing evaluation questions. Evaluation will include the impact on the LGBT population, assessment of objectives, and planning issues. The brief survey questions will be done via an iPad every time a patient within the LGBT population is checking out from their appointment and setting up for next appointment times. Step three consists of the development of an evaluation method. The evaluation method will be used as a monitoring and feedback system. As aforementioned, the brief survey questions will be done via iPad when the patient is checking out. The survey will consist of five brief questions inquiring how they perceived there visit that day. This data will be accessible weekly and improvements will be made along the way based on the feedback received. The final step will be to analyze and tally the information to determine what improvements need to be implemented into the new program. NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population. he final step (step four) is the development of a timeline of evaluation activities. This step should begin in the beginning of any project. The evaluation needs to be planned and thought about upfront. To get a concise idea of what the staff and employees will be doing and how well it is being done, it is important to always try to pay attention to the evaluation from the very start. The pilot project will be planned and evaluated for success. When any needed changes, problems, or improvements are needed; these will be added when appropriate. NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population
Project Dissemination
The step by step approach of this project dissemination uses the IOWA Model. The Iowa Model was selected for this project because clinicians find it intuitively understandable and it has been used in numerous academic settings and healthcare institutions (Brown, 2014). The results and data from the surveys will be disseminated and shared among clinicians and staff members. If changes or improvements are needed, it will be implemented. As the results are disseminated, ways to consistently improve this will be added and carried out. Once the pilot has been in place and outcomes to be achieved are selected, analysis of the data has to be done to see what the overall outcome is. Baseline data has to be collected prior to the implementation. The process and outcomes are evaluated after a Pilot is done. Modification of the practice guideline is done as needed. Other evidence to use is case reports, expert opinions, scientific principles, and theory (Melnyk et al., 2014). The project will be presented to the Clinical Practice Manager, Physicians, Nurse Practitioners, the Interdisciplinary team, the Education department, and both Congress and Legislation that are involved in the support of the LGBT population. Last but not least, this will be presented to the LGBT patients involved. Once approved, using EBP guidelines the project will be fully implemented in the facility/organization.
Once the change is implemented into practice, there must be proper monitoring and analyzing of the process and outcomes. The outcome reveals that the overall specific training that is mandatory has an effect on the attitudes and care provided for this patient from the clinician and all other employees perspective. The overall LGBT patient felt as if they were not discriminated against, rated the care they received as better, and were more compliant. The goal is for the patient in the LGBT population to feel more comfortable with clinicians, less discrimination, and have a better overall experience since all of the employees and staff will have already had the specialized training for caring and approaching the LGBT population. New knowledge and evaluation of quality care should continuously be evaluated (Brown, 2014). NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population
Conclusion
EBP has shown that this change is very much appropriate for adoption and implementation into practice. Pushing for the best well-being for the LGBT patients is important (Rice & Schabath, 2018). When they have feelings of non-discrimination, they will seek health care more often and be compliant (Rice et al., 2018). They will also feel more comfortable and have a trusting relationship with their providers and seek medical attention when needed. It is important to consistently continue to educate all clinical and non-clinical staff in these settings. Initiating proper care while at the same time leaving the LGBT patient with feelings of non-discrimination at all times is the goal and outcome (Butler et al, 2019). NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population
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References
Butler, M., Schwer, N., Burgess, D., Call, K., Przedworski, J., Rosser, S., Larson, S., Allen, M., Fu, S., & Kane, R. (2017). Improving Cultural Competence to Reduce Health Disparities. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles
Hafeez, H., Zeshan, Z., Tahir, T., Jahan, and Naveed, S. (2017). Health care disparities among lesbian, gay, bisexual, and transgender youth: A literature review. Doi: 10.7759/cureus.1184 . Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478215/
Hanneman, T. (2014). Healthcare equality index 2014: Promoting equitable and inclusive care for lesbian, gay, bisexual and transgender patients and their families. Retrieved from Human Rights Campaign Foundation.
Healthy People 2020 (2018). Lesbian, Gay, Bisexual, and Transgender Health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health
Kenya, S., Lebron, C. N., & Carrasquillo, O. (2017). Beyond Sensitivity. LGBT Healthcare Training in U.S. Medical Schools: A Review of the Literature. American Journal of Sexuality Education, 12(2), 148–169. https://doi.org/10.1080/15546128.2017.1298070
Keuroghian, A., Ard, K., & Makadon, H. (2017). Advancing health equity for lesbian, gay, bisexual and transgender (LGBT) people through sexual health education and LGBT-affirming health care environments. Sex Health, 14(1): pp 119-122. Doi: 10.1071/SH16145
Lunn, M.R., Wanjun, C., Zack, M., Thompson, W.W, Blank, M., & Yehia, B.R. (2017).
Sociodemographic Characteristics and Health Outcomes Among Lesbian, Gay, and Bisexual U.S. Adults Using Healthy People 2020 Leading Health Indicators. Doi:10.1089/lgbt.2016.0087
Margolies, L., Joo, R., McDavid, J (2012). Best practices in creating and delivering
LGBTQ cultural competency trainings: for health and social service agencies.
Retrieved from https://cancer-network.org/wp-content/uploads/2017/02/best_practices.pdf
Martos, A. J., Wilson, P. A., & Meyer, I. H. (2017). Lesbian, gay, bisexual, and transgender (LGBT) health services in the United States: Origins, evolution, and contemporary landscape. PLoS One, 12 NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population
Rice, D., & Schabath, M. B. (2018). The future of LGBT cancer care: practice and research implications. Seminars in Oncology Nursing, 34(1), 99–115. https://doi.org/10.1016/j.soncn.2017.12.007
Shetty, G., Sanchez, J. A., Lancaster, J. M., Wilson, L. E., Quinn, G. P., & Schabath, M. B. (2016). Oncology healthcare providers’ knowledge, attitudes, and practice behaviors regarding LGBT health. Patient Education and Counseling, 99(10), 1676–1684. Retrieved from South University Library at https://doi.org/10.1016/j.pec.2016.05.004
World Professional Association for Transgender Health [WPATH]. (2019). Guidelines and standards of care. Retrieved from https://wpath.org/ NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population
Appendix
I. Evidence/Evaluation Table
| SU Library
Database, CIAHNL, PubMed |
Study #1:
Lunn, M.R., Wanjun, C., Zack, M., Thompson, W.W, Blank, M., & Yehia, B.R.
Sociodemographic Characteristics and Health Outcomes Among Lesbian, Gay, and Bisexual U.S. Adults Using Healthy People 2020 Leading Health Indicators |
Study #2:
Butler, M., Schwer, N., Burgess, D., Call, K., Przedworski, J., Rosser, S., Larson, S., Allen, M., Fu, S., & Kane, R.
Improving Cultural Competence to Reduce Health Disparities |
Study #3:
Kenya, S., Lebron, C. N., & Carrasquillo, O.
Beyond Sensitivity. LGBT Healthcare Training in U.S. Medical Schools: A Review of the Literature |
Study #4:
Shetty, G., Sanchez, J. A., Lancaster, J. M., Wilson, L. E., Quinn, G. P., & Schabath, M. B.
Oncology healthcare providers’ knowledge, attitudes. And practice behaviors regarding LGBT health |
Study #5:
Martos, A. J., Wilson, P. A., & Meyer, I. H.
Lesbian, gay, bisexual, and transgender (LGBT) health services in the United States: Origins, evolution, and contemporary landscape. |
| (p) Population: |
Sexual minority adults |
LGBT adolescents (ages 13-17), young adults (ages 18-25) and adults
Overall gender disparities experienced by women (in relationship to men) were not considered in this review.
Biological sexual development and disorders of sexual development are not part of this review. |
The LGBT Population |
388 oncology providers at a single institution focused on the LGBT population |
The population density of LGBT people was explored
NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population |
| (i) Intervention: |
The study aimed to characterize the sociodemographic characteristics of sexual minority (i.e., gay, lesbian, bisexual) adults and compare sexual minority and heterosexual populations on nine Healthy People 2020 leading health indicators (LHIs). |
Cultural competence/culturally appropriate care provider education and training
Cultural competence/culturally appropriate care clinic-based interventions targeted to patients
Cultural competence/culturally appropriate care clinic-based interventions targeted to providers |
Training future physicians to address the health needs of the lesbian, gay, bisexual, and transgender (LGBT) population can potentially decrease health disparities faced by such individuals. |
This study was conducted and done to assess knowledge, attitudes, and practice behaviors of oncology providers regarding LGBT health. |
The intervention focused on the location and types of services provided by “LGBT community health centers” today in relation to the population density of LGBT people |
| (c) Comparison |
Heterosexual adults |
Usual care
Head-to-head trials of different strategies |
As compared to the non-LGBT population |
Survey based responses of providers in one institution, (not compared to another institution) |
As compared to non-same sex (Non-LGBT) households. |
| (o) Outcome: |
Differences between sexual minorities and heterosexuals suggest the need for targeted health assessments and public health interventions aimed at reducing specific negative health behaviors. |
Intermediate outcomes
Provider training and motivation outcomes (competencies, knowledge, changes in attitudes).
Provider behavior, such as clinical decision making, communication
Provider beliefs/cognitions about the priority population, reducing stereotyping, stigmatization
Improved access to health services
Utilization of health services
Patient experience/satisfaction
Patient health behaviors
Use of preventive services and other access to care measures
Final health or patient-centered outcomes – reduced disparities in terms of
Patient medical care outcomes
Patient mental health care outcomes (depression, substance use)
Adverse effects of intervention(s)
Unintended negative consequences of intervention
|
The 13 programs reviewed provided data suggesting a positive impact of LGBT healthcare training. |
Providers that receives cultural competency training can understand the need to inquire about the patients’ gender identity and sexual orientation. |
LGBT community health centers are concentrated within urban hubs and coastal states and are more likely to be present in areas with a high density of same-sex couples. LGBT community health centers do not operate in 13 states. The most common health services provided are wellness programs, HIV/STI services, and counseling services.
|
| (t) time: |
Over one year. |
Depends on the purpose of the intervention. |
90 days
|
3 months |
6 months |
- Evidence Synthesis Table
| Citation
Lunn, M.R., Wanjun, C., Zack, M., Thompson, W.W, Blank, M., & Yehia, B.R. (2017).
Sociodemographic Characteristics and Health Outcomes Among Lesbian, Gay, and Bisexual U.S. Adults Using Healthy People 2020 Leading Health Indicators. Doi:10.1089/lgbt.2016.0087 |
Design
Randomized Clinical Trial |
Sample size:
228,893,944 adults with sexual minority adults represented 2.4% of the U.S. population |
Major Variables:
Using a nationally representative, cross-sectional survey (National Health Interview Survey 2013–2015) of the civilian, noninstitutionalized population (228,893,944 adults), nine Healthy People 2020LHIs addressing health behaviors and access to care, stratified using a composite variable of sex (female, male) and sexual orientation (gay or lesbian, bisexual, heterosexual), were analyzed individually and in aggregate. |
Study findings: Strengths and weaknesses
Factors negatively affects LGBT adults (∼2.4% of the U.S. population); health.
Social determinants of health warrant further investigation and consideration for targeted interventions |
Level II
Evidence obtained from at least one well designed Randomized Controlled Trail (RCT)
|
Evidence Synthesis
This study provided evidence that LGBT adults represent ∼2.4% of the U.S. population and experience a number of significant health disparities. |
| Butler, M., Schwer, N.,NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population Burgess, D., Call, K., Przedworski, J., Rosser, S., Larson, S., Allen, M., Fu, S., & Kane, R. (2017).
Improving Cultural Competence to Reduce Health Disparities. |
Design
Qualitative Analysis |
Sample size: Adequate?
12 studies were included |
Major Variables:
Over 37,000 nonduplicated English-language citations were reviewed; 56 unique studies were identified as of June 2015: 20 randomized controlled trials (RCTs) and 5 observational studies for individuals with disabilities; 5 RCTs (6 manuscripts) and 6 observational studies for LGBT populations; and 14 RCTs (15 manuscripts), 4 observational studies, and 2 systematic reviews for members of racial and ethnic minorities. Interventions fell into four broad categories: (1) provider trainings and education; (2) interventions providing alteration of an established protocol, or the delivery of an established protocol, to meet the needs of a target population; (3) interventions prompting patients to interact with the formal health care system or health care providers; and (4) interventions aimed at providing culturally competent care at the point of service. |
Study findings: Strengths and weaknesses
The medium or high risk of bias of the included studies, the heterogeneity of populations, and the lack of measurement consensus prohibited pooling estimates or commenting about efficacy in a meaningful or responsible way. The term “cultural competence” is not well defined for the LGBT and disability populations and is often conflated with patient-centered or individualized care. There are many gaps in the literature; many large subpopulations are not represented. |
Level of evidence
Level V
Evidence from systematic reviews of descriptive and qualitative studies.
|
Evidence Synthesis
None of the included studies measured the actual effect of cultural competence interventions on health care disparities. Rather, the training interventions measured changes in professional attitudes toward the population of interest. |
| Kenya, S., Lebron, C. N., & Carrasquill, O. (2017). Beyond Sensitivity. LGBT Healthcare Training in U.S. Medical Schools: A Review of the Literature. American Journal of Sexuality Education, 12(2), 148–169. https://doi.org/10.1080/15546128.2017.1298070
NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population |
Design
Comprehensive database analysis w/ at least one RCT |
Sample size: Adequate?
A specific number was not included in the sample size.
A comprehensive literature search to identify studies on LGBT healthcare training in U.S. medical schools. Studies published between January 2000 and September 2016 that described the program and reported on at least one quantitative evaluative measure were included in our review. With the found 13 studies meeting our inclusion criteria. The programs had high levels of variability in curricular content, educational strategies used, duration, and evaluation methods.
|
Major Variables:
Despite wide variability in their training approaches, the 13 programs we reviewed provided data suggesting a positive impact of LGBT healthcare training.
NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population |
The programs had high levels of variability in curricular content, educational strategies used, duration, and evaluation methods. Many programs utilized an interactive experience involving a standardized patient. The majority of participants in such programs felt this approach was an effective learning strategy. All programs reported that participants felt the training improved their ability to provide more effective healthcare to LGBT patients. |
Level III
Evidence obtained from well-designed controlled trials without randomization, quasi-experimental
|
The 13 programs reviewed provided data suggesting a positive impact of LGBT healthcare training that improved their ability to provide more effective healthcare to LGBT patients. |
| Shetty, G., Sanchez, J. A., Lancaster, J. M., Wilson, L. E., Quinn, G. P., & Schabath, M. B. (2016). Oncology healthcare providers’ knowledge, attitudes, and practice behaviors regarding LGBT health. Patient Education and Counseling, 99(10), 1676–1684. https://doi.org/10.1016/j.pec.2016.05.004 |
Design
Observational study |
Sample size: Adequate?
Sample size was 388. The size of the study group was adequate. |
Major Variables:
This study revealed knowledge gaps about LGBT health risks. Cultural competency training may aid oncology providers to understand the need to inquire about patients’ gender identity and sexual orientation |
Study findings: Strengths and weaknesses
108 providers participated in the survey (28% response rate). <50% answered knowledge questions correctly. 94% stated they were comfortable treating this population. 26% actively inquired about a patient’s sexual orientation when taking a history. 36% felt the need for mandatory education on LGBT cultural competency at the institution.
|
Level IV
Evidence from a well-designed case control/cohort studies.
|
The study was survey based. With the surveys completed by the providers, intervention for providing competency for the providers did provide a significant benefit for them and the care of the LGBT patients. |
| Martos, A. J., Wilson, P. A., & Meyer, I. H. (2017). Lesbian, gay, bisexual, and transgender (LGBT) health services in the United States: Origins, evolution, and contemporary landscape. PLoS ONE, 12(7), 1–18. https://doi.org/10.1371/journal.pone.0180544 |
Design
Comprehensive Data base analysis |
Sample size: Adequate?
The population density of LGBT people was explored. An online search of LGBT community health centers was conducted between September-December 2015. |
Major Variables:
LGBT community organizations in the United States have been providing health services since at least the 1970s. However, available explanations for the origins of LGBT health services do not sufficiently explain why health in particular has been so closely and consistently linked to LGBT activism. Little is also known regarding how LGBT health services may have evolved over time with the growing scientific understanding of LGBT health needs. |
Study findings:
LGBT community health centers are concentrated within urban hubs and coastal states and are more likely to be present in areas with a high density of same-sex couples. LGBT community health centers do not operate in 13 states. The most common health services provided are wellness programs, HIV/STI services, and counseling services. |
Level III
Evidence obtained from well-designed controlled trials without randomization, quasi-experimental
|
With the comprehensive data base analysis, it was found that the LGBT community health centers have adapted over time to meet the needs of LGBT people but significant gaps in service remain in the United States, and LGBT community health centers requires significant transformation going forward in order to continue serving LGBT people. |
