Institutionalizing LGBTQ+ Health Equity in Dane County, Wisconsin

State: WI Type: Model Practice Year: 2020

Public Health Madison & Dane County (PHMDC) is a City/County health department with a staff of more than 140 people, serving over 500,000 residents in approximately 60 cities, villages, and towns across Dane County, the largest city of which is Madison. PHMDC is located in southcentral Wisconsin, and is the second-most populous county in Wisconsin (second to Milwaukee County). The racial makeup of Dane County is approximately 85% White, 5% Black or African American, 0.4% Native American, 5% Asian, and 2.5% from two or more races. 6% of the population is Hispanic or Latinx (Dane County Wisconsin, 2019). Across the state of Wisconsin, an estimated 3% of residents identify as LGBTQ+, though sources suggest that this proportion is much greater in Dane County, and the Madison metropolitan area is often cited as one of the most LGBTQ+ friendly cities in the nation (Madison makes Top 10 list of most-friendly LGBTQ cities. Wisconsin Gazette, 2011).

PHMDC works to enhance, protect, and promote the health of the environment and well-being of all people. Promoting systems of Health and Racial Equity (HRE) is both a core value and a strategic priority for PHMDC. Our collective vision for health equity is that all people in Dane County will have fair and just opportunities to be healthy. This cannot happen without confronting and addressing the obstacles that make it more difficult for certain groups and individuals to achieve maximum health because of characteristics like race, class, gender, sexual orientation, and/or ability.

The public health problem identified for this NACCHO application relates to the health systems, policies, and structures that disproportionately impact the health of our LGBTQ+ population. In fact, national data suggests that people who identify as LGBTQ+ continue to experience worse physical and mental health outcomes than their heterosexual or cisgender peers (Harcourt, J. 2006). In the fall of 2016, the National Institutes of Health (NIH) announced the formal designation of sexual and gender minorities (SGM) as a health disparity population for NIH research (Sexual and Gender Minorities Formally Designated as a Health Disparity Population for Research Purposes. Perez-Stable, 2016). Data shows that economic and social conditions, along with policies and laws, profoundly shape health outcomes (World Health Organization, Social Determinants of Health, 2016) and people who identify as LGBTQ+ experience worse health in part because of these conditions and structural impediments (Centers for Disease Control and Prevention, Social Determinants of Health, 2015). In Dane County, local data mirrors statewide and national trends and shows that LGBTQ+ inequities persist across the life course. LGBTQ+ youth are more likely to try tobacco, cocaine, inhalants, heroin, report feeling depressed, and feel unsafe in school (Healthiest Wisconsin 2020 Baseline and Health Disparities Report: Lesbian, Gay, Bisexual, and Transgender Populations, January 2014). LGBTQ+ adults are less likely to have health insurance or regularly visit a dentist (Jennings, L., Barcelos, C., McWilliams, C. & Malecki, K. (2019). Inequalities in lesbian, gay, bisexual, and transgender (LGBT) health and health care access and utilization in Wisconsin. Preventive Medicine Reports). LGBTQ+ older adults commonly feel isolated and face higher rates of housing and employment discrimination (Cahill S., South K., Spade J. (2009). Outing age: Public policy issues affecting gay, lesbian, bisexual and transgender elders. Washington: National Gay and Lesbian Task Force). Furthermore, few data systems or health surveys collect comprehensive LGBTQ+ health related data, rendering targeted interventions difficult to plan and implement.

The goals of our efforts to tackle these disparities are threefold. First, to increase transgender health access at PHMDC's Sexual and Reproductive Health Clinic. Second, to institutionalize LGBTQ+ health equity into The City of Madison policies and training schedule. Third, to develop a local index of LGBTQ+ health equity indicators for Dane County health care systems to assess their own policies, practices, and environments as they relate to LGBTQ+ health care. A future goal is to provide technical assistance to health care systems in order to support them in changing their existing structures to be more inclusive and welcoming for all.

This work has been in process for the last three years. PHMDC's LGBTQ+ health equity work began with a county-wide LGBTQ+ community needs assessment, which resulted in the creation of a data profile, replete with numerous recommendations to improve LGBTQ+ health outcomes across Dane County. The recommendations led to the inception of the projects stated above. PHMDC partnered with a transgender health system advocate to design internal trainings for our Sexual & Reproductive Health (SRH) clinic staff, and required attendance for all employees. We also worked with members of our LGBTQ+ community to develop and facilitate LGBTQ+ Health Equity trainings for city/county staff, and are currently working towards designing and implementing city-wide policies for transgender employees. We are currently in the process of implementing a health care assessment strategy, which will lay the groundwork for the local LGBTQ+ health equity index to be applied in 2020.

While the profile has more recommendations that have not been initiated, we are proud of the projects we have successfully implemented and their results. Writing the initial data profile was instrumental in our project's successes. Using data to drive recommendations, we were able to make impactful change to systems that are currently failing Dane County's LGBTQ+ population. Furthermore, we gained institutional buy-in from PHMDC's leadership team as well as the City of Madison Human Resources Department. PHMDC's website can be found here:

LGBTQ+ populations across the country suffer from worse health outcomes than their cisgender and heterosexual peers, and these trends persist for Madison and Dane County's LGBTQ+ communities. Many of the poorer health outcomes are rooted in inequitable economic and social systems that shape the access, quality of health care, and health promotion opportunities provided to LGBTQ+ people. In fact, our research indicates that people identifying as LGBTQ+ face specific health risks and weaker protective factors for behavioral health than their heterosexual and cisgender peers. Through a community-engaged Mobilizing Action through Planning and Partnerships (MAPP) process, PHMDC identified that Dane County LGBTQ+ residents cite the following as the greatest barriers to accessing health care: lack of culturally specific care, limited availability of services, healthcare provider discrimination, and data collections being biased toward heterosexual orientations and traditional gender identities (as categorized by biological male & female definitions). Furthermore, this same process highlighted the most commonly experienced behavioral health risks among LGBTQ+ residents: accumulated stress from social stigmatization and marginalization, increased rates of cardiovascular disease, diabetes and asthma, mental illness including depression and anxiety, and an increased likelihood of tobacco use, alcohol use, and illicit drug use. Dane County LGBTQ+ residents are also at higher risk to experience violence, victimization, and experience social isolation from their families.

To date, there have been few initiatives specifically focused on the health of the LGBTQ+ population. One of the main reasons for this is due to large data gaps that exist for LGBTQ+ patients, a problem that is not unique to Dane County alone. The US Department of Health and Human Services has made Sexual Orientation and Gender Identify data collection a strong focus of their Healthy People 2020 objectives, recognizing it as a national concern (Lesbian, Gay, Bisexual and Transgender Health (2019). Retrieved from     

In planning this project, we noted that community-specific data collection would be pivotal to understanding LGBTQ+ needs and inequities. Collecting data using questions that appropriately measured LGBTQ+ identifies, reporting those data effectively, and developing data-driven recommendations to guide priority planning were a few of the key strategies used to innovatively tackle this problem.

The Dane County data that does exist for LGBTQ+ residents tells an incomplete story. US Census data reveals that Dane County boasts 1,938 same-sex couples, with 983 being same-sex male and 955 being same-sex female. Among these same-sex couples, 24% of them are raising their own children (Gates, G. & Cooke, A. (2010): Williams Institute Wisconsin Census Snapshot). The City of Madison does not collect employee data as it relates to sexual orientation or gender identity. The Dane County Youth Assessment, which is administered every three years to all Dane County high schools, reveals that 86.1% of our youth identify as straight/heterosexual, and 13.8% of youth identified as gay, bi-sexual, pansexual, asexual, questioning their sexual orientation, or other. 1.3% of Dane County youth report being transgender (Dane County Youth Assessment (2019). Retrieved from

Gallup poll data for the state of Wisconsin indicates that LGBT populations are more likely to be unemployed, lack health insurance, be food insecure, and have annual incomes less than $24,000. LGBT populations fare far worse in all of these areas compared to their heterosexual/cisgender peers (LGBT Demographic Data Interactive, January 2019, The Williams Institute), which is information we confirmed through our data collection process.

To develop the data profile, PHMDC utilized the MAPP tool. While this tool is a stronghold of public health practice, it was new to our Public Health Department, and was used for the first time with our LGBTQ+ population. In fact, this process was part of a broader strategic plan in our Department that identified key health disparity topic areas to focus on, and each topic area developed their own process, profile brief, and action plan to tackle the specified health disparity. PHMDC is unique in its targeted approach to address health disparities through policy, system, and environmental change. Utilizing the MAPP framework to gather data among our LGBTQ+ community allowed us to draw informed conclusions about priority decision making.

This process began by convening a core team of PHMDC staff who informed the process and would later gather data for the profile. Data was collected through both qualitative and quantitative processes, with a focus on locally-driven data collection and recommendations. The quantitative interview questions were compiled from reputable sources and were rooted in an evidence-based community readiness framework that could be applied widely to many different stakeholders working in a variety of systems. Once the questions were peer-reviewed, we compiled a list of partners who were representative of Dane County's LGBTQ+ community. Through interviews and data compilation, we then conducted the four MAPP assessments (Community Themes and Strengths Assessment, Local Public Health System Assessment, Community Health Status Assessment, and the Forces of Change Assessment). From there, we analyzed and synthesized the data to draw out the most pressing health disparities and promising priorities for our target population. We then formulated goals and strategies, and have since been working to advance the recommendations outlined in the profile.

The transgender health trainings were a key component of our efforts. In spring 2017, PHMDC's SRH Clinic staff attended a comprehensive, multi-part training to improve sexual health care for transgender people in Dane County. The goal of the training was to increase access to affirming, affordable, high-quality health care. Our vision was of PHMDC's SRH Clinic being increasingly utilized as a trusted provider for sexual health care to transgender and gender nonconforming (TGNC) community members. The 4-part trainings took place between the spring and summer of 2017 and included: 1) screening, identifying, and referring for behavioral and mental health concerns, 2) describing various paths that TGNC people take to transition and explaining changes to sexual and reproductive anatomy that may occur though medical and surgical types of transitions, 3) practicing and demonstrating TGNC-inclusive sexual health history-taking and discussion of/education about pleasure and sexual health 4) analyzing current practices for TGNC inclusion and incorporating impactful practices in policy, systems, and environmental changes. Additionally, these trainings included a 1-hour session for staff that focused on improving practitioner's self-efficacy, knowledge, awareness, and skills around assessment of and referral for emotional and mental health concerns.  Approximately 40 staff, including local Planned Parenthood affiliate clinic and education staff and sexual health educators from a local sexuality resource center, attended the trainings. The curriculum was designed and delivered by staff and volunteers from the Wisconsin Transgender Health Coalition, which is a group dedicated to improving health care settings for transgender patients. Due to the fact that there is a dearth of curricular resources specific to this topic area, this partnership was innovative and extremely valuable to our training efforts. This partnership has since led to subsequent collaborative initiatives, and has centered PHMDC as a transgender health advocate.

Training evaluations indicated that participants benefited from a broader understanding of both applied interpersonal skills (e.g., use of chosen pronouns and names; client-centered history-taking) and institutional and structural barriers affecting the provision of inclusive healthcare (e.g., gendered intake forms and restrooms). PHMDC SRH clinic staff identified several areas needing change in programmatic operations. All clinic documentation was reviewed and revised to include more expansive demographic questions, specimen collection instructions were updated, and waiting & clinic room resources were diversified to better reflect the diverse population attending the clinic. Since the training, we have experienced a 500% increase in transgender patient visits, from 2 in 2018 to 12 in 2019. We consistently get positive feedback from our transgender clients expressing that they feel very comfortable receiving sexual and reproductive health care from our clinic staff, and have expanded our mental health resource list to include a greater number of high quality referrals who are equipped to manage transgender mental health care for our patients.

Institutionalizing LGBTQ+ health equity into the City of Madison was unprecedented, and the projects related to this effort continue to evolve and emerge with growing needs. Per the recommendations that came out of the profile, PHMDC partnered with three members of the LGBTQ+ community to develop and deliver trainings for government officials, non-profit partners, and health care system staff. After completing the half-day training, attendees left with tangible and implementable improvements they can make to their workplaces in order to be more inclusive and welcoming to LGBTQ+ patrons and residents.  PHMDC is currently assisting the City of Madison with the creation of a policy that supports transgender employees who undergo a gender transition on the job. This policy, replete with non-discrimination language and guidelines for supervisors, will also include a mandatory training for, at a minimum, management level staff to attend. PHMDC will ensure that this training is culturally relevant, taught by members of the transgender community with lived experience, and comprehensive. Being a government agency well versed in the needs of the community, and with so many deep connections to transgender residents, allows us to be in an incredible position to advocate for transgender health and wellness. An internal example of the way we are institutionalizing LGBTQ+ health equity in PHMDC is through our Environmental Health gender neutral bathroom initiative. We developed a resource guide and training for our sanitarians, and are providing technical assistance towards their efforts to make bathroom signage gender neutral and more inclusive. Per Wisconsin law, multi-stall bathrooms cannot be designated as gender neutral, but single stall bathrooms can be changed to gender neutral with a simple swap of signage. Leveraging the relationships our sanitarians have with business owners is creative, and shows the department's ability to design interdisciplinary and cross-divisional collaborations.

Our future goal to assess health care systems is evidence-based, and relies heavily on the Community Readiness Framework. Using this framework as a guidepost, we plan to assess the five major health care systems in Dane County to better understand what services they currently offer, and how inclusive their policies, systems, and practices are towards LGBTQ+ populations. We will begin by piloting this Framework at one health care system, and have already received verbal agreement for this effort. Our assessment tool will mirror that of the Human Rights Campaign (HRC), which designated multiple health care systems in Dane County as excellent stewards of LGBT health. While this was flattering to our health care systems, local data and lived experience tells us that there are large gaps between what is being touted and the quality of care delivered in these health care settings. Creating a more localized index that is informed by health care systems will make the assessment more relevant and usable to hospital administrators, health care providers, and patients. We envision this project to result in additional training for health care staff, a thorough review and update of the Electronic Medical Record system to include SOGI questions as well as more gender-expansive options, and more inclusive health system marketing materials.

We initiated the MAPP process by developing an expert team of PHMDC staff who were interested in the topic area. This team consisted of cross-divisional staff with a range of professional experience. We engaged with Public Health Nurses, an Epidemiologist, a Health & Racial Equity Coordinator, Program Specialists, and Public Health Coordinators. Forming this team with intention allowed us to approach the topic of LGBTQ+ health equity with a wide lens. As a team, we developed a weekly meeting schedule and a feasible timeline for data collection, writing the profile, crafting recommendations, and implementing the recommendations. We aimed to complete the profile within a 9 month period, and develop recommendations shortly thereafter. It was difficult to schedule past the recommendation development stage because we weren't sure how complex the recommendations would be to implement. Since implementation began in late 2017, we have been working strategically through the recommendations that exist within PHMDC. We are reconvening as a group in January 2020 to map out the rest of the recommendations, and will likely develop a 3-5 year plan for our department, which will also include accountability metrics and consistent communication.

We began the process by pulling preliminary data on the health and well-being of LGBTQ+ people across the country. Relying on sources such as Fenway Health, Gay Lesbian Straight Education Network (GLSEN), Center for Disease Control and Prevention (CDC), and the National Center for Transgender Equality, we were able to identify high level persistent health disparities. Using these disparities as a foundation for our work, we then acknowledged relevant stakeholders in the Dane County community who would be key informants to our assessment, and mapped out an engagement strategy that spanned a variety of industries. We included school district staff, non-profit organizations, health care systems, media outlets, mental health care providers, LGBTQ+ focused organizations, state legislature, academic partners, and state level advocates. We planned to conduct the assessment, identify strategic issues, and formulate goals to tackle these issues, and then receive comments from our partners and update our recommendations based on their feedback. A detailed description of how we prioritized our stakeholder and subsequent partnerships is below.

Understanding the critical role that health systems play in either hindering or supporting LGBTQ+ health, we prioritized working with specialists in the fields of transgender health, and LGBTQ+ health promotion. We interviewed a family doctor who has extensive experience in hormonal therapy for gender transition, fertility options for queer families, puberty blocking for appropriate adolescents, and other sexual health related services. Her story is one that highlights the deficits of mainstream medicine, and provided great insight into the ways that medical systems are ill-equipped to deal with the complex medical needs of LGBTQ+ patients. Speaking with her highlighted many potential projects to engage with, including increased LGBTQ+ provider training for medical and nursing students, the imperative relationship between specialty clinics and comprehensive insurance, the importance of using correct language to instill patient trust, and the need for holistic treatment that includes mental health screening and treatment. Connecting with mental health providers was paramount to our profile, and elucidated the vast mental health needs of our LGBTQ+ community and the dearth of affordable and specialized options available to them.

Given that Madison is home to multiple esteemed academic institutions, we felt it was important to connect with local research experts. This perspective was crucial to capture because many of our faculty and staff at University of Wisconsin-Madison are engaging in excellent and emergent strategies to address the pressing needs of our LGBTQ+ communities, especially those that live in rural areas with fewer resources. We interviewed an Assistant Professor from the Department of Counseling Psychology, and one from the Department of Communication Arts. Through these interviews, we spoke extensively about the role of intersectionality and LGBTQ+ health, which cannot be untangled. Given the rural nature of Dane County, our recommendations therefore needed to directly address strategies to reach and provide care to these vulnerable populations.

Conversations centering intersectionality encouraged us to develop deeper relationships with LGBTQ+ professionals of color. We connected with and interviewed the director of an organization committed to ending violence against people of color, women, and those that non-traditionally gender identify. This interview led to a long-term partnership that concentrated PHMDC's community health education focus, and expanded our reach to include youth of color who we would not have otherwise connected to. Additionally, this process introduced us to an incredibly impactful mental health provider who works with Latinx youth who are questioning their gender identity and or sexual orientation. Due to the religious-based nature of many Latin American cultures (and specifically, the lack of support for LGBTQ+ people in the Catholic Church), we found that youth in these families were experiencing additional hardships and feelings of isolation. Madison is home to an after-school program that provides a safe and supportive space for Latinx youth to express themselves and explore their identity. Interviewing this program's LGBTQ+ identified Latinx director provided us greater knowledge into the cultural needs of Latinx youth and the potential for family engagement to shift these narratives. We incorporated lessons gleaned from this conversation into the recommendations we made to school districts, especially related to working with Latinx families and communities.

Youth who identify as LGBTQ+ have distinct and prevailing needs associated with school safety and familial/social support. In order to best capture these stories and opportunities, we connected with school district officials, school staff, and also statewide workers who provide supportive services to school districts. Madison's school district boasts a LGBTQ+ coordinator position, who we interviewed for this project. She gave us incredible insight into the great work the district is already participating in to promote LGBTQ+ safety, but highlighted the need for additional teacher training and systems level change as it relates to name and pronoun acknowledgement during a youth's transition. Our interview with state-level Department of Public Instruction staff clarified the regulations around the standardized human growth and development curricula, and a high level overview of the ways districts institutionalize health equity into their curricula, or not. For a more thorough understanding of what happens to LGBTQ+ youth who leave the educational system, we interviewed a number of staff from the local youth service organization, which includes a runaway shelter. These conversations were heartbreaking, and illuminated harrowing stories of youth who escape their homes for fear of their own safety. While we are grateful that these shelters exist, there needs to be greater emphasis on acceptance in families, and more common language for youth to express their feelings around questioning their gender identity. We produced 5 recommendations from these conversations all that relate to school level policies, more inclusive curriculum development, training and education for staff, and cultivating a culture of acceptance.

The media is an incredibly powerful influence on how LGBTQ+ people are represented in mainstream cultures. In Dane County, we have one LGBTQ+ monthly magazine, and a LGBTQ+ non-profit organization that sends out news blasts with relevant happenings and upcoming events. Interviews with reporters has since led to a more robust communication strategy for PHMDC, and keeps us looped in to community events that promote and support LGBTQ+ health. Furthermore, Dane County is home to a number of LGBTQ+ advocacy groups, and engaging them in the profile work both afforded us the opportunity to understand the local landscape and politics surrounding LGBTQ+ health in Dane County, but also allowed PHMDC to become a visible ally to this population.

Once we conducted all of our qualitative interviews, we came together as a core team and identified the major themes and strategic issues. Our epidemiologist was integral in ground-truthing the narrative stories and the themes that were emerging with data analysis. With both local anecdotes and national statistics, we were able to develop a profile that was representative of the Dane County community, but also supported by external advocates.

As the recommendations emerged, we confirmed our findings with stakeholders we had interviewed to make sure that the ideas were relevant and feasible to our partners in this work. We received some valuable feedback during this time. For example, our senior care specialist working at a non-profit LGBTQ+ organization, made the point that in our recommendations to expand data collection”, we had no formal question about age, which would leave out elder adults. In an effort to better advocate for this often overlooked population, we added a section on this in our profile, and have since connected with the senior center and other geriatric service providers to ensure that our efforts are reaching this age group. Ultimately, we sent out the data profile brief to all of our interviewees, and invited them to continue engaging with the process as we worked to implement the recommendations.

Deciding on what recommendations to tackle was also a calculated, collaborative, and community-informed process. We focused on health care access for transgender patients within our SRH clinic, government trainings, and city-wide policy development because they operated within our direct locus of control. Now that these efforts have been in existence for two years, we are expanding outwards to work with Dane County's healthcare systems. In fact, we conducted an 11-week systems thinking process with Dane County health care systems to better understand scope and capacity for this type of project. We developed a mind map that emphasized five inherent flaws within our current medical model for LGBTQ+ patients seeking care. This effort showcased our ability to network effectively with decision makers in health care systems, and our facilitation skills in shepherding a strategic mapping process among them.

The transgender health training came to fruition directly out of the recommendations put forth by the LGBTQ+ profile. Profile data revealed harrowing health inequities experienced in the LGBTQ+ population, and our SRH clinic was not treating many transgender patients. As a public health clinic, part of our mandate is to reach people with no other access to care. As the profile states, transgender people are less likely to have health insurance, or to have negative health care experiences. We realized that in order to reach a more diverse audience, our clinic staff required additional training on the knowledge, attitudes, and skills needed to be excellent stewards of health for our transgender patients. To fill this gap, we sought trainings that focused on the basics of transgender inclusion in health care settings, but could not find adequate resources related to the sexual practices of transgender people, or the language to talk about the experience of transitioning and its impact on reproductive health care needs. We had personal connections to the Wisconsin Transgender Coalition, and worked directly with them to develop a comprehensive training that covered our needs. With supervisorial support, PHMDC's Community Health Division budget funded this effort.

Developing the LGBTQ+ Health Equity trainings was a deeply cooperative process. We worked with three partners from the LGBTQ+ community who emerged from our profile interviews – a transgender mental health provider, a non-binary executive director, and a lesbian state worker. Using data and the MAPP process to identify priorities, we developed a training curriculum that both celebrated the resilience of Dane County's LGBTQ+ population, but also highlighted the harrowing health disparities and systems of oppression that need reform. We focused the training on concrete steps that government agencies and other organizations could take to transform their practices, policies, and environments to be more inclusive and welcoming to our LGBTQ+ clients and residents. Our outreach for the training began within government agencies, but quickly expanded to include all of the high priority populations that had been identified through the profile process. Because these trainings filled to capacity and received such glowing recommendations, we developed a secondary training with the same staff with more explicit planning towards taking transformative action through policy revision, environmental scans, and trainings.

The city of Madison is in the process of expanding its policies related to LGBTQ+ inclusivity, which is a direct result of the PHMDC-coordinated LGBTQ+ trainings.  Many government officials that participated in the trainings recognized the need to transform their systems and are starting to advocate explicitly for LGBTQ+ rights. In the fall of 2019, the City of Madison made an official statement supporting its LGBTQ+ employees, and we are currently writing a policy to support transitioning employees on the job. It is PHMDC's goal to play an integral role in the subsequent training development that comes with these policies, as we have extensive experience in successfully implementing a training schedule that remains relevant and wanted. It will be important to focus on financial sustainability as we build out our training capacity and city-wide goals.

The MAPP process did not cost PHMDC any additional funding. However, we prioritized paying our Health Equity trainers handsomely, and each training cost $3,000 to host. The transgender inclusion training, which came out of the Community Health budget was $3,600. We are currently in the process of identifying ways to make these efforts more financially sustainable, while still providing a fair and just wage to our partners who are critical in the success of this work.

With representation from the Policy, Planning, and Evaluation Division of PHMDC, we understand the intrinsic value of evaluation, and the crucial ability to adjust programs and policies to reflect evaluation needs. To that end, our evaluation approach has varied with each initiative, the results of which have impacted subsequent decision making processes.

The transgender health training implemented a pre/post evaluation for each training session. Results following the first training indicated that attendees felt an increase in comfort using chosen names, gender identities, and pronouns, and in using gender inclusive instructions to guide clients toward gender neutral bathrooms. Following the second training, which focused on clinical sexual health care, attendees felt at increased comfort in using culturally sensitive and client-centered language for gender identity, anatomy and sexual practices. Attendees also reported a strong increase in confidence in their ability to incorporate transgender-inclusive education regarding pleasure and sexual health, as well as confidence in ability to assess and discuss sexual risk with transgender clients. Attendees of the third training, which focused on effective systems-level interventions, reported an increased understanding of methods to improve conditions of inclusion for transgender populations. The most impactful outcome of these trainings, beyond an increase in knowledge and self-efficacy to work with transgender clients among our clinical staff, is the dramatic increase in transgender clients that use our clinical services for their routine and ongoing sexual health care.

As mentioned, the goal of the LGBTQ+ Health Equity training was to increase knowledge and comfort for government agencies in interacting with people in the LGBTQ+ community, as well as to encourage and provide assistance in efforts to create more LGBTQ+ friendly environments. We conducted an evaluation at the end of each training session, and adapted subsequent training sessions to reflect the evaluation results. For example, trainees expressed wanting more time for question/answer, and so we adjusted the meeting schedule to allow for more open-ended time with the facilitators. After completing 6 of these trainings, it became clear that many people were interested in receiving more in-depth and complex training, specific to their organization becoming more LGBTQ+ inclusive. We were able to consult with the training facilitators, and develop an expert level training that consisted of deeper action planning around institutional and environmental change. All told, these trainings reached 438 people, and 75 staff from PHMDC were trained on LGBTQ+ concepts. Training attendees included myriad City and County departments, as well as healthcare organizations, homeless shelters, neighborhood centers, youth social service programs health insurance companies, school district staff, domestic violence shelters, and mental health providers. Many participants reported that the training helped them incorporate new knowledge about LGBTQ+ identities into their work, and that the training helped them understand and internalize their learning. Additionally, the training contributed to tangible improvements at multiple organizations. For example, offices removed gender-specific pronouns in new policies that had been created since the trainings. Our City Clerk's office reviewed their website and election materials to make sure they were gender-neutral. One social service organization used the training materials to do a complete evaluation of their client facing applications and the office space. Amidst other environmental updates, they began subscribing to the LGBTQ+ publication and encouraged staff to include gender pronouns in their email signatures.

The City of Madison transgender policy implementation will begin in 2020, and PHMDC is currently developing an employee evaluation that will reflect the LGBTQ+ inclusivity of the City's policies and practices.

The health systems project that we aim to conduct in 2020 hinges on a comprehensive assessment and evaluation process. Through this effort, we plan to develop a local health system index analogous to the Human Rights' campaign Health Equity Index. We have developed an assessment tool that examines what health care systems are doing as they relate to LGBTQ+ non-discrimination policies and staffing, patient services and support, employee benefits and policies, and patient and community engagement. In the summer of 2019, PHMDC hosted a systems mapping exercise with five of Madison's health care systems. This process focused on the root problem and guiding framework that structure our priorities and work plan. Utilizing the Acumen Systems Thinking online module, we met weekly for 11 weeks to examine components of the healthcare system that are perpetuating inequities for Madison's LGBTQ+ patients. Together we unpacked” each healthcare system component, and developed a strategy for change. We are confident that utilizing the assessment tool with each health system, and equipping them with their score along with technical assistance for systems change will lead to successful transformative steps. 

Our Community Health Division is currently in the process of developing a client satisfaction survey. Asking patients to identify their experience at the clinic as well as specific questions related to their sexual orientation and gender identity will allow for more reflexive practices that assure we are meeting the needs of our LGBTQ+ clients. Implementation of this survey is slated to begin in 2020.

PHMDC has had budget surpluses in years past that were able to fund the public facing LGBTQ+ Health Equity trainings. Since this funding is no longer available, we have had to get creative with funding streams that can sustain this work in the future. One facilitator was eager to offer additional services to attendees, and came up with a menu-type list of fee-based follow-up services that ranged from additional training to a complete workplace assessment. We are currently in the process of designing a 3 – 5 year strategic plan that highlights our budget requests both from within our Public Health Department, but also more broadly from the County funding structure.

All of our efforts to date have taught us that this work is incredibly important, needed, and impactful. The emerging nature of LGBTQ+ health naturally encourages this work to be responsive, flexible, and developmental.

We have learned many lessons in relation to practice. Perhaps the most important lesson we have learned is that public-facing indicators of being LGBTQ+ inclusive must be matched with adequate training and cultural competence amongst all staff. This principle is a major guiding force in the LGBTQ+ Health Equity work across the City of Madison. Staying informed with relevant data and implementable recommendations is paramount to effective change. When we distribute a transgender policy for all City of Madison employees, we must be prepared to leverage that policy with the necessary training for all people implicated in the policy. For example, the policy states that a transitioning employee will have the opportunity to meet with a LGBTQ+ liaison to encourage their transition is nurtured and supported by surrounding staff. The City must be able to offer an adequate number of liaisons who have time and capacity to serve in this role. PHMDC commits to holding the City of Madison accountable to its plan highlighted in these and other similar policy documents.

In regards to partnership, the lessons we've learned center around the ability for PHMDC to sustain the level of commitment that is needed to advance this work. Our training partners are dedicated to providing as many training sessions as we can fit in a calendar year. Other community-based LGBTQ+ partners are beginning to see PHMDC as an advocate and ally in this work, as evidenced by invitations to speak at upcoming LGBTQ+ health fairs and events. In order to become more ingrained into the City of Madison infrastructure, PHMDC must make public statements about the impact of our work, and the important of promoting LGBTQ+ health equity in all policies, practices, and procedures. To this point, a Position Statement is currently being written, and will be passed by the Board of Health before it becomes public. This public-facing effort will ground our work in a document that will hold us accountable.

At a NACCHO conference