Cultural Safety and Humility

In 2015, all Health Authorities committed to advancing cultural safety and cultural humility in health services in British Columbia.

What does ‘cultural safety’ and ‘cultural humility’ mean?

CULTURAL SAFETY

Cultural safety is an outcome based on respectful engagement that recognizes and strives to address power imbalances inherent in the healthcare system. It results in an environment free of racism and discrimination, where people feel safe when receiving health care.

CULTURAL HUMILITY

Cultural humility is a process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Cultural humility involves humbly acknowledging oneself as a learner when it comes to understanding another’s experience.

Declaration-of-Commitment-on-Cultural-Safety-and-Humility-in-Health-Services

Cultural Safety and Cultural Humility in the Child & Youth Health Network

What does ‘cultural safety’ and ‘cultural humility’ mean for the Child & Youth Health Network?

Trans Youth Health Survey

Being Safe Being Me (2015) is a report from the Candian Trans Youth Health Survey. The following are some excerpts from this report relating to Health and Connectedness.

Trans Youth

Being Safe, Being MeWe have chosen to use the word trans in this report to describe youth whose gender identity and sex assigned at birth differ (Being Safe, Being me, 2015, p. 4).

The survey contained several different questions asking trans youth about their gender identity in slightly different ways. The question “What is your gender identity?” was rated the highest by trans youth, both in how much they liked it and how well the options fit them. This question allowed them to select their gender identity or identities from a long list of options, and to select more than one option from the list: just under one third checked one option on the list, and about half checked two or three options on the list. Younger participants were more likely to choose only one option from the list. Participants could also write in additional options if they felt their identity was missing from the existing list. More than 1 in 5 trans youth wrote in an identity that was not on the list. Some of the most common additions were: non-binary, agender, gender-neutral, and to a lesser extent, transmasculine or transfeminine. The comments after this question suggest that the ability to self-identity in unique ways resonated very positively with trans youth (Being Safe, Being me, 2015, p. 11).

Youth who have a non-binary gender identity (and might use different pronouns than he or she) also face the additional barrier that people tend to be unfamiliar with gender-neutral pronouns, which can complicate the process of asking people to use different pronouns (Being Safe, Being me, 2015, p. 68).

I identify under the trans* umbrella but as someone who is genderqueer, and does not want to transition in a traditional way but stay somewhere between the lines. I feel as if I am appropriating an identity that is not mine by stating that I am transgender.” Youth survey participant (Being Safe, Being me, 2015, p. 11).

I am technically a transsexual man, having transitioned my sex to male, but I don’t identify as transgender. I have spent more than half my life as a boy, having transitioned as a kid.” Youth survey participant (Being Safe, Being me, 2015, p. 12).

I’m non-binary/genderqueer. Most days I feel like there is no way for me to actually live in my “felt gender” in a way that other people can understand when they look at me.” Youth survey participant (Being Safe, Being me, 2015, p. 14).

Demographics

  • The survey included 923 trans youth participants from all 10 provinces and one of the territories and included somewhat different questions for younger (14-18 years) and older (19-25 years) trans youth (Being Safe, Being me, 2015, p. 2).
  • 1 in 10 participants identified as Aboriginal (Being Safe, Being me, 2015, p. 10).
  • 40% identified as boys or men, and nearly as many identified in “some other way,” and only about 1 in 6 identified as girls or women. Older trans youth were more likely to identify as girls or women (Being Safe, Being me, 2015, p. 13).
  • Nearly three quarters of trans youth in our survey were assigned female at birth. This could be because trans female and transfeminine youth might be more marginalized in our society, and so harder to reach, for example, if they are less connected to community organizations. Older trans youth were more likely to have been assigned male at birth (29% compared to 18% of younger participants), and trans youth in Québec were also more likely to have been assigned male at birth (45% compared to 26% overall in Canada) (Being Safe, Being me, 2015, p. 13).

Findings

Many of these youth face rejection, discrimination and even violence, within their families, at school or work, in their community, and in health care settings. They report significant stress and mental health challenges, a profound lack of safety in navigating their daily lives, barriers to supportive health care, and worrying rates of poverty (Being Safe, Being me, 2015, p. 69).

Living in Felt Gender

  • While the majority of youth (83%) reported living in their felt gender at least part of the time, only about half lived in their felt gender full time. Those who lived in their felt gender all the time were almost 50% more likely to report good or excellent mental health (Being Safe, Being me, 2015, p. 2).
  • The majority of our participants (83%) reported that they were currently living in their felt gender at least part of the time, and only about 1 in 5 were not living in their felt gender at all. Younger youth were more likely to be living in their felt gender part-time, while older youth were more likely to be living in their felt gender full-time. Trans youth in British Columbia were more likely than those in other provinces to be living full-time in their felt gender (53%), and least likely not to be living in their felt gender at all (10%) (Being Safe, Being me, 2015, p. 14).
  • In the comments about this question, trans youth pointed out this question is complicated to answer for people who have a non-binary identity. Since we live in a society that often does not recognize genders other than female and male, someone with a non-binary identity might experience themselves as living in their gender full-time, yet not be seen as such by others (Being Safe, Being me, 2015, p. 14).
  • Participants living in their felt gender only part-time were less likely to report “very good” or “excellent” physical health (15%) than those living in their felt gender full-time (24%). Those living in their felt gender fulltime were also more likely to report their mental health was “good” or “excellent” (29%) than those not living in their felt gender or living in their felt gender part-time (20%) (Being Safe, Being me, 2015, p. 68).

Violence

  • Safety, violence exposure, and discrimination were major issues. For example, two thirds of participants reported discrimination because of their gender identity and about half reported discrimination due to their physical appearance (Being Safe, Being me, 2015, p. 2).
  • Most youth (70%) reported sexual harassment; more than 1 in 3 younger participants had been physically threatened or injured in the past year (36%); and nearly half of older youth reported various types of cyberbullying (Being Safe, Being me, 2015, p. 2).
  • Most youth reported having been in a romantic or dating relationship (88% of older youth, 69% of younger youth). Among those who had ever had a romantic or dating relationship, 27% had been physically hurt by the person they were going out with. “Being hurt” included being shoved, slapped, hit, kicked, or forced into any sexual activity. Older youth were more likely to report relationship violence than younger ones (28% vs. 24%), in part because they were more likely to have been in a romantic relationship (Being Safe, Being me, 2015, p. 56).
  • On average, trans students felt safe overall at school: on a scale of 0 to 10, where 0 means a student never feels safe, and 10 means a student feels safe always, the average score was 6.5. Students felt least safe in washrooms and changing rooms, and the most safe in classrooms and the library. We also asked younger participants how many times they had been bullied at school in the past year, defined as being repeatedly teased, threatened, kicked, hit or excluded. Just under half had not been bullied at all (45%), while more than half had been bullied once or more (55%). Just under 1 in 4 (24%) reported being bullied 1 to 3 times, and 13% had been bullied 12 or more times in the past year (Being Safe, Being me, 2015, p. 57).
  • More than 1 in 3 younger participants reported they had been physically threatened or injured in the past year (36%), and 9% had been threatened or injured with a weapon. Almost 2 in 3 reported being taunted or ridiculed (64%) (Being Safe, Being me, 2015, p. 58).
  • 70% said they had experienced unwanted sexual comments, jokes or gestures directed at them. Physical sexual harassment was less common, but 37% of younger participants said another person had touched, grabbed, pinched or brushed against them in a sexual way that they did not want (Being Safe, Being me, 2015, p. 60).
  • Nearly 1 in 4 participants (23%) reported being physically forced to have sexual intercourse when they did not want to (Being Safe, Being me, 2015, p. 60).
  • 40% had been the target of hateful comments on the web, in email or instant messages, and 5% reported someone else had sent out threatening emails using their identity. Another 30% reported being cyberbullied in ways other than those already mentioned (Being Safe, Being me, 2015, p. 61).

Health & Health Care

I’m afraid that I’ll take my life before I can get the surgery to help me, because it’s such an arduous and unnecessarily difficult path. I just want to live.” Youth survey participant (Being Safe, Being me, 2015, p. 33).

I’ve never reached out for mental health care. I’m worried they’ll be more concerned about my gender identity and sexuality (which I am fairly confident in) than they will be about my actual problems.” Youth survey participant (Being Safe, Being me, 2015, p. 34).

  • Access to health care is especially important for trans youth, because many of them require specialized care for medical transition. They often face discrimination in health care settings (Being Safe, Being me, 2015, p. 31).
  • As with school staff, professionals from all the different health care disciplines who deliver services to youth need further training to improve their competency in providing high quality care, which is more than just “trans friendly” care. This should include general education about gender identity and barriers that trans people face in accessing health care, and discipline-specific training in appropriate protocols for addressing trans youth health issues. Young people especially need safe access to and support around hormone therapy, and mental health services to help them cope (Being Safe, Being me, 2015, p. 70).
  • Just under half of youth (44%) used walk-in clinics as their main source of health care, with youth in Quebec and British Columbia most likely to rely on walk-in clinics. More than a third of youth were “very uncomfortable” discussing their trans status and trans-specific health care needs with doctors at a walk-in clinic (Being Safe, Being me, 2015, p. 31).
  • Nearly half of older youth (47%) and one third of younger youth (33%) had not received physical healthcare when they needed at some point during the last year (Being Safe, Being me, 2015, p. 33).
  • Among younger youth, two thirds (68%) also reported at least one time in the last 12 months when they had not received needed mental health services. The most common reasons these youth gave for not getting mental health services included not wanting parents to know, thinking or hoping the problem would go away, afraid of what the doctor might say or do, previous negative experiences, and not knowing where to go (Being Safe, Being me, 2015, p. 33).
  • Only 1 in 5 participants said their health was very good or excellent (Being Safe, Being me, 2015, p. 22).
  • More than 1 in 4 (27%) younger youth and more than 1 in 3 older youth (38%) told us they have a physical health problem that has lasted at least 12 months (Being Safe, Being me, 2015, p. 22).
  • Many youth reported missing needed physical health care during the past year (33% of younger and 49% of older youth) and even more missed needed mental health care (68% of younger youth) (Being Safe, Being me, 2015, p. 2).
  • Over half of youth with a family doctor (53%) said their current family doctor knew about their trans identity. However, only 15% of youth with a family doctor felt “very comfortable” discussing their trans status and trans-specific health care needs. Even fewer felt comfortable at walk-in clinics (Being Safe, Being me, 2015, pp. 2-3).
  • Healthcare providers and clinics should work with trans communities to ensure adequate and timely access to gender-affirming healthcare for trans youth. Professionals from all health care disciplines need further training to improve their ability to offer high quality care, including discipline-specific training in protocols for addressing trans youth health issues (Being Safe, Being me, 2015, p. 3).
  • Youth who are unable to access hormones through a health care provider may seek access to hormones without a prescription. A third of all youth (34%) reported they had ever taken hormones for trans-related reasons at some point, including 20% of younger youth and 42% of older youth. Youth in British Columbia were twice as likely (41%) as those in the Prairie Provinces (19%) to take hormones (Being Safe, Being me, 2015, p. 35).
  • Many youth who had taken hormones reported getting these medications without a prescription at some point, whether through friends or relatives (10%); strangers or on the street (5%); herbals or supplements (5%); internet pharmacy (2%); or other means (8%) (Being Safe, Being me, 2015, p. 37).

Mental Health

  • Mental health issues were a key concern. Nearly two-thirds reported self-harm in the past year; a similar number reported serious thoughts of suicide; and more than 1 in 3 had attempted suicide (Being Safe, Being me, 2015, p. 2).
  • Fewer than half of trans youth rated their overall mental health as excellent or good (Being Safe, Being me, 2015, p. 38).
  • Almost half of younger youth feeling stressed to the point that they could not do their work or deal with things during the last 30 days (Being Safe, Being me, 2015, p. 40).
  • More than half the youth reported they had hurt themselves on purpose without wanting to die in the last 12 months. Older youth were less likely (51%) than younger youth (75%) to have engaged in self-harm in the last 12 months (Being Safe, Being me, 2015, p. 42).
  • Within the last 12 months, 65% of younger youth had seriously considered suicide, more than a third had attempted suicide at least once, and nearly 1 in 10 had attempted suicide 4 or more times (Being Safe, Being me, 2015, p. 42).
  • Almost three-quarters of older youth had seriously considered suicide at some point during their lives, and many of them had made at least one suicide attempt (Being Safe, Being me, 2015, p. 43).

Connectedness

When young people felt cared about, they reported much lower levels of distress and better health (Being Safe, Being me, 2015, p. 69).

Family & Community Connectedness

  • Family relationships are important, and while trans youth generally reported feeling their parents cared about them, 70% reported their family did not understand them, and about 1 in 3 did not have an adult in their family they could talk to about problems. When youth had high levels of parent support and family connectedness, they reported much better health (Being Safe, Being me, 2015, p. 2).
  • More than 1 in 4 younger trans youth reported they had run away from home in the past year and this was much more likely among those who had reported a history of physical or sexual abuse (Being Safe, Being me, 2015, p. 3).
  • The majority felt safe at home often (64%), with 24% feeling safe sometimes, and 9% feeling safe rarely, and 3% never (Being Safe, Being me, 2015, p. 55).
  • Trans youth who had supportive adults both inside and outside their family were four times more likely to report good or excellent mental health, and were far less likely to have considered suicide (Being Safe, Being me, 2015, p. 2).
  • One third of younger youth (33%) had no adult that they could talk to if they were having a serious problem. Another third had an adult in their family that they could go to for support, and almost half (47%) had an adult outside their family they could go to for support. Younger youth with supportive adults both in and outside the family were about four times more likely to report good or excellent mental health (as opposed to poor/fair), and were over four times less likely to have considered suicide. Additionally, those with a supportive adult in the family were about four times less likely to have self-harmed in the past 12 months” (Being Safe, Being me, 2015, p. 63).
  • Younger youth were also asked how much they felt various adults outside their family cared about them. These adults included police officers, teachers, community adults, adult relatives and church leaders. Youth scored an average of 3.5 on this 10-point adult caring scale (Being Safe, Being me, 2015, p. 64).
  • We asked older trans youth how they would describe their sense of belonging in their local community, on a 0-10 scale from “very weak” to “very strong.” Participants scored an average of 3.6 on that scale, indicating a low sense of belonging overall (Being Safe, Being me, 2015, p. 68).

School Connectedness

  • Trans youth generally reported low connectedness to school, but those who reported higher school connectedness were twice as likely to report having good mental health (Being Safe, Being me, 2015, p. 2).
  • Trans youth reported that they did not feel very connected to their school: on a scale of 0 to 10, they scored 4.9 in school connectedness (Being Safe, Being me, 2015, p. 18).
  • As with other youth, for trans youth, school connectedness can have an important link to positive mental health: participants with higher levels of school connectedness were almost two times more likely to report good or excellent mental health compared to those with lower levels of connection to school (Being Safe, Being me, 2015, p. 18).

 

School Connectedness

Research consistently shows that high levels of school connectedness are associated with better health outcomes for children and youth:

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While the positive impacts of school connectedness are greatest on the students involved, here is a spill-over effect on our communities and society:

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This information is available at BC Healthy Schools. Find the full report (& all the evidence) here.

Indicators: A shortlisting exercise

VisionAt the meeting of the Shared Measurement constellation on Tuesday January 13th at CRD Headquarters, we started the process of shortlisting indicators for use in the Shared Measurement system for the Child & Youth Health Network.

We recognize that selection of indicators will be an iterative process. It will be informed by the work of the Framework/Common Agenda constellation and will be refined by the collective.

It will take some time to get it right.

This is just a first step, but the more perspectives we can bring to this process, the better.

To participate in this initial exercise:

  1. Look at the Summary of Indicator recommendations from the Child and Youth Health and Well-being Indicators report (print pages 30-33).
  2. Choose 15 of the 51 indicators on this list. Focus your selections on the shared measurement system of the Child & Youth Health Network, rather than your particular area of interest. (Keep in mind: what get’s measured, get’s done. We want our measurement system to reinforce the activities what will get us to our our collective goal).what gets measured
  3. E-mail your top 15 indicators #s to petra@ypsn.ca. In the e-mail, describe the criteria you used for selecting those 15 indicators.
  4. Share this exercise with anyone/everyone with a stake in the health & well-bring of children, youth & families in the capital region.

“The moral imperative of human rights work means that results can be amorphous, long-term and potentially unattainable- the opposite of measureable.” ~Michael Quinn Patton (2015). Let’s try select meaningful indicators anyway!

 

Vulnerability is not a Permanent State

In 2007, Canada’s Minister of Health asked Dr. K. Kellie Leitch to serve as the Advisor on Healthy Children and Youth. Dr. Leitch consulted with experts, parents, and children and youth across Canada, and developed a number of recommendations. The full report can be found here.  

The following is an excerpt from the report:

Vulnerability not permanentAs Canadians, we believe that ours is a society in which our children and youth should lead happy, healthy lives. At the time this Report was written, Canada ranked 13th out of 21 OECD countries in terms of the health and safety of our children and youth, showing that there is much room for improvement. We owe it to our children to do better.

That starts with setting bold, visionary goals. Canada has the potential and the ability to be the number one place in the world for a child to grow up in from a health perspective. We have the resources and the capabilities to reach this goal.

Canadian children and youth from all socio-economic backgrounds are vulnerable. Vulnerability is measured by key behavioural and cognitive tests measuring vocabulary, mathematics, emotional health, and violent behaviour tendencies.

Vulnerability in childhood and youth is not a permanent state~

The Canadian National Longitudinal Survey of Children and Youth revealed that many vulnerable children did not remain the same from one cycle to the next. The percentage of vulnerable children (28%) remained unchanged; however, in the second cycle, 16% were no longer considered vulnerable, while a new 15% of children became vulnerable. While 13% remained vulnerable throughout both cycles, the results suggest that 87% of children may experience vulnerability, but the situation is not permanent.

New Research: Vulnerability is Not Permanent

Graph indicating percentage of children experiencing levels of vulnerability from 1994 to 1996
Source: Human Resources Development Canada – Applied Research Branch (2000).

This is great news: it means that investments in best practice services and targeted initiatives can have a direct impact on improving and shaping the lives of Canadian children and youth. But to be successful, investments need to be made in the right programs and policies. These policies and programs must be built upon evidence based research, and performance-based techniques. They must also be delivered in a professional, outcome-driven way.

Social Determinants of Health: Indicators

Social Determinants of HealthWe’re working on our Common Agenda, including fine-tuning long-term outcomes, setting targets & selecting indicators for our Collective Impact Initiative.

To engage in shared measurement, we need to adopt shared indicators that can be measured by each service-delivery partner in the initiative, so we can track our collective progress toward our goals.

We know much of this work has already been done, and can be adapted to our purposes.

For example, here’s a list of indicators for monitoring the social determinants of health (SDH) found on the Action:SDH website (find the full list here). The following relate directly to young people in a Canadian context:

  • Proportion of young people not in school or employment, by age and sex;
  • Literacy rate;
  • Completion of primary/secondary education by ethnic/ “race” group in a country;
  • Newborns with low birth weight (% by mother’s education);
  • Children aged <5 years with moderately or extremely low values for weight and height;
  • Prevalence of obesity (by wealth quintiles).

Applying the Social Determinants of Health

Sam Bradd graphically documented strategic-level dialogue around the Social Determinants of Health by the the First Nations Health Authority, First Nations Health Directors Association, and First Nations Health Council in BC in October 2013. Find the graphics he created based on that dialogue here.

Upstream is a Saskatchewan-based organization devoted to using the Social Determinants of Health to leverage social change. According to Upstream: “Upstream interventions start at home. When everyone has access to adequate housing, nutritious food, and support for early childhood development, we are thinking and acting upstream.”

Measuring the Social Determinants of Health

As for using the Social Determinants of Health for measurement, the Action: SDH site notes that “Effective action on social determinants requires monitoring and measurement to inform policy-making, evaluate implementation, and build accountability. Inequities in health outcomes, social determinants, and the impact of policies must be monitored. Key requirements are collecting and monitoring indicators of social determinants from different sectors, linking with health outcomes, and monitoring inequities; establishing whole-of-society targets towards the reduction of health inequities; and disaggregating data to better understand baseline levels and potential impacts of policies.

Indicators selected for monitoring policies aimed at reducing health inequities need to be clearly understood by policy-makers across the different sectors that influence the social determinants as well as by communities. Thus simpler measures may be more transparent and easier to interpret than complex summary measures.”