“What is your knife and how are you using it?”: Holding Power and Creating Change in LGBTQ+ Health
It all begins with an idea.
This talk was originally given at the Dalla Lana School of Public Health, at the invitation of the 2SLGBTQ+ Health Hub, in May 2024.
Introduction
In an August 2023 blog post for Change Elemental, Elissa Sloan Perry asks, “What is your knife and how are you using it?” This question emerges from Perry’s observations on how the work of dismantling white supremacy, building resilient organizations and fomenting revolution asks us to be and act differently, and to tend to those ways of being with intentionality.
As a queer femme who came of age in communities of Leatherdykes, queer perverts and witches, knives have a way of grabbing my attention. In this spirit, I have engaged with Perry’s question as a means of sharpening my thinking on what I have learned about holding power and creating change in LGBTQ+ health.
What is my knife? What is yours? What becomes possible when we wield them together in service of queer and trans survival and liberation?
Part 1: Knife
Let’s begin with the thing itself: A knife is an instrument with plenty of uses.
I might use a knife to help me survive under inhospitable conditions, or to nourish myself and others. A knife can cut, slice, chop, dice or peel. It can pare down or pare away, slash, stab or sever. A knife can be a threat or a promise: I might carry a knife for protection, bring it with me into battle or use it to cut through the bullshit. A knife can be a means of focusing my power toward sacred or erotic ends as I cast circles in the air or trace my blade over a lover’s skin, time slowing as I take care to not pierce their flesh. A knife can be a source of entertainment and delight—picture a juggler tossing knives in the air or a carver transforming a piece of wood into something beautiful and unexpected.
Most of us wield knives with our hands but our hands don’t do this work alone. Using a knife is an action that engages our bodies, minds and senses. It demands our focus. We might inadvertently hurt ourselves or someone else when our hand or our attention slips. I am clumsier when I am not careful. I have the scars to prove it.
A knife has its own anatomy: handle, blade, edge, point, spine. I can tell when a knife feels especially good in my hand, the place where our anatomies meet. A knife can be a pleasure to hold or it can be something functional, a means of getting a job done. Some knives must be kept hidden to protect their owners from being targeted. Others are stashed away for emergencies. Some are worn on belts or clipped to pockets. Queers are experts at flagging; a knife can be a semaphore.
A knife is an object we can grasp but it is also an action. When I looked up the root of this word, I found it alongside other expressive words “designating objects and actions that [suggest] knocking, pushing, bending, pressing and so forth” (Liberman 2020). She knifed through a gap in their defenses. Sometimes, the knife is us.
While I was working on this talk, someone wrote to tell me they thought my use of a knife as a metaphor was inherently violent, which they did not like. They explained why this imagery doesn’t align with how they use their power, though they were willing to concede the utility of certain kinds of knives, telling me they suspect my power aligns more with a jackknife than a filet knife.
I felt angry when I read this email, but at first, I couldn’t pinpoint precisely why. It wasn’t that I thought everyone should like or want to use the same metaphor as me to describe their power. A knife isn’t the only form our power can take, and having a knife doesn’t necessarily make us powerful. After sitting with this message for a time and peeling back the layers of my reaction to it, I uncovered several things that are crucial to the argument I am building here:
I reject the idea that a knife is inherently violent. There are many kinds of knives, and even more ways to wield them.
Don’t tell me what kind of knife I am or how I get to use mine.
I reject the idea that only soft tools or tactics are acceptable, or that it is unacceptable to bring weapons into battle with the people, institutions and systems that are hurting and killing our loved ones and communities. The stakes are too high to limit ourselves only to the tools or tactics that feel safe, comfortable or palatable.
As a queer femme, softness is fundamental to who I am and how I move through the world. Yet as my friend and fellow queer femme Hannah McGregor (2022) writes, “softness can also be a way out” when we use it to elide the responsibilities that come along with the unearned power our privilege affords.
Central to McGregor’s queer feminist ethic of care is what she calls “ferocious care,” an inherited lineage she describes as “a way of caring so much about the world that you refuse to stop fighting for it” (McGregor, 2022, p. 33). It is within this ethical frame that McGregor deploys her softness. As she writes, “My own softness is not inherently radical, but I can make it into a weapon if I point it in the right direction” (McGregor, 2022, p. 41).
Heather Berg (2023) articulates a sex worker ethics of care she calls “militant care” in “Today Solidarity Means, Fight Back,” an article whose title pays tribute to a line by sex worker collective Other Weapons. Militant care insists that “love requires a willingness to fight back” (Berg, 2023, p. 32). Berg points to how, for sex workers, “care and violence are necessarily linked—mutual care will not be possible without doing some violence (symbolic or otherwise) to those who make the flourishing of those we care for impossible” (p. 34). She points to examples like the Hookers Army of Los Angeles, a sex worker-led peer support group whose mission is to “to provide real-world, self-defense training for sex workers” (Carlisle, 2021). Through their militant care, Berg writes, “sex workers confront a feminist line that is wary of the sharp edge of care” (Berg, 2022, p. 32).
If a blade is too soft, it won’t hold an edge. Dull blades require more force, which increases the likelihood of injury. Do you know what too soft feels like in your body? My edges become porous. I say “yes” too much. I go out of my way to make other people feel comfortable. I hold my tongue. I collapse under the weight of my responsibilities.
If a blade is too hard, it will be prone to breaking. Do you know what too hard feels like in your body? My thinking becomes rigid. I hold myself tightly, refusing to bend. My horizon of possibilities narrows. I crash into others, our edges colliding. I talk more than I listen. I feel an outsized sense of responsibility. I want to be the hero, but I also resent it.
Like wielding a knife, the work of creating change and holding power is somatic. That means it happens in our bodies and with the bodies of others. How do hardness and softness move in you as you discern which blade to use? If you are lucky, you will have more than one knife to choose from, though in terms of our survival, any blade is better than none.
Part 2: Change
A knife is rarely the only tool we have at our disposal, yet I am curious about who among us feels the need to carry a knife, or become one? This might be where object and metaphor begin to collapse. The stakes of carrying what some will perceive as a weapon can be far higher—and more lethal for the carrier, especially if they are Black, Indigenous and/or disabled—than the act of sharpening ourselves into instruments capable of confronting institutional violence.
When I imagined who I was writing this talk for, I thought of the researchers, clinicians, activists and non-profit or public sector workers I know who have dedicated their careers to ameliorating LGBTQ+ health. Some of you are at the beginning of this journey, others have been at it for years or even decades. This work is personal. All of you have stories to tell about how the systems or institutions you are part of, and working to transform, have harmed you and your communities. Words and phrases like “LGBTQ+ health disparities,” “stigma” or “minority stress” are inadequate containers for what our bodies know and remember, and for that which is held in the bodies of our loved ones and communities.
Like me, you might be instinctively wary when someone is too quick to celebrate your resilience. As Brianna Suslovic and Elle Lett (2023) write, “resilience functions as the result of exposure to traumatic stimuli” (p. 340). Suslovic and Lett call resilience an “adverse event” and advocate that it is better conceptualized as a form of “scar tissue” (p. 340). They point to the necessity of shifting our focus to the “individual and collective mechanisms by which harm is mitigated and prevented, rather than focusing on the aftereffects of harm” (p. 341).
I believe many of us do this work because we are hungry for change. We want something—maybe everything—to be different. We want our communities to suffer less harm. We want more people to stay alive long enough to grow old. Sometimes, we let ourselves want even more for them: ease, pleasure, flourishing, freedom. The systems and institutions we are working to change will try to shrink the scale of our dreaming. It is an act of resistance to want more than they tell us is possible.
To do this work is to fight for the living and those yet to be born while carrying the memories of those we have lost. Whose names do you speak aloud as a reminder of why you do this work and where you come from? Who is in a place of honour on your altar or in your prayers? Who inspired the memorial tattoo etched into your skin? As Hil Malatino writes in Trans Care, “To love the dead is for them to remain with you, introjected, present. Haunting and love are very close, indeed” (2020, p. 57).
Our work for change can be an outlet for our grief. I wonder how much grief you are holding for our communities now and what might happen if you were to let it flow freely. I am picturing a vast river with many tributaries that moves with awe-inspiring force and power, reshaping the terrain around it. It, too, can be a knife.
Our work for change can be an act of love. We might be pressured to set our love aside in the name of professionalism, or feel the need to smuggle our love in under our coats. Love is sometimes positioned as too sentimental—too saccharine, too messy, too feminine—to have a place in our work. Yet the love I feel for queer and trans people is integral to my work. It is a source of power, especially when anchored in a clear understanding of where my accountabilities lie.
I find those accountabilities in my relationships and in my values, which include care and solidarity. It can be tricky to enact our relational accountabilities when working in organizational contexts that ask us to place our allegiance with institutions instead of people and communities. I think of what a university research ethics review board might deem ethical, for example, in contrast to what situated ethical practices look like in communities, or when organizations insist we stay silent on matters of grave importance to our communities, like rising fascism and anti-trans hatred. I am also thinking of how universities across North America are violently repressing student, staff and faculty organizing in protest of Israel’s genocide against Palestinians.
Experience has taught me that the institution will always protect itself. As Sarah Ahmed writes in The Feminist Killjoy Handbook, “Institutions are reproduced by stabilizing the requirements for what you need in order to survive or thrive within them” (2023, p. 152). Her 2021 book, Complaint!, is a study of how universities discipline, punish or drive out those who go against their interests by speaking out against abuse and harm. Silence and compliance are rewarded. Ahmed points out that the word “reward derives from warder, to guard…You are rewarded for watching what you say or do or watching what others say or do” (2021, p. 100). Be wary when someone in power offers to trade you something better in exchange for your knife, or when they attempt to confiscate your weapons or dull your edges.
In the acknowledgements of their book, Atmospheres of Violence, Eric A. Stanley offers the following description of their mentor, Angela Davis: “She exemplifies the almost impossible position of inhabiting an institution without becoming its terrible logic” (2021, p. xii). How might we engage in similar practices from where we are? Our work for change will inevitably transform us. What shapes do we hope to embody? What safeguards will keep the institution from worming its way under our skins? In her 2016 book, Living a Feminist Life, Sarah Ahmed identifies how “institutions are built on promises of happiness; promises that often hide in the violence of these institutions” (p. 257). In this spirit, she invites us to join her in embracing a willingness to cause unhappiness. Ahmed writes, “Killing joy is a world-making project. We make a world out of the shattered pieces even when we shatter the pieces or even when we are the shattered pieces” (Ahmed, 2016, p. 261).
The work we do is world-making work, and we must take care to not let our imaginations be constrained by the limitations of the systems that exist. My training as a health services researcher taught me to think in systems, but it also reinforced a tendency to look comparatively at health systems without sufficient critical inquiry into their origins and underlying assumptions. It wasn’t until I began engaging more deeply with disability justice and prison-industrial complex abolition that I came to understand the extent to which our health systems are shaped by settler colonialism, white supremacy, ableism and eugenics. Thinking with disability justice and prison-industrial complex abolition helped me understand that these systems aren’t broken, they are working as designed.
In her book We Do This ‘Til We Free Us, abolitionist organizer and educator Mariame Kaba invites us to begin from boundless possibilities by asking, “What can we imagine for ourselves and the world?” rather than starting from “What do we have now, and how can we make it better?” While there is value in both lines of inquiry, too much of our work in LGBTQ+ health—including some of my own—gets stuck at “What do we have now, and how can we make it better?” When we stop at this level of inquiry, we set too low a threshold for the changes we deem necessary or possible, dulling our knives.
Accepting that the system isn’t broken, it’s working as designed sharpened my analysis by helping me situate the roots of LGBTQ+ health inequities outside our bodies. It helped me grasp just how vast and deep those roots are. It cut through the limits I had unconsciously placed on my imagination, challenging me to take a broader and more daring view of how we might create systems of care that enable all LGBTQ+ people and communities to flourish.
As Jules Gill-Peterson says in a 2022 interview with Beatrice Adler-Bolton, “These feelings of want, which we have been commanded to see in the language and in the economy of deprivation and scarcity: let them overflow. Imagine what we'll build for one another.” It can be painful to let ourselves want what we don’t have, but our desires can also be a force of creation and transformation. May they overflow.
Part 3: Power
Our efforts to create change often involve working with and against power. We do this at many levels: within ourselves, in our relationships and communities, and in the groups, organizations and institutions we are part of and working to transform. There is much that can be said about what happens when power is wielded in authoritarian, harmful and carceral ways. There are examples of this everywhere, including within each of us. Yet for our purposes I am more curious about how we might wield our power in service of liberation, transformation and healing.
In How to Hold Power, queer, trans and non-binary somatic leadership coach Pavini Moray defines power as our “ability to choose [our] response to situations,” “direct or influence the behaviour of others” and our “internal and external access to the resources [we] require to meet [our] needs.” They emphasize the connections between growing our capacity to feel our power in somatic or embodied ways and becoming more adept at intentionally using it.
Moray distinguishes between formal power—as tied to our title or position in an organizational hierarchy, for example—and informal power, which derives from our identities, relationships and experiences. Power might be earned or unearned. Privilege and oppression mediate our ability to access different forms of power. Unearned power derives most directly from privilege.
For example, I accrue unearned power in many contexts simply by being a non-disabled thin white cis person. These facets of my identity have given me access to education, training and opportunities. Through them, I gain knowledge, experience and relationships that buttress my status and credibility as an expert. When I’m consciously aware of the presence of my unearned power, it might feel outsized, like I’m taking up more than my fair share of space. It might feel shameful, like I’m compromising my values or getting away with something unfair. It’s also true that unearned power can feel good for how it creates ease and smooths the pathways between me and what I want. It’s seductive that way, so I need to keep practicing using it wisely and with intention.
My earned power comes from decades of learning and practice and being committed to my own ongoing process of transformation. It comes from staying open to new possibilities and knowing there is much I don’t know or can’t know. My earned power derives from interdependence and from making repair when I inevitably fuck up or cause harm. My earned power comes from developing relationships with my ancestors and learning our histories. It feels grounded, present and right-sized. My senses are awake without being vigilant. I am curious and open to learning. I feel sure of myself without being cocky. I feel more connected and able to honour the dignity of others. My earned power helps me make hard decisions from a place of integrity.
Informed by their learnings from Starhawk’s analysis of power, Moray delineates several different ways of using our power: power-over, based on domination, control and coercion; power-under, or acting in covert resistance to power structures (which we could also think of as topping from the bottom); power-with, the power we share and build with others; and power-within, our personal power. While we may not use the same words to describe them, I am sure we have each experienced manifestations of these forms of power in our personal and professional lives.
The work we do within institutional contexts can harm us and feel profoundly disempowering because of how power operates in these environments. When we try to create change, we can become targets for institutional violence—the institution wielding its power against us. Power is not equitably distributed, nor are the risks inherent in wielding it.
Yet it is also true that we each hold power, individually and collectively, and we can make choices about how to use and embody it. Given who I am speaking to, I am interested in the positional power that comes with our roles as researchers, clinicians, activists and non-profit or public sector workers. There is power in defining a research question or generating evidence, or in applying diagnostic criteria to a patient. There is power in designing and administering programs or determining how resources are allocated. There is power in being affiliated with an institution or part of a profession. There is power in having credentials and being perceived as an expert. There is power in having a platform to teach others and share your knowledge.
Part of the work of acknowledging and learning to wield the different forms of power we hold is resisting the urge to deny our power or pretend it isn’t there. We are living in times that call on us to be purposeful and courageous in discerning how to use our power, not as heroes or saviours but as people committed to building collective power in service of liberation. To wield our power more intentionally, we need to get to know it.
How does your power feel in your body today? Can you easily locate it, or is it hidden or pushed to the edges? Does it feel right-sized, constricted or does it take up too much space? Where does your power feel alive and flowing and where does it feel stagnant or stuck? Our answers to these questions will vary by context and from moment-to-moment, because power isn’t static.
I am attracted to the image of a knife as a way of thinking about how to embody and use our power because I came of age in communities of Leatherdykes, queer perverts and witches. It was they who taught me about holding power as a whole-body experience and showed me the kinds of magic we can generate when we wield our power together. It was these communities who showed me how knives can be a tool for focusing our intentions toward transformation, connection, pleasure and healing.
It is in this spirit that I will offer some thoughts on what we might learn from the knife itself as a way of thinking about holding power in service of creating change, with thanks to my friend Carly Boyce for helping me unpack this idea.
Recall the anatomy of a knife: handle, blade, edge, point, spine.
HANDLE: The handle is the part of the knife that we hold. A knife can be a shared tool; the handle might be touched by many hands. When we pass a knife to someone, we do so by the handle to ensure no one gets cut. Here, in this gesture, is an act of care and solidarity. To pass a knife from hand-to-hand is an act of trust. Some knives are a gift or an inheritance.
To handle something is to manage a situation or problem. This problem might originate from, or result in, people being mishandled. Sometimes, we get a handle on things by becoming the problem. As Sarah Ahmed writes, “To expose a problem is to pose a problem” and “We have to keep saying it because they keep doing it” (2023, p. 240). She calls these killjoy truths, hard won wisdoms that can make us feel less alone.
BLADE: The blade is the part of the knife we cut with. A blade has an edge. To edge forward is to advance by short moves; big changes are often created in small increments. An edge can be a boundary, the line between where something ends and another begins; a boundary can be where we find our “yes” or our “no.” A boundary can be a space of refusal or an invitation. The work of holding power and creating change will help us find our edges; it might challenge them.
When I think of edges, I am reminded of the “Resilient Edge of Resistance,” a concept I learned from sex educator Barbara Carrellas (2012) in her book Ecstasy is Necessary. Carrellas was taught this idea by her late teaching partner, Chester Mainard, who initially coined it to describe a form of touch that perfectly captures someone’s desired balance between too much and too little pressure. Carrellas expands the idea of The Resilient Edge of Resistance to risk-taking more generally. She invites us to reflect on what is needed to create the conditions in which we feel “sufficiently supported to take a risk;” which “occurs at different depths in different situations for each individual” (Carrellas, 2012, p. 68).
To use a blade is to accept at least some degree of risk. In their writing on anarchist responses to the drug poisoning crisis, Zoë Dodd and Alexander McClelland (2017) assert that “rule-breaking and risk-taking are ethical actions in an unjust world.” Here, risk-taking is understood as an ethical practice, grounded in our relational accountabilities. Dodd and McClelland write, “We have to take risks because we are being swallowed up, because we have no choice but to do so, and because we must take care of each other.” The stakes are too high for those of us in positions of power to always prioritize our safety and comfort. What risks are you willing to take in using your power to effect change? How might you become better acquainted with your Resilient Edge of Resistance so as to support you in discerning which risks to take, and how? What will help you hone your edges?
POINT: The point is the end of the knife used for piercing. It can also be a location or destination, or a reason—an end or an object to be achieved. Someone might say to you, “That’s not the point,” and you will know otherwise, a piercing insight. The institution might try to distract you with reasons to score points or offers of bonus points. When we know the point of our work, it can be easier to sniff out a distraction or a bribe. What will aid you in divesting from institutional cultures focused on scoring points?
When asking yourself, “What is my knife and how am I using it?,” it is helpful to remember that a knife is an instrument with many possible uses. What changes are you seeking to create and why? The point has to be more than just scoring points. My community work includes being a death doula and hospice volunteer. To some, this might seem like a total bummer, but to me it is an affirmation of life and an invitation to live each day with my legacy in mind: What do I want to leave in my wake? How do I want to be remembered? Who and what matters most to me? Asking myself these questions helps me find the point. As you wield your knife, consider asking yourself: Why am I here and who am I doing it for? Ask yourself as many times as you need to; keep finding the point.
SPINE: The spine supports the whole knife and facilitates energy transfer between the handle and the cutting edge. Without the spine, the whole structure would collapse. The spine is integral to our anatomy; it is a complex structure made up of many parts that helps us move and be flexible. A spine can be a sharp rigid process on an animal or plant that serves as a defense mechanism. Don’t underestimate the power of such defense mechanisms: The crested porcupine has quills powerful enough to fight off a lion. “Spine” can mean resolution or strength of character. What helps you feel into yours? What can it teach you?
Each morning, before I begin work for the day, I do a somatic centering practice that helps me feel into my length, width, depth and centre. In this practice, which has lineages in the work of generative somatics and the Strozzi Institute, we feel into our length—from our feet rooting into the ground to the tops of our heads. It is a means of anchoring into our dignity and becoming better able to recognize the dignity of everyone around us. How might we use our power in ways that dignify ourselves and others? How might we use our power as an antidote to dehumanization? How might we use our power in service of more aliveness and possibility?
Conclusion
I want to wield my knife with ferocious care, grounded in the knowledge that it is by wielding our knives together—as well as the many other tools we have at our disposal— that we will win. I am not naive about what we are up against, and I sometimes feel immobilized by despair. What keeps me going is remembering who I am accountable to and what is at stake. Change is both necessary and possible, and while I may not see the results in my lifetime, I have a knife and I’m damn well going to use it.
Queering Leadership
It all begins with an idea.
This talk was originally given at Q-Med: Building LGBTQI+ Leaders in Health Care, a conference held at the Yale School of Medicine in March 2019.
Introduction
It’s an honour and a privilege to be in this room with so many people who are working to transform health care, both through your work and through your very presence as LGBTQ+ leaders in health care, education and research. I want to thank each and every one of you for taking time out of your busy lives and in some cases traveling long distances to be here. Thank you for doing whatever it took to bring you to this moment, to the remarkable fact that we get to spend the next two days learning together, building relationships and finding allies and accomplices in our work to make health care more inclusive and just.
In honouring our presence in this room, I also want to honour those who can’t be here with us today for all of the complex reasons that keep queer and trans people out of health care and higher education, including the racialized, classed, gendered and ableist barriers that prevent some of our kin from accessing rooms like this one. I want to recognize the long history and ongoing actions of LGBTQ+ leaders working outside of formal institutions to bring affirming, accessible health care to our communities. May we honour them through our work together this weekend and remember that we are part of a strong lineage and a diverse community of resilient, creative queer and trans people whose efforts both enable and complement ours. It’s a joy and a privilege to be here; let’s feel into both of these things as we embark on this journey together.
Being invited to speak at this conference feels like an unexpected gift, because although I’ve been deeply engaged in thinking about and practicing leadership over the past decade, this is the first time I’ve had the opportunity to explore leadership from an explicitly queer perspective. What’s been affirmed for me in the process of writing this talk is that my leadership style is fundamentally shaped by my experiences and vantage point as a queer person, and that I see radical potential in the act of queering leadership. In offering this idea, I want to draw a distinction between queer as an identity and queer as a verb. As Meg-John Barker and Julia Scheele put it, “queering is something we do rather than something we are (or are not).” The word “queer” may or may not resonate with how you describe yourself but my hope is that the idea of queering leadership will be useful to you now and as you progress through your career.
My invitation to queer leadership takes inspiration from a definition of “queer” written by Black queer feminist scholar and poet Alexis Pauline Gumbs. She writes:
Our definition of queer is that which fundamentally transforms our state of being and the possibilities for life. That which is queer is that which does not reproduce the status quo.*
My perspective on leadership is rooted in abundance - the idea that we all have the opportunity and the potential to lead. If we work from this assumption, it requires us to consider two key questions Jeremy Dale asks in a recent article on the role of a leader. He writes, “Since we are all leaders, we must ask what type of leader we want to be? What characteristics do we want to possess?” My hope is that this talk will offer you useful ideas and questions to explore as you seek to imagine the kind of leader you want to be, and that it will encourage you to lead with authenticity and pride in your identity as an LGBTQ+ leader.
What is leadership?
Before we figure out how to queer it, I want to begin by getting us on the same page about what leadership is. The Rockwood Leadership Institute defines it as, “The ability to inspire and align others to successfully achieve common goals.” Leadership scholar John P. Kotter describes it as a set of behaviours rather than individual attributes. As he puts it, “leadership is about vision, about people buying in, about empowerment and, most of all, about producing useful change.” He emphasizes that in our complex, fast-moving world, we need leadership from people at all levels of organizations, a perspective echoed by Nick Petrie in a report on future trends in leadership development. Petrie points to a trend towards understanding leadership as a process, not as a person or role tied to a position of authority in a hierarchy. In her book Dare to Lead, Brené Brown defines a leader as “anyone who takes responsibility for finding the potential in people and processes, and who has the courage to develop that potential.” As Claudio Feser explained in a recent episode of the McKinsey podcast, we learn leadership by doing, trying and failing, and these behaviours become skills if we carry them out consistently. What these definitions have in common is the idea that leadership is a set of behaviours that can be learned by anyone, regardless of their role.
I want to underscore the notion that leadership is something you learn by doing, not something you’re born with or are vested with by virtue of your job title, particularly in recognition that many of you are at earlier stages in your careers and may not yet be in formal leadership roles or higher up in your organizational hierarchies. Leadership is still relevant to you and is something you can and should practice. I encourage you to embrace your identity as a leader, which also means embracing the accountabilities and commitments that come along with it. In my experience, leadership is an ongoing process of learning, curiosity, self-reflection, humility, vulnerability, experimentation and adaptation. You can practice leadership at school, at work, at home and in your communities, whether through formal roles or just by how you show up. The best leaders understand and commit to leadership as a lifelong journey. It’s okay if you don’t figure it all out this weekend! I’ve been in formal leadership roles for over a decade and I’m still practicing and learning every day.
Who taught you to lead, and what have you learned from them?
If we understand leadership as a set of behaviours that can be practiced over time, it follows that leadership can be learned. We’re at a conference on leadership so I’m willing to bet that we’re all invested in learning more about it. This shared commitment to learning about leadership has me wondering what leadership lessons we’re each bringing into the room with us today. Who taught you to lead, and what have you learned from them? Maybe, like me, your professional education and training have included little to no explicit curriculum or teaching about leadership. In 2011, Warren and Carnall pointed out that good leadership is essential to delivering high-quality patient care, yet it’s often untaught, undertaught and unassessed in medical education. Rotenstein and colleagues reaffirmed this in 2018 when they wrote, “to be a physician is to lead,” yet “leadership skills are rarely taught and reinforced across the continuum of medical training.”
I don’t think that the problem of a lack of formal leadership training is exclusive to medicine. Between my undergraduate, Master’s and PhD I spent eleven years in university and none of my courses included content on leadership. I remember feeling acutely aware of this knowledge gap when I was first hired into a leadership role early in my career. I felt confident as a subject matter expert in my field but I sometimes felt woefully unprepared for the challenge of leading. I did a lot of on-the-job learning - including learning from my mistakes - and I eventually sought out (and continue to seek) mentorship and continuing education on leadership.
Whether or not you’ve received formal training in leadership as part of your education, you probably have ideas and opinions about it based on your experiences to date of leading and being led. I want you to take a moment to reflect on those experiences in answering the following questions:
What have you learned, implicitly or explicitly, about leadership from your education, work experience and the communities you’re part of?
What has this taught you about the kind of leader you want to be?
Be as specific as you can in answering these questions; leadership is experiential and the qualities and examples that come to mind will offer clues to your own leadership style and preferences. Some of you may have more negative than positive examples on your list. Bear in mind that the counterexamples may be just as instructive as those you want to emulate.
If we had more time today I would love to collectively develop lists of the leadership qualities we aspire to as LGBTQ+ leaders - and those we want to avoid. My hunch is that patterns would emerge in both lists, and that there might be an experiential and aspirational gap between how we’ve been led and how we want to lead. The gap between experience and aspiration is likely different for each of us, and is shaped in part by our professional, educational and personal backgrounds as well as our identities and experiences of privilege and oppression. The latter feels important to mention because many of us are leading and being led in institutions and organizations that mimic the oppressive structures and power dynamics of the larger societal contexts in which they’re situated.
This brings me back to one part of the definition of queer I introduced earlier. As Alexis Pauline Gumbs writes, queer “does not reproduce the status quo.” If we’re seeking to transform the status quo, we need to begin by understanding what it looks and feels like. In many settings, such as the formal hierarchy of a medical school, a hospital or a university, how leadership is practiced both individually and institutionally is entangled with homophobia, biphobia, transphobia, racism, sexism, ableism and other forms of oppression. Many of us are learning, training and working in environments that harm us and our communities and that limit our capacity to fully express our identities. LGBTQ+ medical students report concealing their sexual and gender identities and experiencing bullying and discrimination from peers and instructors (see, for example, Feroe, 2018, Mansh et al., 2015 and Nama et al., 2017). These experiences don’t end after graduation, as LGBTQ+ health care providers also report harassment, ostracization and witnessing discrimination against LGBTQ+ colleagues and patients (see, for example, Eliason et al., 2011 and Eliason et al., 2018). While research suggests that the climate has improved over time, it’s clear that there’s still considerable work to be done to create affirming, inclusive learning and working environments for LGBTQ+ people in the health sector, particularly for folks who are trans, non-binary or gender diverse.
In highlighting the homophobia, biphobia and transphobia faced by LGBTQ+ health care providers and trainees, it’s important to emphasize that many people are simultaneously experiencing other forms of oppression and discrimination in their learning and working environments. Trainees and health care providers who are members of racialized groups experience racism and discrimination in educational settings and at work, from colleagues, patients, instructors and others (see, for example, Okwerekwu, 2016, Vogel, 2018 and Tello, 2017). The student-led group White Coats For Black Lives has a racial justice report card that evaluates medical schools on 15 racial justice metrics. Of the ten schools they graded in 2018, none received higher than a B-. There’s also growing recognition of the prevalence of sexual assault, harassment and inequality primarily experienced by women and gender and sexual minorities in health care learning and working environments (see, for example, Phillips et al., 2019, Vogel 2018). The launch of TIME’S UP Healthcare is just one example of resistance against this culture.
As medical student Jennifer Tsai puts it, “professional structures—in the hospital and at large—were never built around women, people of color, workers with disabilities. These systems cannot be diverse and undisrupted.” She goes on to explain that this results in conditional inclusion, “one that hinges on a mandate that [we] cover [our] identities, abandon [our] assets and tie down the very superpowers that would improve the...health care system.” The idea of covering our identities refers to the work of legal scholar Kenji Yoshino, who heads the Center for Diversity, Inclusion and Belonging at NYU. Yoshino, himself a gay man of colour, describes covering as a demand for assimilation. When we cover ourselves, we alter how we look and how we act, we don’t stick up for the stigmatized group (or groups) we’re part of and we avoid contact with members of the same group(s). His research affirms that covering is detrimental to our sense of self, our feelings of support and safety at work and our perception of whether we’re the “right” kind of person to move into a formal leadership role at our organization. In short, it’s a barrier to authentic leadership.
All of this is taking place in a wider professional context characterized by entrenched hierarchies and power differentials between learners and teachers, employees and managers, different health professions and providers and patients. Medical students and residents report bullying and harassment from attending physicians and program directors in their medical training, and there’s a strong push to conform in the face of significant power differentials that can make or break people’s careers. What are the consequences of this for diverse learners and health care providers, especially at earlier stages of your training and professional lives? I know that many of you are actively working to change this culture, and change can’t come fast enough. Leadership has the potential to be transformative, yet it can also be stifling and violent in how it manifests in our organizational cultures and in our interactions with others. Moving towards the leadership we need requires us to acknowledge the ways it can do harm.
Queering leadership: Transforming the status quo
What would it look like to practice leadership in ways that enable all of us to thrive? How will it require us to transform our leadership practices to better reflect the world we are working to build? How does this intersect with our work in health and healing? Here I want to return to the second part of Alexis Pauline Gumbs’ definition of queer: “that which fundamentally transforms our state of being and the possibilities for life.” I want us to create space for forms of leadership that are expansive, robust and supportive enough to hold and honour the diversity of our lives, identities, experiences and ways of leading. To queer leadership is to transform our state of being and possibilities as leaders and members of the LGBTQ+ community. It is to resist assimilation and reproducing the status quo in favour of building something more nurturing and liberatory.
By describing what queering leadership looks and feels like to me, I hope to encourage you to reflect on your own practice of queering leadership, and to begin a conversation about what we can learn from each other. Some of the questions I’m sitting with include: how have my experiences as a queer person informed how I understand and practice leadership? What strengths do I bring as a queer leader? How might queering leadership transform our institutions and how we relate to one another within those institutions? As a way to begin answering these questions, I’ll share some of what I’ve learned about the practice of queering leadership, with recognition that it’s a set of ideas grounded in my own experience and therefore both shaped and limited by my perspective as a white, cisgender femme.
When I think about what queering leadership looks and feels like to me, several qualities come to mind:
I lead with my whole body.
I practice being right-sized in how I take up space.
I honour the messy, the uncategorizable and the vulnerable.
I feel into accountability and interdependence.
I lead in service of surviving, thriving and collective liberation.
Let me tell you more about what this means to me.
Lead with your whole body:
One of the ways I queer leadership is by leading with my whole body. There’s something deeply embodied about queerness. Our identities as LGBTQ+ people are rooted in our bodies - how we inhabit them, how we adorn them, how we relate to them alone or in the company of others. Queerness has taught me to come back into a deeper and more intimate relationship with my body, and to trust in its wisdom and intelligence. I’ve learned how to tune into the signals my body sends me when I feel anxious, stressed and overwhelmed, or relaxed, open and receptive. I’ve learned how to embrace pleasure and play. I’ve learned how to rest. It’s made me more skillful, creative and empathetic as a leader. For example, I’ve gotten good at noticing when my anxiety gets triggered at work. When this happens my shoulders feel tense and I interact with other people in a way that’s controlling and shuts down possibilities. As I’ve become better at tuning into that response early on (something my body always figures out way earlier than my mind), I’ve learned strategies for tending to those feelings in ways that lessen the impact on me and others. Even simple things like slowing down, consciously relaxing my shoulders and taking deeper breaths make a big difference. I’ve also learned to be more attuned to other people’s bodies by noticing their body language, encouraging them to attend to their physical and emotional well-being, and by leading in a way that is trauma-informed. At the most basic level, this means acknowledging that our interactions with others can trigger trauma responses - fight, flight, freeze or appease - in them and us. (Ronald Heifetz and colleagues have explored this idea in the context of adaptive leadership and supporting others through change and uncertainty.)
Leading with my whole body feels like an antidote to a culture of ableism and overwork that falsely divides our minds from our bodies and rewards us for working through hunger, exhaustion, physical and emotional pain, even the most basic drives like stopping work long enough to eat or pee. I’m conscious of the fact that I’m standing in a room full of people - and I include myself here - who’ve been conditioned to believe that our worth is rooted in how academically and professionally successful we are and how much work we churn out. (If you want to have a real talk with yourself about this, check out the signposts of workaholism from Workaholics Anonymous. I suspect that I won’t be the only person who had an “IT ME” response to this list.) Maybe you also experience some combination of perfectionism, shame, fear and impostor syndrome - I know I do. So I want to remind you of this: you are worth more than your work, you are inherently good and worthy, and your body is wise. How would it feel to lead from this knowing and from a place where you’re valued for who you are, not how much you do?
Practice being right-sized in how you take up space:
The second quality of queering leadership that I want to explore is being right-sized in how we take up space. I once went to a workshop where we were invited to embody what it felt like to be right-sized. It went like this: the facilitator gave us several different feelings to convey only through our body language - no talking. One of the feelings was pride. First, we were invited to show what it feels like when we have an outsized amount of pride. I remember walking around with my chest puffed up tightly and my head held so high that I couldn’t make eye contact with anyone. Then, we were invited to embody what it looked like to have too little pride in ourselves. I went from big to small, curled in on myself, shoulders slumped forward, not looking at the others because my eyes were cast down. Finally, we were invited to embody right-sized pride and that’s when it really clicked for me. I stood tall with my head up, and I felt confident and in my power. But I also felt a softening across my chest that felt like openheartedness to me. As I walked around the room I made eye contact with others, and I remember feeling connected to them and able to see and honour the pride they had in themselves.
What this exercise taught me is that there’s something powerful about being right-sized, and we can learn from this as leaders. This sometimes means attending to privilege and ego and being intentional about taking up less space, and it sometimes means taking up more space than we’re accustomed to. Here I want to emphasize the idea of calibration, which is something I’ve learned from the queer community: how much space I take up as a leader is going to shift depending on the context and circumstances. For example, if I’m the only woman leader in a roomful of straight, white male leaders, I may strategically take up more space; by contrast, if I’m the only white, cisgender person in a roomful of trans people of colour, I will intentionally take up less space - including asking whether it’s appropriate for me to even be there in the first place. Calibration asks those of us who carry specific forms of privilege like white privilege or cisgender privilege to do the important and ongoing work of understanding how it shapes the ways we take up space, and how being right-sized doesn’t mean taking the space we’ve been conditioned to think we’re entitled to. Calibration invites all of us to ask ourselves how much space we ought to take up in any given moment, and to embody an adaptive kind of right-sized leadership. I encourage you to get curious about this. What does being right-sized look and feel like for you in different contexts, and how might that knowledge inform your leadership practice?
Honour the messy, the uncategorizable and the vulnerable:
The third quality of queering leadership that stands out to me is how we honour the messy, the uncategorizable and the vulnerable. One of the things I love most about queerness is our capacity to defy binaries and categories. Queer folks are boundlessly creative in how we embody and name our identities, our relationships and our family structures. As a queer leader I’ve learned to feel comfortable with ambiguity, doing things differently and thinking outside the box. It’s taught me to honour the messy and the uncategorizable. Now don’t get me wrong - I also love a colour-coded to-do list and I definitely own a label-maker - but in our complex and rapidly-shifting world, being able to stay grounded and see potential in the face of ambiguity is an asset.
Queerness has also taught me to embrace vulnerability. I have a print by trans artist and poet Lora Mathis on my bedroom wall that reads, “Radical softness as a weapon.” Here’s how Mathis describes what they mean by this: “Radical softness is about embracing emotions and combating the social stigma surrounding vulnerability. It’s about being forgiving with yourself for having a hard time, and recognizing that healing is not linear...It’s about trying to work against shame and viewing softness as strength.” Working against shame is something many queer and trans people are intimately familiar with as we push back against messages telling us that who we are and how we love is wrong. It’s no wonder we want to protect ourselves. As Brené Brown puts it, “When we’re raised in unsafe environments, confronted with racism, violence, poverty, sexism, homophobia, and pervasive shaming, vulnerability can be life-threatening and armour is safety.”
To queer leadership is to resist shame. It’s an invitation to take off our armour and reveal the glorious, imperfect, brilliant selves hiding underneath. I understand that self-protection is necessary and life-saving for many of us, and I’m not telling you to throw your armour in the recycling bin. What I am saying is that leadership doesn’t need to be hard, sharp and invulnerable to be effective. Some of my most powerful moments of leadership have come when I’ve given myself permission to be vulnerable - to open to my emotions instead of denying them, to soften into empathy for myself and others, to embrace the messiness and unpredictability that can come with connection. What would it look like to lead from a place that honours your vulnerability instead of from a place of fear and shame? How would it feel to take off your armour and let yourself soften and shine?
Feel into accountability and interdependence:
The fourth aspect of queering leadership that I want to explore is feeling into accountability and interdependence. Author and speaker Nilofer Merchant asks us to reflect on the questions, “Who are you?,” “Whose are you?” and “Who are you for?” These questions point to what I see as a core aspect of queer leadership: understanding who we are accountable to and feeling into the interdependence that comes along with that accountability. As a queer person, I’m aware that I’m part of something much larger than me, a community and a lineage that is broad and deep and spans generations. I understand that I have accountabilities to my community, both in the specific ways that come with being in relationship with particular people in a particular place and time, and in a broader sense of asking what I need to do in this lifetime to follow through on my commitment to be a good ancestor to the queer and trans people who will come after me. So much of health care can be about attending to what is immediate or urgent that we sometimes forget to think beyond this moment and remember that we are part of a whole lifespan and lineage.
When I feel accountable to a person or group, I’m attuned to how my actions might affect them, both positively and negatively. I take responsibility for the impacts of my behaviours and build my skills around conflict resolution, apology and repair. These are all critical skills to develop as a leader. Being accountable means thinking beyond myself. Feeling into interdependence reminds me that I’m not doing this work alone. It’s helpful in shifting out of a mode of leadership that rests on my contributions as an individual and it creates a much more resilient, supportive structure. It feels good to know that I don’t have to create all of these momentous changes by myself, and I don’t have to do it all in this lifetime! It gives me permission to ask for help instead of leading from a place of autonomy, lone wolf heroism or unhealthy self-sacrifice. It supports me to move out of feeling obligated and chronically overwhelmed into having healthy boundaries in my work and relationships. It enables me to lead from “we” instead of from “I,” and to move from individualism to collectivism without losing myself in the process. What would it feel like to know that you’re not in this alone, and that you don’t have to carry the weight of this work all by yourself? Whose are you, and how might your answer to that question enable you to lead from a place of accountability and interdependence?
Lead in service of surviving, thriving and collective liberation:
The final dimension of queering leadership I want to explore is to think about leadership in service of surviving, thriving and collective liberation. Sometimes, as queer and trans folks, we need to focus on our survival. But if we’re perpetually in survival mode and habitually covering who we are - including the magnificent fact of our identities as LGBTQ+ people - how can we lead authentically and build solidarity with fellow LGBTQ+ folks and members of other stigmatized groups? As Kenji Yoshino reminds us, assimilation is not the path to authentic leadership. My hope is that by queering leadership we can develop the tools and resources we need to lead authentically and to move from surviving to thriving. In turn, I hope that this becomes the foundation for us to take up the important work of supporting others to survive and thrive - and ultimately, to move towards individual and collective liberation. Like leadership, this is not a linear journey but rather an iterative process of learning and practice over a lifetime.
Survival is often a victory in and of itself for queer and trans folks. The very fact of our presence in this room today is a victory. We are alive and we are here together and that’s a beautiful thing. What would it look like for us to move from survival to thriving? What do you need to thrive as an LGBTQ+ leader in health care? The word “thrive” has its roots in an old Scandinavian word meaning to “grasp to oneself.” How might we hold fast to our identities as queer and trans people as integral to our thriving and our leadership? What resources and supports do we need to thrive in our work and in our lives as LGBTQ+ people, not just now but sustainably over time?
One of the things I find most exciting about working in health care is that it has the potential for both individual and systemic transformation. Many of us are called to this work out of a desire to do good, yet the liberatory potential of our work sometimes gets lost in the everyday challenges of being a small cog in a big, bureaucratic machine. As someone deeply committed to moving systems towards equity and justice, I’m very interested in understanding how to enable social accountability in health care - that is, to move from knowing about health disparities to doing something about them. Being a leader in health care brings with it a specific kind of power and responsibility. I invite you to think about how you’ll use the power afforded to you now and in the future in service of enabling others to thrive. Leadership in service of our own survival, even our own thriving, is insufficient. Our call to action as LGBTQ+ leaders in health care is to be part of facilitating movement towards collective liberation. It is to do something about the health disparities that disproportionately affect our queer and trans kin and other groups who also experience unjust barriers to care.
I recognize that this might feel like a daunting task. Some of you might be thinking, “I’m just starting out in my career. I don’t have any power yet, and it’s hard enough navigating my overwhelming workload!” Some of you might be living through the painful realities of discrimination or bullying in your learning or working environments. I know that I’m in a very different social and professional location than many of you, and I’m lucky to be in a position where I have enough power and seniority to be an out, vocal queer leader. I don’t take that for granted, and it inspires me to work towards a world where everyone is supported and celebrated to lead authentically, and where every LGBTQ+ person has access to the affirming health care they deserve.
I’m not asking you to radically transform leadership or the health system all by yourself in one fell swoop, now or ever. What I am inviting you to do is think about what you can commit to today - and the very first step might be figuring out how to keep surviving so you can figure out how to thrive. But I want us always to keep the collective in mind, and to remember the liberatory potential of this work. We can be agents of change within the health system so our queer and trans kin don’t have to suffer discrimination anymore. Let’s work together to build a health system that enables all of us to survive and thrive, and that realizes its true liberatory and healing potential.
It’s big work and it’s hard work, and it’s our work to do, because as the Social Transformation Project’s Jodie Tonita says,
In the face of daunting challenges, we must summon the courage to believe we are the ones we have been waiting for, take risks, and experiment towards solutions. We’re being asked to believe in our inherent capacity, step into the unknown, and challenge deeply held assumptions. For most of us, that’s radically disruptive and contrary to how we’ve organized ourselves to succeed in life to date.**
We are the ones we’ve been waiting for. If you trace back the history of this phrase, you can find it in a poem about resistance against apartheid by Black bisexual writer June Jordan. As LGBTQ+ people and leaders we are part of a lineage of pride, resistance and transformation. It is our privilege and our responsibility to be part of continuing the work of moving our health system and indeed our society towards justice and liberation, so that everyone has the opportunity to thrive.
Conclusion
In their book Leadership on the Line: Staying Alive through the Dangers of Change, Ronald Heifetz and Marty Linksy write, “At its best, leadership is a labour of love.” Cornel West, in turn, reminds us that, “Justice is what love looks like in public.” Our work as LGBTQ+ leaders in health care may feel risky and terrifying at times, yet the practice of queering leadership is also a profound act of love for ourselves and our communities. How will you put that love into action this weekend and beyond in your lives as LGBTQ+ leaders in health care? How will you lead with pride, authenticity and a commitment to the health and liberation of all queer and trans people? How will you answer the question, “What type of leader do I want to be?”
When I look around this room I see the future of health care, and that makes my heart want to burst with joy, because you are magnificent. You are magnificent in your queerness, in your transness, in wherever you situate yourself in the marvellously vast galaxy of gender and sexual diversity. You are magnificent in your strength and vulnerability, and in every facet of your identity and every part of your story that brought you into this moment. I am so grateful to be in this work with you because it is love made tangible. Let’s take that love and use it to build a better world together, a world where everyone can thrive.
Notes:
*This quote is from a piece by Alexis Pauline Gumbs in the anthology Revolutionary Mothering, edited by Alexis Pauline Gumbs, China Martens and Mai’a Williams (p. 115).
**This quote is from an interview with Jodie Tonita in adrienne maree brown’s book Emergent Strategy (p. 177).
Dear First-Year Medical Student
It all begins with an idea.
A version of this letter was originally given as a talk to the incoming class of medical students at the Stanford University School of Medicine during their orientation in August 2019.
Dear First-Year Medical Student,
Congratulations on starting medical school! This is the beginning of your journey of becoming a doctor. You worked very hard to get to this moment and for many of you it’s the realization of a long-held goal or dream. It might also be a little bit scary, because “holy sh#t this is real I’m really in medical school when is somebody going to figure out I don’t belong here?” You belong there, and I’m grateful to you for embarking on this journey. The world needs more healers and I hope you’ll be one of them.
This is the beginning of a remarkable process of learning and change. You’re at medical school to learn how to do something, to practice medicine. Yet the next four years will also teach you how to be. What I mean by this is, over the next four years (and after), you’ll learn the concrete skills and clinical knowledge you’ll need to be a competent physician. Through both a formal and an informal curriculum, you’ll learn to think and act like a doctor and how to interact with your patients and colleagues. You’ll learn ways of knowing, ways of perceiving your patients and ways of embodying what being a doctor looks and feels like. The next four years will change you. They will teach you a new way of being. They will make you into a doctor.
My question for you in this moment is, what kind of doctor do you want to be? I don’t mean which specialty or subspecialty – you do you! – I mean, how do you want your patients to feel before, during and after a visit with you? Your answer to this question matters to me because how you care for someone can be as healing as whatever medicine or medical interventions you offer them, or as harmful as the health issue that brought them to you in the first place. For many people, and certainly for many LGBTQ+ folks and other sexual and gender minorities, going to the doctor isn’t simply a neutral experience of accessing health care. It’s a visceral, embodied experience that carries with it physical and emotional legacies of past and present traumas – including at the hands of the medical system – and the felt impacts of the intersecting oppressions that may be limiting their ability to thrive or even survive.
I’m writing to you because I care about the kind of doctor you become and what this means for your future patients. As an LGBTQ+ health advocate, I’m passionate about helping queer and trans people and communities survive and thrive and I see you as allies and accomplices in this work. Research from the US, Canada and Europe shows a consistent pattern of LGBTQ+ people avoiding or postponing needed medical care and preventative screenings because they’ve experienced disrespect or discrimination from health care providers; transgender people report this at much higher rates than sexual minorities.* I know far too many LGBTQ+ people who avoid or delay accessing health care because they’re afraid of discrimination. I feel fiercely hopeful that this can change and I want to be part of making it happen.
I’m writing to you because of the joy I hear in people’s voices when they tell me about receiving LGBTQ+-affirming care. I see relief in their bodies when they feel safe enough to let down the burden of fear and self-protection and open to the possibility of health care that feels genuinely healing. I’m writing to you because I know what that feels like in my queer body. I want all LGBTQ+ people – indeed, all people – to have access to this kind of care. I want to be part of making health care more affirming, equitable, liberatory and just. Let’s imagine this kind of health care into being, and then let’s work together to make it a reality.
I know that you’re a diverse group when it comes to your knowledge of LGBTQ+ health. Some of you already know a lot about LGBTQ+ people and communities while others might be newer to this topic. Some of you are members of the LGBTQ+ community and others aren’t, or aren’t yet. (I started grad school thinking I was straight and look at me now!) Some of you are coming into medical school with a strong interest in LGBTQ+ health and others might be drawn to different topics, populations or specialties. Some of you might feel very comfortable with LGBTQ+ people, others less so. So there’s already a lot of difference among you when it comes to this particular topic, but you have one thing in common: as physicians, you’ll all care for LGBTQ+ patients. It’s the thread that weaves us together and it’s what makes this topic relevant to you now and during medical school, no matter what knowledge and experience you’re bringing into school with you or where you end up four years from now.
We have another thing in common: we all have experience being patients. Think back to those experiences. Have you ever had an encounter with a doctor or health care provider that felt uncaring? Like they weren’t listening or didn’t get you? What about a time where you felt like you had to omit information or not tell your doctor or other care provider the truth because you felt afraid of being judged or shamed? How many of you have had experiences as patients that felt downright discriminatory? What was going through your mind during those experiences? How did it feel in your body? How did it affect your willingness and motivation to go back to that provider or seek care again?
When have you felt really cared for and comfortable with a doctor or other health care provider? What did they do to make you feel that way? What was going through your mind during those experiences? How did it feel in your body? How did it affect your willingness and motivation to go back to that provider or seek health care again? I encourage you to reflect on your answers to these questions. It’s helpful to remember and feel into your experiences as patients, not because these experiences are one-size-fits-all – they aren’t, particularly if you’re white or cisgender like me – but because I hope these recollections will help you empathize with your patients. It’s hard work to be a patient! And it can be scary, vulnerable, emotional work, too. There’s the pain and distress of whatever brought your patient into the hospital or the clinic, and then there’s the experience of actually accessing and receiving care. Think back to your answer to the question, how do you want your patients to feel before, during and after a visit with you? What would it be like to use your answer to this question as a touchstone during your medical training as you learn, practice and imagine your way into becoming the doctor you aspire to be? What can you learn from your own experiences as a patient?
It feels meaningful to write to you because my book The Remedy: Queer and Trans Voices on Health and Health Care was inspired by my early experiences teaching first-year medical students about LGBTQ+ health. Back then, I would come to class with PowerPoint slides crammed full of statistics about the health disparities the LGBTQ+ community faces. It was like I was trying to build a case for why LGBTQ+ health should matter to future physicians, but if documenting and quantifying our health disparities were enough all LGBTQ+ people would be healthy today. It’s important to me to ground my work in evidence and I’m grateful to the growing community of researchers advancing our knowledge of LGBTQ+ health, and to the educators and clinicians who are translating that evidence into curriculum, protocols, policies and practice. Yet The Remedy grew out of my realization that something was missing from this body of knowledge: people’s stories. I decided to create a book that centred LGBTQ+ people’s voices and perspectives on health and health care; I knew that our stories could foster empathy and understanding in a way that statistics couldn’t.
Stories are powerful systems change tools. As Ella Saltmarshe puts it, “Stories make, prop up, and bring down systems. Stories shape how we understand the world, our place in it, and our ability to change it.” Let’s change the story of what LGBTQ+ health care looks and feels like. As future physicians, how can you develop the skills and knowledge you need to help your LGBTQ+ patients change their stories about accessing health care? I want us to create new stories together, and I want those stories to change systems. A systems change lens is important because there are connections between your actions as a physician and the larger systems and structures in which your work is situated. Health and illness don’t exist only in individual patients; they emerge out of how people interact with and are acted upon by the larger dynamics of privilege and oppression that operate at the levels of groups, communities and whole societies.
Medicine is part of society, which means it’s shaped by the same oppressive dynamics that shape the world around it. Power and privilege are in our medical school classrooms, hospitals and clinics. Racism is there. Colonialism is there. Gender inequity, sexism and sexual violence are there. Ableism is there. Fatphobia is there. Classism is there. Ageism is there. Homophobia, biphobia and transphobia are there. I name these things in part as a reminder that they’re present, and so we remember that these oppressive forces are working on all of us, whether as student or teacher, patient or provider, advocate or administrator. They are working on me and they are working on you, both to our advantage and disadvantage, in the way that we each carry with us a unique combination of intersecting privileges and oppressions. This is as relevant to your success and wellbeing as a medical student and physician as it is to the health of your patients, and it’s a call to action to work against all the ways systemic oppression shows up in medicine so we can build a health system that is more liberatory and just.
If you’ve read The Remedy, you’ve been introduced to some of the ways these dynamics play out in LGBTQ+ people’s experiences of accessing health care, particularly for community members who experience greater stigma and discrimination on the basis of their identities. Here I’m thinking of trans and gender-diverse people, especially trans women and trans feminine people. I’m thinking of LGBTQ+ people who are racialized, particularly Black and Indigenous trans women and trans women of colour. I’m also thinking of bisexual people, who experience higher rates of stigma and discrimination both in medicine and in the LGBTQ+ community. I’m thinking of LGBTQ+ people who are poor, undocumented, disabled, fat, those who use drugs, do sex work, are homeless or incarcerated. I have no doubt in my mind that the health system can and must do better for gender and sexual minority patients in the contexts of their intersecting identities and health needs.
Because that’s the thing: your LGBTQ+ patients will never show up as just one part of their identities; they’ll show up as complex and multifaceted people with their own stories, relationships, joys and challenges. They’ll bring their histories with them, including their past experiences of accessing health care. They’ll bring their health risks and disparities, and they’ll also bring strength, resilience and courage. They’ll bring their whole selves into their encounters with you, though they may be inclined to conceal or guard some parts of themselves out of fear that they won’t be met with respect, understanding and compassion. As you begin your medical education, what do you need to learn to prepare you to care well for your LGBTQ+ patients and enable them to bring their whole selves into an encounter with you? How will you meet them, and what skills, knowledge and parts of yourself will you bring into these patient encounters?
As you begin this learning process – this process of becoming a doctor – I want to offer you some ideas to bring with you into your medical education. They’re a distillation of some of the things I’ve learned about how shifts in health care providers’ mindsets or practices can have a substantive impact on the care of LGBTQ+ patients.
It’s okay to not know everything and it’s okay to make mistakes.
Not knowing stuff and making mistakes can feel super uncomfortable, especially when you’re used to feeling and being seen as smart and accomplished. Being smart and accomplished probably got you into medical school! My advice to you in this moment is, practice getting comfortable with the discomfort of not knowing, of not always being an expert, of making mistakes and being wrong. It can feel shameful when this happens, and as physician and medical educator Sandy Miles (2019) reminds us in a recent paper on shame in the formation of medical professional identities, shame can make us withdraw or lash out at ourselves and others. You’re going to bump up against this experience repeatedly in medical school and in clinical practice (not to mention in life). Build your resilience and skills around how to respond with curiosity, humility and compassion – including for yourself! – when you don’t know everything or when you get something wrong. Not knowing stuff and making mistakes is a normal part of the learning process and it’s part of the mindset you need to grow and develop as a physician.
This mindset is especially helpful when you’re caring for LGBTQ+ patients. My observation is that successful LGBTQ+ patient care is often built in micro-moments of discovery, connection and repair. Imagine you’re seeing a trans patient for the first time and you get their pronoun wrong. What do you do? Do you: A) Freeze up and quietly panic for a second and then pretend like nothing happened? B) Sink into shame and self-recrimination, apologizing so much that your patient starts comforting you? Or C) Say, “I’m sorry. I got your pronoun wrong. Let me start that part over.” I encourage you to choose option C.
Your LGBTQ+ patients won’t expect you to know everything about us, our identities or our communities. We know that you’re human and that you sometimes make mistakes – maybe you get our pronoun wrong, or you make an assumption about the kinds of sex we have (or don’t have) or who we have (or don’t have) it with. Where you show yourself as a physician is how you choose to respond in those moments. What will you do when you make a mistake or don’t have all the answers? How can you have compassion for yourself and also commit to ongoing learning, growth and doing better next time? How do you do that in a way that doesn’t cause you to sink into shame and stop you from connecting with your patients? What can your experiences as a learner teach you as you prepare to move into your clinical work with patients?
Look in the mirror, look out the window.
Implicit and explicit bias show up in medicine and medical education, as they do in other sectors and parts of our lives. Many people are doing the important work of researching and implementing strategies to mitigate against these biases so as to foster more equitable and affirming health care. As you do the important work of examining your own biases and how they show up in your learning and practice, I encourage you to make links to the bigger picture. In a recent article on the connections between implicit bias and structural racism, Kathleen Osta and Hugh Vasquez remind us that, “in order to lead to meaningful change, any exploration of implicit bias must be situated as part of a much larger conversation about how current inequities in our institutions came to be, how they are held in place, and what our role as leaders is in perpetuating inequities despite our good intentions.”
In this vein, Osta and Vasquez call on us to do two things**: first, “to look in the mirror to notice how our particular lived experiences have shaped our beliefs, attitudes and biases about ourselves and others.” With this increased self-knowledge, they say, “we also need to look out the window to understand how racism, classism, sexism and other forms of systemic oppression operate in our institutions to create systemic advantage for some groups...and disadvantage for other groups.” Implicit and explicit bias don’t just exist in individual bodies; they’re connected to larger systems and structures.
To care well for your LGBTQ+ patients requires you to look in the mirror, and then look out the window at the structural reasons that might be impeding their ability to survive or thrive. Racism is an LGBTQ+ health issue. Poverty is an LGBTQ+ health issue. Mass incarceration is an LGBTQ+ health issue. Disability justice, environmental justice, prison abolition, decriminalization of drugs and sex work and supporting people’s rights to move freely and safely across borders are LGBTQ+ health issues. As you begin your medical education, what can looking in the mirror teach you about yourself and how that might shape the way you practice medicine? What can you learn by looking out the window at the larger systems and structures you and your patients are embedded in?
Find out what good health means to your LGBTQ+ patients.
There are many ways to understand what good health consists of, something I’m sure you’ll learn much more about over the next several years as you deepen your understanding of illness, disease, treatment, cures and care. As you do, I encourage you to remember the difference between textbook definitions of health and what good health means to your LGBTQ+ patients. Health and illness are felt, embodied experiences that affect and are affected by every aspect of our lives – where we live, who we’re in relationship with, what resources we have access to, and also what brings us joy, fulfillment and pleasure and where we find connection, strength and resilience.
Your LGBTQ+ patient isn’t just a name on a chart, a medical concern or an anonymous person sitting in front of you in the treatment room. Like all patients, they’re people with their own lives, gifts, challenges, passions, wounds, families, relationships and communities. They’re people with their own stories. You may be the medical expert, but your LGBTQ+ patient is the expert on their life, their body and what good health looks and feels like to them. Experiment with asking your patients what good health means to them and charting their answers alongside other clinically relevant information. Think of it as an extremely low-tech form of personalized medicine. What would it look like to move from a one-size-fits-all definition of health to one that’s anchored in your patient’s lived experience and what matters most to them? How might this enable you to support your patient’s overall wellness and quality of life?
Centre pride and pleasure, not shame and risk.
Some of you might know what it’s like to be treated like a risk factor, like you’re somehow inherently dangerous because of who you are. Discussions of LGBTQ+ health are often framed in terms of risk factors and disparities, all of the ways we are less well or at higher risk of ill health because of the minority stress, oppression and violence we experience on the basis of our intersecting identities. Many LGBTQ+ people already feel shame or stigma because of messages we’ve received about ourselves from our families, our communities and the larger society. Being viewed through a lens of risk, disparity or stigma can contribute to feelings of shame, and that’s not health-promoting. It also doesn’t make people want to go to the doctor!
I see radical potential in approaching LGBTQ+ health and health care from a place that centres pride and pleasure. I don’t mean ignoring risks or evidence of disparities; I mean shifting the lens through which you understand and interact with your patients. Think back to my advice about learning what good health looks and feels like for your LGBTQ+ patients. This is another layer to that advice, anchored in the idea that access to affirming, strengths-based, pleasure-centred, sex-positive health care grounded in principles of harm reduction could transform LGBTQ+ people’s experiences of going to the doctor.
For example, I encourage you to keep an open mind and not make assumptions or judgements about your patients’ drug use and sexual behaviour. Offer them evidence-informed, developmentally sound advice and support grounded in principles of harm reduction. Learn how to practice affirming care and get curious about what helps your LGBTQ+ patients feel strong, resilient and happy. Imagine if our health system operated from a place where we supported and enabled people to feel pride in their identities, where we worked to understand what brings them pleasure and where we shared the information and tools they needed to reduce harm. How might you learn to use information on risk and disparities as a tool, not as the lens through which you perceive your LGBTQ+ patients? How might you find ways to work with them from an affirming, strengths-based perspective? As a future physician, how might learning about sex positivity, pleasure and harm reduction help you care better for your patients?
Learn about trauma-informed care and consent.
At a population level, the LGBTQ+ community experiences higher rates of violence and trauma. These experiences can be both triggered and exacerbated by the health system, and it can make it harder to go to the doctor. I recently listened to an interview with Carl Streed, a primary care physician and researcher at the Boston University School of Medicine. In it, he gave a beautiful example of how he acknowledges the history his LGBTQ+ patients might be bringing into the room with them during their visits. He tells those patients, “I’m glad you’re here. I know it was probably hard to come here. Tell me what I can do better and how we can do this. Thank you for being here.” I must’ve listened back to that part of the interview three times in a row. What a profound and simple way to welcome a patient and help create a feeling of safety.
I encourage you to learn about trauma-informed care and how to practice good consent skills. By doing so, you can minimize the likelihood of triggering a trauma response in the person you’re caring for and help your patient feel seen and safe. My observation is that, in health care, consent sometimes gets treated as a “one-and-done” sort of transaction where we ask for it once at the beginning of an encounter and assume that it covers every interaction that follows. Instead, approach the process of asking for consent as an ongoing conversation with your patient.
This doesn’t need to add a lot of extra time or complexity to your interactions – it can be as simple as checking in before touching, moving or otherwise interacting with your patient’s body, listening to what they say and, if they say no or not right now, figuring out an alternative strategy that allows you to do what’s clinically necessary while respecting your patient’s boundaries. This will look different depending on how emergent or acute the situation is, and the extent to which you’re able to communicate with your patient, but it’s essential in fostering a feeling of safety and trust. As you begin your medical education, what knowledge and skills do you need in order to practice trauma-informed care? What knowledge and skills do you need to become skilled at consent, and how might you need to go beyond the textbook to gather this knowledge?
Put on your own oxygen mask first.
My last piece of advice is to figure out what you need to do this work in a healthy and sustainable way, now and throughout your training and practice. Find ways to hold onto your empathy and buffer against burnout; both are integral to your wellness and effectiveness as a physician, especially in your care of marginalized populations. Understand what you need for self-care and commit to it; hold yourselves and others lovingly accountable to those commitments. Become part of a caring community of medical students – in my experience, generosity goes a lot further than competition. Have your classmates’ backs; practice being in allyship with each other across your intersecting identities.
To the LGBTQ+ medical students reading this, I know that we often feel called to this work because it’s so tightly interwoven with our identities and relationships. We are trying to save ourselves and our loved ones; we’ve already lost too many of our kin to the cumulative health impacts of oppression. Please know that you don’t have to do this work alone and that you’re allowed to rest and take breaks. Remember that you’re part of a lineage of healing, survival and activism that spans generations; you don’t need to fix everything all at once, or all by yourself. The work of making health care more affirming, equitable, just and liberatory belongs to all of us, regardless of sexual orientation, gender identity or other aspects of who we are.
You’ve got a lot of learning ahead of you so might want to take these suggestions and tuck them into the pockets of your brand-new white coats or another place you can keep them close. I also encourage you to identify one learning goal. What’s one thing you’d like to learn to help you care for your future LGBTQ+ patients, and what steps will you follow to gain that knowledge? By putting this learning into practice, you’ll become a better doctor, not just for your LGBTQ+ patients, but for every person you care for.
It’s the beginning of medical school. My question for you in this moment is, who do you want to be four years from now? How do you want this experience to change you? My invitation to you is to change on purpose, and to change in service of equity, justice and liberation. As a future physician you’re stepping into a position of power, even if you may feel like you’re at the bottom of the hierarchy right now. As a medical student and future physician, you have the potential to bring care and healing to people and communities who have been systematically denied that equity and justice. Imagine how it would feel to be part of changing this, and then learn and practice your way into making that imagining real. That is how healing happens. That is how you become the kind of doctor we need. That is how we rewrite the story of LGBTQ+ health.
Thank you for the courage, curiosity and dedication I know you’ll bring to your medical education. I’m grateful to be in this work with you. I’m excited to witness the doctor you become and to find out what you learn along the way. Good luck!
Zena
Notes:
*For example, see the Lambda Legal Report When Health Care Isn’t Caring, the European Union LGBT survey, recent survey data from the Center for American Progress, the results of the Canadian trans youth health survey, and research on trans people’s experiences with family doctors and in emergency departments.
**Osta and Vasquez credit Emily Style of the SEED Project with originating the metaphor of the window and the mirror.
Empowering LGBTQ+ Youth to Thrive
It all begins with an idea.
This talk was originally given at Access, Advocacy and Empowerment: Health and Well-being of LGBTQ Youth, a symposium held at the University of Pittsburgh in October 2018.
Introduction
This is my first visit to Pittsburgh and I’m glad to be here. The main reason I said an enthusiastic yes to this invitation is because I was asked to speak on the theme of LGBTQ+ youth empowerment. As a queer and trans health advocate and member of the queer community, I often feel acutely aware of the tensions that exist between doing the work of naming the health disparities, risks and violence LGBTQ+ communities are disproportionately exposed to and not getting stuck in a deficit-based narrative. Queer and trans people are among the most resilient, creative, brilliant people I know, and like many marginalized communities we have survived and thrived for generations in the face of systemic oppression.
I am standing here today as an out, proud, alive queer person because the generations of queer and trans people - including queer and trans youth - who came before me loved hard, worked hard and fought hard to make my existence possible. I’m here because I feel accountable to the generations of queer and trans folks who will come after me, including the queer and trans youth of today. I want to be part of doing the important work of empowering them to feel strong and confident, to claim and assert their rights and power, and to envision and create healthy lives that enable them to thrive during and well beyond their youth.
As I explore the theme of empowering LGBTQ+ youth to thrive, I’ll invite us to reflect on several key questions:
Who are the experts on queer and trans youth empowerment and health?
How am I using my power in service of queer and trans youth empowerment?
How am I in relationship with queer and trans youth?
Why is dreaming necessary for queer and trans youth empowerment and health?
And since I’m closing out the symposium, I’ll end with the all-important question: Now what? because my hope is that, based on everything you’ve learned today, you’ll leave here with some concrete strategies to apply in your work with and about queer and trans youth.
A note on terminology: You may notice that I primarily use the phrases “queer and trans youth” or “LGBTQ+ youth” in my talk. For me, they serve as shorthand for an expansive and varied galaxy of sexual and gender identities including and certainly not limited to lesbian, gay, bisexual, pansexual, asexual, questioning, transgender, genderqueer, nonbinary, intersex, Two-Spirit and many others. Language is complex, ever-shifting and powerful in its capacity to include and exclude and render folks visible or unseen. Please know that in using this shorthand I’m not seeking to erase the brilliant diversity of identities and embodiments no word or acronym can ever fully convey.
Who are the experts on queer and trans youth empowerment and health?
My first question - “who are the experts on queer and trans youth empowerment and health?” – aims to trouble the notion of expertise, in part because it feels complicated for me to stand here today and claim the status of expert. At a broader level, it’s imperative that we reflect on how we define who are the experts on LGBTQ+ youth health. Expertise can be empowering or disempowering, depending on whether your expertise is recognized and perceived as valid. Still, it feels risky to begin this talk by troubling my own expertise. I don’t want to fall prey to impostor syndrome or discredit myself with you, an audience of experts, before you’ve heard what I have to say. My aim is to use myself as an example and as an invitation for you to reflect on where your own expertise comes from, and what its limits are.
There’s a lot of knowledge in this room and I’d wager that many of us are deeply engaged in acquiring and practicing expertise. Being an academic or a health care provider involves a career path where you gradually accumulate enough knowledge and proficiency in the skills of your profession that you are eventually deemed an expert. It often comes with prestige, a title and an expensive piece of paper. Maybe people call you “doctor” and defer to your superior understanding of what is happening in their body or mind, whether you accumulated that knowledge through medical education, clinical practice or your research program.
And I am an expert, in the way we typically understand that word in rooms like this one, in institutional contexts like a university. I have many years of experience in the field of LGBTQ+ health, several hard-earned letters after my name, and I’ve published two books. I even make people call me “doctor” sometimes - especially if they send me professional correspondence addressed to Mrs. Zena Sharman, PhD. I’m also an expert because I’m queer. This topic is personal to me, and I’ve done my deepest and most sophisticated learning about gender, sexuality and health by being part of the queer community. It’s a key reason why my work centres queer and trans voices and stories, and why you’re more likely to find me editing an anthology or writing creative non-fiction essays than publishing a peer-reviewed journal article.
The trouble with the bodies of knowledge that we tend to lift up in academic or clinical environments is that they often exclude or elide the brilliance of our “subjects” or patients. Community-engaged and patient-oriented research methods take steps to remedy this, and yet: the experts we are trained to pay attention to and listen to are the ones with letters after their names, not the people and communities who are entire bodies of knowledge in the most literal and expansive sense of the term. This is exacerbated when we are researching or treating children and youth, who may not even be able to give informed consent as defined by ethicists or professional bodies, and whose knowledge and expertise is often treated as less valid or important than adults’. What would it look like and how might our research, clinical and professional practice change if we were to centre the voices and expertise of queer and trans youth, if we treated our expertise as equal or secondary to theirs?
The second place I want to trouble the notion of expertise is by acknowledging the limits of my own and what that means for the position of authority I’m holding in this room today. First things first: I’ve been very queer for a rather long time, but I didn’t come out until my early twenties when I was working on my master’s degree and doing an unofficial minor in figuring out my sexuality. There’s a whole story wrapped up in that, about how I grew up in a place and at a time where it wasn’t possible for me to imagine being queer, so I didn’t, because I couldn’t - nobody had showed me how.
The point of telling you this is, I don’t know what it feels like to be a queer youth because I’ve never been one, at least not consciously. There are of course vast generational differences between what it was like for me to grow up in the eighties and nineties and what it’s like to grow up as a young queer or trans person now (for one thing, I probably would’ve figured myself out a lot earlier if I’d had Tumblr). What I want to emphasize is that my expertise - my embodied knowing - doesn’t include the experience of being a queer youth. I’ll wager that’s the same for many of us in this room, for a variety of reasons. No matter how smart I am, how much I read or how hard I apply myself to learning about it, I will never have the knowledge that comes with the direct experience of being a queer or trans youth. I think that matters to how I orient to expertise on this topic - both mine and others’.
My expertise - my situated, embodied knowledge - is both shaped and limited by my experiences, my identity, my context and the privilege that buffers me from harm. What I know about being queer, I have learned through my body, this body - this white body, this cisgender body, this body that lives on lands violently stolen from Indigenous people, this body that has citizenship in Canada, access to a publicly funded health system and the autonomy and decision-making power accorded to some adults. This body has a steady job, lives in a safe, secure home and can afford to buy nourishing food. This body has community and social support. This body is not disabled. This body is not incarcerated. This body can pass as straight if I need it to. Unlike far too many of our beloved queer and trans kin, this body is alive.
My body is rarely the target of the violence wrought upon queer and trans bodies by the health system and by society. Here, in this place, I especially want to name my whiteness, and the fact that being a white queer person both protects me from violence and implicates me in the violence of white supremacy, a violence that hurts and kills black, brown, Latinx and Indigenous queer and trans bodies every day.
In saying this, I want to acknowledge the larger context of anti-black racism and police violence that exists here in Pittsburgh, just as it exists in Canada. I want to say the name Antwon Rose. I want to say Black Lives Matter. I want to tell you that research has shown a causal relationship between police killings of unarmed black people and adverse effects on the mental health of black people living in those states. Anti-black racism and police violence are health issues that affect black queer and trans youth every day and must therefore be part of how we understand the root causes of their health disparities and what is necessary for them to thrive.
I want to say the name Londonn Moore Kinard. Londonn was a twenty year-old living in Florida and in September she became the 14th black trans woman murdered in the US in 2018. I want you to know that the murder rate for the general population in the US is 1 in 19,000 and for young black trans women, it’s 1 in 2,600. I want to say Black Trans Lives Matter. Transmisogyny and racism are killing young trans women of colour in your country and mine, and we have a responsibility to end this violence as we work toward the empowerment of queer and trans youth. If this is not part of our conceptualization of health, then it is dangerously incomplete.
I want to acknowledge the limits of what my white queer body can know, no matter how “woke” I might aspire to be. I may have letters after my name, but there is so much I don’t know and will never know. I want to acknowledge the limits of my expertise and honour the brilliance in this room. You know this place and this community in ways I never will, and you hold knowledge in your minds and bodies that I don’t. Today, I come to you in humility as a visitor to this place, out of what I hope is a shared desire to see all queer and trans youth thrive and live full, joyful lives free of violence. I want them to grow into the elders the queer and trans youth of the future need.
What will it take to realize that beautiful, necessary vision of the future? How can we empower queer and trans youth to thrive? If you take one idea away from my talk today, let it be this: queer and trans youth are not a problem to be solved, subjects to be researched or a population to be served. They are the experts on their own lives and bodies and what health and empowerment look and feel like for them. It is our job to listen to them and let them lead. It is our privilege and our responsibility to support their empowerment and wellbeing. Today’s youth should not have to wait until adulthood to be empowered or to thrive.
How am I using my power in service of queer and trans youth empowerment?
This brings us to my second question: “how am I using my power in service of queer and trans youth empowerment?” The opposite of empowerment is disempowerment - to deprive a person or group of authority or influence, to render them weak, ineffectual or unimportant. The common thread is power: how much a person is accorded, how powerful they feel, and the extent to which they can use that power to have control and influence over their own lives. In an ageist society, youth are often accorded less power and autonomy than adults. As adults, we are given more power, agency and the capacity to influence or even control the trajectories of young people’s lives. This is especially the case in a roomful of people with the power to diagnose queer and trans youth as healthy or sick, to grant them access to gender-affirming health care, to theorize or generate evidence about them, to teach other people about them or design services, programs and policies for them. We each hold many forms of power. How are you using yours? What ethics, values and accountabilities are guiding your decisions about how you use your power over LGBTQ+ youth?
Are you actively working toward queer and trans youth empowerment and wellbeing? Are you listening to and being led by them? How do you understand the connections between healing and justice? Are you making an effort to transform the root causes of the stigma, violence and oppression that prevents all queer and trans youth from thriving? Are you working to remove the barriers that stand in the way of their wellness? Are you unintentionally being one of those barriers? Are you a gatekeeper to the care or services they need? If yes, what strategies might you use to prop open or even remove the gate? Are you a cisgender person working primarily with trans and gender-diverse youth, or a white person working primarily with racialized LGBTQ+ youth? If you answered yes to one or both questions, how are you practicing self-reflection and accountability about the privilege you hold in relation to these young people? How might you root your relationships with them in a commitment to equity and justice?
As a roomful of adults exploring the theme of youth empowerment, I want us also to engage in critical reflection about the actions we are empowered to take in service of the broader goal of empowering LGBTQ+ youth to thrive. I want us not to look away from or deny the differential power we hold in relation to queer and trans youth, but rather to use that power - our power - in service of their empowerment. I take inspiration from the movement for social accountability and social justice in medicine that calls on physicians and others in the health sector to move from knowing about health disparities to doing something about them. As Buchman and colleagues remind us, we must use our power at multiple levels, from macro-level actions focused on influencing the laws and policies that affect LGBTQ+ youth at the population level, to meso-level actions focused on creating safer, more supportive communities for these youth and their families, to the micro-level of how we understand and enact our relationships with them.
How am I in relationship with queer and trans youth?
My third question - “how am I in relationship with queer and trans youth?” - is an invitation to reflect on these micro-level interactions. This extends from my earlier points about these youth being the experts on their lives, identities and wellbeing in contexts that often puts us in positions of power over them. One way to disrupt and shift this power dynamic is to approach our relationships with queer and trans youth from a perspective grounded in a commitment to their empowerment and an ethic of care. I feel a deeper accountability when I’m in relationship with someone, and a greater awareness of how the effects of my actions toward them - both positive and negative - might ripple through their life across time.
Your relationships with queer and trans youth may take many forms - maybe you’re a researcher who studies them, a health care provider who takes care of them or a service provider who designs and runs programs for them. You might be a queer or trans youth yourself, a member of the LGBTQ+ community, a family member or loved one of young people who might now or someday be a queer and trans youth, or an ally to the LGBTQ+ community. These aren’t mutually exclusive categories, of course - many of us hold multiple identities and forms of relationships simultaneously, each with different levels of intimacy and durations. You might love someone for a lifetime or treat them once as a patient; what they have in common is that I see each as an opportunity to have a positive impact on the wellbeing of queer and trans youth, particularly in the context of what we know about the health disparities, violence, trauma and social isolation these young people face in so many other parts of their lives.
There is ample research evidence to prove what some of you in this room already know in the visceral way that comes from living an experience we are discussing in the abstract: despite societal gains and increasing acceptance, far too many queer and trans youth still suffer rejection, lack of support and outright violence from the families and communities meant to care for them. They experience higher rates of bullying, violence, trauma, social isolation and family rejection. It affects them at home, at school, at work, in the health system and in the community. These experiences have a profoundly negative impact on their physical and mental health, leading to higher rates of anxiety, depression, suicidal ideation and self-harm, having sex or using substances in ways that are riskier to their health, and an increased likelihood of homelessness. LGBTQ+ youth of colour are disproportionately affected by these disparities, as are low-income youth and those who lack access to health care.
In the face of all these risk factors, how can we be a protective factor? How can we show up for queer and trans youth in ways other people in their lives and communities might not be? As you reflect on these questions, consider them in the context of research evidence showing that queer and trans youth who have supportive, caring adults inside and outside their families are healthier and happier than their peers who don’t, as are those who live, learn and access health care in safe, supportive communities. For example, the Canadian trans youth health survey found that trans youth who had supportive adults inside and outside their family were four times as likely to report good or excellent mental health, and far less likely to have considered suicide. A US study on intersectionality and well-being among racial/ethnic minority LGB youth found that “extended family members and close friendships are a key developmental asset.” This same study highlighted the protective effects of cultures where there is high familism and extended kinship networks, like in Latinx and Black communities.
As sexualities researcher Rob Cover explains, queer and trans youth resilience isn’t a personal asset, it’s “interactional...a shared quality by which individuals recover and sustain liveability against threats through engagement with and by communities, cultures, families, populations and institutions.” You don’t have to be related to build relationships that promote the health and wellbeing of queer and trans youth - you can be a friend, a neighbour, a doctor, a teacher, a service provider. Be an adult who shows up for them.
I recently read an evaluation of an alternative high school program for youth experiencing many barriers similar to those faced by queer and trans young people, like family instability or rejection, mental health diagnoses, substance use or addiction and exposure to violence and trauma. The program model, which is grounded in the social determinants of health, seeks to balance self-determination and nurturing. In an interview with one of the program’s teachers, she was quoted as saying, “It’s important to build a program that acts as a family.” This quote stuck with me because it got me wondering what it might look like to orient toward the empowerment of queer and trans youth in this way. What would it look like to not just support them and the families they are born into or raised up in, but to become part of their extended kinship network and play an active role in building affirming, safer communities that enable them to thrive?
As I’ve worked on this talk, I’ve thought a lot about how I’m in relationship to queer and trans youth, my hopes for them and how I’m accountable to them. I come to this relationship primarily through my role as a queer community member, so I keep circling back to the interconnected themes of community and family – in particular, the kinds of extended kinship networks exemplified by the queer practice of creating chosen family. As Indigenous literary studies scholar Daniel Heath Justice wrote in Why Indigenous Literatures Matter, “...how we imagine family and who’s included in or excluded from that circle of relationship says much about what we believe and what we value in the world.”
Chosen family - the practice of creating our own families outside of traditional markers, like shared DNA or being branches of the same family tree - is a defining feature of my experience of being in queer community. Queer and trans people are adept at creating our own families because so many of us are rejected by our families of origin, and because it is both joyful and necessary to band together in the face of systemic violence and oppression. Those of you who lived through the AIDS crisis will understand this firsthand. I know it because it’s the queer community, not the people I’m related to, who’ve held me through every trauma and major life transition I’ve experienced since I came out almost twenty years ago.
Last year, Patrisse Khan-Cullors, a black queer artist, organizer and co-founder of Black Lives Matter, published a memoir called, When They Call You A Terrorist. I want to share a quote from that book with you. She wrote: “My community of friends, this chosen family of mine, loves in a way that sets an example for love. Their love as a triumph, as a breathing and alive testimony to what we mean when we say another world is possible.”
“Another world is possible.” This phrase points to a critical aspect of how notions of family can shift our relationships to time. Being part of a family means being part of a lineage and a web of relationships that span the past, present and future. As a queer adult I feel an intergenerational responsibility to do my part to enable queer and trans youth to survive, thrive and dream their futures into being. Lineages of queerness and transness will continue long after me, and I want to be a good ancestor.
I see a connection between thinking and acting intergenerationally and what we know about epigenetics, the long-term effects of our experiences as children and young people and how wellness and trauma are carried across generations. Developmental psychologist Arnold J. Sameroff describes the process of development as “nature dancing with nurture over time.”* The timespan in question is both within and beyond a single lifetime, in that we carry the histories of previous generations in our bodies, just as our descendants will carry our histories in theirs. As Maori author Patricia Grace puts it, “Genes are the ancestors within us.”** And we, in turn, are future ancestors.
Exposure to adversity in childhood and young adulthood can have lifelong health effects that may be compounded or mediated by events in our ancestors’ lives. Our cells remember further back than our minds are able to, but they don’t exclusively determine our future. Research has shown that the presence of caring and responsive adults mediates the effects of toxic stress in young people’s lives. By mediating these effects, we have the potential to positively intervene upon health and wellness across and beyond an entire lifespan. I’m pushing us to think beyond the present because by supporting the healing and empowerment of this generation of LGBTQ+ youth, we are both setting them up for a healthier adulthood and promoting the health of the generations who come after them.
Why is dreaming necessary for queer and trans youth empowerment and health?
I see a connection between thinking intergenerationally, imagination and dreaming, because envisioning the future is an inherently imaginative act and one that’s often imbued with hope. It’s why I want us to reflect on the question, “Why is dreaming necessary for queer and trans youth empowerment and health?” My answer is that a critical aspect of facilitating LGBTQ+ youth empowerment and health is working with them to co-create the conditions they need to move beyond survival into dreaming the futures they want to create, and then using the power and privilege accorded to us as adults to support them in realizing those dreams. If we do our jobs properly, they will be alive long after us to bring that other, better world into being.
Research has demonstrated the interconnections between empowerment and dreaming the future. A study on resilience among trans and gender-expansive homeless youth found two primary themes in how they demonstrate resilience in the midst of “structural constraints and oppressive narratives about who they are and who they can become: personal agency and future orientation.” Personal agency means having the power to make choices, to advocate for yourself and to define who you are, while future orientation involves positive meaning-making and re-visioning, including speaking back to negative or deficit-based narratives about yourself. Both are grounded in awareness and recognition of a young person’s strengths.
Last summer I read an article on healing centred engagement by Shawn Ginwright, an Africana Studies researcher whose work focuses on youth activism and youth development. I’ve been thinking about his article for months because it offered me a new way of thinking about how we conceptualize and respond to violence and trauma in individual lives and in communities. As Dr. Ginwright describes it, healing centred engagement seeks to move beyond trauma-informed care and treatment of the emotional and behavioural symptoms of trauma. Instead of asking, “What happened to you?” it asks, “What’s right with you?” Agency is key to this approach, in that it views people who are exposed to trauma as agents in the creation of their own well-being, not victims of traumatic events.
I see a connection to dreaming because this approach is both imaginative and future-oriented. It calls on us to support youth in engaging in “practices of possibility” where they can play, reimagine, design and envision their lives. Healing centred engagement is culturally grounded, sees healing as a collective process and is explicitly political through a focus on transforming root causes of oppression. As Ginwright explains, healing centred engagement calls on us to “take loving action, by collectively responding to political decisions and practices that can exacerbate trauma.”
Now what?
It’s in the spirit of taking loving action that I want to bring us to my final question: “Now what?” We’ve spent today hearing many perspectives on promoting LGBTQ+ youth health, barriers to their health and health advocacy. My hope is that each one of us will leave here with concrete ideas for our next actions in service of the broader goal of supporting LGBTQ+ youth health and empowerment. I’ll begin by offering some suggestions for potential actions and will also invite you to come up with your own.
Listen to queer and trans youth and trust in their expertise - ask them to define what health, empowerment and thriving look and feel like to them and work with them to bring that vision into being. Remember that they are the experts on their identities, bodies and lives.
If you’re a researcher, explore how this might inform or shift your research practice. How might hearing directly from LGBTQ+ youth about their priorities change your research questions and how you apply your findings? How might you build participatory or community-driven approaches into your research practice?
Cultivate an attitude of humility and curiosity: Don’t assume we have all the answers because we’re adults.
Share power – work in partnership, and wherever possible let yourself be led by queer and trans youth. As the Fenway Institute put it in a 2015 report on risk and resilience among LGBTQ+ youth of colour, invite youth “to be active partners in developing strategies to improve the health and social conditions of their lives.”
Build structures, processes and relationships that generate capacity among queer and trans youth: Instead of working in an extractive or ad hoc way where you take the knowledge or input you need from LGBTQ+ youth and then leave, build relationships and trust with them over time. Find out what capacity and skills they want to build and then work with them or find other ways to help them develop those skills.
If you’re involving LGBTQ+ youth in your research, program design or other activities, compensate them for their time and expertise. This can look like payment as well as other forms of compensation, such as access to training and other development opportunities - ask youth how they want to be compensated.
Wherever possible and desired by queer and trans youth, create roles that include benefits like health insurance and opportunities for career advancement. Hire them and provide them with ongoing support so they can thrive and grow in their careers.
Share credit: if you are working in collaboration with youth, look for opportunities to co-present with them or share authorship with them on reports and papers.
Support youth and their families – ask the LGBTQ+ youth who you work with how they define family and how best you can support their families. Family is diverse and complex so it’s important to begin by understanding what family looks and feels like for queer and trans youth, then find ways to support their families. This may include understanding and responding to the emotional and mental health needs of parents, caregivers, siblings, chosen family and others, and in some cases mitigating the effects of family rejection.
Make your office, clinic or centre a safer, more inclusive and affirming space. As the American Academy of Pediatrics put it in their recent policy statement on caring for trans and gender-diverse children and youth, “Maintaining a safe clinical space can provide at least one consistent, protective refuge for patients and families, allowing authentic gender expression and exploration that builds resiliency.” Be a refuge.
Include physical symbols that signal that your space is welcoming to LGBTQ+ youth, like rainbow flags, relevant posters or health information or gender-neutral washrooms. Ensure that all staff receive training in LGBTQ+ cultural competency and that your forms and other documents match up with your values.
Creating a safer, more inclusive space includes supporting your LGBTQ+ staff by fostering a safer, more inclusive affirming workplace and by not assuming that they always have the desire or capacity to educate you or be your in-house expert on all things queer and trans health-related.
It can also mean learning about and supporting community-led programs aimed at creating safer health care for LGBTQ+ people.
Ensure that all queer and trans youth have access to comprehensive, affirming, culturally competent and developmentally appropriate health care. Advocate for increased access to health care for all LGBTQ+ youth. In doing so, look to increase access both to basic health care and health care that is specifically designed to benefit queer and trans people, including gender transition-related care. Advocate for access to culturally competent, youth-focused mental health care.
If you’re working with trans or gender-diverse children and youth, practice gender-affirming care. Speak back against narratives that suggest they’ll “grow out of it” (e.g., desistance) or are being unduly influenced by the media and peers (e.g., rapid onset gender dysphoria).
Educate health care providers at all career stages on LGBTQ+ youth health. The amount of education that medical students receive on anything related to LGBTQ+ health is woefully inadequate – a survey of US and Canadian medical schools put it at a median of five hours. How can you work to ensure that health care providers receive education on queer and trans health across the lifespan at all stages of their training and practice?
Advocate for policies and laws that support queer and trans youth wellness at the community and population level. For example:
Laws and policies that protect LGBTQ+ youth from discrimination and violence, including in schools, workplaces and community organizations.
Increased access to safe, secure, affordable, physically accessible LGBTQ+ youth-friendly housing and homeless shelters.
Advocate to make it easier to change your name or gender marker on identification.
Help make sure everybody has a safe, accessible place to pee!
Address root causes of LGBTQ+ youth health disparities. Understand how stigma, discrimination and minority stress are rooted in homophobia, transphobia and biphobia, and how they intersect with and are exacerbated by ageism, racism, poverty, transmisogyny, ableism, fatphobia, colonialism and other forms of oppression. Take action against racialized and transmisogynistic violence committed by individuals and by the state. We cannot have LGBTQ+ health without racial justice, economic justice, environmental justice and disability justice.
These are just some of my suggestions. I’m sure you have lots of ideas of your own, and I’m going to invite you to reflect on those for a moment and then share them with someone else, because I think that speaking our commitments out loud creates a different kind of accountability. What loving action will you take next in support of empowering LGBTQ+ youth to thrive?
Conclusion
The words I’ve shared with you today are rooted in hope, humility, grief, rage, accountability and above all, love. It can feel complicated to bring affect – especially love – into spaces like this one. Academia and medicine tend to privilege the head over the heart and valorize objectivity. Feelings, on the other hand, are messy, embodied, unruly and feminized, and thus devalued. We’re not supposed to love our subjects. I know that, like me, some of you walk between two worlds: your role as a researcher, clinician or service provider, and your role as a member of the LGBTQ+ community, or as an ally to an LGBTQ+ loved one. Maybe, like me, you know what it feels like to do this work from a place of love. I love queer and trans folks and I want to see all of us thrive today and long into the future.
I feel more urgency about the future because I recently became a parent. It’s one reason why the theme of ancestors and descendants is woven into this talk. There were seven of us in the room when my partner gave birth to our baby – a midwife, a nurse and our extended queer family. Our child came into the world encircled by love and rooted in a community of caring, supportive adults. My wish is for all queer and trans youth – indeed, all young people – to have this kind of love and community in their lives. We each have the power to help make this happen. How will you use yours?
Notes:
*Sameroff is quoted in Shonkoff et al. (2012).
**Grace is quoted in Why Indigenous Literatures Matter by Daniel Heath Justice (2018).
Acknowledgements: Thank you to Claire Bodkin, Gen Creighton and Kyle Shaughnessy for having conversations with me and sharing resources that helped inform my thinking about this piece.