A call to dismantle structural heteronormative care [PODCAST]

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“The visit with my patient helped to change my perspective. I should not have made assumptions about her based on my implicit bias. I highly recommend the Harvard Implicit Bias tests as an exercise in introspection. We also need to share and reflect on our experiences — especially when we were clearly incompetent.

There are a number of systems in place that reinforce structural heteronormative care. We need to identify these structures and work to make them more inclusive. The confines of iPLEDGE are exemplary of the problem — the health care system is structurally heteronormative.”

Naila Russell is a nurse practitioner. She can be reached on Twitter @nailarussell.

She shares her story and discusses her KevinMD article, “A call to dismantle structural heteronormative care.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Naila Russell. She is a nurse practitioner. She wrote the KevinMD article “A call to dismantle structural heteronormative care.” Naila, welcome to the show.

Naila Russell: Thank you for having me.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Naila Russell: Absolutely. So I am a nurse practitioner. I practice in Maryland in dermatology, and I like to share my experiences in practice. I also am a director for a family nurse practitioner program, where previously I taught in our health policy courses. One of the things I stress to my students is that nurses need to be sharing their stories and advocating for change. So everything I write is really a reflection of those experiences, where I see structural issues that I’m hoping to change and that I think nurses and other health care professionals need to be thinking about and working toward changing.

Kevin Pho: So give me an example of how you or one of your nurse colleagues did share their story that led to making a difference.

Naila Russell: Sure. So we have students who write opinion pieces, and they are required to, well, not all the students, but the doctoral-level students are required to submit them to their local newspapers. A lot of times they’ll weigh in on things such as legislation that’s pending that is health care-related, and those are huge. You know, our local legislators, our state legislators, do read their local papers. They want to know what their constituents are thinking. So that is certainly a way.

I do the same. I’m the president of the Nurse Practitioner Association of Maryland and active on our legislative committee, so I use that as a tool to call attention to the legislation that’s being passed, and then testifying on the legislation and connecting with those legislators. That’s what we teach our students to do too, because there’s a lot of power in those opinion pieces.

Kevin Pho: Obviously, I talk to health care professionals all the time, and I essentially share similar advice, that we can use these platforms to share our voices and make a difference. But I certainly want to hear, just from your perspective, can health care professionals really make a difference when it comes to legislation by making their voices heard?

Naila Russell: I think so. I mean, I guess I can give you an example from just this year in the legislative session in Maryland. You know, this may not seem like a huge win, but it absolutely is, because of the impact it has on real patients’ lives. We had a nurse practitioner who came to us and said, “Did you know in the state of Maryland, a camp nurse who’s a nurse practitioner cannot prescribe EpiPens for the campers?” That is obviously problematic, because in the state in general, we can prescribe EpiPens and teach our patients how to administer them, et cetera. So, you know, what happens when a child is at camp, gets stung by a bee, and has an anaphylactic reaction, but the refill wasn’t called in because physicians are really busy?

This was just an example of legislation or regulation that hadn’t caught up with the reality of the times, and there are all sorts of laws like that. You know, nurse practitioners have had full practice authority in Maryland since 2015, and prescriptive authority way before that. So clearly, this regulation was just old and outdated. He had a patient who experienced an anaphylactic reaction, and he had to make the decision of what to do at that time. Fortunately, even though there wasn’t a prescription, there was an EpiPen available. He was able to administer it and kind of go outside into that gray zone of, you know, what do you do in this situation?

So he brought this legislation. We found sponsors, we brought it forward, and the child who had the anaphylactic reaction shared her story. She came to the legislators and testified, as did the nurse practitioner, and the law was passed unanimously. So now that’s no longer going to be an issue for children in Maryland. Those are just the crazy things that exist, but it makes a huge difference for the lives of kids who could be affected.

Kevin Pho: All right, let’s talk about the KevinMD article that you wrote. It’s titled “A call to dismantle structural heteronormative care.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Naila Russell: So this is a story that I’ve wanted to write for a while. I just never had the time. It actually happened last fall. It was a patient encounter with somebody who had come to our office before but whom I had never seen, and she was interested in starting oral isotretinoin, which is a treatment for acne and requires quite a bit of legwork in order to take.

So when we met, my MA had prepped me right before I went into the room and said, “Oh, this patient wants to take Accutane,” which is the brand name, and we no longer call it that, and said, “But their acne is not that bad.” And I’m like, “OK.” So I was already kind of biased and had preconceived notions before even going into the room. When I went in, I kind of looked at her and said, “OK, let me see.” It really wasn’t too severe, but it did meet requirements. She had been on it in the past and really wanted to go on it, so I’m like, “OK.”

I felt like I was kind of on autopilot at that point, where I then launched into my story about, “OK, well, this is all you have to do in order to be on it.” And what quickly happened is I said, “You know, the FDA monitors this. You need to be on two forms of birth control, and these are your options.” I said most people use male latex condoms as their second choice. I could tell that she was getting kind of agitated, and I wasn’t really sure why. And I’m like, “So what are you going to do?” waiting for her to let me know. And she said, “Well, there are other options.” And I very offhandedly said, “Well, abstinence is an option, but we don’t recommend using that.”

So finally, it comes out. She tells me that she’s gay, and I was absolutely mortified, because I hadn’t even considered that in my discussion with her about the requirements and everything that she had to do. As somebody who, I would say, in general, considers myself to be open-minded and inclusive, it was just a reflection on, wow, I came into this room with these preconceived notions, my own life experiences, and projected it all onto this patient in front of me.

And then, kind of taking a step back, first of all, I’d never been in that situation in dermatology before. And second of all, just the fact that the system doesn’t really allow for that type of patient. There’s no workaround when somebody tells you, “Yes, I have childbearing potential, but I don’t have sex with males.” So it’s like, “OK, well, what do we do?” And she really quickly called me out and was like, “Well, that’s very heteronormative.” And I was like, “It is heteronormative.”

I was really just kind of shaken, with how to move forward with this visit, because you know how important it is to establish that trust and have patients have confidence in you, and it was really quickly deteriorating right in front of us. Eventually, we came to a determination that she would pledge to abstinence and what that means in iPLEDGE. And then, “Oh, but you still need to do these pregnancy tests. So I need you to give me this pregnancy test.” And she’s like, “Well, there’s no way I can be pregnant.” And I’m like, “Again, iPLEDGE does not allow for us to say that there’s no way for you to be pregnant.” So she’s like, “OK, I’ll do it, whatever I need to do in order to get this done.” And we kind of left it at that. But it was probably the most dissatisfying patient encounter I’ve ever had.

I just knew that I had to know more about this. Was anybody talking about this issue of iPLEDGE and how it’s not really very inclusive? And there are people who talk about it. You know, there have been some articles, there have been some opinion pieces, and there has been some change. So even after this had happened, as of December, there is now more gender-inclusive language in how iPLEDGE is utilized, but it still doesn’t really account for the patient who is a cisgender woman having sex with a cisgender woman. So I think there’s still a long way to go.

I promised her before we left. I said, “I hear you, and I’m going to do something about this.” For me, that meant I have to share this story, even though it’s not a good reflection on me as a provider. But I need to share this so that people are thinking about it and they’re talking about it. So that’s why I wanted to write the piece. This is really a structural issue. I mean, the system that we work within doesn’t recognize her and her unique situation and her life.

I’ve done a lot of research on structural racism in nursing and health care, which I was inspired to complete after the death of George Floyd. And you know, talking about structural racism, I think, is much more normal now within health care, but nobody’s really talking about it through a structural heteronormative lens, which it certainly is. I couldn’t even find a term. You know, is this something people are saying? And so I was like, “I’m just going to call it structural heteronormative.” I don’t even know if that’s a thing, but that’s what it felt like to me. And that’s why I wrote the piece, because I promised her that I would do something, and I was just so uncomfortable and dissatisfied with the entire encounter.

Kevin Pho: Now, for those who aren’t familiar with what iPLEDGE is, just briefly share with us what that is.

Naila Russell: Yes, sorry. iPLEDGE is a system that is used to assess risk for patients who are prescribed oral isotretinoin, which is an acne medication. The reason is that oral isotretinoin can cause birth defects or spontaneous abortion in people who are pregnant. So ultimately, iPLEDGE states that the goal is to prevent pregnancy in people who could become pregnant taking isotretinoin, and to prevent those who are pregnant from being started on oral isotretinoin. So that’s the ultimate goal.

It’s very, very, I mean, if you don’t do all the steps in iPLEDGE, a pharmacist can’t even dispense you the medication. So it’s very by the book. You know, there’s no gray with iPLEDGE, and sometimes we need a little bit of gray, but there is none. So we have to just make it work, which is what we had to do for this patient.

Kevin Pho: Now, you mentioned that since this story, the wording in iPLEDGE is a little bit more inclusive. How does one even go about changing some of the language in iPLEDGE?

Naila Russell: Well, I think it was something that came about because health care professionals were talking about it. You know, they recognized that we need to have gender-affirming systems and structures like iPLEDGE, and it just really didn’t account for those people who were transsexual. You know, a trans man who still has reproductive potential needs to be put into one of these categories. It used to be three categories, and it was basically males, females of reproductive age, and then females who had had a hysterectomy. Those were basically the three options. And so now it’s just those who can get pregnant and those who cannot. iPLEDGE does provide language for providers to say, “These are people who can get pregnant, and these are people who cannot.” That was seen as a big win for health care, to really have this gender-affirming system.

And I do believe that did come from, you know, physician groups making a stand and saying, “This needs to change.” So like I said, when I had done some research after this encounter, and I was so mortified, I did find that people were talking about it. The FDA started making the change, or talking about the change, in 2018, and it wasn’t until 2021 that it actually went into effect. So these things take a really long time, but that’s kind of the process that it went through.

Kevin Pho: We’re talking to Naila Russell. She’s a nurse practitioner, and she wrote the KevinMD article “A call to dismantle structural heteronormative care.” Naila, what are some of your take-home messages that you want to leave with the KevinMD audience?

Naila Russell: So I just want to leave people thinking about the LGBTQIA+ community. I think it’s important as health care professionals that we do recognize the importance of seeing the patient who’s in front of us. So number one, checking our own implicit biases, you know, reflecting on what those are. We’re all going to make mistakes, because, I mean, I’m somebody who developed curriculum for my school on implicit bias, but I still had this horrible, dissatisfying patient encounter. So we need to share those mistakes, and we need to feel OK talking about it, and if we have the power to change it, to do something about it, because change can happen, and it only happens when we have these conversations.

I also would like to just acknowledge that in 2022, there have already been over 240 laws brought into state legislatures, you know, into their houses, that are related to the LGBTQIA+ population, and the majority of them are to take away rights from that population, including the rights of health care professionals to provide gender-affirming care. So you know, that’s something that we have to be thinking about and know about and talk about, and certainly make our opinion heard, because it’s not OK. These are our patients, and we will be encountering them in the care that we provide. So I think just knowing that we can make a difference is so important.

Kevin Pho: Thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Naila Russell: Thank you.

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