Psychiatry Residents Need More Training in LGBT Issues, Survey Finds

A new study finds that psychiatry residents training in the US is failing to teach LGBT cultural competence.

Chia Po Cheng
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A recent study, published in the Journal of Gay & Lesbian Mental Health, underlines the importance of LGBT patient exposure and formal education on LGBT issues in US psychiatry training. The results of a national survey of psychiatry resident’s LGBT cultural competency highlight significant gaps between best practices and the current state of training.

“Since the LGBT population faces significant rates of mental health disparities, psychiatry residents are in important roles as both learners and mental health providers to this population,” the author, Dustin Nowaskie from the Department of Psychiatry at Indiana University School of Medicine, writes. “This study is the first known to examine and characterize psychiatry residents’ involvement and education in LGBT healthcare.”

Gender and sexual minorities often experience discrimination in both day-to-day life and healthcare settings. Research finds that psychiatry and mental health fields exhibit stigmatizing attitudes toward LGBT patients. Knowing LGBT acceptance is a major factor in promoting LGBT mental health and reducing suicidality, healthcare providers have a responsibility to improve their knowledge about LGBT patients and increase their knowledge of LGBT health.

“Healthcare students and provides are in unique positions not only to understand these disparities but also to intervene and alleviate poor health outcomes,” Nowaskie adds. “Both students and provides have been shown to harbor biases and negative attitudes, infrequently inquire about sexual orientation and gender identity, and demonstrate shortcomings in education and cultural competency.”

The current US internal medicine residents have limited education and training on LGBT health, particularly regarding best practices for transgender healthcare. For example, only one-third of emergency medicine residency programs reported LGBT-related topics within their curricula.  More than half of US psychiatry residency programs provided less than 5 hours of training on LGBT health, and less than 30% of them offered a clinical LGBT rotation.

“There appears to be a significant lack of educational attention and resident preparedness in LGBT health care,” Nowaskie writes.

Given that LGBT people face disproportionate rates of mental health disorder and suicide, psychiatry residents are in crucial roles as:

  1. Learners to understand the unique associations between demographics, health risks, and psychosocial factors among the LGBT populations.
  2. Providers to utilize this experience and knowledge in the provision of care for the LGBT population.

This study was conducted with an anonymous survey with 304 completed responses. The author collected information on participants’ demographics, their training experiences in LGBT health (experiential variables), and the LGBT Development of Clinical Skills Scales (LGBT-DOCSS).

With the training experiences, the participants were asked to disclose how many hours of LGBT education they had received at their current residency program, how many total hours of LGBT education they had ever received, and how many LGBT patients they had worked with.

The LGBT-DOCSS was used to assess participants’ clinical preparedness, attitudinal awareness, and basic knowledge. The higher the participants’ score in one section, the better capability it reflects in such section.

Overall, the survey showed that psychiatry residents caring for many LGBT patients receive a low number of curricular hours and a moderate number of extracurricular training. Particularly, they reported significantly higher attitudinal awareness compared to basic knowledge and clinical preparedness. For example, in Asia, medical students are pushing for greater LGBT acceptance in their training curricula to promote LGBT health.

In addition, the residents reported significantly less adequate clinical training and supervision, experience, and competence to work with transgender patients compared to LGB patients. This result is consistent with the past literature that healthcare providers are more knowledgeable and comfortable about LGB health than transgender health. This might also explain why transgender youth face a higher rate of psychiatric diagnosis.

The survey showed that psychiatry residents who reported higher scores in LGBT-DOCSS had more LGBT patient exposure and had more formal education on LGBT health.

“Psychiatry residents who had cared for 40 or more LGBT patients reported significantly higher Overall LGBT-DOCSS and Clinical Preparedness, and psychiatry residents who received 20 or more LGBT total hours (training) reported significantly higher LGBT-DOCSS scores except for Attitudinal Awareness,” Nowaskie reports. “Psychiatry residents who had received four or more LGBT curricular hours had significantly higher LGBT-DOSCC scores.”

The author concludes:

“To lessen the current gap of nationally inadequate LGBT cultural competency, psychiatry residency programs should heavily consider an LGBT educational curriculum that is comprised of approximately five annual hours over the course of the typical four-year residency timeline for a total of 20 hours.”

 

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Nowaskie, D. (2020). A national survey of US psychiatry residents’ LGBT cultural competency: The importance of LGBT patient exposure and formal education. Journal of Gay & Lesbian Mental Health24(4), 375-391. (Link)

21 COMMENTS

  1. Given the overall illegitimacy of psychiatry (see Is
    MIA’s “Is Psychiatry Evidence Based?) what difference would it make “boosting” specific training for LGBT patients, other than to cash in by adjusting/exploiting such idiocies as “attitudinal awareness,” and “clinical preparedness,” which simply means finding new exploitative rhetoric to “prepare” (bamboozle) LGBT patient to take same meds prescribed non-LGBT under guise of “attitudinal awareness. ” In other words, as with non-LGBT patients, LGBT patients do not suffer from “psychiatric diseases.” Makes no sense.

    • Psychiatry residents need more training in the actual root causes and effective interventions for people who are suffering emotionally and come to them for help, and more training in the fact that the current system is utterly ineffective and in fact destructive in many if not most cases. Though going into another specialty sounds like a good option, too.

      • I repeat: Psychiatry residents should go into a legitimate field of medicine. Neither diagnosis nor psychiatric drugs provide actual help. They provide medical language to explain what’s wrong with people and drugs to subdue their reactions so that they no longer complain or bother others enough to require such interventions. Psychiatry does not practice medicine, it is a tool of social control.

        What is perhaps debatable is whether social control is sometimes warranted. But we can do better than pretend that mental illness vis a vis psychiatric diagnosis and drugging tailored to specific disorders is an actual thing. If the disorders aren’t real illnesses then drugging targeted to treat specific illness states is not backed by solid premises and the entire construct collapses.

        There could be some room then for an honest discussion about which drugs might have a place in emergency use when someone actually requires emergency sedation or is so chronically impaired that they require some sort of behavioral control at the chemical level. Say perhaps an acutely floridly psychotic person acting aggressively. But I think we’d all be better off if we didn’t pretend that it was medical treatment and just honestly admit that there are situations that sometimes benefit from behavioral control. Then we could start to move away from the idea that some people are mentally ill with a specific diagnosis requiring specific drugs and instead move toward a more compassionate culture with a renewed social contract to leave no human behind.

        • Couldn’t agree with you more! Detaining someone for being dangerous should NOT in any way be considered as or associated with “treatment” or “diagnosis” at all. Social control is social control. As I’ve said many times, without even arguing about the obvious failings of the destructive psychiatric model, as soon as you introduce force, it can no longer be considered in the realm of “treatment.”

  2. To me, and I am only speaking for myself here, with my schizophrenia I feel I have a mental illness. I feel devastatingly ill when my hallucinations and delusions and paranoia give me no moment to even think about practically how to suicide. If that is not the definition of a mental illness I do not know what is. If you were to live three minutes of my illness, if you even survived the shock of it, I doubt you would criticize or judge me for using the words mental illness to describe what I have.
    I respect that you may not want to call what you have got a mental illness but that is your choice not mine. Mental means of the mind. My mind feels ill, ill, ill, ill, ill. I do not care whether whatever will help it gets called treatment or medical treatment or peroxide blonde hair dye. I can sort of hear the bit where you all want to see psychiatry crumble but in your rude haste to achieve it you seem to want the long queue of what you might regard as the walking ignorant to dismiss being ill enough to need their illness taken seriously, because if they don’t take their illness seriously then presumably the shrinks cannot push crass or zany treatments on them….but the treatments and the illnesses are two different issues. Please listen to me here saying that I have no choice but to take my illness of schizophrenia seriously since it has been destroying me hourly for well over a decade. Right now laughably a psychiatrist is the only one who is taking schizophrenia seriously and I guess that is why millions of schizophrenics would rather sit in a shrinks office than flounce on a beanbag or a yoga mat listening to a woozy inept meditator tell them they have a blocked chakra.

    You really do not have to undermine other peoples illnesses to nail your victory of dismantling psychiatry. You can uphold the illnesses that people regard themselves as having and still dismantle psychiatry for having been cruel to those ill people. Instead what you seem determined to do is claim that psychiatry bodily bestowed those feelings of illness, as if through a transfusion that occurred long before the person even booked an appointment. I am not talking here about iatrogenic illness, which in my opinion is different from the original illness. My illness did not get given to me by a medical faculty who only named it an inpronouncable name. At no point in all of my dealings with psychiatrists did any of them seduce me into believing anything. That is not to suggest that some crooked employees of psychiatry do not behave scandalously. But commenters seem to zone in on them for their headline grabbing rogue value to which commenters cast the presumably idiotic schizophrenic as “victim of psychiatrists” rather than victims of a horrible mental…yes mental…illness…in as much as they feell ILL and feel ILL mentally. It is not my foot that feels ill. It is not my wrist that feels ill. It is my mind, my brain, whatever I want to call it. It is my brain not your brain and if I say it has something out of balance going on it then who are you to thump a wedge of “data” of other peoples brains and tell me mine is identical. You sound like the worst grandiosity of psychiatry. Surely you do not want that? Surely you want to be healing? For all. Healing means letting people heal themselves according to their own treatment choices and preferrences. You can offer persuasive new research to a schizophrenic that says they maybe do not have that but something else but you miss the point if you think that is ever going to stop the crucifying agony of an awful illness.

    You all seem to be a chorus that says get rid of psychiatry by demolishing their labels and diagnosis and DSM book of bed time stories but you leave the schizophrenics and bipolar sufferers and autism sufferers, who never gave a damn about that prop department memorabilia, shivering and out in the cold simply because that is not what they care about. They care about being treated equally.

    Equality is always an inconvenience in the ranks of any campaign that wants to create a vision of equality.

    I am sorry dear passionate people. I am cross and whining tonight because having mended my migraine now my pericarditis is hurting my heart. I got it as a present for being on antipsychotics. I am the first person to say wipe out all of the psychiatric drugs. Every heel crunchy fusty dusty pill.

    • “Instead what you seem determined to do is claim that psychiatry bodily bestowed those feelings of illness, as if through a transfusion that occurred long before the person even booked an appointment.”

      No. This isn’t what anyone is saying.

      What gets labeled schizophrenia has at least nine known etiologies. No one here could possibly know what the etiology of your particular suffering is or whether a physical illness is involved. I can tell you that Lyme disease has been frequently misdiagnosed as schizophrenia and that schizophrenia patients often respond well to antibiotic treatment. One known etiology of the phenomena with that label is infection.

      Our objections to the DSM labels and “treatments” are that they do more harm than good, they shorten lives, they don’t explain what is actually afflicting the individual and they don’t treat the underlying issue.

      No one here has said what you experience isn’t real and your agency to call it what you wish has been respected. I’m not sure what more you want out of advocacy.

      “I am the first person to say wipe out all of the psychiatric drugs.”

      And someone else out there feels as passionately about their savior drug cocktail as you do about your label and doesn’t understand why you’re coming for their drugs. You’re really not any different than the rest of us except that you want your label. And we are here saying keep your label if it makes you feel better. But don’t assume that label tells you literally anything about what is causing your distress or how it might be alleviated.

      “ They care about being treated equally.”

      And this where you’re positively dead wrong because most commenters here are on the side of expanding the rights and protections for those who present and act differently than the accepted cultural norm for whatever reason – whether they are lgbt or experience extreme states or antiauthoritarian or misbehaving children. Rights protections are fundamental. We might disagree about content or language but if you think the psychiatrists care more about protecting your rights than the people commenting here, I’m going to be very confused.

      Of course, many here are angry and lashing out at having experienced harm from the system and so your lashing out at the activists you seem to misunderstand is not taken personally.

      • “Our objections to the DSM labels and “treatments” are that they do more harm than good, they shorten lives, they don’t explain what is actually afflicting the individual and they don’t treat the underlying issue”.

        Who is “our”. What “our” are you referring to? And why can you not speak from your own self to lonely me without referring to gang?

        Are you talking about a cabal of forty or fifty like minded people who all parrot each other on this political website? Is that the “our” I am meant to pay full attention to? I thought this website welcomed newcomers without limit or expectation. Of forty or fifty people there can form a common bond and this can feel like plugging in to a super power. Power can become very addictive if you feel powerless in life but addictive power sometimes is sought to the exclusion of other forms of healing and wellbeing. Forty or fifty adherents to any regime is not the other billions of minds who inevitably have diverse and colourful ideas and understandings about the psyche of the human.

        I looked at an article by Paula Caplan the other day. It was about using quotation marks for words like schizophrenia. I think it may have been Steve who agreed in a comment he made to that 2019 article that using such signifiers would be great because as he says using quotation marks…

        “usually indicates a degree of disrespect or scorn for the term”.

        I firmly suspect that there are many people who have dearly wanted to join your “our” or forty to fifty regular gang members but who get frisked for their political credentials and feel vaguely more or less “disrespected” and “scorned” for choosing to use a word for their illness that they have no problem with. Are those name changing stipulations “rules” and “regulations”. If so, why are they not emblazoned on the Mad In America flag? Are you the bouncer who weeds out the ones who cannot be accepted into the “our”? Are you some kind of official or president of the “our”. Does there even need to be an “our”? By its very nature “our” excludes.

        I suspect people gather a sense of identity by joining the “our”. To the extent that anyone who quibbles the “our” with its policy and rules and regulations is deemed to offend each members sense of “identity”. That all swiftly becomes deemed an attack on personal identity, even in a website that should be maganamous and welcoming of multifarious viewpoints. The core group doubles down on protecting itself from the threat to each members personal sense of identity as derived by “belonging” to the “our”, by picking away at anyone with a quite different identity.

        I repeat, Kindred Spirit, if I got forty or fifty political people, whether left or right, to keep referring to your Lymes Disease diagnosis scornfully as “a label” I think you might soon feel not quite “our” as you currently have the pleasure of feeling.

        I notice how you lump a sentence together to imply that a label and ‘treatments’ are harmful. I have never said treatments cannot be harmful. I think many of them are. But you seem eager to erase all common affiliation between us in your hurry to convince me that my word choice for my illness is harmful. Harmful to whom, Kindred Spirit? Harmful to you? How does my using my own description of myself have anything to do with you? It is entirely my business what I choose to say my illness is called and what I believe has caused it. You spend alot of time describing an illness that you do not have nor have ever experienced, like many of the “our”. It is quite bizarre. Like a ward of dermatology patients spending inordinate amounts of time ironically “academically” and “scientifically” and even “scornfully” describing the minutiae of illness theories of gall stone patients.

        I am here because your “our” has wanted me. In the world in general any person who is alienated by a group has little option but to become an exile and even a terrorist. The most noble groups bring the terrorist back in to yhe fold..
        But surprisingly alot of failing groups who are not getting enough spark and vibrancy anymore from within the group of same old tired faces…the “our”…devour with gusto and relish any newcomer, as if fresh essential enzymes, with which to cemente the disappearing bosom bond again. But a conflict ensues on the group doorstep because the welcome mat has printed on it “rules” and “regulations” to which the newcomer objects. The group then must bond against the newcomer who is ludicrously deemed to threaten each members personal identity, all bound up in the power of the “our”. A threat that is a preposterous projection. And so a perpetual scuffle breaks out that sees the newcomer bewilderingly depart, for not abiding by the doormat label custom, and as he or she leaves with a chorus of political heckling in suit, he or she is further blamed for not being “nourishing” as a packet of enzymes should be.

  3. I also add, with respect to the actual article, that when I was lost in the body hatred dimension and had taken to shredding my skin with broken coffee cups, it was a very impressive out there lesbian psychiatrist that helped me heal from my distress about routine sexual assaults from male strangers.

  4. Dear Kindred Spirit,

    I’ve just had my veggie lasangne and as I was washing it down with pineapple juice I thought deep.

    You said this…

    “No one here has said what you experience isn’t real and your agency to call it what you wish has been respected. I’m not sure what more you want out of advocacy”.

    Well, looking at the above quote you made I want to say this. Borrowing from the current onus on race there have been incidents where a new employee of colour has been welcomed. But welcomed “at the same time” as being scapegoated. When that occurs there are no overt expressions of excluding but rather far more subtle, intangible pressures are brought to bear, within the “our” welcome. Everyone may be sitting around the same table in the canteen. Perhaps they call the new employee to come join the canteen gang but rather than include him in the co-creation of the discussion, there is a code or etiquette that he is expected to emphatically resonate with. If he has a different point of view he may not be stopped from airing it, nor be scowelled at, but instead the backslapping cameraderie amidst the gang suddenly intensifies noticeably, with everyone practically in eachothers arms with unbridled devotion, and all leaning in staunch alighnment with the church line. All buddies. The moment the person of colour senses something does not quite feel right and mentions this, he is “welcomed” with open arms, only to be given an affable “explanation” of what the canteen gang, or the “our” believes. And after a month or two this process keeps occurring, almost as if the person of colour is a push button to be pushed and prodded until he objects to feeling force fed the canteen gang ideology, which then leads to the flipping over of prodding into overt apology that conveniently services the prompt to produce yet more echoes of what the canteen gang believes, which feels like another sort of force feeding….of “logic”. So there is the initial pushing by ranting stock phrases of belief at the new employee, and then similar pushing of the same content under the auspices of an apology that ushers yet more “logic” in the guise of sounding not excluding at all but “reasonable”. And while everything on the surface appears gentlemanly and academic and explanatory and understandable and verbose and “logical”, the person of colour feels metaphorically kicked under the canteen table but he cannot tell where it is coming from. Each time he peeks beneath the surface the feet scatter and he tries to follow which way they went, like following a soccer ball of grievance from under the shadow of one seat to the next.

    You also mention that you are not sure what I want from “advocacy”. To me this comes over as evading that I might want something from “you”.

    And you tell me more or less that I am entitled to use my “label”. Why do you not say the word schizophrenia if you are happy for me to enjoy calling myself schizophrenic? You may say you do not believe there is such a thing as schizophrenia, as if it is my personal belief, but on a level of courtesy does that stop you calling a Muslim a Muslim if you are not of that belief? Or a Christain a Christain? Or if a deluded old lady with Altzheimers disease insited she was a Japanese Empress who has schizophrenia would you chide her and tell her that her beliefs about herself were a “label”. Whose beliefs are we talking about? Hers or yours? Nobody is going to force you to believe Jesus is real or not real. Nobody is going to force you to believe schizophrenia is real or not real. That is because you are free to believe utterly whatever you love to believe. Everyone should be basking in such freedom of choice, freedom means “free” from kicking under the table.

    Just because we should respect everyone’s freedom of choice does not mean we “have to” love them. Love should flow organically and even mystically and never be subject to deadening demands. I have no demand that anyone in the comments section should love me. You do not have to love someone to “welcome” them. You are free to absolutely detest me in your heart, but the moment your dislike of me leaks out all over the metaphorical canteen, or indeed the moment my antipathy does this to you, then a step has been crossed from our freedom to believe and feel and think whatever we want, to acting our “behaviour”. And although inner feelings are never harmful, even the horrible, nasty, hateful feelings, outward “behaviour” most definitely can be. When that line is crossed we go from having an uncomfortable feeling to justifying our outward bad behaviour towards anyone who seems ludicrously to have caused the discomfort….the “them”. The “them” who are not our “our”…. or our “me”….which is what “our” or “we” usually really means. You could almost join the words together “ourweme” around all the ubiquitous canteen tables of the world and fuel the “ourweme” hype with overwhelming feelings that start acting out as bad behaviours that bewilder each new employee.

    I have no problem with your freedom to think or feel any way you choose to. I would say the same to anyone in the comments section in regard of their thoughts or feelings. You can have trillions of thoughts and feelings each day and not one of them need overtly “unwelcome” a stranger or the different, even if deep down you feel convinced they are responsible for everything awful in your work, your home life, your street, your world. Every human is at liberty to loathe the stranger and the different, but “within” their feelings and thoughts. The moment they ventilate their inner loathing they may do so bullyingly, in a way that curbs the excesses of the stranger or the different in such a hostile that way that stops the stranger or the different from enjoying “their” free choice to feel and think as they do within. If you honour your own feedom of choice to believe whatever you like to then you will be more inclined to honour that in other people whose choices seem to you quite barking mad. If you want to regard schizophrenia as a myth then love whatever you love to believe. If you really love it to the hilt you wont need to enlist backslapping cameraderie to entrench your freedom of choice to believe as you like. You wont need buddies to help you turn your freedom of choice into bullying of the new person’s freedom of choice that differs from yours and which you regard as bullying you.

    Why I dig my heels in about the quotation marks regime is that whilst for some it looks like a way of exorcising vile words from off the clean white page, flicking them off like vile crumbs from a canteen table. But for others those words are “home” in as much as they are user friendly familiar words with no ability to put bruises on anyone. Words are exhaled air travelling over the tongue and through the pursing lips and then meeting votices of air currents and bouncing off canteen doors and vending machines and getting asorbed in cushions and hairdos and at no point whatsoever do words physically hurt anyone. What may instil fear are not the words themselves but the intentions with which they are uttered. It is never going to be possible in todays busy frenetic world to police “intentions” without being an “intentions bully”, which then cuts into the freedom to feel the feelings you choose to feel. But you can police bullying when it seems to have gotten out of hand, by stepping from inner feelings to overt outward bad behaviour or mob behaviour and has spiralled into a regime of regulations. The guild of psychiatry as Robert Whitaker first called it, has been those bullies with overt outward bad behaviour. But when activist sites fight bad behaviour by bullying the bullies back, rather than containing all the essential beauty of “freedom of choice” to believe and feel and think as you wish to, then activist sites run the risk of chasing off the person of colour.

    Probably none of this makes any sense. Never mind. As for nine eiteologiess cant even spell it and I have the illness, I dont know why in binning the authority of dodgy science people feel they must tirelessly come up with yet more dodgy science. You are at pains to tell me I can accept my freedom of choice and yet seconds later you are butting in with a “logical” yes but it’s probably a rubbish choice because other brains have been bathed in antibiotics.

    If you knew the amount of antibiotics I have transfused through my poor brain you would not say that. You seem to need me to have not tried everything, as if my free choice to merrily call my illness schizophrenia is down to an oversight. This critiquing of my horrible illness is well….horrible. You know that feeling so indelibly from having your Lymes Disease abolished by a “well meaning” critique. As if in the history of humanity’s love of “freedom of choice” there has ever been such a thing as a “well intentioned critique”. Staight out of the demise of the caves that one came from.

    Lastly, as for “lashing” I really don’t. I just like to speak common sense. It is so rare that people think it is a weapon. I am incapable of lashing, as my sister said often on pony trecking trails. I lash like a girl, it hobbles my ankles and turns into a taught cello. But if you would like me to show my lashing proficiency skills perhaps we could team up as a double act, to get rich consultant psychiatrists to drop a coin in Mr Robert Whitaker’s shoe box.

    • You may call yourself whatever you wish, but remember that you chose the word they, the shrinks, coined.
      Perhaps just so that the listener would know what you mean by the word. But the meaning was also designed by the authority.

      I shriek against children adopting the word ADHD. I shriek against non consent and so no thanks to anything psychiatry offers, not even labels.

      But you are a consenting adult, not the millions of kids who have no knowledge about meanings.

    • The simple fact is that unless we change the rules of language you cannot have a “mental illness,” as the mind is an abstraction and not subject to physical characteristics such as “color” or “illness.” I have taken of late to telling people that when they can show me a mind in a plastic bag they can start talking seriously about “mental illness.”

      Nor, would I add, is “schizophrenia” simply a bad term that “really” means such and such, as this falsely implies that there is a consistent and definable “thing” signified by similar modes of thought or behavior, when you’re really just talking about how people relate to their experience.

      I’m not sure why you find it reassuring to identify as “mentally ill,” though you certainly have that “right”; however expecting others to enthusiastically accept your self-definitions when they see them as demeaning is a tricky proposition.

      I enjoy the flourishes of your perceptual impressions and writing style, and think you should consider seeing yourself and your life beyond the anemic boundaries of psychiatric terminology. But I don’t think anyone is challenging your right to make your own choices, or trying to bring you down.

      • POSTING AS MODERATOR:

        At this point, this discussion seems to be moving in a more personalized direction that I don’t think is going to be productive. A couple things are clear: 1) Everyone has a right to identify as they please; 2) Everyone has a right to object to terminology they find objectionable; 3) when there is a general objection a term that an individual might find workable for him/herself, there is a very distinct possibility of feelings getting hurt.

        It seems to me that the primary conflict is around whether the general discussion of the damage done by psychiatric labels is in some way disrespectful to those who identify with such a label. I’m not going to try and be the final judge on this point, but I will say that the conflict is one that is inherent in the subjectivity of the diagnostic system itself, and is unlikely to be resolved by further discussion of this nature.

        So at this point, I am going to ask that we leave this discussion where it is at, with the acknowledgement that the conflict is not resolved, and that different people have different feelings about it, to which each is fully entitled. Others who want to discuss this further with each other are certainly entitled to do so by direct communication off line. If anyone needs/wants to connect with someone through email for further discussion, I am always happy to assist with making such connections.

        Steve

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