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The first artifact I have chosen is a short video called What is it like to be a mental health nurse. The video showcases many different mental health nurses who talk about why they joined this field of nursing and how they work towards helping individuals who struggle with their mental health. Relating this back to my podcast and topics we covered in class, these nurses demonstrate the importance of having therapeutic relationships with patients and how the care they provide is crucial for helping improve the overall well-being of their patients. Furthermore, they demonstrate the use of compassionate and committed care (5C’s).

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Birmingham Women's and Children's NHS Trust

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What Is It Like To Be A Mental Health Nurse?

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The second artifact I have chosen for this topic is my own art project. My drawing encompasses the importance of the 3 nursing obligations we learned about and how they benefit our patients daily. These 3 obligations included ethics, safety and health promotion. On one side of my drawing, a thriving environment is shown which demonstrates that with the use of these obligations, our patients will thrive. The other side is decaying, which represents not using these obligations in our practice. Overall, I believe using these nursing obligations in mental health nursing can be quite beneficial for our patients. As nurses, we must reflect on our actions, judgements and justifications daily and make ethical decisions that benefit our patients. We must focus on safe practise that benefits both our patients and the well-being of nurses. Lastly, we promote healing that focuses on reaching a state of complete physical, mental and social well-being.

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The first artifact I have chosen is an image from the Trans Pride March which took place in Portland in 2019. I believe this image conveys a powerful message regarding the need for equal access to healthcare for the LGBTQ+ community. As a future healthcare provider, I wish to continuously educate myself about this community and provide culturally affirming care throughout my practice. Every individual deserves to feel safe and respected when they enter a healthcare facility. This community often faces barriers such as healthcare providers being uneducated about LGBTQ+ populations, pronouns not being respected, stigma and much more. Overall, healthcare providers need to take the initiative to learn about different communities and their needs.

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If you want the best surgeon, you want the best surgeon, you don't want the second best.
-Krista Contreras, reflecting on her six-day-old child being turned away by a pediatrician, Ferndale, MI, January 18, 2018

A substantial body of research indicates that lesbian, gay, bisexual, and transgender (LGBT) populations across the United States encounter significant barriers to health care. Many LGBT people have difficulty finding providers who are knowledgeable about their needs, encounter discrimination from insurers or providers, or delay or forego care because of concerns about how they will be treated. In the absence of federal legislation prohibiting healthcare discrimination based on sexual orientation and gender identity, LGBT people are often left with little recourse when discrimination occurs.

In May 2017, the US Department of Health and Human Services (HHS) signaled it would roll back regulations that prohibit discrimination against transgender people in federally funded healthcare programs. In April 2018, HHS submitted a draft of a proposed rule to this effect to the White House. At the same time, HHS has recently proposed regulations that would give providers wide latitude to discriminate or refuse to provide certain key services to LGBT people, women, and others by asserting a moral or religious objection. HHS has also created a new division within HHS's Office of Civil Rights to address claims brought by healthcare workers who raise objections to providing medical care to certain patients based on the provider's religious beliefs. Together, these developments threaten to exacerbate the barriers to care that LGBT people already encounter, and give insurers and providers who would deny services to LGBT people, women, and others a license to discriminate against them.

This report documents some of the barriers that LGBT people face in obtaining health care, and the toll that sweeping moral or religious exemptions can take on the health and well-being of those who are turned away by providers. It illustrates the scarcity of competent healthcare services for LGBT people in many states, the discrimination that LGBT people too often experience from providers, and the ways that negative experiences can deter LGBT people from seeking and obtaining the care they need.

The rollback of federal healthcare antidiscrimination protections and the expansion of religious exemptions for healthcare providers are each likely to impede LGBT people from obtaining healthcare services. Taken together, these moves will be devastating for many LGBT people, women, and others. Lawmakers at the federal, state, and local levels should enact laws and regulations that expressly prohibit discrimination based on sexual orientation and gender identity in health care, and should repeal or revise sweeping religious exemption laws that allow insurers and providers to deny healthcare services to LGBT people and women seeking reproductive care.

Human Rights Watch conducted the research for this report between August 2017 and July 2018. To identify interviewees, a researcher conducted outreach through national and state LGBT groups, legal advocates, and service providers who circulated information about the project to their networks. The outreach for this report primarily focused on Mississippi and Tennessee, two of the states where statewide antidiscrimination protections do not prohibit discrimination based on sexual orientation and gender identity and where lawmakers have recently enacted exemptions permitting some providers to refuse service to LGBT people because of their religious or moral beliefs. A researcher conducted a total of 81 interviews specifically related to healthcare discrimination, including 33 with individuals who said they had been discriminated against in medical settings and 48 with advocates and providers working with affected individuals.

Most interviews were conducted in person from November 2017 to February 2018, with additional interviews conducted by telephone. No compensation was paid to interviewees. The researcher obtained verbal informed consent from interviewees, and notified interviewees why Human Rights Watch was conducting the research and how it would use their accounts, that they did not need to answer any questions, and that they could stop the interview at any time. Interviewees were given the option of using pseudonyms in published materials for the project; where pseudonyms are used in this report, that is reflected in the footnote citation.

As this report describes, many LGBT people already face difficulties obtaining accessible, inclusive health care. The Trump administration's proposed rollback of antidiscrimination protections and expansion of religious exemptions are likely to have devastating consequences, exacerbating health disparities for a population that already experiences high rates of healthcare discrimination.

Discrimination by Healthcare Providers

LGBT people also have unique needs related to their sexual orientation and gender identity. Same-sex couples who decide to have children, for example, may seek out fertility specialists or utilize assisted reproductive technologies as part of the process. While not limited to LGBT people, gay and bisexual men and transgender women may be more in need of HIV-related health care, including treatment for those who are living with HIV and access to preventive care such as pre-exposure prophylaxis (PrEP), a daily pill that significantly lowers the risk of HIV infection. Transgender people who medically transition may seek access to puberty blockers, hormone replacement therapy (HRT), or gender-affirming surgeries as part of their transition.

This data and interviews conducted by Human Rights Watch suggest that transgender and gender non-conforming people are at a particularly high risk of discrimination in health care. LGB interviewees most often encountered discrimination when they disclosed their sexual orientation or mentioned a same-sex partner, and occasionally described how they would not disclose these facts to providers to avoid discrimination. Nondisclosure was more difficult for many transgender interviewees, particularly when their medical records did not align with their gender identity, providers perceived them to be transgender, or they sought or were undertaking medical transition. While there are significant barriers to care for LGB people, especially in fertility and sexual health services, discrimination against transgender and gender non-conforming people is particularly acute.

Although this data suggests that discrimination can be detrimental to LGBT people's health and well-being, protections against such discrimination remain uneven at both the federal and state levels.

Limited Antidiscrimination Protections

Recent Setbacks for LGBT People's Health and Rights

Instead of taking action to remedy the discrimination and healthcare disparities that LGBT people experience, the Trump administration has advanced two regulatory changes that are likely to exacerbate these problems.

First, in May 2017, the Department of Health and Human Services began the process of rolling back the rule clarifying section 1557. Rather than defending the rule in court, the Trump administration announced it planned to eliminate language clarifying that sex discrimination includes discrimination based on gender identity. In April 2018, it notified the court that it had submitted a proposed rule to that effect to the White House for approval. As of June 2018, six appellate courts had concluded in other contexts that discrimination based on gender identity is a form of discrimination based on sex, and two appellate courts had reached a similar conclusion with regard to discrimination based on sexual orientation. Nonetheless, rolling back the rule would have practical consequences, leaving transgender people less certain of their rights, providing little guidance to insurers or providers about their responsibilities under section 1557, and signaling that federal agencies will not advance trans-inclusive interpretations of section 1557 in their rulemaking and enforcement capacities.

In addition to these federal developments, three US states have enacted laws or regulations that give wider latitude to discriminate in the provision of healthcare services.

As the research in this report illustrates, many LGBT people in the United States face significant obstacles when seeking healthcare services. Retreating from antidiscrimination protections while expanding exemptions that permit insurers and providers to deny care based on their moral or religious convictions is a dangerous combination.

The withdrawal of antidiscrimination protections and expansion of religious exemptions is occurring in a climate in which LGBT people already face significant barriers to accessible and inclusive health care. LGBT people in states that enacted exemptions described four major obstacles, independent of the proposed federal changes, to obtaining the care they need: lack of accessible services, discrimination by insurers and providers, refusals by providers, and reluctance to seek care. As discussed in this section, each of these obstacles is exacerbated where legal protections against discrimination are absent or unclear and where the expansion of religious exemptions allows providers to refuse care.

Lack of Accessible Services

Even where there are multiple providers in an area, material and logistical barriers may prevent LGBT people from being able to access them. When providers are not trained on LGBT issues or services are scarce in an area, LGBT people may have few options when a provider discriminates against them or turns them away.

Scarcity of Providers

Most interviewees told Human Rights Watch that they had little or no access to LGBT-friendly healthcare providers in their area. As the head of one community center in rural Michigan said, "I do not know of any trans-affirming healthcare providers in the area. And I've talked to many trans people in the area." One pediatrician in Alabama remarked that religious refusals are "dangerous in a predominantly rural state, [where] health disparities are massive to begin with. Huge, huge, huge swathes of our state not only have no pediatricians, but have as few as two or three physicians per county." Interviewees described LGBT individuals driving two hours from Tennessee to attend a weekend support group for gender-expansive youth in Birmingham, traveling two hours from Arkansas or Mississippi to attend therapy or meet with a trans-affirming doctor in Memphis, driving across Michigan to find a friendly nurse practitioner or medical practice, or driving from East Tennessee to North Carolina for regular hormone injections.

The lack of providers was especially acute in rural areas, but certain services were difficult to find in metropolitan areas as well. As one mother of a transgender child noted:

Barriers to Access

For many LGBT people, unemployment and poverty combine with other barriers to care to make particular types of care virtually unattainable. A study examining data collected from 2010 to 2014 found that households headed by same-sex couples are more likely than those headed by demographically similar heterosexual couples to live in poverty. Data from the 2015 U.S. Transgender Survey indicated that 15 percent of transgender respondents were unemployed and 29 percent were living in poverty. Without employment, individuals may have a more difficult time maintaining insurance and affording health care. In early 2017, an estimated 25 percent of transgender individuals were uninsured. In the 2015 U.S. Transgender Survey, a third of the transgender respondents indicated that they had foregone medical care they needed in the past year because of concerns about cost.

Discrimination and Mistreatment

Although many interviewees described negative experiences in hospitals, discrimination occurs in counseling and therapy as well, as described elsewhere in this report. KT Hiestand, a therapist in Memphis, observed:

This kind of overt discrimination can be especially damaging to those seeking mental health care. Shane Bierma, who provides psychological services at Positively Living in Knoxville, underscored the tenor of the discrimination that many LGBT people encounter from mental health professionals:

Refusals of Service

As Human Rights Watch has previously documented, LGBT people face service refusals across the healthcare field. LGBT people have been denied fertility treatments, turned away from counseling sessions, denied a checkup because they are gay, refused basic health care because they are transgender, and in one instance, told that a pediatrician's religious beliefs precluded her from evaluating a same-sex couple's six-day-old child.

In recent interviews, mental health professionals in Tennessee said they continue to see new clients who have been turned away by other providers. Jessica Shea, a clinical social worker in Memphis, described how one transgender child was turned away from a religiously affiliated psychiatric practice:

KT Hiestand, a psychologist in Memphis, underscored that these are not isolated incidents:

Reluctance to Seek Care

Effects of Discrimination and Refusals

In interviews, LGBT people and medical practitioners voiced concerns about the practical and symbolic effects of discrimination and refusals by healthcare providers.

Still others were unable to obtain care, and struggled with the toll it took on them. Sandra R., a transgender woman in Flint, Michigan, who had been unable to obtain gender-affirming surgery, explained:

The US federal government's proposed withdrawal of regulatory language explicitly prohibiting discrimination in healthcare services, combined with its simultaneous expansion of religious exemptions, jeopardize the health and rights of a population that already faces stark healthcare disparities. The rights to equality and freedom of thought, conscience, and religion may seem at odds with each other in this context, but jurisprudence developed under international human rights law offers guidance on how to reconcile the two without compromising the right to freedom from discrimination.

Harmonizing Equality and Freedom of Thought, Conscience, and Religion

The United States is party to the International Covenant on Civil and Political Rights (ICCPR), which guarantees equal protection under the law as well as the freedom of thought, conscience, and religion.

The Human Rights Committee has emphasized that article 18 "does not permit any limitations whatsoever on the freedom of thought and conscience or on the freedom to have or adopt a religion or belief of one's choice," but-recognizing that religious exercise may affect others-does permit limited restrictions on the freedom to manifest one's religion or beliefs. Under article 18(3), states may regulate the manifestation of religion or belief if, and only if, such regulations "are prescribed by law and are necessary to protect public safety, order, health, or morals or the fundamental rights and freedoms of others."

Other Rights at Risk

The religious exemptions discussed in this report jeopardize the enjoyment of several fundamental human rights.

Right to Information

The proposed HHS rule expands existing protections to allow providers to decline to provide information they deem morally or religiously objectionable to their patients, while doing nothing to ensure that those patients have reliable alternative routes to secure that information. Denying medically accurate information to patients leaves them in the dark about their treatment options and prevents them from making an informed choice about which options to pursue.

Right to Health

When states enact laws allowing healthcare providers to deny service based on their personal objections to an individual's sexual orientation or gender identity, they undermine the right to health. Individuals may be denied services outright; have difficulty finding services of comparable quality, accessibility, or affordability; or avoid seeking services for fear of being turned away.

To the US Congress

Enact the Equality Act or other legislation which would prohibit discrimination based on sexual orientation and gender identity in all federally funded healthcare programs and activities.

Enact the Do No Harm Act, which would prevent the Religious Freedom Restoration Act from being used to carve out exemptions from federal laws and protections regarding nondiscrimination, labor, children's rights, and health care.

To the US Department of Justice

Ensure that existing conscience protections are not misused to excuse or justify discrimination on the basis of race, sex, religion, sexual orientation, gender identity, and other classifications.

To the US Department of Health and Human Services

Preserve and enforce protections against discrimination on the basis of sexual orientation and gender identity.

Withdraw the proposed rule expanding religious exemptions that allows insurers and providers to deny available healthcare services because of a person's sexual orientation or gender identity.

To State Legislatures

Prohibit discrimination on the basis of sexual orientation and gender identity in all state-funded healthcare programs and activities.

Repeal sweeping religious exemptions that allow insurers and providers to deny available healthcare services because of a person's sexual orientation or gender identity.

Ryan Thoreson, a researcher in the LGBT Rights Program, wrote this report based on research that he undertook from August 2017 to July 2018.

The report was reviewed by Graeme Reid, director of the LGBT Rights Program; Alison Leal Parker, managing director of the US Program; Amanda Klasing, senior researcher in the Women's Rights Division; Megan McLemore, senior researcher in the Health and Human Rights Division; Chris Albin-Lackey, senior legal advisor; and Joseph Saunders, deputy program director. Production assistance was provided by MJ Movahedi, LGBT Rights Program coordinator; Rebecca Rom-Frank, Photo and Publications coordinator; Fitzroy Hepkins, administrative manager; and Jose Martinez, senior coordinator.

Human Rights Watch would like to thank the experts and organizations that provided information for the report, especially the Movement Advancement Project, American Civil Liberties Union (ACLU), Tennessee Equality Project, the Tennessee Transgender Political Coalition, Positively Living, Nashville CARES, Friends for Life, Choices, OutMemphis, Equality Michigan, Affirmations, the OutCenter, the AIDS Services Coalition, and the ACLU of Mississippi.

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If you want the best surgeon, you want the best surgeon, you don't want the second best. -Krista Contreras, reflecting on her six-day-old child being turned away by a pediatrician, Ferndale, MI, January 18, 2018 A substantial body of research indicates that lesbian, gay, bisexual, and transgender (LGBT) populations across the United States encounter significant barriers to health care.

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The second artifact I have chosen is a video titled LGBTQ Health Issues. The indivisuals in this video discuss the importance of how healthcare workers should get more cultural competency training about the LGBTQ+ community and their needs. Individuals in the video discussed the fear people in the LGBTQ+ community have when it comes to walking into these healthcare settings and sharing their stories with their healthcare providers. This further encompasses the need for more therapeutic and understanding relationships among healthcare providers and their patients who identify as being a part of this community. By having these therapeutic nurse-client relationships, a safer environment to discuss healthcare needs can be created.

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The first artifact I have included is an image I found online which encompasses several statements that are stigmatizing and judgemental about mental health conditions and substance use. This image stuck out to me as after reading all these remarks, it made me think about the importance of educating our communities about what mental health illness feels like for those who are struggling with it every day. This semester, I have received the opportunity to learn so much more about mental health conditions and how difficult it can be for indivisuals to overcome them. Reading these statements aloud made me realize how harmful they can be to people with mental health conditions. Overall, I believe that it is crucial to educate our communities and healthcare professionals more about mental health illnesses so that we can eliminate false stereotypes and narratives created about these indivisuals. Furthermore, by incorporating the HP lens into this education, we can work towards understanding how people are situated and constituted by their environments and why we should not simply judge others based on misinformation.

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The second artifact I have chosen for this concept is a video titled Overcoming Stigma which was posted by the World Health Organization. This video really stood out to me as it allows the viewer to hear firsthand the negative stigmatization faced by individuals who struggle with their mental health. Many of these individuals discussed the stigmatization they faced which included things like assumptions that they are weak and experiencing labelling by society. Overall, I think that this video helps capture the feelings and thoughts of the individuals who have to endure this stigmatization and helps those watching understand the consequences of contributing to these negative judgements and ideas.

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Overcoming stigma: more than my mental health diagnosis

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The first artifact I have chosen is a video that demonstrates how the family can assist mothers who are breastfeeding. This video in particular encompasses dads who are discussing what they do to help and contribute during breastfeeding to support their partners. I believe this video adds to my podcast and discussion about family and family-centred care. As a future nurse, providing family-centred care and helping other members of the family understand how they can contribute and assist the parent who is breastfeeding can be quite beneficial and help reduce the barriers to breastfeeding. Often many individuals do not wish to breastfeed due to the lack of support they are receiving from their loved ones. Hence, I believe this video demonstrates the importance of family and how barriers can be overcome through prioritizing family-centred care.

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The second artifact I have chosen is an image/statistic that demonstrates one of the barriers to breastfeeding. Often, many parents find themselves leaning away from breastfeeding practices due to social judgment. The statistic above shows that 60 percent of individuals do not feel confident breastfeeding and 43 percent try to avoid it. This image stuck out to me because I believe it demonstrates our need as a society to help create safer and more accepting environments for those who choose to breastfeed. We must respect each individual's decisions about their choice of feeding and not give judgemental stares or make judgmental remarks about someone who is simply trying to provide nutrition to their baby. It is also quite upsetting to think that some people choose not to breastfeed because of these judgemental behaviours from people they don't even know. Hence, as a future healthcare provider, I wish to do my best to educate individuals about the benefits of breastfeeding and also advocate for better breastfeeding environments such as advocating for more public breastfeeding facilities for parents.

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The first artifact I have chosen for this topic is a video titled Improving Indigenous Maternal Health. Something that stood out to me during this video was that after conducting various studies which included about 450,000 indigenous women, it was found that there is a 62 percent increased risk of developing mental health problems during pregnancy for these women. This statistic really puts into perspective the unfair treatment faced by this community during pregnancy. When an individual is pregnant, they go through an abundance of changes and they wish to seek guidance from their healthcare providers. It is unfortunate to think that Indigenous women do not have equal access to this guidance and resources during this time. It is important that as healthcare providers, we provide equal and fair care to all of our patients.

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The second artifact I have chosen for this topic is a piece of artwork that stood out to me. Throughout my nursing education, I have learned about many different traditional practices that indigenous communities practise during and after birth. However, in hospital settings, these communities are sometimes unable to practise their traditions. As a future healthcare provider, I believe that it is important for us to advocate for our Indigenous patients so that they can participate in their traditional practices after birth. Creating these safe and accepting environments for these communities to practise their traditions will overall improve their healthcare experiences. Often, Indigenous communities avoid healthcare settings as their practices and traditions and overlooked. Hence, I believe that it is important for us to create safe spaces for all communities coming into healthcare facilities.

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Bacciaglia, M., Tait Neufeld, H., Neiterman, E., Krishnan, A., Johnston, S., & Wright, K. (2023). Indigenous maternal health and health services within Canada: A scoping review. BMC Pregnancy and Childbirth, 23(1). https://doi.org/10.1186/s12884-023-05645-y

Corrigan, P. W., & Watson, A. C. (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry : Official Journal of the World Psychiatric Association (WPA), 1(1), 16–20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489832/

Dahlhamer, J. M., Galinsky, A. M., Joestl, S. S., & Ward, B. W. (2016). Barriers to Health Care Among Adults Identifying as Sexual Minorities: A US National Study. American Journal of Public Health, 106(6), 1116–1122. https://doi.org/10.2105/ajph.2016.303049

Dieterich, C. M., Felice, J. P., O’Sullivan, E., & Rasmussen, K. M. (2013). Breastfeeding and Health Outcomes for the Mother-Infant Dyad. Pediatric Clinics of North America, 60(1), 31–48. https://doi.org/10.1016/j.pcl.2012.09.010

Furness, B. W., Goldhammer, H., Montalvo, W., Gagnon, K., Bifulco, L., Lentine, D., & Anderson, D. (2020). Transforming Primary Care for Lesbian, Gay, Bisexual, and Transgender People: A Collaborative Quality Improvement Initiative. The Annals of Family Medicine, 18(4), 292–302. https://doi.org/10.1370/afm.2542

Hartley, S., Raphael, J., Lovell, K., & Berry, K. (2020). Effective nurse-patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance. International Journal of Nursing Studies, 102(1), 1–9. https://doi.org/10.1016/j.ijnurstu.2019.103490

Laranjeira, C. (2021). Therapeutic relationship in mental health nursing: A scoping review. European Psychiatry, 64(S1). https://doi.org/10.1192/j.eurpsy.2021.1935

Office of the Surgeon General (US), Centers for Disease Control and Prevention (US), & Office on Women's Health (US). (2011). Barriers to Breastfeeding in the United States. Nih.gov; Office of the Surgeon General (US). https://www.ncbi.nlm.nih.gov/books/NBK52688/

Pullen, R. L., & Mathias, T. (2010). Fostering Therapeutic nurse-patient Relationships. Nursing Made Incredibly Easy!, 8(3), 4. https://doi.org/10.1097/01.NME.0000371036.87494.11

Rössler, W. (2016). The stigma of mental disorders. EMBO Reports, 17(9), 1250–1253. https://doi.org/10.15252/embr.201643041

Sarmiento, I., Paredes-Solís, S., Morris, M., Pimentel, J., Cockcroft, A., & Andersson, N. (2020). Factors influencing maternal health in indigenous communities with presence of traditional midwifery in the Americas: protocol for a scoping review. BMJ Open, 10(10), e037922. https://doi.org/10.1136/bmjopen-2020-037922

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Birmingham Women's and Children's NHS Tru. (2022, May 11). What Is It Like To Be A Mental Health Nurse? Www.youtube.com. https://youtu.be/34DPAzumKFM?feature=shared

The Badger Herald. (2017, April 16). LGBTQ Health Issues. Www.youtube.com. https://youtu.be/H3Y8VDyovOE?feature=shared

USDA Food and Nutrition Service. (2019, June 4). Real Dads. Www.youtube.com. https://youtu.be/iX02pICiS50?feature=shared

Adobe Stock Images . (n.d.). Pregnant woman painting in aboriginal dot style Stock Vector. Adobe Stock. Retrieved April 5, 2024, from https://stock.adobe.com/images/pregnant-woman-painting-in-aboriginal-dot-style/433896218

Department of Mental Health and Substance Abuse Services. (n.d.). Reducing Stigma. Www.tn.gov. https://www.tn.gov/behavioral-health/stigma.html

Human Rights Watch. (2018, July 23). “You Don’t Want Second Best” | Anti-LGBT Discrimination in US Health Care. Human Rights Watch; Human Rights Watch. https://www.hrw.org/report/2018/07/23/you-dont-want-second-best/anti-lgbt-discrimination-us-health-care

Lansinoh UK. (2021, February 26). Social media’s impact on breastfeeding. Lansinoh-Uk. https://lansinoh.co.uk/blogs/breastfeeding-pumping/social-media-s-impact-on-breastfeeding

McMaster University Health Sciences. (2019, October 15). Improving Indigenous maternal health. Www.youtube.com. https://youtu.be/cJm_PcLWp_g?feature=shared

World Health Organization (WHO). (2022, April 12). Overcoming stigma: more than my mental health diagnosis. Www.youtube.com. https://youtu.be/oK7d0g02DQs?feature=shared