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MULTIPLE STUDIES SUPPORT evidence that gay, lesbian, bisexual, transgender/transsexual, queer, and/or questioning (GLBTQ) individuals don't feel comfortable providing information to healthcare professionals because of previous discrimination.1-3 Midlife and older GLBTQ individuals, like heterosexuals in the same age group, are in a stage in which they need to be tested for diseases (such as cervical, colon, and breast cancer) that tend to appear later in life but are detectible early through screening. Many GLBTQ individuals avoid regular screening because of previous negative experiences with the healthcare system.4
GLBTQ individuals, or sexual minorities, describe their experiences as psychologically stressful or mentally uncomfortable or judgmental because of their sexual orientation or gender identity. Researchers are seeing a higher incidence of disease in individuals who don't take part in early preventive care.5
A clear understanding of each patient's needs is critical for quality patient care. This article emphasizes the importance of knowing a patient's sexual orientation and gender identity in order to provide comprehensive and sensitive nursing care. It will review some of the key issues that sexual minorities encounter in the healthcare setting and provide guidance on assessing GLBTQ patients.
Knowing the GLBTQ patient's sexual orientation enables a better understanding of unique life perspectives and daily challenges that may contribute to health problems. These experiences may have had a negative impact on the patient's interactions with healthcare providers. (See Coming to terms for definitions of GLBTQ terminology.)
Additionally, healthcare professionals must be aware of specific risk factors that GLBTQ patients encounter because of their sexual identity. Examples include both mental health issues and physical problems, such as hypertension that arises after years of exposure to high levels of psychological stress.
Someone living in a stressful environment produces chronic, dangerously high levels of cortisol that negatively impacts the individual both mentally and physically. Chronic and excessive glucocorticoid activity is such an area of concern that current research is focusing on the possibility of using glucocorticoid antagonists to compete with cortisol in clinical practice when treating patients with chronic, excessive, internal stress.6
Prejudices or preconceived notions and/or judgments and narrow belief systems contribute to a negative environment. Providing all patients with encouraging, positive thoughts and attitudes, understanding, and empathy can help increase levels of endorphins, dopamine, and immune cells in the bloodstream.7
The prevalence of cardiovascular disease is another example because the rate of smoking in GLBTQ individuals is 38% to 200% higher than in non-GLBTQ individuals.8 Also, obesity, dyslipidemia, and impaired glucose tolerance are common in the lesbian population.9 Some homosexual men experience health problems from using club drugs or anabolic steroids, and from HIV infection.10
A few characteristics related to chronic psychological stress are common among most members of sexual minorities. For most homosexual people, being attracted to someone of the opposite sex is as foreign to them as same-sex attraction is to a heterosexual person. One interesting characteristic that most sexual minorities have in common is that they all possess varying amounts of internalized homophobia.4
Surprised to hear that individuals can actually internalize fear (and possibly hatred) of what and who they are? Consider that GLBTQ people grow up in a society where heterosexuality is the norm. Many discover their "otherness" during their teenage years, at a time in their development when the very thing they want most is to fit in. They're likely to receive many of the same messages as heterosexuals regarding the unacceptability of being gay. Consequently, most members of sexual minorities experience a period of denial and/or dislike for their sexual identity and for themselves directly. It's no coincidence that one in three attempted adolescent suicides is committed by a GLBTQ teen.11
One important factor to consider when caring for a GLBTQ patient is age. Midlife gay or lesbian patients have probably had a much different life experience than those in their teens, 20s, and 30s. Lesbians in their 50s today would have been teenagers when the women's movement was gaining momentum in the United States. Lesbians currently in their 60s and older lived much of their lives before the events that took place at Stonewall in 1969.
Stonewall was the name of a gay bar that was raided by police in New York City in 1969. Gay men were incarcerated under the guise of indecency. After this event, lesbians and gay men took to the streets and publicly marched, initiating the gay rights movement in the United States.12
Older lesbian women tend to be the most closeted and would be more inclined to hide their sexual orientation from a nurse if they didn't feel completely safe disclosing this important aspect of their lives.13 This closeted behavior may be particularly risky at this stage of life when the need for healthcare typically increases.
A hierarchy exists within the sexual minority subculture. An example of angst that exists within the transgender and queer community is frustration over the implied need to fit into any category.
Another variable that will alter the experiences among GLBTQ patients is where they grew up. Those who spent their adolescence and early adulthood in an urban setting may have lived in a more tolerant community where people from diverse groups and/or subcultures are easily accepted. Political events that take place to further the advancement of sexual minority rights usually occur in prominent coastal and urban centers in the United States. In contrast, GLBTQ individuals who spent their formative years in a conservative suburb or isolated rural area may have faced daily challenges in their environment that urban GLBTQ individuals may have had fewer occasions to encounter. It's for those reasons that many of them leave family and friends to live in a community where they feel accepted.14,15
Still today, in most rural areas and some suburban areas, the only places GLBTQ people can go to relieve the sense of isolation are online websites or a gay/lesbian bar. The gay/lesbian bar has and still does take on an important function for individuals who find themselves isolated from other sexual minorities. This may contribute to the reported higher-than-average consumption of alcohol among this group.15
Another concept to consider is that of "coming out." The age at which GLBTQ individuals "come out" to themselves and then to others differs widely. The level to which an individual is "out" to friends, family, coworkers, and the public in general also influences the comfort level at which he or she may be "out" to a healthcare provider. For example, individuals may only be "out" to those they can trust within their own inner circle. At all other times, sexual identity is kept private. Maintaining constant mental vigilance about whether to be "out" during each social encounter is a significant source of stress, frustration, and fatigue.16
Homophobia in healthcare is a reality. A 1998 survey of nursing students showed that 8% to 12% "despised" lesbian, gay, and bisexual people; 5% to 12% found them "disgusting"; and 40% to 43% thought they should keep their sexuality private. These individuals who were students in the 1990s are now practicing nurses.17
Federal statutes prohibit discrimination on the basis of race, color, national origin, age, disability, and sex in virtually all hospitals nationwide. Federal laws, however, don't specifically provide blanket protection against discrimination for all hospitals based on sexual orientation and gender.2 The laws that are in place contain qualifiers; for example, they may pertain only to facilities that receive federal dollars for Medicare and Medicaid patients or to facilities that receive money from specific federal grants.
In addition, many same-sex couples continue to experience discrimination while trying to acquire care or visit their loved one. This includes not being able to visit or attend to a loved one as he or she lies uncommunicative or dying. To avoid this, GLBTQ individuals must thoroughly plan ahead, using expensive legal counsel, and provide documentation to ensure that life partners can remain by their side in the event of an illness or injury that results in hospitalization.16
The Joint Commission provides practical advice to help clinicians incorporate nonjudgmental language into the healthcare environment. Follow these tips to provide a safe, healing environment for GLBTQ patients.
Create a welcoming environment. Display a sign or poster in waiting areas that indicates patients are in a nondiscriminatory safe zone and that all individuals are welcome to receive care at the facility. This will help patients relax and relieve their fears about a negative reception.4
It's important that the staff's attitudes reflect the message that the poster communicates. If patients have another individual with them, make sure to ask if they'd like that person to accompany them as they're receiving care.4
Become familiar with language that doesn't assume heterosexuality. Consider role-playing with a colleague before caring for a GLBTQ patient. How a question is phrased can make all the difference to patients by indicating how accepting the caregiver is about their sexual orientation. For example, instead of asking if they're married, ask who they consider to be their family.4
Refrain from making assumptions about sexual orientation or gender identity based on how a person looks or dresses. If all members of the health team commit to using language that's universally appropriate, no one will have to "guess" what language is correct to use with each patient. Using terms like "your partner" or "your significant other" is appropriate no matter what the patient's sexual orientation.4
Facilitate openness and honesty from patients by using forms that contain inclusive, gender-neutral language. For example, in the category regarding relationship status on a nursing admission assessment form, provide the word partnered along with married, single, or divorced, the traditional choices. Reflect in conversation the terms patients choose when describing their sexual orientation, gender identity, and relationships. For example, pay attention to the gender-specific pronoun the patient may use when describing his or her partner. It's okay to directly ask patients the pronoun they prefer for themselves and their partner. Never make any assumptions and fill in an answer for them. Don't assign a label to patients that they haven't revealed themselves.4
Provide specific healthcare information and guidance for subgroups of the GLBTQ community. Become familiar with community and online resources available for specific healthcare needs such as Healthy People 2020, a publication from the U.S. Department of Health and Human Services that contains objectives to improve the health, safety, and well-being of GLBTQ individuals (see GLBTQ resources). Stay up-to-date with this information to share it with patients and make informed referrals.4
Ask sexual orientation and gender identity questions. Include these questions, both on the nursing admission assessment form and as part of the health history. For example, regarding sexual orientation, provide a question such as, "Do you consider yourself to be: Straight (heterosexual), gay or lesbian, or bisexual?" When asking about sexual behavior, ask, "In the past year, with whom have you had sex? Men only, women only, both men and women, or I haven't had sex in the past year?"4 Use a matter-of-fact tone of voice and avoid expressing surprise at any answer the patient offers.
To assess gender identity, ask, "What sex were you assigned at birth? Male or female?" followed by "What's your gender?" Appropriate choices to offer include male, female, transgender-male to female, transgender-female to male, or transgender (don't identify as male or female).4
Nurses are in a privileged position to be able to provide an open, receptive, nonjudgmental, caring environment for all patients. Doing so promotes a positive difference in the health of GLBTQ patients.
Gay: An attraction and/or behavior focused exclusively or mainly on members of the same sex or gender identity; a personal or social identity based on one's same-sex attractions and membership in a sexual-minority community.
Lesbian: As an adjective, used to refer to female same-sex attraction and sexual behavior; as a noun, used as a sexual orientation identity label by women whose sexual attractions and behaviors are exclusively or mainly directed to other women.
Bisexual: One whose sexual or romantic attractions and behaviors are directed at both sexes to a significant degree.
Transgender: This term doesn't imply a medical or psychological description; rather, it describes a variety of cross-gender behaviors and identities. Avoid using this term as a noun. A person is not "a transgender;" he or she may be a transgender person.
Transsexual: A medical term applied to individuals who seek hormonal and (often, but not always) surgical treatment to modify their bodies so they may live full time as members of the sex category different from their birth-assigned sex. Some individuals who have completed their medical transition prefer not to use this term. Avoid using this term as a noun. A person is not "a transsexual"; he or she may be a transsexual person.
Queer: This term has been reclaimed by some members of the sexual minority population. This reclamation represents what some describe as genderqueer. This is a person who defies or doesn't accept stereotypical gender roles and may choose to not be identified as lesbian or gay. They may or may not seek hormonal or surgical treatments.
Coming out: A figure of speech that refers to lesbian, gay, bisexual, and transgender people disclosing their sexual orientation and/or gender identity to others.
These resources can help you better understand your GLBTQ patients.
* The Gay and Lesbian Medical Association's Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients http://allies.sdes.ucf.edu/docs/glma-guidelines.pdf
* Healthy People 2020: Lesbian, Gay, Bisexual, and Transgender Health http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25
* Make Room for All: Diversity, Cultural Competence and Discrimination in an Aging America (National Gay and Lesbian Task Force) http://www.thetaskforce.org/reports_and_research/make_room_for_all
* Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE) http://www.sageusa.org
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2. Center of Excellence for Transgender Health. Transgender terminology. http://transhealth.ucsf.edu/trans?page=protocol-terminology. [Context Link]
3. Fenge LA, Hicks C. Hidden lives: the importance of recognizing the needs and experiences of older lesbians and gay men within healthcare practice. Diversity in Health and Care. 2011;8(3):147-154. [Context Link]
4. The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. Oak Brook, IL: The Joint Commission; 2011. [Context Link]
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12. Galas JC. Gay Rights. San Diego, CA: LucentBooks; 1996. [Context Link]
13. Services and Advocacy for Gay, Lesbian, Bisexual, and Transgender Elders. Improving the Lives of LGBT Older Adults. http://www.lgbtmap.org/policy-and-issue-analysis/improving-the-lives-of-lgbt-old. [Context Link]
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