An 18-year-old male-bodied patient presents to the ED after an attempted suicide. The nurse completes the initial assessment and upon auscultation of the lungs notices that the patient is wearing a female undergarment. A flash of panic crosses the patient's face and they break out in a cold sweat. The nurse averts her eyes and continues the assessment without a word. Unfortunately, this is a scenario that plays out in the healthcare system all too often.
In the US, 5.6% of the general population identifies as lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ), according to Gallup's latest update, up from 4.5% in 2017. Individuals who identify as LGBTQ face many disparities of which nurses need to be aware. One driving factor is difficulty finding and accessing quality and timely healthcare. This can be due to the inability to find healthcare providers who provide nonjudgmental care or lack of health insurance. Patients who identify as transgender or who are of a racial and ethnic minority face the most disparity. When they're able to access care, patients who identify as LGBTQ may not feel comfortable disclosing sexual orientation and gender identity to healthcare providers.
This lack of comfort disclosing aspects of identity and personal habits may impede important health promotion conversations. For example, if the healthcare provider doesn't fully understand their needs, transgender patients may not receive proper screenings for health issues such as cancer. In practice, this can manifest as a transgender male not getting cervical cancer screenings or a transgender female not receiving screenings for prostate cancer. In addition, depression and suicide disproportionately affect LGBTQ youth who are more likely to be bullied at school, which can lead to suppression of their identity and unwillingness to seek proper care.
In this article, we discuss adding affirming care to nursing curricula, need-to-know terms and assessment techniques, and ways to bring inclusive and affirming care to the bedside to close the disparities gap for LGBTQ patients.
Enhancing nursing education
Caring for LGBTQ patients can prove challenging if the nurse is unsure of how to approach the patient holistically. Nurse unpreparedness to care for LGBTQ patients can impede an accurate physical assessment and can be intensely distressing for the patient. There are many confounding factors that may affect nurses' ability to provide inclusive care for LGBTQ patients. One reason is lack of intentional, standardized inclusion of LGBTQ care in nursing curricula and inadequate preparation for nurses already in practice.
Although nurses historically hold values of holistic care and social justice, only recently have nurses taken a clear stance on LGBTQ issues at a national level. In a review of literature from 2005 to 2009, only 0.16% of nursing articles focused on LGBTQ health, many of which were authored outside of the US. However, in recent years nursing science and education have looked toward an increased awareness and intentional inclusion of LGBTQ health in nursing curricula and practice. Despite the potential for positive change, a disconnect remains between inclusion of LGBTQ issues in nursing curricula and nurses' ability to provide inclusive and affirming care in practice.
LGBTQ patients, particularly those who are transgender, can face significant discrimination by the healthcare community. In a 2017 study by Rowe and colleagues, almost a third of transgender patients reported delaying contact with healthcare providers due to previous experiences of harassment and violence in the healthcare setting. Health concerns specific to transgender patients are underrepresented in nursing education and on-the-job training for nurses already in practice. A systematic review examining the effects of curricula and training for both healthcare students and providers found that although LGB health was becoming a part of the curriculum, transgender health wasn't.
Health educators may feel overwhelmed at curricular changes to include topics related to LGBTQ health and may not consider themselves content experts on the subject or have institutional support for this change. However, all nurses can be prepared to provide affirming care, which is a step toward building safer, more inclusive practice. Affirming care recognizes the significant impact of sexual/gender minority status on a person's health.
The health assessment course is a natural place to begin discussions of LGBTQ affirming care; for example, when teaching the sexual orientation and gender identity (SO/GI) assessment. SO/GI is a basic component of the electronic medical record and a simple way to introduce affirming language to nursing students. From an assessment standpoint, educators may consider including assessment of gender conforming or nonconforming clothing and whether the patient presents socially in a way that aligns with their gender identity. This is also a time to discuss appropriate vocabulary depending on the patient's preference.
The fundamentals course is another opportunity to discuss affirming care; for example, when discussing bowel and bladder elimination. It's important to discuss that a transgender patient may still have organs present that don't align with their reported gender. Nurses should be sensitive to this and ask patients which urinary collection device they prefer. For example, a transgender male may not prefer a urinal and may instead prefer a bedside commode or bedpan while a transgender female may prefer to use a urinal.
Addressing health promotion in all courses throughout the curriculum allows for opportunities to discuss preventive health counseling for LGBTQ individuals; for example, how SO/GI data can inform the healthcare provider of which patient screenings are appropriate. Reproduction and sexuality courses provide a forum for nursing faculty to include discussions of sexual risk faced by LGBTQ individuals and other issues such as childbearing and breastfeeding.
Psychiatric mental health or population health nursing courses provide another opportunity to discuss the stress of discrimination for individuals whose gender identity doesn't align with their assigned sex at birth. Candid discussions about suicide risk among LGBTQ individuals, particularly transgender patients, may occur when examining gender identity and sexual orientation in this context, along with self-reflection about how to care for LGBTQ patients without further contributing to gender dysphoria.
In short, there are many opportunities to incorporate affirming care into the curricula. Nursing faculty may need training to remain current on LGBTQ care topics to educate future nurses so affirming care continues to the bedside.
Knowing the vocabulary
There are many unique terms that are specific to the LGBTQ community. Nurses who aren't familiar with these terms can easily feel intimidated to use them, mostly in fear of making the patient uncomfortable. Proper use of these terms is a way for nurses to provide affirming care.
A basic term is assigned sex at birth, which is generally listed as male or female. Gender identity describes a person's sense of maleness or femaleness. Two umbrella terms to know are gender nonconforming or genderqueer, where the patient doesn't identify with traditional gender norms of male or female. Because gender identity can be viewed as a spectrum, there are numerous terms with which a patient may identify themselves. It's often best to ask the patient how they would describe their gender identity. If a term is unclear or unfamiliar, ask for a definition.
Assessment of sexual orientation is also important. Sexual orientation refers to whom the person is romantically and sexually attracted. For example, patients who are heterosexual are attracted to the opposite sex, patients who are bisexual are attracted to both males and females, and patients who are homosexual are attracted to the same sex. These definitions are the most basic and familiar terms, but like gender identity, patients may use less familiar terms to describe their sexual orientation, including pansexual, polysexual, or asexual. Again, the nurse may ask the patient how they describe their sexual orientation and clarify any unfamiliar terms.
Transgender is the term used when a person's assigned sex at birth is incongruent with their gender identity. This has no bearing on sexual orientation. Nurses may hear this abbreviated as trans. Cisgender means a person's gender identity and assigned sex are the same. For example, a person whose sex assigned at birth is female who identifies as a female is cisgender. Another important term is gender dysphoria, which is psychological stress related to having a gender identity that differs from one's assigned sex at birth. Not all transgender individuals experience gender dysphoria. In practice, gender dysphoria may be addressed through mental health support or by making changes to the body to better align with the patient's gender identity.
Learning to incorporate these terms in your everyday assessments can feel unfamiliar and challenging. It will take practice; however, it's an important component of providing affirming care. Use of appropriate terminology and normalizing assessment of SO/GI can decrease stress, build rapport, and increase safety for patients identifying as LGBTQ. Assessment and discussion of SO/GI requires cultural humility on behalf of the nurse-an honest recognition of the power relationship between nurse and patient and maintenance of an open, reflective, and individualized approach to each person. You may be afraid that you'll misspeak and offend your patient; however, being treated with dignity, even if there are missteps in terminology, is far superior to having significant aspects of one's identity ignored. Often, being open to feedback about the proper use of terms and preferred pronouns is a chance to build a trusting relationship with patients and increase lines of communication.
Adapting assessment techniques
Providing affirming care to individuals who identify as LGBTQ begins with the collection of SO/GI data. These data set the stage for the nurse to have open communication with the patient. In 2015, the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology mandated that SO/GI data become a part of the demographic information obtained on admission of every patient. In addition to setting a positive precedent for communication, the SO/GI assessment can become a template that informs the patient's health promotion needs. For example, if a transgender female still has her prostate, then prostate-specific antigen evaluation is warranted after age 50.
Studies have found that a lack of education for our current and future healthcare workers on the importance of and know-how for collecting SO/GI data results in a deficiency in data collection. However, nurses would likely be surprised by the willingness of patients to share information about sexual identity. There seems to be a disconnect between healthcare workers and patients regarding the collection of SO/GI data. Maragh-Bass and colleagues found that healthcare workers felt that collecting SO/GI data would offend patients, whereas patients said they wouldn't be offended by the collection of SO/GI data. This disconnect can impede gathering this information and opening communication with patients.
Nurses can use the patient's SO/GI information to conduct a review of systems and assess social and lifestyle practices. For example, one important aspect in providing affirming care for LGBTQ patients is the organ inventory. When assessing a patient who identifies as anything other than cisgender, you might ask the patient, "Have you had any surgical procedures or taken any medications to change your body to align with your gender?"
Some transgender patients may have had what's known colloquially as top surgery or bottom surgery, meaning surgery to alter the chest or genitals to match their gender identity. Some patients may have taken hormones to change their body, whereas others choose only social expressions of gender such as changes in hairstyle and clothing. Some patients choose to present their gender differently depending on the social situation they're in at the time. Any combination of these options may be possible.
Once you gather this information, you can conduct the organ inventory. Depending on the setting, you may go through a checklist of organs or simply ask, "Do you still have all of your organs that were present at birth?" To foster patient comfort, you may qualify this assessment with, "It's important that we know what organs are present so we can conduct any necessary health screenings and discuss your health promotion activities. I'll read a list of organs to you now and let me know if you have had any surgeries related to them."
The reproduction and sexuality assessment may also need to be adapted; for example, to consider menstrual history in transgender males. Some transgender males suppress the menstrual cycle, whereas others don't. Regardless, nurses should consider this as part of the assessment. When assessing LGBTQ patients' sexual practices, approach it like you would any other sexual history taking, maintaining an open and unbiased attitude. Often, open-ended questions may be more appropriate than simply asking, "Are you sexually active?" For example, "Are you in a relationship and, if so, how do you express physical intimacy?" This allows the patient to guide the discussion while you listen for opportunities to promote health and safe sex practices.
Bringing it all to the bedside
When providing inclusive and affirming care for LGBTQ patients, it's most important to remember that assuming a person's preferred gender isn't appropriate. The best start to any conversation is asking the patient how they would like to be addressed and their preferred pronouns. Simplify SO/GI questions by saying, "I ask all patients these questions." Just as you would in any conversation, apologize if you make a mistake. Questions about the patient's sex assigned at birth and gender identity can be asked together: "Can you tell me your assigned sex at birth? Is this how you identify?" Sexual orientation can be inquired about by asking if the patient is attracted to "males, females, both, or neither." Shying away from these questions can limit your ability to gain important knowledge about the patient's health needs.
Let's revisit the scenario of the patient in the ED. How could this have gone better? One simple way would be for the nurse to communicate with the patient before beginning the assessment. An 18-year-old male-bodied patient presents to the ED after an attempted suicide. The nurse begins the interview by asking the patient how they would like to be addressed. The patient states that her pronouns are she/her/hers. Once this is known, the nurse states, "I ask all of my patients the following questions." Collection of the patient's sex at birth and SO/GI data continues. In the electronic medical record, the nurse notes that this patient identifies as a transgender female and wishes to notify those who care for her. The nurse continues with the physical assessment and, upon auscultation of the lungs, notices that the patient is wearing a female undergarment. The patient is relaxed, and the nurse asks the patient if the undergarment can be moved to complete the assessment. Both the patient and the nurse are comfortable, and the patient has a sense of dignity and transparency.
Stepping up
As nurses, we must step up and be the leaders in our work settings and in nursing education for providing inclusive and affirming care. Ask fellow nurses if they've collected SO/GI data and help them become comfortable with the process. Ensure that other healthcare providers are aware of the SO/GI data and are using the data to guide treatment plans. Learning the process of affirming care for LGBTQ patients takes practice. One way to learn is to ask managers for training in this area. There are also many free continuing-education resources through organizations such as the Fenway Institute. Normalizing these assessments as routine will help us provide dignified and safe patient care.
cheat sheet
did you know?
You may see LGBTQ+. What does the + mean? It stands for all other gender identities and sexual orientations that aren't represented by the five main initials.
on the web
INSTRUCTIONS Providing affirming care for LGBTQ patients
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