An estimated 5.6% of people in the US identify as Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, Intersex, and Asexual (LGBTQIA+; see Definition of terms).1 Despite progress in the social recognition of these populations, intentional and unintentional bias remains in the healthcare setting.
In 2018, the American Nurses' Association2 wrote: "[we support] efforts to defend and protect the human and civil rights of all members of the LGBTQIA+ populations." In addition, the US Department of Health and Human Services set goals to reduce bullying, drug and alcohol abuse, and suicidal thoughts. They also plan to increase surveys that include sexual orientation and gender identity in their 10-year plan, Healthy People 2030.3 This article discusses how nurses can help achieve these goals.
Health disparities
Individuals who identify as LGBTQIA+ are more likely to delay or avoid necessary medical care than individuals who identify as heterosexual. In addition, socioeconomic factors in the LGBTQIA+ population in the US may limit access to healthcare. Of this population, 25% have a yearly income of less than $24,000, 27% report food insecurity, and 15% lack health insurance.4 In 2019, 48% of patients who identify as transgender postponed care due to the cost of treatment.5. These barriers can delay access to healthcare and may worsen health outcomes.
Individuals who identify as LGBTQIA+ report higher incidences of depression, anxiety, eating disorders, suicidality, substance abuse, and certain cancers.6 Furthermore, individuals who identify as LGBTQIA+ tend to have higher rates of anal cancer, asthma, cardiovascular disease, obesity, substance abuse, and cigarette smoking.7-14 Youth who identify as LGBTQIA+ are up to eight times more likely to experience suicidal ideation than their heterosexual and cisgender counterparts.15-17 Older adults who identify as LGBTQIA+ have reported discrimination throughout their lifetime, associated with higher rates of substance use, depression, and cardiovascular disease.18
Unfortunately, a lack of trust in the healthcare system, denial of care, discrimination, and violence discourage individuals who identify as LGBTQIA+ from seeking treatment.19 A 2020 study from the Center for American Progress20 reported that 15% of patients who identify as LGBTQIA+ postponed medical care due to discrimination. For example, an Act in Arkansas passed in 2021 allows clinicians to refuse to provide medical treatment because of religious or moral objections.21
Creating a welcoming environment
All persons deserve a safe, welcoming environment to receive healthcare. It is the responsibility of all team members to provide this; however, nurses are often the strongest advocates for patients.
Healthcare organizations can incorporate cultural humility, using preferred pronouns, creating a visual welcome, having gender-neutral bathrooms, and LGBTQIA+ available referrals (see Keys to inclusion). Furthermore, these can help create a safe and friendly welcome for all patients.
Cultural humility
Cultural humility is not traditional cultural competence; it is a lifelong process of self-exploration and self-critique combined with a willingness to learn from others.18 This involves examining one's cultural identity while honoring another's beliefs, customs, and values. Cultural competence suggests a top-down approach where the clinician is the expert, while cultural humility acknowledges the patient as the expert.22
Cultural competence is also problematic because it implies that nurses are implicitly incompetent if they are not culturally competent.23 Cultural humility eliminates this false dichotomy because it is an ongoing process never mastered.
Keys to cultural humility include being self-aware; self-reflective; inquisitive; open to lifelong learning; egoless; and mindful of others' backgrounds, preferences, and needs.24 Cultural humility also acknowledges how oppression and discrimination impact the lived experience and outcomes for groups of individuals and asks us to consider how institutions may perpetuate or positively alter this pattern.25 Nurses who practice cultural humility are more likely to advocate for and empower patients who identify as LGBTQIA+ and their families.
"Do Ask, Do Tell"
People who identify as transgender and agender may be subject to others trying to "read" or "figure out" their gender, and to bias and discrimination. In addition, the experience of being misgendered can be hurtful, and the incident of accidental misgendering can be embarrassing for both parties.26
When one does not know the gender of a person they refer to, they often use gender-neutral pronouns, such as "Someone left their cell phone in the exam room. I hope we can find them before they leave." Although the English language lacks a gender-neutral singular pronoun, the plural "they" can also refer to an individual whose gender identity is nonbinary or unknown.27
When entering an exam room, nurses can identify themselves with their preferred personal pronouns. For example, say, "Hello, I am your nurse [insert name]. My pronouns are "she" and "her." How may I address you?" Identifying personal pronouns during patient introduction invites the patient to offer theirs. This introduction creates a safe space, builds rapport, and allows the nurse to clarify if the patient's information and the records do not match. For instance, if there has been a change in gender identity since the patient's last visit.
Other inclusive steps include having pronouns listed on all personnel name tags and having patients' preferred pronouns listed in the electronic health record.
Visual welcome
Patients commonly choose a healthcare practice or facility based on online reviews. An active welcome can be demonstrated by listing if a practice specializes in LGBTQIA+ care and including clinicians' preferred pronouns. The Gay and Lesbian Medical Association29 provides a free, online LGBTQIA+ Healthcare Directory for finding LGBTQ+-affirming healthcare providers (HCPs) in the US and Canada. Another important resource is the Human Rights Campaign's Healthcare Equality Index (HEI).26 The HEI is a national LGBTQIA+ benchmarking tool that evaluates healthcare facilities' policies and practices regarding the equity and inclusion of LGBTQIA+ patients, visitors, and employees. The HEI 2022 evaluates more than 2,200 healthcare facilities nationwide.
Most healthcare practices and facilities have an electronic or paper "face sheet" for their patients, including demographic and insurance information. Face sheets commonly list a patient's gender, but both fields are equally important in addressing an individual's healthcare needs. Patients should never have to choose "other" to describe themselves.28 Rather, a blank space for patients to enter their response allows them to identify more comfortably. Having a patient's preferred pronouns, sexual identity, and sexual orientation information readily available, and reviewing this before interacting with them, can avoid uncomfortable interactions that may prevent a patient from returning for care.
It is essential to use appropriate language when addressing patients and their partners. For example, providing an option for relationship status on intake forms can help identify whether a patient prefers the term partner, spouse, husband, or wife.
It can be difficult not knowing the right words at first, and it takes time for anyone to learn a new concept. Therefore, if one makes a mistake, it is important to apologize quickly and move on. Being willing to acknowledge an error and correct oneself shows a patient they are valued, which is a significant step in establishing good rapport.
Providing literature in the healthcare setting that depicts the LGBTQIA+ community sends a welcoming message. Pamphlets of services with pictures of same-sex couples or a family with same-sex parents should be available. Brochures and other available reading material should include topics relevant to LGBTQIA+ patients and general brochures. Recognize periods of observation, such as World AIDS Day, National Transgender Day of Remembrance, and Pride month (see Helpful links).29 LGBTQIA+ relevant magazines, posters, and information about local LGBTQIA+ resources should be available. Post a confidentiality and nondiscrimination statement in a readily visible location.30
Accessibility
Public restroom experiences for patients who are LGBTQIA+ are more likely to be positive if gender-neutral or single-stall restrooms are available. For example, in a study on LGBTQIA+ youths' bathroom experiences and preferences, the respondents reported having more positive experiences with gender-neutral or single-stall restrooms and feeling uncomfortable, unsafe, or frightened with traditional men's and women's facilities.31 Public restrooms that do not require patients to identify their gender minimize a healthcare barrier. Single occupancy or stalls with floor-to-ceiling doors allow for more privacy.
Referrals
One healthcare practice or facility may not offer all the health services that an LGBTQIA+ patient may require. Therefore, maintaining a separate document for LGBTQIA+-qualified referrals in various service areas can be helpful.32 For example, an HCP may need to refer a patient to endocrinology, psychiatry, or surgery for a gender-affirming mastectomy and hysterectomy. Having a list of HCPs known to be inclusive of LGBTQIA+ patients and provide appropriate services saves the patient time and effort and reduces potential rejection.
Summary
LGBTQIA+ populations experience considerable health disparities. Therefore, patients need to feel comfortable when they need healthcare and safe when sharing personal information. The steps outlined in this article can reduce fear and improve patient satisfaction and outcomes.
Keys to inclusion34
* Ask about and use the patient's preferred pronouns and introduce yourself with your own.
* Use gender-neutral terminology when obtaining a health history-say "spouse" instead of husband or wife; "partner" instead of boyfriend or girlfriend."
* Most documents include titles such as "Mr.," "Mrs.," "Miss," and "Ms." Adding "Mx." as a gender-neutral honorific allows an option for people who identify as nonbinary, gender fluid, and gender nonconforming.
* Provide gender-neutral bathrooms.
* Prepare a list of LGBTQIA+-friendly referrals.
Helpful Links:
GLMA Healthcare Directory Listing: http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageId=943&grandparentID=
Healthcare Quality Index: http://www.hrc.org/resources/healthcare-equality-index
LGBTQ Holidays and Commemorations: http://www.lgbtqnation.com/2018/10/heres-complete-list-lgbtq-holidays-commemorat
REFERENCES