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Delivering Culturally Sensitive Care to LGBTQI Patients
Delivering Culturally Sensitive Care to LGBTQI Patients Jessica Landry, DNP, FNP-BC ABSTRACT
Many health care providers are uncomfortable having conversations with patients about their sexual identity or sexual behaviors. Avoiding this discomfort is causing a serious threat to the mental and physical health of Americans, particularly those in the lesbian, gay, bisexual, transgender, questioning, or intersex (LGBTQI) community. The health-related disparities among LGBTQI patients range from bullying and physical assault to refusal of health care and housing. Many individuals choose not to seek health care due of fear of being judged, marginalized, or abused. This article focuses on the many disparities faced by the LGBTQI community and describes how simple changes in the practices of health care providers can potentially improve their health outcomes. Keywords: care of LGBTQI patient, cultural sensitivity, gender fluidity, gender identity, LGBTQI health disparities Ó 2016 Elsevier Inc. All rights reserved.
THE STAGGERING STATISTICS
H
ealth care professionals strive to provide culturally sensitive and high-quality mental and physical health care to children and adult patients, regardless of their age, race, religion, sexual practices, or personal belief system. Conveying a sense of understanding of a patient’s culture and a nonjudgmental attitude toward their behaviors may be a means to “meet patients where they are,” and lay a foundation for a trusting relationship that can lead to improved health outcomes. According to the Gay Lesbian Straight Educational Network, 74.1% of lesbian, gay, bisexual, transgender, questioning, or intersex (LGBTQI) students are harassed or threatened in American schools.1 Of the 7,898 LGBTQI students involved in the study, 5,852 were subjected to derogatory remarks referencing their sexuality. Ninety percent of these students indicated feelings of distress during their time on campus, and 30.3% missed at least 1 day of school due to harassment or bullying.1 Grant and colleagues2 studied 6,400 transgender and gender nonconforming people in kindergarten through grade 12 and found that 78% experienced harassment, 35% suffered physical assault, 12%
www.npjournal.org
were victimized by sexual violence, and 15% discerned a sense of threat severe enough to quit school completely. The discrimination of transgender persons continued into the workplace, with 90% of those surveyed reporting incidents of harassment and mistreatment. Nineteen percent of the economically disadvantaged and less educated individuals in this group reported being refused home rental or apartment leasing contracts, found themselves homeless at some point during their life, or experienced outright refusal of health care due to their sexual orientation.2 Of this disadvantaged population, 55% of those who sought asylum in homeless shelters reported being harassed by shelter employees, 29% were outright refused entry, and 22% were sexually assaulted by either shelter residents or staff. The United States Centers for Disease Control and Prevention (CDC) named suicide as the second leading cause of death among people between age 10-24 years in the United States between 1994 and 2012, with 5,178 of these deaths in 2012 alone.3 The CDC also reported that, among students attending American schools and enrolled in grades 9-12, 14.8% of heterosexual students attempted suicide compared The Journal for Nurse Practitioners - JNP
1
VIGNETTE A family nurse practitioner (FNP) in a busy emergency department read the triage note of a 12-year-old boy that stated he had “tried to tie a belt around his neck to hang himself.” The medical history exhibited no significant findings, as he had no physical or mental illnesses. The FNP introduced herself and began small talk for a few minutes, but noted only silence from the young patient. She began asking him questions about why he had tried to hurt himself, and he refused to answer. She asked him questions about his school, grades, did he have “girl trouble,” was his teacher unkind or unfair? He just shook his head “no,” with his eyes turned down. She continued gently questioning him to determine if he was experiencing physical, sexual abuse, verbal abuse, parental neglect, or bullying from others. Again, he just shook his head and avoided eye contact with her consistently. She proceeded to the examination portion of the visit and the only abnormal finding was redness around his neck from the belt. She ordered a soft tissue X-ray of his neck and left the room to question his parents. They reported that he had many friends, achieved honor roll several times, and his teacher had positive reports of behavior and academic performance; yet, in spite of all the positive aspects of his life, he had begun to express more sadness over the last year and this concerned them. The FNP decided she would approach him once more, this time without his parents, nurse, or social worker present. She sat on the side of his bed and touched his arm, she asked him to please make eye contact with her. He appeared defeated and worn, much too young to wear such an expression. She asked him directly again, “Why did you try to hurt yourself? You have much goodness in your life; you are handsome, smart, and your friends, teacher, and parents love you and are concerned about you. I want to understand why you want to die.” He looked the FNP squarely and stated, “Because I am a girl and no one understands that.” When she tried to respond she realized she was afraid she would use the wrong words and possibly make him feel worse. She had been preparing to have him committed to a psychiatric facility, and she was concerned he would assume he was being committed for his gender identity and not his suicide attempt. The FNP attempted to explain this, she felt she was unclear. He was discharged to a psychiatric facility from which he was shortly discharged. Four months later he attempted suicide again, this time he was successful.
with 42.8% of gay, lesbian, or bisexual students within the 12-month period prior to being surveyed.4 The survey further reported that, compared 2
The Journal for Nurse Practitioners - JNP
with heterosexual students, nearly twice as many gay, lesbian, and bisexual students were threatened or injured with a weapon, such as a gun, knife, or club, on school grounds at least once. HEALTH DISPARITIES IN THE LGBTQI COMMUNITY
The CDC reported that gay, lesbian, bisexual, and students are 30.5% more likely to feel sad or hopeless, 13.6% are more likely to be victims of sexual violence, 23% are more likely to attempt suicide, 15.4% are more likely to use marijuana, and twice as likely to experiment with hallucinogenic drugs as their heterosexual peers at the same age.5 The survey also revealed that students who questioned their sexual identity were 14.9% more likely to suffer from physical violence during dating and 9.5% more likely to use or abuse cocaine than their heterosexual peers. The responsibility for the health of sexual minority students has largely been placed on schools, which often play very limited role in educating students on sexual and mental health. The School Health Policies and Practice Study showed that about half of American high schools discuss sexual identity or orientation as part of the curriculum at any grade level.5 The study further noted that only 34.6% of these high schools provide health care specifically to LGBTQI students. Many psychological textbooks and current literature still refer to those questioning their gender or displaying gender-nonconforming traits as have a gender-identity disorder (International Classification for Disease-10th revision, F-64.9), which causes more confusion for teachers, nurses, and physicians who are trying to advocate in the best interests of their students or patients. Often, health care providers lack the education, terminology, and basic understanding of LGBTQI culture, and this does not go unnoticed by pediatric or adult patients. The National LGBT Health Education Center: Fenway Institute researched why many people in this group do not seek basic health care. Overwhelmingly, the collective answer was that they felt “invisible” to their provider.6 The “Don’t ask/don’t tell” model that has been unintentionally applied in general practice is ineffective and is contributing to the staggering number of health disparities seen in this population. The National LBGT Cancer Network Volume
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2017
reported that patients often fear the responses from providers. This may, in part, explain some of the cause for health disparities among this group.7 UNDERSTANDING GENDER FLUIDITY
Health care professionals cannot change societal norms nor force the majority population to accept any race, religion, culture, or sexual orientation, but we are responsible for their health care collectively. National LGBT Health Education Center: Fenway Institute expressed the importance of understanding gender fluidity, in contrast to traditional binary viewpoints of sexual identity, as a means to grasp the basic understanding of this culture.8 This understanding will allow for the health care provider to appreciate a more comprehensive assessment of the patient’s current and future health needs. Traditionally, gender has been expressed in a binary view—male and female. Boys and men were expected to behave in a masculine manner as leaders of the home and family, whereas girls and women were expected to respect the male authority and to dress with femininity and modesty. It is not surprising that anyone who chooses to believe or behave outside of what is considered normal by the majority at that given time are discriminated against to varying degrees. Societal norms are expectations of the group’s majority and those desiring acceptance within the group should conform, or suffer potential consequences. The concept of gender fluidity suggests that gender identity and sexual preference are multidimensional and multifactorial in nature. One may be born male and be attracted sexually to another male, a female, or both. This male may be comfortable (cisgender) or tormented (transgender) in his male body (see Table 1 for glossary). How one identifies their gender does not have to be consistent with the sex to which they are attracted, nor to the gender to which they were assigned at birth. Some are not specifically sexually attracted to any gender, but rather to the person themselves, regardless of their biologic sex. The expression of “self” may vary greatly among this diverse group. Some simply want to “pass” as their gender identity instead of their biologic sex. Some may prefer to dress extravagantly as one gender or another, whereas others are incapable of expressing the gender they identify with, and suffer from isolation, www.npjournal.org
depression, and even attempt or commit suicide.9 Potential warning signs could be recognized and addressed by astute health care providers and the number of suicide successes and attempts could decrease. PROVIDING INCLUSIVE QUALITY CARE
Many LGBTQI people have difficulty finding health care where they feel they are accepted, understood, and do not fear discrimination.10 LGBTQI people are extremely diverse and can be of any race, nationality, religion, wealthy, or impoverished, and anything in between.11 It is the role of the health care provider to understand how their identities and experiences with others can potentially affect their health. Barriers to this type of affirmative and inclusive care may be limited access, past negative experiences, and lack of knowledge and experience of the health care professional who is delivering care.10 The National LGBT Health Education Center: Fenway Institute has developed strategies that have been shown to foster an inclusive, safe environment for LGBTQI people.6 The first strategy recommended is that providers keep realistic expectations with communication. Many times, LGBTQI people have experienced discrimination or lack of awareness from previous providers and may come to expect this reaction when they are seeking care. For example, if the health care provider uses the wrong pronoun or makes the verbal assumption that a pediatric patient lives with a mother and father instead of 2 mothers or 2 fathers, the provider can simply apologize, correct the mistake, and try to reestablish constructive dialog while focusing on the reason they are seeking care. Strategies that can be employed by health care providers include: improving basic communication; avoiding assumptions and stereotypes; and using preferred pronouns and names.12 When a health care provider is unsure of how the patient wishes to be addressed, it is acceptable to politely ask them, and document this information for other coworkers to be aware. Respect, concern, and an inclusive environment is perceived when all hospital/clinic staff are addressing the patient as they express themselves (Table 2). The Journal for Nurse Practitioners - JNP
3
Table 1. Glossary of Terms Ally
A person who does not identify with the LGBTI group but shows support and advocates for the rights of LGBT people.
Asexual or ACE
Has no sexual orientation and exhibits a lack of interest in sex; not considered in the same domain of celibacy.
Bisexual
A person who is attracted to both men and women.
Bottom surgery
A means of describing external genitalia reassignment surgery.
Cisgender
Comfortable with the external genitalia present at birth; not transgender.
Disorders of Sexual development
A congenital condition in which reproductive organs do not develop into a definite male or female reproductive system.
Drag king/queen
The theatrical performance of women dressed as men (drag king) and men dressed as women (drag queen).
Gender fluid
Describes a person whose gender identity is not static, it is a mixture of the 2 traditional genders in which the person may be attracted to males or females. This group is a attracted to a person’s authenticity and personal compatibility regardless of the external genitalia.
Gender nonconforming
A person whose gender expression does not conform to societal norms
Gender dysphoria
Distress by those whose gender identity is not incongruent with birth gender, presents clinically with signs of mental distress, and has impaired social and occupational functioning.
Gender expression
The person acts, dresses, speaks, and behaves in ways that may or may not correspond to assigned sex at birth.
Intersex
An individual’s biologic anatomy (fetal development of reproductive system) vary from the expected norm (eg, ambiguous genitalia or those born with both a penis and vagina or a testicle and ovary).
MSM
Men who have sex with men.
Omnigender
A person who is sexually attracted to someone regardless of the gender identity, gender expression, or either biologic sex.
Queer
A label that describes those who identify with a sexual orientation outside the social norms. Some consider this term empowering (younger generation), whereas others strongly dislike the term.
Transsexual
Gender identity is not congruent with their biological external genitalia. They may or may not desire hormonal or surgical means to feel more congruency to their perception of self.
Transgender
Describes a person whose biologic anatomy does not correspond with their sexual identity and many have a desire to outwardly express the gender to which they identify.
Questioning
Describes those who are unsure and taking time to determine their gender identity; searching for their authentic self.
Adapted from the National LGBT Health Education Center: Fenway Institute15 and the Gay Alliance.16
If the name and gender on records do not match, it is recommended to ask, “Could your chart be under a different name?” or “What is the name on your insurance card?”8 It is not recommended to refer to their birth name as their 4
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“real” name, as this may imply that their wish to be called by their preferred name is not respected. Sometimes their name is changed on the driver’s license or other medical documents, but, for legal or safety reasons, their gender is not changed. Volume
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Table 2. Communicating Respectfully in Health Care Best Practices
Examples
Addressing a new patient: Do not assume a pronoun like “sir’ or “ma’am,” but rather keep your remarks open and general.
“How can I assist you?” or “Welcome, what brings you to the hospital/office?”
If you unsure of the pronoun a patient wants used, simply ask politely. If you use the wrong pronoun, apologize and document the patient’s preferred name and pronoun so others are aware.
“I am sorry for using the wrong pronoun and I did not mean any disrespect, I will note this in your chart so other’s hopefully will not make the same mistake” or “How would you like to be addressed while you are staying in the hospital/while you are at the clinic?”
If you cannot find the patient’s preferred name in the electronic health record, ask about other names they have used in the past.
“Could your record be under another name, perhaps?” or “How does your name read on your insurance card?”
In conversation, you should use the terms that the person uses to describe themselves. Some identify as queer and it is acceptable to address them this way, if it is consistent with how they personally identify.
If a person verbalizes that he is “queer,” do not call him “gay or homosexual.” If a woman refers to her partner as her “wife,” you should follow suit.
Adapted from the National LGBT Health Education Center: Fenway Institute.8(p21)
Consider the negative consequences that could result if a transgender person (female to male) is arrested and placed in a cell with male inmates. Sometimes gender documentation change is not done because specific screening services may be excluded by insurance carriers. An example is the female-to-male transgender patient, whose insurance carrier may refuse to pay for a Pap smear if there is a male gender on file. Knowledge of this information can play a role in improving health outcomes, promoting culturally sensitive care, and reducing health disparities. AFFIRMING CLINICAL ENCOUNTERS
Beyond having a welcoming environment for LGTBQI patients, health care providers should be open and nonjudgmental when taking sexual and social history data.13 Best practices include using open-ended and general questions and avoiding asking questions with specific answers that can exclude individuals who are not mainstream. When inquiring about partner/marital status, asking “Who lives at home with you?” or “Who is family to you?” is more inclusive than “Do you have a wife/ husband?” Questions should be worded to initiate discussion about their intimate relationship and/or sexual behaviors that may affect their health. An example of an open-ended question is, “What does www.npjournal.org
safe sex mean to you?” Eliciting honest answers allows for the provider to have a better understanding about what screening tests to order, currently relevant patient education to provide, and to anticipate guidance in preventing future possible negative outcomes. Knowledge of this information can play a role in improving health outcomes, promoting culturally sensitive care, and reducing health disparities. Once a trusting relationship has been established between the patient and the health care provider, a sexual risk assessment should be conducted. This assessment is commonly known as the 5 P’s: partners; practices; past sexually transmitted disease history; protection from sexually transmittable diseases; and pregnancy plans.12 These questions assist the provider in stratifying a patient’s risks for poor health outcomes or diseases. Registered nurses, advanced practice nurses, and physicians are encouraged to become trained in how to provide respectful, quality care to LGTBQI patients.14 CONCLUSION
Effective health care is based on the foundation of providing quality care to patients with a holistic approach. Part of giving quality care is for the provider to begin by having an awareness of the cultures of the patients they care for, including the many cultures of the LGBTQI population(s). Having this The Journal for Nurse Practitioners - JNP
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awareness will allow the health care provider to begin to better meet the mental and physical needs of the population for which they are caring.
11.
12. References 1. Kosciw JG, Greytak EA, Palmer NA, Boesen MJ. The 2013 national school climate survey: the experiences of lesbian, gay, bisexual, and transgender youth in our nation’s schools. 2013. http://www.glsen.org/sites/default/files/ 2013%20National%20School%20Climate%20Survey%20Full%20Report_0 .pdf/. Accessed November 25, 2016. 2. Grant JM, Mottet LA, Tanis JT. Injustice at every turn: a report of the national transgender discrimination survey. 2011. http://endtransdiscrimination.org/ PDFs/NTDS_Report.pdf/. Accessed November 25, 2016. 3. US Centers for Disease Control and Prevention. Suicide trends among persons aged 10-24 years in the United States 1994-2012. 2015. http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm6408a1.htm/. Accessed November 25, 2016. 4. US Centers for Disease Control and Prevention. Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9-12 United States and selected sites. 2015. http://www.cdc.gov/mmwr/volumes/65/ss/ ss6509a1.htm/. Accessed November 25, 2016. 5. School Health Policies and Practice Study. 2014. 6. National LGBT Health Education Center: Fenway Institute. Understanding the health needs of LGBT people. 2016. http://www.lgbthealtheducation.org/wp -content/uploads/LGBTHealthDisparitiesMar2016.pdf/. Accessed November 25, 2016. 7. National LGBT Cancer Network. Barriers to healthcare. 2016. http://www .cancernetwork.org/cancer_information/cancer_and_the_lgbt_community/ barriers_to_lgbt_healthcare.php/. Accessed November 25, 2016. 8. National LGBT Health Education Center: Fenway Institute. Providing inclusive services and care for LGBT people. 2016. http://www.lgbthealtheducation.org/ wp-content/uploads/Providing-Inclusive-Services-and-Care-for-LGBT-People/. Accessed November 25, 2016. 9. National LGBT Health Education Center: Fenway Institute. Ten things: creating inclusive health care environments for LGBT people. 2015. http:// www.lgbthealtheducation.org/wp-content/uploads/Ten-Things-Brief-Final -WEB.pdf/. Accessed November 25, 2016. 10. National LGBT Health Education Center: Fenway Institute. Building patient-centered medical homes for lesbian, gay, bisexual, and
6
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13.
14. 15.
16.
transgender patients and families. 2016. http://www.lgbthealtheducation .org/wp-content/uploads/Building-PCMH-for-LGBT-Patients-and-Families .pdf/. Accessed November 25, 2016. Healthy People 2020. Healthy People 2020. 2016. https://www.healthypeople .gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health/. Accessed November 25, 2016. National LGBT Health Education Center: Fenway Institute. Collecting sexual orientation and gender identity data in electronic health records. 2016. http://www.lgbthealtheducation.org/wp-content/uploads/Collecting-Sexual -Orientation-and-Gender-Identity-Data-in-EHRs-2016.pdf/. Accessed November 25, 2016. National LGBT Health Education Center: Fenway Institute. 2016. Building patient-centered medical homes for lesbian, gay, bisexual, and transgender patients and families. http://www.lgbthealtheducation.org/wp-content/ uploads/Collecting-Sexual-Orientation-and-Gender-Identity-Data-n-EHRs -2016-pdf/. Accessed November 25, 2016. Healthcare Equality Index. Healthcare Equality Index (HEI). 2016. http://www .hrc.org/hrc-story/. Accessed November 25, 2016. National LGBT Health Education Center: Fenway Institute. Glossary of LBGT terms for health care teams. http://www.lgbthealtheducation.org/wp-content/ uploads/LGBT-Glossary_March2016.pdf/. Accessed November 25, 2016. Gay Alliance. Safe zone: Train the Trainer Certification Program. 2016. http:// www.gayalliance.org/programs/education-safezone/safezone-train-the-trainer -certification-program/. Accessed November 25, 2016.
Jessica Landry, DNP, FNP-BC, is an Nursing Instructor in the School of Nursing at the Louisiana State University Health Sciences Center in New Orleans. She can be reached at jland7@ lsuhsc.edu. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/17/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.12.015
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Many health care providers are uncomfortable having conversations with patients about their sexual identity or sexual behaviors. Avoiding this discomfort is causing a serious threat to the mental and physical health of Americans, particularly those in the lesbian, gay, bisexual, transgender, questioning, or intersex (LGBTQI) community. The health-related disparities among LGBTQI patients range from bullying and physical assault to refusal of health care and housing. Many individuals choose not to seek health care due of fear of being judged, marginalized, or abused. This article focuses on the many disparities faced by the LGBTQI community and describes how simple changes in the practices of health care providers can potentially improve their health outcomes. Keywords: care of LGBTQI patient, cultural sensitivity, gender fluidity, gender identity, LGBTQI health disparities Ó 2016 Elsevier Inc. All rights reserved.
THE STAGGERING STATISTICS
H
ealth care professionals strive to provide culturally sensitive and high-quality mental and physical health care to children and adult patients, regardless of their age, race, religion, sexual practices, or personal belief system. Conveying a sense of understanding of a patient’s culture and a nonjudgmental attitude toward their behaviors may be a means to “meet patients where they are,” and lay a foundation for a trusting relationship that can lead to improved health outcomes. According to the Gay Lesbian Straight Educational Network, 74.1% of lesbian, gay, bisexual, transgender, questioning, or intersex (LGBTQI) students are harassed or threatened in American schools.1 Of the 7,898 LGBTQI students involved in the study, 5,852 were subjected to derogatory remarks referencing their sexuality. Ninety percent of these students indicated feelings of distress during their time on campus, and 30.3% missed at least 1 day of school due to harassment or bullying.1 Grant and colleagues2 studied 6,400 transgender and gender nonconforming people in kindergarten through grade 12 and found that 78% experienced harassment, 35% suffered physical assault, 12%
www.npjournal.org
were victimized by sexual violence, and 15% discerned a sense of threat severe enough to quit school completely. The discrimination of transgender persons continued into the workplace, with 90% of those surveyed reporting incidents of harassment and mistreatment. Nineteen percent of the economically disadvantaged and less educated individuals in this group reported being refused home rental or apartment leasing contracts, found themselves homeless at some point during their life, or experienced outright refusal of health care due to their sexual orientation.2 Of this disadvantaged population, 55% of those who sought asylum in homeless shelters reported being harassed by shelter employees, 29% were outright refused entry, and 22% were sexually assaulted by either shelter residents or staff. The United States Centers for Disease Control and Prevention (CDC) named suicide as the second leading cause of death among people between age 10-24 years in the United States between 1994 and 2012, with 5,178 of these deaths in 2012 alone.3 The CDC also reported that, among students attending American schools and enrolled in grades 9-12, 14.8% of heterosexual students attempted suicide compared The Journal for Nurse Practitioners - JNP
1
VIGNETTE A family nurse practitioner (FNP) in a busy emergency department read the triage note of a 12-year-old boy that stated he had “tried to tie a belt around his neck to hang himself.” The medical history exhibited no significant findings, as he had no physical or mental illnesses. The FNP introduced herself and began small talk for a few minutes, but noted only silence from the young patient. She began asking him questions about why he had tried to hurt himself, and he refused to answer. She asked him questions about his school, grades, did he have “girl trouble,” was his teacher unkind or unfair? He just shook his head “no,” with his eyes turned down. She continued gently questioning him to determine if he was experiencing physical, sexual abuse, verbal abuse, parental neglect, or bullying from others. Again, he just shook his head and avoided eye contact with her consistently. She proceeded to the examination portion of the visit and the only abnormal finding was redness around his neck from the belt. She ordered a soft tissue X-ray of his neck and left the room to question his parents. They reported that he had many friends, achieved honor roll several times, and his teacher had positive reports of behavior and academic performance; yet, in spite of all the positive aspects of his life, he had begun to express more sadness over the last year and this concerned them. The FNP decided she would approach him once more, this time without his parents, nurse, or social worker present. She sat on the side of his bed and touched his arm, she asked him to please make eye contact with her. He appeared defeated and worn, much too young to wear such an expression. She asked him directly again, “Why did you try to hurt yourself? You have much goodness in your life; you are handsome, smart, and your friends, teacher, and parents love you and are concerned about you. I want to understand why you want to die.” He looked the FNP squarely and stated, “Because I am a girl and no one understands that.” When she tried to respond she realized she was afraid she would use the wrong words and possibly make him feel worse. She had been preparing to have him committed to a psychiatric facility, and she was concerned he would assume he was being committed for his gender identity and not his suicide attempt. The FNP attempted to explain this, she felt she was unclear. He was discharged to a psychiatric facility from which he was shortly discharged. Four months later he attempted suicide again, this time he was successful.
with 42.8% of gay, lesbian, or bisexual students within the 12-month period prior to being surveyed.4 The survey further reported that, compared 2
The Journal for Nurse Practitioners - JNP
with heterosexual students, nearly twice as many gay, lesbian, and bisexual students were threatened or injured with a weapon, such as a gun, knife, or club, on school grounds at least once. HEALTH DISPARITIES IN THE LGBTQI COMMUNITY
The CDC reported that gay, lesbian, bisexual, and students are 30.5% more likely to feel sad or hopeless, 13.6% are more likely to be victims of sexual violence, 23% are more likely to attempt suicide, 15.4% are more likely to use marijuana, and twice as likely to experiment with hallucinogenic drugs as their heterosexual peers at the same age.5 The survey also revealed that students who questioned their sexual identity were 14.9% more likely to suffer from physical violence during dating and 9.5% more likely to use or abuse cocaine than their heterosexual peers. The responsibility for the health of sexual minority students has largely been placed on schools, which often play very limited role in educating students on sexual and mental health. The School Health Policies and Practice Study showed that about half of American high schools discuss sexual identity or orientation as part of the curriculum at any grade level.5 The study further noted that only 34.6% of these high schools provide health care specifically to LGBTQI students. Many psychological textbooks and current literature still refer to those questioning their gender or displaying gender-nonconforming traits as have a gender-identity disorder (International Classification for Disease-10th revision, F-64.9), which causes more confusion for teachers, nurses, and physicians who are trying to advocate in the best interests of their students or patients. Often, health care providers lack the education, terminology, and basic understanding of LGBTQI culture, and this does not go unnoticed by pediatric or adult patients. The National LGBT Health Education Center: Fenway Institute researched why many people in this group do not seek basic health care. Overwhelmingly, the collective answer was that they felt “invisible” to their provider.6 The “Don’t ask/don’t tell” model that has been unintentionally applied in general practice is ineffective and is contributing to the staggering number of health disparities seen in this population. The National LBGT Cancer Network Volume
-,
Issue
-, -/-
2017
reported that patients often fear the responses from providers. This may, in part, explain some of the cause for health disparities among this group.7 UNDERSTANDING GENDER FLUIDITY
Health care professionals cannot change societal norms nor force the majority population to accept any race, religion, culture, or sexual orientation, but we are responsible for their health care collectively. National LGBT Health Education Center: Fenway Institute expressed the importance of understanding gender fluidity, in contrast to traditional binary viewpoints of sexual identity, as a means to grasp the basic understanding of this culture.8 This understanding will allow for the health care provider to appreciate a more comprehensive assessment of the patient’s current and future health needs. Traditionally, gender has been expressed in a binary view—male and female. Boys and men were expected to behave in a masculine manner as leaders of the home and family, whereas girls and women were expected to respect the male authority and to dress with femininity and modesty. It is not surprising that anyone who chooses to believe or behave outside of what is considered normal by the majority at that given time are discriminated against to varying degrees. Societal norms are expectations of the group’s majority and those desiring acceptance within the group should conform, or suffer potential consequences. The concept of gender fluidity suggests that gender identity and sexual preference are multidimensional and multifactorial in nature. One may be born male and be attracted sexually to another male, a female, or both. This male may be comfortable (cisgender) or tormented (transgender) in his male body (see Table 1 for glossary). How one identifies their gender does not have to be consistent with the sex to which they are attracted, nor to the gender to which they were assigned at birth. Some are not specifically sexually attracted to any gender, but rather to the person themselves, regardless of their biologic sex. The expression of “self” may vary greatly among this diverse group. Some simply want to “pass” as their gender identity instead of their biologic sex. Some may prefer to dress extravagantly as one gender or another, whereas others are incapable of expressing the gender they identify with, and suffer from isolation, www.npjournal.org
depression, and even attempt or commit suicide.9 Potential warning signs could be recognized and addressed by astute health care providers and the number of suicide successes and attempts could decrease. PROVIDING INCLUSIVE QUALITY CARE
Many LGBTQI people have difficulty finding health care where they feel they are accepted, understood, and do not fear discrimination.10 LGBTQI people are extremely diverse and can be of any race, nationality, religion, wealthy, or impoverished, and anything in between.11 It is the role of the health care provider to understand how their identities and experiences with others can potentially affect their health. Barriers to this type of affirmative and inclusive care may be limited access, past negative experiences, and lack of knowledge and experience of the health care professional who is delivering care.10 The National LGBT Health Education Center: Fenway Institute has developed strategies that have been shown to foster an inclusive, safe environment for LGBTQI people.6 The first strategy recommended is that providers keep realistic expectations with communication. Many times, LGBTQI people have experienced discrimination or lack of awareness from previous providers and may come to expect this reaction when they are seeking care. For example, if the health care provider uses the wrong pronoun or makes the verbal assumption that a pediatric patient lives with a mother and father instead of 2 mothers or 2 fathers, the provider can simply apologize, correct the mistake, and try to reestablish constructive dialog while focusing on the reason they are seeking care. Strategies that can be employed by health care providers include: improving basic communication; avoiding assumptions and stereotypes; and using preferred pronouns and names.12 When a health care provider is unsure of how the patient wishes to be addressed, it is acceptable to politely ask them, and document this information for other coworkers to be aware. Respect, concern, and an inclusive environment is perceived when all hospital/clinic staff are addressing the patient as they express themselves (Table 2). The Journal for Nurse Practitioners - JNP
3
Table 1. Glossary of Terms Ally
A person who does not identify with the LGBTI group but shows support and advocates for the rights of LGBT people.
Asexual or ACE
Has no sexual orientation and exhibits a lack of interest in sex; not considered in the same domain of celibacy.
Bisexual
A person who is attracted to both men and women.
Bottom surgery
A means of describing external genitalia reassignment surgery.
Cisgender
Comfortable with the external genitalia present at birth; not transgender.
Disorders of Sexual development
A congenital condition in which reproductive organs do not develop into a definite male or female reproductive system.
Drag king/queen
The theatrical performance of women dressed as men (drag king) and men dressed as women (drag queen).
Gender fluid
Describes a person whose gender identity is not static, it is a mixture of the 2 traditional genders in which the person may be attracted to males or females. This group is a attracted to a person’s authenticity and personal compatibility regardless of the external genitalia.
Gender nonconforming
A person whose gender expression does not conform to societal norms
Gender dysphoria
Distress by those whose gender identity is not incongruent with birth gender, presents clinically with signs of mental distress, and has impaired social and occupational functioning.
Gender expression
The person acts, dresses, speaks, and behaves in ways that may or may not correspond to assigned sex at birth.
Intersex
An individual’s biologic anatomy (fetal development of reproductive system) vary from the expected norm (eg, ambiguous genitalia or those born with both a penis and vagina or a testicle and ovary).
MSM
Men who have sex with men.
Omnigender
A person who is sexually attracted to someone regardless of the gender identity, gender expression, or either biologic sex.
Queer
A label that describes those who identify with a sexual orientation outside the social norms. Some consider this term empowering (younger generation), whereas others strongly dislike the term.
Transsexual
Gender identity is not congruent with their biological external genitalia. They may or may not desire hormonal or surgical means to feel more congruency to their perception of self.
Transgender
Describes a person whose biologic anatomy does not correspond with their sexual identity and many have a desire to outwardly express the gender to which they identify.
Questioning
Describes those who are unsure and taking time to determine their gender identity; searching for their authentic self.
Adapted from the National LGBT Health Education Center: Fenway Institute15 and the Gay Alliance.16
If the name and gender on records do not match, it is recommended to ask, “Could your chart be under a different name?” or “What is the name on your insurance card?”8 It is not recommended to refer to their birth name as their 4
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“real” name, as this may imply that their wish to be called by their preferred name is not respected. Sometimes their name is changed on the driver’s license or other medical documents, but, for legal or safety reasons, their gender is not changed. Volume
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Table 2. Communicating Respectfully in Health Care Best Practices
Examples
Addressing a new patient: Do not assume a pronoun like “sir’ or “ma’am,” but rather keep your remarks open and general.
“How can I assist you?” or “Welcome, what brings you to the hospital/office?”
If you unsure of the pronoun a patient wants used, simply ask politely. If you use the wrong pronoun, apologize and document the patient’s preferred name and pronoun so others are aware.
“I am sorry for using the wrong pronoun and I did not mean any disrespect, I will note this in your chart so other’s hopefully will not make the same mistake” or “How would you like to be addressed while you are staying in the hospital/while you are at the clinic?”
If you cannot find the patient’s preferred name in the electronic health record, ask about other names they have used in the past.
“Could your record be under another name, perhaps?” or “How does your name read on your insurance card?”
In conversation, you should use the terms that the person uses to describe themselves. Some identify as queer and it is acceptable to address them this way, if it is consistent with how they personally identify.
If a person verbalizes that he is “queer,” do not call him “gay or homosexual.” If a woman refers to her partner as her “wife,” you should follow suit.
Adapted from the National LGBT Health Education Center: Fenway Institute.8(p21)
Consider the negative consequences that could result if a transgender person (female to male) is arrested and placed in a cell with male inmates. Sometimes gender documentation change is not done because specific screening services may be excluded by insurance carriers. An example is the female-to-male transgender patient, whose insurance carrier may refuse to pay for a Pap smear if there is a male gender on file. Knowledge of this information can play a role in improving health outcomes, promoting culturally sensitive care, and reducing health disparities. AFFIRMING CLINICAL ENCOUNTERS
Beyond having a welcoming environment for LGTBQI patients, health care providers should be open and nonjudgmental when taking sexual and social history data.13 Best practices include using open-ended and general questions and avoiding asking questions with specific answers that can exclude individuals who are not mainstream. When inquiring about partner/marital status, asking “Who lives at home with you?” or “Who is family to you?” is more inclusive than “Do you have a wife/ husband?” Questions should be worded to initiate discussion about their intimate relationship and/or sexual behaviors that may affect their health. An example of an open-ended question is, “What does www.npjournal.org
safe sex mean to you?” Eliciting honest answers allows for the provider to have a better understanding about what screening tests to order, currently relevant patient education to provide, and to anticipate guidance in preventing future possible negative outcomes. Knowledge of this information can play a role in improving health outcomes, promoting culturally sensitive care, and reducing health disparities. Once a trusting relationship has been established between the patient and the health care provider, a sexual risk assessment should be conducted. This assessment is commonly known as the 5 P’s: partners; practices; past sexually transmitted disease history; protection from sexually transmittable diseases; and pregnancy plans.12 These questions assist the provider in stratifying a patient’s risks for poor health outcomes or diseases. Registered nurses, advanced practice nurses, and physicians are encouraged to become trained in how to provide respectful, quality care to LGTBQI patients.14 CONCLUSION
Effective health care is based on the foundation of providing quality care to patients with a holistic approach. Part of giving quality care is for the provider to begin by having an awareness of the cultures of the patients they care for, including the many cultures of the LGBTQI population(s). Having this The Journal for Nurse Practitioners - JNP
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awareness will allow the health care provider to begin to better meet the mental and physical needs of the population for which they are caring.
11.
12. References 1. Kosciw JG, Greytak EA, Palmer NA, Boesen MJ. The 2013 national school climate survey: the experiences of lesbian, gay, bisexual, and transgender youth in our nation’s schools. 2013. http://www.glsen.org/sites/default/files/ 2013%20National%20School%20Climate%20Survey%20Full%20Report_0 .pdf/. Accessed November 25, 2016. 2. Grant JM, Mottet LA, Tanis JT. Injustice at every turn: a report of the national transgender discrimination survey. 2011. http://endtransdiscrimination.org/ PDFs/NTDS_Report.pdf/. Accessed November 25, 2016. 3. US Centers for Disease Control and Prevention. Suicide trends among persons aged 10-24 years in the United States 1994-2012. 2015. http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm6408a1.htm/. Accessed November 25, 2016. 4. US Centers for Disease Control and Prevention. Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9-12 United States and selected sites. 2015. http://www.cdc.gov/mmwr/volumes/65/ss/ ss6509a1.htm/. Accessed November 25, 2016. 5. School Health Policies and Practice Study. 2014. 6. National LGBT Health Education Center: Fenway Institute. Understanding the health needs of LGBT people. 2016. http://www.lgbthealtheducation.org/wp -content/uploads/LGBTHealthDisparitiesMar2016.pdf/. Accessed November 25, 2016. 7. National LGBT Cancer Network. Barriers to healthcare. 2016. http://www .cancernetwork.org/cancer_information/cancer_and_the_lgbt_community/ barriers_to_lgbt_healthcare.php/. Accessed November 25, 2016. 8. National LGBT Health Education Center: Fenway Institute. Providing inclusive services and care for LGBT people. 2016. http://www.lgbthealtheducation.org/ wp-content/uploads/Providing-Inclusive-Services-and-Care-for-LGBT-People/. Accessed November 25, 2016. 9. National LGBT Health Education Center: Fenway Institute. Ten things: creating inclusive health care environments for LGBT people. 2015. http:// www.lgbthealtheducation.org/wp-content/uploads/Ten-Things-Brief-Final -WEB.pdf/. Accessed November 25, 2016. 10. National LGBT Health Education Center: Fenway Institute. Building patient-centered medical homes for lesbian, gay, bisexual, and
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14. 15.
16.
transgender patients and families. 2016. http://www.lgbthealtheducation .org/wp-content/uploads/Building-PCMH-for-LGBT-Patients-and-Families .pdf/. Accessed November 25, 2016. Healthy People 2020. Healthy People 2020. 2016. https://www.healthypeople .gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health/. Accessed November 25, 2016. National LGBT Health Education Center: Fenway Institute. Collecting sexual orientation and gender identity data in electronic health records. 2016. http://www.lgbthealtheducation.org/wp-content/uploads/Collecting-Sexual -Orientation-and-Gender-Identity-Data-in-EHRs-2016.pdf/. Accessed November 25, 2016. National LGBT Health Education Center: Fenway Institute. 2016. Building patient-centered medical homes for lesbian, gay, bisexual, and transgender patients and families. http://www.lgbthealtheducation.org/wp-content/ uploads/Collecting-Sexual-Orientation-and-Gender-Identity-Data-n-EHRs -2016-pdf/. Accessed November 25, 2016. Healthcare Equality Index. Healthcare Equality Index (HEI). 2016. http://www .hrc.org/hrc-story/. Accessed November 25, 2016. National LGBT Health Education Center: Fenway Institute. Glossary of LBGT terms for health care teams. http://www.lgbthealtheducation.org/wp-content/ uploads/LGBT-Glossary_March2016.pdf/. Accessed November 25, 2016. Gay Alliance. Safe zone: Train the Trainer Certification Program. 2016. http:// www.gayalliance.org/programs/education-safezone/safezone-train-the-trainer -certification-program/. Accessed November 25, 2016.
Jessica Landry, DNP, FNP-BC, is an Nursing Instructor in the School of Nursing at the Louisiana State University Health Sciences Center in New Orleans. She can be reached at jland7@ lsuhsc.edu. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/17/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.12.015
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