BEST PRACTICES FOR CULTURALLY COMPETENT CARE

LGBTQ+ patients, particularly those who identify as transgender or nonbinary, often face barriers to accessing healthcare services due to the lack of provider understanding of their gender identities. Providing high-quality, culturally competent, patient-centered care is a complex process that requires ongoing learning and awareness of the various factors that affect the LGBTQ+ population.

Even healthcare organizations that have taken positive steps toward improving cultural competency for LGBTQ+ patients will find new ways to address barriers to care and engage staff in improvement initiatives. Improving skills and knowledge among healthcare leaders, providers, and staff should be looked at as opportunities rather than as organizational or individual weaknesses.

Physical Space

Best practices start at the front door and extend into the provider’s office and treatment areas. Everything from the hospital website to the front desk and waiting areas should reflect a healthcare setting that is welcoming, open, and inclusive.

Include gender-neutral restrooms and signage.
Post signage to affirm nondiscrimination policies that include sexual orientation, gender identity, and gender expression.
Evaluate environmental factors of potential concerns for LGBTQ+ patients and families, such as bathroom designations, artwork, posters, educational brochures, etc.
(Reynolds, 2020; GLMA, n.d.)

Internet and Website

Informational, educational, and support materials should be designed to help LGBTQ+ patients feel comfortable and supported in the healthcare setting.

Include inclusive language on any websites and marketing materials that describes a commitment to high-quality, culturally competent, patient-centered care.
Ensure that marketing, advertising, and informational materials reflect diverse populations, including same-sex couples and families.
Create a separate webpage or portal for information and resources related to LGBTQ+ care.
(National LGBTQIA+ HEC, 2021; GLMA, n.d.)

Supportive Communication

An individual may delay or avoid accessing care due to the fear that their provider may not take their gender identity and pronouns seriously or be entirely dismissive of them, causing them to feel “invisible.” There are many ways that a healthcare provider and support staff can communicate with patients to help them feel respected and comfortable.

Avoid the use of gendered titles such as “Sir” or “Ma’am.” Instead of Mr. or Ms., patients may also wish to be addressed as Mx. (pronounced with a “ks” or “x” sound at the end).
Introduce yourself with your pronouns. Ask patients for information such as their pronouns, preferred name, and gender identity. Pronouns may include: he/his/him, she/hers/her, or a range of options for nonbinary transgender patients, such as they/their/them, ze, sie, hir, co, and ey. Always respect the patient’s pronouns and apologize if the wrong pronouns are used by mistake.
Always ask for clarification when not clear what a patient would like to be called or how the patient would like to be addressed. Apologize if you refer to a patient in a way that seemed offensive.
Ask patients what terms they use to refer to their anatomy, and mirror those terms during the patient interaction. Transgender patients may experience gender dysphoria and/or may not be comfortable with traditional terms for body parts.
Ask the patient to clarify any terms or behaviors that are unfamiliar, or repeat a patient’s term with your own understanding of its meaning to make sure you have a good understanding of what it means to them.
Do not make assumptions about patients’ sexual orientations, gender identities, beliefs, or concerns based on physical characteristics such as clothing, tone of voice, perceived femininity/masculinity, etc.
Do not be afraid to tell a patient about one’s own inexperience working with LGBTQ+ patients. Honesty and openness will often stand out to a patient from their previous healthcare experiences.
Do not ask patients questions about sexual orientation or gender identity that are not material to their care or treatment.
Do not disclose patients’ sexual orientations or gender identities to individuals who do not explicitly need the information as part of the patients’ care.
Keep in mind that sexual orientation and gender identity are only two factors that contribute to a patient’s overall identity and experience. Other factors—including race, ethnicity, religion, socioeconomic status, education level, and income—also contribute to the patient’s experiences, perceptions, and potential barriers to healthcare.
(TJC, 2011; Reynolds, 2020; GLMA, n.d.; LGBTQ+ Resource Center, n.d.; Garrett, 2022.)

CASE

James is a 23-year-old patient brought to the emergency department by a close friend who is concerned about James’s symptoms of depression and a statement James made about “wishing I were dead.” James has no significant medical or mental health history according to the medical record.

The clinician enters the room and greets the patient, saying, “Hello, I am Tonya. My pronouns are she/her. I am a nurse and will be taking care of you today. May I ask what name and pronouns you use?” James doesn’t respond right away, and Tonya notices James looking at her name badge, indicating her own pronouns, and also staring at the rainbow flag hanging on the wall of the exam room.

After a moment of silence, James quietly tells Tonya her name is Jenna and her pronouns are “she/her.” Jenna then breaks down in tears and says she has never shared her preferred name with a “stranger” before. She says that she sometimes just wants to die because she feels like she is supposed to be a woman but is afraid this will never be a reality or possibility. Jenna worries about how her family will react and about losing her job and healthcare coverage if she comes out to others with her true gender identity.

Tonya responds with understanding and stresses that the most important thing now is to make sure that Jenna is safe and has the support she needs. Tonya brings in the social worker to complete a behavioral health assessment and to address the possible risk of imminent self-harm. The social worker also documents Jenna’s preferred name and pronouns in the medical record and then provides Jenna with a national suicide hotline number for transgender people, a list of local support groups, the name of a psychologist who specializes in gender issues, and an insurance contact to review her benefits related to gender care.

Jenna states that she was previously unaware of all these support resources. She adds that she feels more hopeful than she has in a long time and that she had never been able to express her feelings so freely before.

Institutional Policies and Practices

In order to provide culturally competent care, institutions must assess current organizational practices and identify gaps in policies and services related to care and services for LGBTQ+ patients. This also includes ensuring that policies comply with all federal and state regulations (see “The Joint Commission Field Guide” earlier in this course).

Recommendations to build awareness within an organization about the LGBTQ+ community include:

Hold an open discussion with healthcare professionals and staff about the difference between sexual orientation (lesbian, gay, bisexual, etc.) and gender identity (transgender, nonbinary, intersex, etc.), since this can be confusing to those who are not familiar with such concepts
If not already in place, establish a point person, office, or advisory group to oversee LGBTQ-related policies and concerns, ideally including members representing the LGBTQ+ community
For inpatient facilities, review visitation policies to empower patients to decide who can visit them and act on their behalf (see also “Legal Issues” earlier in this course)
Review codes of conduct and ethics to ensure they include expectations for respectful communication with all patients, visitors, and staff members and that they specify consequences for code violations
Provide training and orientation on a regular basis to professionals and staff on culturally competent care and organizational policies related to conduct, ethics, privacy, nondiscrimination, and antiharassment policies
(GLMA, n.d.; National LGBTQIA+ HEC, 2021)