CULTURALLY COMPETENT CARE FOR LGBTQ+ PATIENTS

Even though social acceptance of LGBTQ+ individuals has been increasing, LGBTQ+ patients continue to face barriers to culturally competent care, including stigma and discrimination. For these patients, access to healthcare that is unbiased and culturally affirming remains a challenge in most parts of the United States (Butler et al., 2016).

It is not uncommon for a person who identifies as lesbian, gay, bisexual, transgender, or questioning/queer (LGBTQ) to have had negative experiences in the healthcare environment due to discrimination and/or stigmatization based on their sexual orientation and/or gender identity. Such encounters may occur due to cultural bias or a lack of awareness and understanding by the provider of the healthcare needs and goals of such individuals.

Negative encounters immediately affect the patient’s trust of the healthcare system and marginalize their needs. Continuing stigma makes many patients reluctant to reveal their sexual orientation or gender identity to healthcare providers even though this information can be important to receiving individualized care.

Even though social acceptance has been increasing and laws and policies are changing, LGBTQ+ individuals continue to face barriers, stigma, bias, and discrimination. Access to healthcare that is unbiased and culturally affirming remains a challenge in most parts of the United States.

People within the LGBTQ+ population are extraordinarily diverse, representing every social class and ethnicity in every geographical area and every profession (HRC, 2020). Healthcare professionals who practice cultural sensitivity in working with LGBTQ+ patients can have a positive impact and increase trust as they continue to understand the individual needs of their patients.

Terms and Definitions

To better understand the LGBTQ+ population and their unique health concerns, it is important to define and clarify some basic concepts of gender identity and sexual orientation. Terms and definitions are ever evolving, and clinicians must update their knowledge regularly to provide effective and respectful care for all patients. It is also important that clinicians have the comfort and sensitivity to ask their patients how they would like to be addressed in terms of identifiers of gender identity and sexual orientation in a respectful, honest, and open-minded manner.

(Terminology described in this course is taken from recognized sources at the time the course was written. These terms may not reflect every individual’s personal preference, may become outdated even as they are mentioned in current clinical references, and may not reflect all local and regional variations.)

• Anatomical sex: the presence of certain female or male biologic anatomy (including genitals, chromosomes, hormones, etc.); also referred to as assigned sex at birth (ASAB)
• Asexual (A): people with no or little sexual attraction to other people
• Bisexual (B): men and women who are sexually attracted to people who are both the same as and different than their own gender
• Cisgender: people whose gender identity aligns with the sex they were assigned at birth, i.e., the opposite of transgender or gender diverse
• Gay (G): a person who is attracted to someone of the same gender; historically, the term referred to men who are attracted to men, but it may also be used by women to refer to themselves
• Gender diverse (also gender nonconforming, gender variant, and gender creative): a person who embodies gender roles and/or gender expression that do not match social and cultural expectations
• Gender expression: the way a person presents their gender in society, through social roles, clothing, makeup, mannerisms, etc.
• Gender identity: a person’s internal sense of being a male/man, female/woman, both, neither, or another gender
• Genderfluid or genderqueer (also called nonbinary): people who do not strictly identify as male or female; a mix of male and female (genderqueer/genderfluid); neither male nor female (nonbinary); or no gender at all
• Intersex (I): people with an indeterminate mix of primary and secondary sex characteristics, such as a person born appearing to be female “outside” who has mostly male anatomy “inside,” a person born with genitals that are a mix of male and female types (a female born with a large clitoris or without a vaginal opening, or a male born with a small penis or a divided scrotum that has formed like labia); may identify as either cisgender or gender diverse
• Lesbian (L): women who are attracted to women
• MSM: men who have sex with men
• Queer: an umbrella term for all who are not heterosexual or who are not 100% clear of their sexual orientation and/or gender identity
• Questioning (Q): a person who is in the process of discovery and exploration of their sexual orientation, gender identity, or gender expression
• Sexual orientation: how a person identifies their sexuality, including who they are physically and emotionally attracted to and with whom they choose to have sex; a person may not have a sexual attraction to others (asexual)
• Transgender (T): People with gender identities that do not align with their assigned sex at birth; some transgender individuals may alter their physical appearance and often undergo hormonal therapy or surgeries to affirm their gender identity. However, medical intervention is not required for a person to identify as transgender. Some transgender people do not undergo the medical transition process for a variety of reasons, including cost or other health concerns. Gender identity terms that may be used by transgender people to describe themselves include:
• Demiboy: a person who feels their gender identity is partially male, regardless of assigned sex at birth
• Demigirl: a person who feels their gender identity is partially female, regardless of assigned sex at birth
• Transgender female/woman, trans woman: a transgender person who was assigned male at birth (AMAB) but who identifies as female; formerly referred to as male-to-female (MTF)
• Transgender male/man, trans man: a transgender person who was assigned female at birth (AFAB) but who identifies as male; formerly referred to as female-to-male (FTM)
• WSW: women who have sex with women
  (AECF, 2021; APA, 2022; PFLAG, 2022)

TERMS AND CONCEPTS THAT MAY BE MARGINALIZING

Terms that marginalize and stigmatize people who are LGBTQ+ are still common. Also, some words previously used and accepted in the medical community may no longer be in common usage or considered acceptable/respectful today. Examples include:

• Homosexual
• Sexual preference
• Transvestite
• Male-to-female (MTF) transgender
• Female-to-male (FTM) transgender
  (PFLAG, 2022; GLAAD, n.d.)

Examples of concepts that may contribute to societal stigmas for LGBTQ+ patients include:

• Heterosexism: the general presumption that everyone is straight or the belief that heterosexuality is a superior expression of sexuality
• Homophobia: negative attitudes and feelings toward people with nonheterosexual sexualities; may include discomfort with expressions of sexuality that do not conform to heterosexual norms
• Internalized oppression: the belief that straight and cisgender people are “normal” or better than LGBTQ+ people, as well as the often-unconscious belief that negative stereotypes about LGBTQ+ people are true
• Transphobia: negative attitudes and feelings toward transgender people or discomfort with people whose gender identity and/or gender expression do not align with traditionally accepted gender roles
  (PFLAG, 2022; Ni, 2020)

Health Disparities and Health Risk Factors

The LGBTQ+ population is diverse in terms of race, ethnicity, disability, and socioeconomic status. Therefore, risk factors and disparities in each patient will vary depending on these individual factors. (See discussion below on specific population groups.)

Research has uncovered that LGBTQ+ individuals often face health disparities related to societal stigma, discrimination, and denial of civil and human rights in some manner. Discrimination has been linked to higher rates of psychiatric disorders, substance abuse disorders, and suicide. Violence and victimization are also more common and have lifelong consequences to the individual and the community as a whole. Personal, family, and social acceptance of an individual’s sexual orientation and gender identity often affects these individuals’ mental health and personal safety (Medina-Martinez et al., 2021).

Individuals who identify as LGBTQ+ may also experience minority stress. Minority stress theory connects health disparities among individuals to stressors induced by a hostile, homophobic culture in society as a whole. This often results in experiences of prejudice, internal expectations of rejection, and internalized homophobia. Aspects of minority stress, including the perception of prejudice, stigma, or rejection, are associated with higher rates of depression and dysfunctional coping strategies (Hoy-Ellis, 2021).

LGBTQ+ populations experience a greater prevalence of mental health distress and diagnosis, such as:

• Anxiety and depression
• Suicidal ideation and attempts
• Other forms of emotional, physical, and sexual trauma (such as intimate partner violence)
  (Hoy-Ellis, 2021; Coleman et al., 2022)

Gay, lesbian, and bisexual adolescents and young adults have higher rates of tobacco and alcohol use, substance abuse, eating disorders, and risky sexual behaviors. This may be due to a higher level of psychological distress (CDC, 2022d; The Trevor Project, 2020, 2022).

MEN WHO HAVE SEX WITH MEN (MSM)

The most researched health disparity among MSM is HIV/AIDS incidence and prevalence. In 2018, 81% of new HIV cases among men occurred in MSM (CDC, 2020a). Gay, bisexual, and other MSM have also been found to be at increased risk of other sexually transmitted infections (STIs) (CDC, 2022a), including:

• Syphilis
• Gonorrhea
• Chlamydia
• Human papillomavirus (HPV)
• Hepatitis A and B

Gay men are also at an increased risk of cancers, including prostate, testicular, anal, and colon, which may be related to limited cancer screening and prevention services for this population (Domogauer et al., 2022). Moreover, MSM are also at higher risk for tobacco and drug use and depression (CDC, 2022b).

Clinical Implications

When providing care for MSM, clinicians and case managers should not assume that the individual is engaged in actions that increase the risk for certain disorders; a history should first be performed to understand the individual’s risk (HEC, 2021). Understanding the risk factors and health disparities for MSM, it is important to address the unique clinical concerns for this population through:

• Regular assessment and screening for STIs and HIV
• Routine vaccination for hepatitis A, hepatitis B, and HPV
• Prevention and screening for prostate, testicular, anal, oral (head and neck), and colon cancers
  (CDC, 2022a)

WOMEN WHO HAVE SEX WITH WOMEN (WSW)

Lesbian and bisexual women are more likely to be obese and to use tobacco and alcohol than heterosexual women. Stress may be a contributing factor to the increased substance use or abuse in this population. WSW are also at increased risk for depression and anxiety disorders and are less likely to receive routine reproductive care. Lesbian women are also less likely to access cancer screening and prevention services (Office on Women’s Health, 2020; Open Access Government, 2020; ACS, 2021).

Lesbian women may be at a higher risk for uterine, breast, cervical, endometrial, and ovarian cancers for some of the factors listed above (ACS, 2021). Also, lesbians have traditionally been less likely to bear children, and hormones released during pregnancy and breastfeeding are believed to protect women against breast, endometrial, and ovarian cancers (WebMD, 2020).

Clinical Implications

Clinicians and case managers working with WSW should carefully assess and address the multiple risks that this population faces by providing:

• Preventive and wellness care to prevent or treat tobacco use/abuse and alcohol use/abuse
• Screening and early identification of behavioral health concerns such as depression or anxiety
• Regular preventive care and screening for uterine, breast, cervical, endometrial, and ovarian cancers
• Programs for healthy weight and exercise
  (WebMD, 2020)

TRANSGENDER AND GENDER DIVERSE

Transgender individuals often face victimization, violence, and minority stress, and they are less likely to have access to health insurance for a variety of reasons. Transgender individuals have a higher prevalence of:

• HIV
• Sexually transmitted infections (STIs)
• Behavioral health disorders
• Suicide
  (CDC, 2022c; CDC, 2021; NAMI, 2022)

Clinical Implications

Caring for transgender patients therefore includes screening for the following risks, as appropriate:

• Access to appropriate health insurance
• Violence
• Minority stress
• HIV
• STIs
• Suicide
• Behavioral health disorders
  (Caughey et al., 2021; Eder et al., 2021; Goldsmith & Bell, 2022)

ADOLESCENTS AND YOUNG ADULTS

Many concerns may impact the health and well-being of an LGBTQ+ individual. This is especially true for adolescents, who are in the process of navigating developmental milestones along with sexual orientation and gender identity.

Young adults who “come out” may be faced with bullying from their peers or family rejection. LGBTQ+ youth have high rates of substance abuse, STIs, and homelessness (Hao et al., 2021). They have an increased risk of depression, suicidal ideation, and substance use, including tobacco, alcohol, cannabis, cocaine, ecstasy, and heroin (The Trevor Project, 2020, 2021).

Research has shown that LGBTQ+ adolescents and young adults with family acceptance have greater self-esteem, more social support, and better health outcomes. This acceptance also reduces the risk of substance abuse, depression, and suicide (Delphin-Rittmon, 2022).

Clinical Implications

Clinicians and case managers working with this population should pay careful attention to subtle clues and risk factors of each individual, as adolescents and young adults may be especially reticent to discuss their concerns. Careful assessment focuses on:

• Evidence or risk of bullying
• Dysfunctional family dynamics
• Substance abuse risks
• Depression screening
• Suicide risks
• STI screening
• HPV vaccination
• Home living conditions
  (Hao et al., 2021; Eder et al., 2021)

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 concern for LGBTQ+ patients and families, such as bathroom designations, artwork, posters, educational brochures, etc.
  (Reynolds, 2020)

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)

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, ve, xe, ze, per, 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.
  (Reynolds, 2020; LGBTQ+ Resource Center, 2024; Garrett, 2022)

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.

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.
• 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.
  (National LGBTQIA+ HEC, 2021)