Cultural Competence in the Care of LGBTQ Patients

Issues of Concern

Learning to care for members of the lesbian, gay, bisexual, transgender, or queer/questioning community involves understanding and being open to multiple special considerations and avoiding unconscious and perceived biases. Members of the LGBTQ community have unfortunately experienced a challenging history, but health professionals can learn to provide comprehensive, compassionate, and high-quality care with education. The following will assist the provider in caring for LGBTQ patients.[9]

Understanding Terms[10][11]

• Androgyny (gender-fluid, gender-neutral) – In between genders, having male and female characteristics.
• Asexual – Individuals who do not experience sexual attraction.
• Bisexual (pansexual, queer) – Individuals attracted to both males and females.
• Cisgender – Denoting a person whose personal identity and gender corresponds with their birth sex.
• Cissexism – Prejudice or discrimination against transgender people.
• Coming out – Sharing gender identity publicly.
• F2M/FTM (female to male) – Female at birth but identifies as male.
• Gay – Identify gender as male but are attracted emotionally, erotically, and sexually to other males.
• Gender – Emotional, psychological, and social traits describe an individual as androgynous, masculine, or feminine.
• Gender attribution – Process in which an observer assigns the gender they believe an individual to be.
• Gender binary – Belief that individuals must be one of two genders, male or female.
• Gender expression – Individual appearance, behaviors, dress, mannerisms, speech patterns, and social behavior associated with femininity or masculinity.
• Gender identity - Personal sense of gender that correlates with individually assigned sex at birth or can differ from it.
• Gender non-conforming – Gender behaviors that are in between feminine or masculine binaries.
• Gender role – Traditional behaviors, characteristics, dress, mannerisms, roles, and traits associated with being male or female.
• Genderqueer – Individuals that identify themselves as both feminine and masculine.
• Hermaphrodite – A no longer acceptable way of describing intersex individuals.
• Heterosexism – Discrimination against gay individuals based on the idea that heterosexuality is the normal sexual orientation.
• Heterosexual – Individuals attracted to members of the opposite sex.
• Homophobia – Prejudice against the gay community.
• Homosexual – Individuals attracted emotionally, erotically, or sexually to members of their sex. This term has been replaced with lesbian, gay, bisexual, transgender, or queer/questioning.
• In the closet – Hiding individual gender identity.
• Intersex – Individuals born with sexual characteristics not typical of male or female binary notions.
• Lesbian – Females that are emotionally, erotically, or sexually attracted to females.
• LGBTQ – Individuals that are lesbian, gay, bisexual, transgender, or queer/questioning.
• M2M/MTF (male to female) – Male at birth but identifies as female.
• Men who have sex with men (MSM) – Men who participate in sexual relations with other men regardless of sexual orientation.
• Queer – A general term refers to lesbian, gay, bisexual, transgender, and queer/questioning individuals, sometimes considered derogatory.
• Questioning – Individuals who are uncertain of their gender identity and sexual orientation.
• Same-gender loving – Bisexual, gay, and lesbian African American individuals.
• Sex assigned at birth – Sex assigned based on an infant's external genitalia.
• Sexual behavior – Individual's display of their sexuality.
• Sexual identity – Individual's description of their sexuality.
• Sexual orientation – Individual's sexual identity concerning their gender attraction.
• Transgender – Individuals whose gender expression is different from their birth sexual assignment.
• Transition – Individual's psychological, medical, and social transition process from one gender to another.
• Transphobia – Discrimination, harassment, and violence against individuals not following stereotypical gender identities.
• Transsexual – A term formally used to describe individuals whose gender identity differs from their assigned birth.

Patient Versus Provider Use of Slang Terms

Members of the LGBTQ community, in describing their sexual orientation or partners, may use terms such as fag, dyke, gay, homo, or queer. While patients may use these terms, they are considered derogatory when describing a patient by a healthcare provider. The provider and staff should listen to the LGBTQ patient and follow their lead, and when in doubt, ask the patient how they or their partner should be described. Once the terms are established, a note should be made in the record to follow the description pattern for future visits. Electronic medical records may require modification to provide appropriate terminology.[12]

Challenges To Caring for LGBTQ Community[9]

Healthcare providers without training and education often face challenges in the care of patients in the LGBTQ community, such as [13]

• Difficulty in openly discussing sexual health-related issues
• Due to higher rates of sexually transmitted infections among MSM, the CDC recommends annual screening for chlamydia, gonorrhea, HIV, and syphilis, as well as immunization for hepatitis A and B
• Failure to be familiar with gender modification surgeries
• Failure to be sensitive in addressing sexual acts or complications unique to the LGBTQ community
• Failure to remember to use gender-neutral terms such as significant other or partner
• Higher rates of anxiety, depression, and stress
• Higher rates of eating disorders
• Higher rates of homelessness
• Higher rates of sexually transmitted infections and HIV transmission
• Higher rates of tobacco and substance abuse
• Individuals may be reluctant to share sexual practices and hormone use
• Individuals may have prior traumatic experiences with clinicians
• Insensitivity towards individuals who may engage in relationships with multiple partners or individuals of the same sex
• Lack of understanding of behavior or terms and being uncomfortable in questioning meanings
• A tendency to make assumptions about behavior based on appearance
• Use of alternative medications such as black market hormones
• Using language or words that are derogatory or discriminate

How to Create A Practice That Welcomes Members of the LGBTQ Community[10]

There are several ways providers can welcome members of the LGBTQ community, such as:

• Advertise practices as accepting of members of the LGBTQ community
• Educate staff and providers to be comfortable in discussing sexual orientation, gender orientation, and sexual practices
• Include members of the LGBTQ community as part of your staff and train your staff to refer to patients by their name and chosen descriptive pronouns (Mr., Ms., Mrs., etc.)
• Maintain an open mind and avoid judgment regarding sexual orientation and practices
• On intake forms, include the term partner in addition to the spouse; include transgender as an option
• Participate in referral programs such as the GLMA or GayHealth
• Post LGBTQ symbols and posters of ethnically and racially diverse transgender or same-sex couples
• Provide patient brochures on sexually transmitted infection prevention, substance abuse, safe sex practices, and hormone therapy
• Provide waiting room magazines about the LGBTQ community
• Support observance of LGBTQ Pride Day, World AIDS Day, and National Transgender Day of Remembrance
• Train staff and provide continuing education on the care of LGBTQ patient

False Assumptions

Healthcare professionals may falsely make assumptions about LGBTQ community members, such as females who do not have children or are at low risk of sexually transmitted infections.

Violence Screening[14][15]

The LGBTQ community is often harassed and may be subject to violence. Transgender patients are particularly at risk. They may also experience domestic violence. As such, ask all patients screening questions such as:

• Are you now or have you ever been physically, mentally, or sexually abused by someone close to you?
• Are you currently abused in any way?
• Have you ever been sexually assaulted?
• Are you afraid of anyone?

Patients should be informed confidentiality will be maintained as much as state reporting levels allow.

Special Needs of Bisexual and Lesbian Women[9][16]

A woman identifying as bisexual or lesbian may range from feminine to masculine. Their needs are similar to those of all women, but they may have the following additional needs. Healthcare providers must ensure these patients feel comfortable disclosing their sexual practices. In general, these patients have similar healthcare needs to heterosexual patients. If they have challenges, they usually stem from lifelong discrimination and harassment, resulting in anxiety, depression, and stress. Bisexual and lesbian women may face additional challenges, such as:

• The belief that pap smears and regular screening are not necessary
• The desire for childbearing and the need to discuss options for conception
• High-risk behaviors such as multiple sex partners result in higher rates of sexually transmitted infections and HIV
• Higher rates of alcohol, drug, and tobacco use are secondary to chronic stress associated with discrimination and homophobia
• Higher rates of being overweight or obese with associated diseases such as diabetes, hypertension, and heart disease
• Higher rates of depression are often associated with a lack of acceptance by friends or family
• Higher rates of some cancers due to less childbearing
• Lower health insurance rates than heterosexual women, with fewer funds available for expensive prescriptions and follow-up visits
• Lower pregnancy rates, and when they do bear children, are more often at an older age
• Some states do not recognize same-sex domestic violence, and women's shelters may discriminate

Special Needs for Bisexual and Gay Men[16]

The healthcare needs of bisexual and gay men are similar to those of the general male population. However, they have higher rates of domestic violence, substance abuse, and depression. Due to a higher rate of homophobia in certain cultures, such as African Americans, Asians, Latinos, and Pacific Island, men may have even higher rates of mental health challenges. Bisexual and gay men may face additional challenges, such as:

• Exclusion from community and family due to shame and embarrassment associated with some cultures
• Higher rates of alcohol, substance, and tobacco use
• Higher rates of anxiety, depression, and suicide
• Higher rates of human papillomavirus-associated with anal cancer
• Higher rates of poverty
• Higher rates of weight problems and obesity
• Higher risk of HIV and sexually transmitted infection transmission associated with anal sex
• Less access to health insurance through a marriage
• Staff sensitivity training

The healthcare provider should ensure that the staff is trained to care for and speak to LGBTQ patients appropriately and ethically, further understanding that discrimination is illegal and morally unacceptable. Religious beliefs or negative feelings must be put aside.[13] Address such issues as:

• Avoid discriminatory beliefs
• Basic knowledge of issues in the LGBTQ community, including depression, discrimination, domestic violence, harassment, HIV, homophobia, safe sex, sexually transmitted diseases, substance abuse
• Use of appropriate language

LGBTQ Is Not A Disease

Regrettably, at one point in medical history, being LGBTQ meant having a psychiatric disease. Fortunately, after years of lobbying, in 1973, the American Psychiatric Association members voted to determine if homosexuality was a disease. The ensuing vote led to a compromise, and homosexuality as a diagnosis was removed from DSM-II. It was replaced with "sexual orientation disturbance" for patients "in conflict with" their sexual practice and orientation. Later, in 1987, homosexuality was removed entirely from the DSM.

LGBTQ Features, Medical, and Surgical Therapy[17][18]

LGBTQ has two distinct features: gender identity and sexual orientation. Therefore, when obtaining a history, providers should ask about gender identity and sexual orientation and gender identity to better understand patients' health risks.

Sexual orientation for gay and lesbian individuals usually involves being attracted to people of the same sex, whereas heterosexuals are primarily attracted to individuals of the opposite sex. Sexual orientation is an identity label and sometimes does not correspond to a person's sexual behavior.

Gender identity for transgender patients identifies sex other than the one assigned at birth, whereas cisgender patients identify with the sex they were given at birth. The term transgender also includes patients who identify gender as non-binary, meaning their gender identity is not exclusive to males or females.

When evaluating a patient, use non-gendered words and assess how they describe the person they are in a relationship with. Listen to how the patient describes the relationship. For example, a transgender couple may prefer to be described as a same-gender couple and not a straight couple. Likewise, people in a relationship with nonbinary genders may prefer the term partner.

Providers should not assume gender or sexuality. While sex may be documented, it is essential to be culturally sensitive and use the name they wish to be called.

Transgender Transitional Care

Transgender individuals may seek medical and surgical gender-affirming interventions. This includes hormone therapy, facial hair removal, surgery, speech modification, genital tucking, and chest binding. Some consider these procedures medically necessary. The current standard of care allows transgender patients to determine what interventions they need to affirm their gender identity.

Surgery

Surgeries available to the transgender populations include feminizing vaginoplasty, masculinizing phalloplasty, scrotoplasty, masculinizing chest surgery, facial feminization procedures, reduction thyrochondroplasty, and orchiectomy. These procedures are considered cosmetic; however, some patients believe they help their gender identity.

Hormone Therapy[17]

Gender-affirming hormone therapy is a common medical intervention used by transgender individuals. Such treatment allows secondary sex characteristics aligned with an individual's gender identity. For example, hormones are used to suppress male secondary sex characteristics in favor of developing female secondary sex characteristics. The therapy approach combines androgen and estrogen and sometimes adds progestogen.

Estrogen 

The estrogen 17-beta estradiol, chemically identical to that produced by the ovary, is commonly used for feminizing therapy. The drug is given via cream, oral, sublingual, or transdermal routes. Conjugated equine estrogens have been used but are no longer prescribed due to potential blood clots, increased cardiovascular risk, and ethical considerations.

Androgen Blockers

Androgen blockers (antiandrogens) often suppress testosterone production and male secondary sexual characteristics. However, the effect is less reliable because the sexual characteristics established by puberty are typically not reversible. Spironolactone, a potassium-sparing diuretic, has an antiandrogen effect on testosterone production at high doses of 200 to 400 mg/day. Hyperkalemia is a severe side effect. In addition, patients may develop polydipsia, polyuria, and orthostasis. Monitoring should be frequent if the patient takes an angiotensin receptor blocker (ARB) or ace inhibitor. Androgen blockers may be used as single agents to decrease masculinization in patients with contraindications to estrogen therapy. Side effects may include reduced energy, mood depression, and hot flashes.

Testosterone

Testosterone that is identical to testosterone secreted from the human testicle is injected or used topically for non-transgender men with low androgen levels. Therefore, higher dosing may be needed in transgender men than in non-transgender men.

Hormonal Therapy Effects[19]

• Body hair reduction
• Enhanced breast development
• Erectile function reduction
• Facial and body fat redistribution
• Feminine emotions
• Feminine odor
• Libido reduction
• Muscle mass reduction
• Reversal of scalp hair loss
• Sperm count and ejaculatory fluid reduction
• Sweat reduction
• Testicular size-reduction

Reproduction[20]

Bisexual women, lesbians, and transgender men face pregnancy challenges. For cisgender, female, same-sex couples who lack a sperm-carrying partner, childbearing requires fertility support. Transgender men are challenged by a male-presenting pregnant.

Gynecologic Risks

Risk factors include:

• Bisexual women, lesbians, and transgender men are less likely to receive pap tests.
• Cisgender women who have sex with women who have both male and female partners may be at increased risk of sexually transmitted infections and HIV.
• Lesbians may be at increased risk of polycystic ovary syndrome.
• Transgender men who have sex with men may be at increased risk for HIV infection.

Promoting LGBTQ Privacy and Confidentiality[21]

Some members of the LGBTQ community may not make their gender or sexual orientation public. Further, they may not be used to discussing their relationships with others. The health provider must assure the patient that their communication and medical records, including tests and results, are confidential.

While no laws specifically address the LGBTQ community, the following regulations address privacy.

HIPAA Privacy Rule respects the patient's wishes on privacy matters. Therefore, hospitals and providers may only disclose a patient's PHI to a family member, relative, close friend, or any other person the patient identifies.

The Patient Protection and Affordable Care Act prohibits sex discrimination in any institution that receives federal funds. In addition, the law prohibits discrimination based on gender identity, requires that all gender identities be treated equally, prohibits the denial of health coverage based on gender identity, pregnancy, and sex stereotyping, and requires individuals to be treated consistent with their gender identity.

Clinical Significance

All healthcare providers interact with members of the LGBTQ community. Interaction in a positive manner will improve patient outcomes. Providers must understand the LGBTQ population's history, unique health concerns, and risks, develop communication skills to avoid discrimination, and provide compassionate care.

Health professionals should know that the LGBTQ population experiences higher challenges due to discrimination, social pressures, sexual behaviors, and less healthcare access. The LGBTQ populations have higher rates of tobacco use, sexually transmitted diseases, and depression. To provide the best care and achieve better outcomes, all healthcare providers need to learn and understand the unique needs of LGBTQ patients.

Other Issues

Mental Health and Suicidal Risk

LGBTQ individuals are observed to have more mental health issues than their heterosexual peers and social support can make a huge difference.[22] Sexual and gender minority adolescents are at an increased risk for suicide. Many studies have established a strong correlation between mental health symptoms and minority stress, as well as suicidality and minority stress.[23] LGBTQ individuals have been observed to have a higher risk of suicidal behavior owing to perceived stigma and psychopathology. However, community connectedness and other protective factors may reduce risk. Exposure to minority stress is the primary mechanism through which LGBTQ youth experience a higher risk for suicide.[24]

Affirmative Psychotherapy

Affirmative therapy embraces a positive view of LGBTQ identities and relationships. It addresses the negative impact that transphobia, homophobia, and heterosexism have on LGBTQ individuals. LGBTQ-affirmative therapy providers in primary care can conduct tailored assessments and interventions to address the sexual and gender minority stress impacts perpetuating psychological distress in LGBTQ individuals.[25]

Risks Associated with Chemsex

Chemsex is using certain drugs before or during planned sexual activities to facilitate, prolong, enhance, and sustain the experience. A minority of men who have sex with men (MSM) appear to engage in chemsex behaviors, which puts them at risk of negatively influencing their health and well-being.[26] In the United Kingdom (UK), more than half of all new HIV infections are attributable to MSM, which shows that they are at higher risk of the disease as opposed to the general population.

LGBTQ Bullying and Adolescent Concerns

LGBTQ youth experience significant bullying, undermining their mental and physical health. Pediatricians and primary care providers, school leaders, government officials, parents, and community members should engage in efforts to provide an inclusive and affirming environment wherein LGBTQ youth could feel comfortable sharing their experiences and identify peers experiencing LGBTQ bullying. This will prevent the adverse effects of bullying on the health and well-being of children and young individuals.[27] Peer victimization of LGBTQ youth and the resultant poor outcomes have been the focus of countless studies. Numerous studies report that peer victimization is an antecedent to depressive features and that school belonging mediates the association.[28] It has also been reported that most physicians do not regularly discuss sexual orientation, gender identity, or sexual attraction while taking a history from a sexually active adolescent. These barriers must be identified and worked on to provide optimal care to LGBTQ adolescents.[29] Schools are often unsafe for LGBTQ students; they frequently encounter negative or hostile school circumstances, such as bullying and discrimination due to sexual orientation and gender identity.[30]

Enhancing Healthcare Team Outcomes

Better patient outcomes will be achieved in the care of the LGBTQ community if providers learn the terms, understand healthcare risks, and maintain a wealth of knowledge in the care of these patients. Remember to use gender-neutral language, consider the possibility of anxiety and depression, and evaluate for sexually transmitted infections.

It is most important to respect LGBTQ patients and remember that the challenges they face from society are substantial.