Enhancing Clinical Skills in Caring for LGBT Clients in a Hospital Setting

Sponsored by the Department of Social Work Programs, Staff Development Committee, LGBT Committee


Nathan Levitt, RN

Registered Nurse, Oncology Unit, Maimonides Medical Center
Community Education Nurse, Callen-Lorde Community Health Center

LGBT people face many barriers within health care, including discrimination, ignorance, and fear. The lack of informed care, sensitive language, research, and data prevents access to competent routine care and screening. LGBT health is emerging as a national concern due to the growing body of evidence indicating significant health care disparities experienced by the LGBT community.

In the last year, the Institute of Medicine (IOM) and The Joint Commission have published reports underscoring the need to address inequalities of care for the LGBT population. These landmark documents have recognized that LGBT health requires specific attention from health care and public health professionals. The more informed social service and health professionals are, the more comfortable LGBT clients will be within a setting that can be alienating.

Learning Objectives:

  1. Using The Joint Commission Field Guide, Advancing Effective Communication, Cultural Competency and Patient and Family-Centered Care for the LGBT Community, participants will be able to identify and address challenges to providing quality health care to LGBT clients in the health care setting.
  2. Participants will learn strategies and skills to enhance clinical screening, assessment, and interventions with LGBT clients.
  3. Through case examples and practice, participants will be able to apply these principles in their daily practice.
  4. Participants will identify community resources available for LGBT clients.

Why it is important to have a training on providing care for LGBT clients

Healthcare providers bring their own biases about sexual orientation and gender to their work, even when they don’t realize it. It’s important to consider what kind of biases we all carry with us while providing care to this community.

Many LGBT people, especially transgender, avoid seeking both preventative care and care for urgent or life-threatening conditions. This is because it has been their experience that very few healthcare providers have supportive and sensitive services for the LGBT population.

Creating A Welcoming Environment for LGBT Clients

LGBT patients enter the environment and immediately ask themselves, “Will I be accepted here? Is this a place where I will feel comfortable? Does anyone here look like me? Are there materials available here for my community?”

We, as healthcare workers, can:

  1. Establish trust and rapport with patients.  Even when workers know how to ask questions about sexual behavior, identity and attraction, they may not feel comfortable doing so. In this situation, their discomfort may be communicated to LGBT patients.
  2. Normalize and validate – ask the questions as you would to any patient.
  3. Ask open-ended questions – “Tell me about yourself?  Are you involved in a relationship?”  Do not assume anything about the relationship, the partner, or the sexual behavior.  Don’t assume you know anything about their sexual behavior based on how they identify or with whom they are partnered.  Let the information that emerges guide the rest of your interview.
  4. Be aware of issues particular to, or different for, the LGBT population:
    • Coming out
    • Having children—reproduction or adoption
    • Parenting and creating families
    • Adolescence
    • Aging
    • Legal rights as parents and partners

Breaking Down the Terms

It is important to think along a continuum, when considering sex, gender, gender identity, and sexual orientation, rather than binary categories.

  • Sex: This refers to the genitalia one is born with – male, DSD (Differences of Sex Development, also known as Intersex), female.
  • Gender relates to:
    • Gender Expression—how one expresses gender—masculine, androgynous, feminine continuum.
    • Gender Identity—how one feels on the inside—man, genderqueer, woman continuum.  Gender identity is determined by the individual, and is felt on the inside, so you need to ask how one identifies—it is not apparent on the outside. 
    • For transgender people, their assigned gender and bodies do not match up with their gender identity.
  • Sexual Orientation: This refers to whom you are attracted. This is different from gender or gender identity. You cannot assume one’s sexual orientation – you have to ask to know.
    • Transgender: People who feel the binary (m/f) gender assigned to them at birth is misleading, incomplete, or does not match how they feel on the inside. 
    • “Transwoman” refers to someone who was assigned male at birth and lives and/or identifies as a woman.
    • “Transman” refers to someone who was assigned female at birth and lives and/or identifies as a man.
    • If someone identifies as a transman, use masculine pronouns; if someone identifies as a transwoman, use feminine pronouns.
    • If you need to ask body-related questions, explain why you need the information, so the person doesn’t think you are just curious. You cannot assume a transgender person’s sexual orientation; again, you must ask to know.
  • Cisgender: People whose gender identity and gender expression align with the sex they were assigned at birth.
  • Gender Non-Conforming: People whose gender identity and expression do not align with the sex they were assigned at birth.
  • Gender Neutral Pronouns: “zie”, “hir”, “they”.  Let patients decide on their own pronoun and do not question its grammatical correctness.
  • Gender Transition: Many different ways exist – medically (hormones, surgery), legally (name, pronoun).  Do not assume that “transitioning” means medically – ask.  If the name that the patient gives does not match the one on the ID, know that this is a scary issue for transgender people and ask with sensitivity.

Understanding the Barriers

LGBT Health Disparities

Transgender and LGBT people experience more fears and concerns about accessing health care across the board.

Common barriers LGBT people experience accessing healthcare:

  • LGBT individuals are less likely to have health insurance than their heterosexual counterparts. [1] 
    • Insurance plan language may exclude coverage for routine care and for transition-related care (hormones, surgery often not covered)
    • Insurance plan may have a narrow definition of families, and not include “chosen” family of LGBT people.
  • Previous negative experiences in healthcare settings can scare LGBT individuals from obtaining medical care.
  • Lack of provider information and knowledge about LGBT health needs and risks prevent LGBT individuals from receiving proper medical care.
  • A lack of LGBT-specific research, policies and procedures can hinder proper medical care and treatment.
  • LGBT individuals may experience multiple stigmas, including race, class, ability, geographic location, and immigrant status. For example, studies show reduced access among LGBT people of color.

Health issues that affect the LGBT community:
 
The following are health issues that the LGBT community faces frequently and what we as healthcare workers should pay attention to. Since LGBT people facing discrimination in healthcare are less likely to come in for care, these issues may be especially pressing and we would want to pay attention to them. Due to perceived discrimination in healthcare LGBT patients are less likely to access healthcare consistently.

Therefore, the LGBT community when presenting for care may be at higher risk for the following health issues or may present with more acute or severe manifestations: [2],[3]

  • Smoking, alcohol, and substance abuse. [4]
  • Mental health illnesses, such as anxiety and depression.
  • Sexual and reproductive health.
  • Eating disorders, obesity.
  • Cardiovascular health.
  • Higher rates of sexually transmitted diseases.
  • Increased risk of cancer, due to decreased screenings. [5]
  • Limited evidence-based research on hormones. [6]
  • Intimate Partner Violence (IPV)
    • Do not assume there is less IPV in the LGBT community. What is unique to LGBT IPV is that abusers may threaten to “out” partner to family, employer, etc.  Also, there are fewer sources of support – LGBT people may not want to be in a support group with heterosexual IPV victims. As a result, IPV is underreported in the LGBT community. [7]

LGBT Needs Across the Life Span

Special considerations for LGBT youth: [8]

  • Increased risk for suicide and depression.
  • Increased smoking, alcohol and substance use.
  • A huge percentage of homeless youth in NYC are LGBT because they have been kicked out of their homes.  [9]
  • Higher levels of violence, victimization and harassment (including bullying in school).  [10]

Special considerations for LGBT older adults: [11],[12]

  • Stigma, discrimination and violence, isolation, and lack of family support can affect all LGBT people, but older adults, in particular, may have a more limited support system. They are subject to the rules and attitudes of nursing homes, assisted living facilities, where they may experience homophobia/transphobia.
  • There may be Social Security and pension plan exclusions. For example, they may be unable to go on a spouse’s plan if their relationship is not legally recognized.
  • Although recently passed federal regulation seeks to insure nondiscrimination for hospital visitation rights, this may still be a concern at some hospitals.
  • Community programs and resources which are specific to the needs of LGBT older adults may be limited.

Transgender Health

Statistics: 

  • 48% of transgender adults have delayed or avoided medical care, compared to 29% LGB adults and 17% heterosexual adults. [13]
  • 41% of transgender adults can’t change their gender on their ID’s (Rules vary by state; in NY state, need physician letter stating you have had gender re-assignment surgery), 57% Transgender people were rejected by their families, 19% have experienced homelessness, 19% have been refused medical care, 47% have attempted suicide. [14]
  • Transgender adults experience significantly higher rates of healthcare providers being unaware of their health needs, refusing to provide care, providing worse care, or treating them poorly during provision of care than LGB adults.  [15]

Barriers to healthcare trans people encounter:  [16]

  • Denial of healthcare.
  • Lack of informed care.
  • Lack of insurance coverage for medically necessary gender-related care. For example, a transman needing gynecological care may be denied by the health insurance.
  • Sex segregated services, like homeless shelters, are based on gender.
  • Inappropriate name or pronoun use. If this occurs, it is important to acknowledge mistakes and apologize.
  • When asking questions about genitalia or transgender status, explain why you need the information, so it is clear you are not just curious.  If you don’t need information about genitalia or transgender status in order to provide care, refrain from asking.
  • If intake forms do not always allow for proper taking of information or if questions are offensive, this creates a barrier.
  • Confidentiality/Privacy are not always respected. You may be the only person in the setting to whom the patient reveals his/her transgender status. Be careful how you treat this information.  Ask the patient how they want the information to be treated. For example, information to be put in the computer system or not, or revealed to the physician or not.
  • In sum, it is very important to provide sensitive care, so that LGBT people will feel comfortable and not be denied, or turn away from, care and treatment.

Integrating Strategies

  • Look around at the environment. Try to imagine what it will be like for an LGBT person to come in the door and use the facility, including the restroom facilities.
  • Think about what LGBT people might have already experienced out on the street, such as violence or discrimination, on their way to the hospital.
  • Take a look at the healthcare brochures available in your setting to see if they seem inclusive for LGBT people.  If not, you can acknowledge that the information is not inclusive and say, “But here are the parts of it that I think are relevant to you.”  Just being aware of this and acknowledging it will make someone more comfortable. 
    • Callen-Lorde Community Health Center, a primary health care center in New York City dedicated to meeting the health care needs of the lesbian, gay, bisexual and transgender (LGBT) communities and people living with HIV/AIDS has helpful resources available.
    • Rainbow stickers go a long way to make LGBT people comfortable in a healthcare environment. For example, employees should feel comfortable exhibiting rainbow stickers at their work station.

Useful Guides for Health Professionals:

Policies:

  • LGBT patients and their will feel most comfortable when written and posted policies regarding discrimination, diversity and non-harassment specifically include LGBT people. Health professionals should know the policies of the hospital, in case they are asked.

Registration forms:

  • Callen-Lorde has good examples of how LGBT needs can be integrated into medical forms:
    • Ask for legal names and chosen names, partner information, sex assigned at birth, gender identity, sexual orientation, gender as listed in health insurance claim, and say why the information is needed. This is important because LGBT people may be afraid to provide this information. 

Asking Questions: 

  • Be sure to use sensitive language when asking relevant questions. Ask necessary questions using sensitive language:
    • “What gender pronoun would you like me to use?”
    • "How do you define/identify your gender?” 
    • “What are the words you use to describe your body parts?” 
  • You have to ask everyone, not just patients who think “might” be LGBT, otherwise this could be offensive. 
  • Ask open-ended questions:
    • “Are you in a relationship? – Tell me about it,” rather than, “Are you married?” or “Do you have a girlfriend/boyfriend?”
  • When talking with patients, do not assume a patient calls himself “gay”.  Everyone has their own terms – ask!  Use the language they use, including pronouns. Be respectful and empathic. If you are not sure what terminology to use, ask the patient.

Documentation: 

  • Be sensitive to pronoun usage. Only document information that is relevant to patient care.

Conclusion

Mr. Levitt ended his presentation with a discussion of several case examples that can occur in a hospital setting.

  • How we can manage differences in the name patients identify versus their birth name, as well as pronoun usage, with our colleagues was addressed. How this is routinely addressed in other health care settings was discussed.
  • Assessment questions that we can routinely be asking in order to obtain more information were explored.
  • How cultural difference/norms impact LGBT terminology and our language as clinicians was discussed.

Kathryn Klingenstein, LMSW, Social Work Programs Department
Emily Reiss, LMSW, Social Work Programs Department


Speaker Bio
Nathan Levitt works as a Registered Nurse on the Oncology Unit at Maimonides Medical Center and as the Community Education Nurse at Callen-Lorde Community Health Center. Nathan has worked as a community organizer, researcher, consultant, trainer, and health educator with international and national organizations for 15 years and currently provides trainings on lesbian, gay, bisexual, and transgender health for hospitals and health centers.

LGBT Health Resources

Footnotes:

1. Movement Advancement Project (MAP). (2011). LGBT Families: Facts at a Glance.
2. Gay and Lesbian Medical Association (GLMA). (2001). Healthy People 2010: Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health.
3. Ard KL., Makadon HJ. (2012). Improving the health care of lesbian, gay, bisexual and transgender (LGBT) people: Understanding and eliminating health disparities. The National LGBT Health Education Center. The Fenway Institute. 
4. U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Prevention. (2012). Top Health Issues for LGBT Populations Information & Resource Kit
5. The National LGBT Cancer Network. (2014). The LGBT Community’s Disproportionate Cancer Burden.
6. University of California, San Francisco (UCSF) Center of Excellence for Transgender Health
7. National Coalition of Anti-Violence Programs (NCAVP). (2013). Lesbian, Gay, Bisexual, Transgender, Queer and HIV-Affected Intimate Partner Violence In 2012. 
8. Human Rights Campaign (HRC). (2013). Growing up LGBT in America: HRC Youth Survey Report Key Findings.
9. Lambda Legal , National Alliance to End Homelessness, National Network For Youth (NN4Y) and National Center for Lesbian Rights (NCLR). (2009). National Recommended Best Practices for Serving LGBT Homeless Youth
10. Kosciw JG. (2004). The 2003 National School Climate Survey: The school-related experiences of our nation’s lesbian, gay, bisexual and transgender youth. The Gay, Lesbian and Straight Education Network (GLSEN). 
11. Services and Advocacy for Gay, Lesbian, Bisexual & Transgender Elders (SAGE). (September 2010). LGBT Older Adults: Facts at a Glance.
12. National Resource Center on LGBT Aging. (2013). 
13. Krehely, J. (2009) How to close the LGBT health disparities gap. Center for American Progress. 
14. Grant, JM., Mottet, LA.,Tanis, J., Harrison, J., Herman, JL., & Keisling, K. (2011) Injustice at every turn: A report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Task Force. 
15,16. Lambda Legal. (2010). When Health Care Isn’t Caring: Lambda Legal’s Survey On Discrimination Against LGBT People and People Living with HIV.

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