Today in the chart

Every year, Pride Month serves as a time to reflect. What good have we done for the LGBTQIA+ community? Where do we still need to improve? Nurses have an essential responsibility as patient advocates to set aside their personal biases and worldview to focus on how to provide inclusive healthcare to all marginalized communities, including those who are LGBTQIA+. Although the scope of this issue is broad and nuanced, taking a birds-eye view of LGBTQIA+ inclusivity in healthcare allows nurses to examine the part they play in improving the system overall.

Discrimination and Social Stigma in Healthcare

Toni Ramirez, MD, a physician and Gender-Affirming Health Services Provider at Centro San Vicente, says that the beginning of understanding the community is to realize that each letter in the LGBTQIA+ acronym has a vastly different experience. 

Although many nurses and healthcare providers are well-intentioned, all types of members of the LGBTQIA+ community still face discrimination that includes unfair treatment, prejudice, and microaggressions (defined as subtle, often unintentional, verbal or non-verbal behavior or comment that communicates derogatory or harmful messages about a marginalized group). 

Microaggressions could include misgendering someone or making assumptions about someone or their relationships. Benjamin Lindsay, MS, RN, CCRN, a Nurse Educator in Rochester, NY, whose pronouns are they/them/theirs, says, “It’s uncomfortable when a provider doesn’t ask for my pronouns.” Lindsay clarifies that it’s incorrect to ask for ‘preferred pronouns,’ and dropping the ‘preferred’ language “removes the choice and leverages respect for the individual.” 

Taking the time to clarify the biological sex and gender identity with patients is important to cater care to the individual, says Lindsay. Although asking a patient these questions can be uncomfortable, Lindsay further explains that the truly vulnerable counterpart in a healthcare situation is the patient, and a thorough intake is necessary for proper care.

‍How Can We Improve?

• Get curious about people’s stories. Most nurses already routinely practice empathy, so asking members of the LGBTQIA+ community about their experiences can reinforce that trait even more.

• Consider learning about the LGBTQIA+ community through media. Lindsay recommends learning more at LGBTQIA Health Education.org or from The Trevor Project. For more lighthearted media, they suggest RuPaul’s Drag Race, which often highlights the backstories of their contests or movies like Rent or Bohemian Rhapsody.

The Pathologization of the LGBTQIA+ Community

The pathologization of the LGBTQIA+ community is when healthcare workers label sexual orientation and gender identities that deviate from the “norm” as mental disorders. A 2016 statement from the United Nations states that this pathologization “has historically been, and continues to be, one of the root causes behind the human rights violations that they [the LGBTQIA+ community] face.”

For example, until 1994, the World Health Organization had “transsexualism” listed as a mental health diagnosis with its own ICD-10 code for medical billing. However, the DSM-5 only recently changed the diagnosis of “gender identity disorder” to “gender dysphoria” in 2012. 

‍How Can We Improve?

• Learn more about gender and sexuality in general. Dr. Ramirez recommends that clinicians opt to learn more about gender in general. This education includes the history of gender, how pervasive it can be in society, and how it impacts medical care. Learning about the history and impact of gender can reveal a lot about how LGBTQIA+ persons might feel excluded or stigmatized when seeking medical care.

• Change language that refers to members of the LGBTQIA+ community. One example Dr. Ramirez gives is to avoid using the term “normal” when discussing sexuality. Dr. Ramirez suggests that medical providers instead use the words “common” or “uncommon.” Another one is to swap “treatment” for “gender-affirming care.” The term “treatment” implies a pathology that needs to be treated, while gender-affirming care assumes that the patient is receiving services that affirm their identity.

Moving Towards Cultural Humility

Also known as cultural competency, Dr. Ramirez says she prefers cultural humility because it reflects an ongoing process. “You can never really say you are fully competent in a culture you don’t identify with,” she adds. You can’t “graduate” from continually being willing to learn about the experiences of those around you.

Kay Nikiforova, MA (they/them/theirs), the Head of Clinical and Research at Violet, a healthcare equity platform, weighs in on cultural humility and says that biases can arise from assumptions about a patient’s experiences. 

Implicit or subconscious bias is unintentional and impacts our outward behaviors toward others. When individuals examine their implicit biases, they become more self-aware of their attitudes toward specific groups. They can then be more inclusive and sensitive with their words and actions. For example, healthcare professionals that exhibit implicit bias may feel especially harmful to members of the LGBTQIA+ community, as seeking healthcare is a vulnerable experience already. 

How Can We Improve?

• Advocate for improved organizational diversity/equity/inclusion (DEI). Not all companies have DEI programs, which often provide training on implicit bias and prejudice. Leaders of established DEI programs often serve as sounding boards to ensure that company policies and culture are non-discriminatory.

• Seek out education from community members. “We assume that as medical providers, we know better. But some of the best things taught to me in medicine were by the layperson”, Dr. Ramirez explains. If her healthcare network wasn’t setting up community involvement programs, she sought these interactions out herself. The best way to learn about the LGBTQIA+ experience is to ask a community member.

‍Barriers to Healthcare

Nikiforova recommends that we take a strength-based approach. “Much of the discussion about LGBTQIA+ health revolves around health disparities and death statistics. Instead, culturally competent clinicians look for protective factors as much as they look for risk factors. In addition, culturally competent care involves being informed about the clinical best practices for communities and how to deliver it in the most sensitive, unassuming manner”, they say.

Dr. Ramirez says that the main barriers to healthcare that the LGBTQIA+ community face is rooted in the fact that medicine sees the world as a binary. Whereas other cultures throughout history have seen gender as a more fluid concept, medicine and medical studies see the world through a gender binary lens.

Some of the main barriers to healthcare she sees in her practice with the transgender community include the struggle of those still on a journey of self-discovery with their sexuality and/or gender identity. These individuals may not feel comfortable even indicating their sex or sexuality on a clinic intake form, which might delay the opportunity they have to receive healthcare. Or they may be assumptively called “sir” or “ma’am” by a receptionist while setting up an appointment, which could prevent them from feeling comfortable with that office. 

‍How Can We Improve?

• Advocate for education for healthcare workers on LGBTQ+ health disparities. Lindsay says they have had experiences where medical providers don’t know that PrEP is a pre-exposure prophylaxis for HIV, and having to explain that to their medical provider doesn’t make them feel safe or adequately cared for. 

• Spread information on which clinicians are competent in serving the LGBTQ+ community. Nikiforova says, “Having that information readily available in any platform they’re using will allow LGBTQIA+ patients to get the safest, kindest, and most clinically effective care. Violet Benchmarks can provide a nuanced understanding of how well a provider delivers inclusive care.”

Nurses As Advocates

The American Nurses Association's statement on LGBTQIA+ advocacy reads, “The nurse-patient relationship is at the core of healthcare. Nurses practice with compassion and respect for the human rights of all individuals regardless of sexual orientation, gender identity, and/or expression.”

As nurses, we are responsible for advocating for all marginalized communities, including the LGBTQIA+. We must push for systemic change that takes care of every human in our healthcare system.