Running head: LGBT BARRIERS 1

Culturally Sensitive Screenings for LGBT Patients Reduce Barriers to Healthcare

Janet Palmer
Western Washington University
Nursing 305
Julie Samms
11/22/16
LGBT BARRIERS 2

Culturally Sensitive Screenings for LGBT Patients Reduce Barriers to Healthcare

Seeking healthcare can be a stressful process if patients do not feel that their lifestyle is

one that is socially approved. For lesbian, gay, bisexual and transgender (LGBT) persons, this is

certainly true. The stigma that surrounds this lifestyle is changing in the U.S., but many parts of

the country are still slow to follow the changes. Health care should be a place this sexual

minority can feel safe in a non-judgmental environment, however, hetero-normative bias can

make these patients feel excluded from services even before these patients come face-to-face

with a provider (Capriotti & Gillespie, 2016). As a person who identifies as LGBT, I have

encountered this bias in my own search for health care and a new primary care provider. I was

given a health history form as a new patient and told to fill it out, but when I got to the sexual

history portion of the paper, the questions left me unable to fit my answers into the blanks and

the questions didnt really apply. What form of contraceptive do you use? was not a question

that applied to my lifestyle. This caused questions of my own to run through my head such as:

would the provider I had chosen to see be able to meet my health care needs; would they judge

me for my life choices? This same sense of confusion and exclusion can cause LGBT persons to

feel like their healthcare provider will not meet their needs.

Stigma, hetero-normative bias, and unease with LGBT needs on the part of providers all

contribute to increased barriers faced by this sexual minority (Capriotti & Gillespie, 2016;

Dahlhamer, Galinsky, Joestl, & Ward, 2016). Fear of stigma and homophobia from providers

can keep LGBT persons from seeking timely healthcare (Khalili, Leung, & Diamant, 2015).

Negative experiences in healthcare can be caused by stigma: either real, perceived or internalized

on the part of the LGBT person (Dahlhamer et al., 2016, p. 1116). Within the LGBT population
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certain sub-groups, such as gay men, also reported to have increased difficulty finding a provider

at rates more than double their heterosexual counterparts. (Dahlhamer et al., 2016, p. 1121).

Fear of disclosing sexual orientation can cause this sexual minority to not only delay

care, but to receive inadequate care when they do seek healthcare services (Dahlhamer et al.,

2016). Reluctance to disclose sexual orientation is more pronounced among older populations

within this minority because historically this lifestyle has been associated with psychiatric labels

and criminal punishment (Harding, Epiphaniou, & Chidgey-Clark, 2012; Skerle & Lawler,

2015). Lack of culturally sensitive and competent care can lead to gaps in health prevention and

screening (Dahlhamer et al., 2016). In one study, Nguyen and Yehia looked at documentation of

sexual partner gender in the electronic medical record (EHR) of primary care practices (2015).

Their findings showed that documentation of gender of sexual partners was low in all areas; only

45% of patients in the study had the gender of their sexual partner documented in the medical

record (Nguyen & Yehia, 2015). If the conversation about sexual orientation is not happening

with providers due to their discomfort with the subject of sexual health, then opportunities for

health risk assessment, preventative screenings, and holistic care are lost (Nguyen & Yehia,

2015). Nursing can recognize and mitigate barriers to healthcare for LGBT patients through

culturally sensitive health screenings, education, and holistic care that includes their partners.

Search Process

To find articles, CINHAL database was searched using keywords of GLBT and sexual

health. Further review lead to changing the search to include GLBT and primary care.

Options were then narrowed by publishing date and country to have articles newer than 2011 and

published in the U.S.

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Improving Health History Taking

Gender inclusive forms can reduce barriers to healthcare for transgender patients yet few

facilities use them. For people who identify as transgender, what gender they present as can

change with the situation and how safe the patient feels. In order to better identify transgender

persons, health history intake forms should be amended to offer more options than just male,

female, or transgender. To capture this population as they transition from one gender to another,

it is best to use two questions on the health history. The first question should be about gender as

assigned at birth and the second question should offer current gender identity options that

include: male, female, transgender, genderqueer, or other. The option to fill in what gender they

would like to be addressed with should also be presented (Carabez, Pellegrini, Mankovitz,

Eliason, & Scott, 2015).

Sexual health histories for LGBT persons need to be detailed and specific, yet performed

in a non-judgmental way. By not doing a detailed health history on LGBT persons, gaps in care

can occur leaving this population open to risk from sexually transmitted diseases (STD) and STD

related terminal illness. Each of the sub groups in this sexual minority needs to be screened for

STDs related to their sexual lifestyles. Gay men, or men who have sex with men (MSM) as

referred to in the medical literature, are at increased risk of human immunodeficiency virus

(HIV), hepatitis, and human papilloma virus (HPV) and should be screened for STDs and HIV

yearly. Many women who have sex with women (WSW), continue to have sex with men as well

or have previously done so; this requires them to be also screened for STDs related to

heterosexual sex. Transgender patients may have sex with men, women or both and need to be

screened for STDs related to specific sexual activity engaged in by the patient. Transgender
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persons also have unique health screenings for cancer risk related to anatomy and surgical

history (Capriotti & Gillespie, 2016).

Education

In order to provide thorough care to LGBT persons providers need to be familiar with the

care needs of the population and feel comfortable with providing this care, but many providers

are not (Khalili et al., 2015, p. 1114). To effectively obtain a detailed sexual history, it needs to

be done in a confidential, sensitive, and non-judgmental way (Capriotti & Gillespie, 2016). If

healthcare workers and providers are not willing to open the conversation about sexuality, their

patients may not feel comfortable with discussing their sexual orientation and an opportunity for

obtaining a thorough health history will be lost (Harding et al., 2012).

Speaking about gender, sexuality, and sexual behaviors can be an uncomfortable topic

that nurses may not have the language to address. Specific language and terms are associated

with sub-groups of this population such as the transgender community. Transgender patients can

feel particularly invisible to their healthcare providers when the nurses and other staff have no

language to address their concerns, behaviors, and lifestyle. When nurses are not aware of the

appropriate terminology, patients may feel unsafe and unseen (Carabez et al., 2015, p. 3312).

LGBT patients have a difficult time finding providers that are comfortable and competent

in taking care of this population. Few facilities have a way of identifying skilled LGBT providers

and rely on the providers self-identifying as LGBT competent within the providers own online

profiles. Education for providers and other healthcare staff can help to overcome the barriers

faced by LGBT patients (Khalili et al., 2015). More medical and nursing schools are now

incorporating LGBT competent care into their curriculum (Khalili et al., 2015; Skerle & Lawler,
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2015). For those who are already practicing, effective competency training has been shown to

reduce healthcare barriers for LGBT patients and improve their outcomes. Unfortunately, some

facilities do not recognize the healthcare barriers faced by this population and consequently do

not perceive a disparity in care (Khalili et al., 2015).

Skerle and Lawler (2015) provide guidance on how to improve therapeutic and culturally

sensitive care. Their suggestions include: nurses should assess their own bias and assumptions,

seek education opportunities about LGBT care, ask questions when in doubt as LGBT patients

will be the best source of information on their preferences in their care, and, finally, the patients

gender and sexual identity does not define their wholeness as a person.

Sexual health education for LGBT needs is an important piece in the care of this

population and, by not having staff educated in the care of this minority, it leads to gaps in care

and poorer health outcomes. Many WSW are told that there is less risk of STD with their

lifestyle; this is not the case. Lesbians are at increased risk of STD through lack of health

education. Women are also more likely to not be educated on how to have safe sex with other

women. Education for this sexual minority needs to include mental health, domestic partner

violence, suicide reduction, and substance use. LGBT persons are at a higher risk in all of these

areas than their heterosexual and cis gender counterparts (Capriotti & Gillespie, 2016).

Holistic Care

Gender identity and sexual orientation are only a portion of the healthcare needs of a

person. Nurses need to look beyond the patients LGBT status and to what unique challenges

may come with being a member of this sexual minority. Skerle and Lawler (2015) state that

LGBT people have higher rates of hypertension and diabetes, and in general face poorer mental
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and physical health. Smoking, alcohol use, and obesity rates are also higher in the LGBT

population (Capriotti & Gillespie, 2016). Further research is still needed that links being a

member of minority populations and poor health outcomes (Skerle & Lawler, 2015).

LGBT patients commonly have different social support networks than the majority of the

population. Because of the history of homosexuality being a mental disorder and the stigma

associated with this lifestyle, many LGBT patients have been rejected by their families,

churches, friends, and communities (Skerle & Lawler, 2015). Often an LGBT person will have

most of their social and emotional support from close friends and their partners rather than from

their own family. This can influence who LGBT patients want involved in making medical

decisions. Many LGBT persons want their partners to be involved with decision making and

want open communication with the healthcare team to include their partner (Harding et al.,

2012). Nurses and other healthcare providers need to recognize a plurality of meanings in

family-centered care (Harding et al., 2012, p. 608). Older LGBT persons may have advanced

directives in place to minimize family involvement with their care. There is a complex system of

laws regarding partner rights and it varies by country (Harding et al., 2012). A recent supreme

court ruling in Obergefell v. Hodges (2015) has made same sex marriage legal in the U.S. It has

yet to be seen how this will affect health practices and policies.

Conclusion

Nurses are the obvious choice to be able to improve how health histories are taken and

documented because a nurses role is to advocate for patients needs and rights. LGBT patients

deserve the same standards of care as any other patient.

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Detailed and comprehensive health histories are the first step to closing gaps and

reducing barriers to care for this patient population. By opening the conversation, nurses can

encourage patients to make their needs known. Comprehensive sexual health screenings can

reduce incidence of STDs. Use of gender inclusive forms can help screen for the transgender

population which may otherwise fall through the gap.

By examining our own bias, we can help eliminate bias in our practice. LGBT patients do

not seek timely healthcare because they have concerns over how they will be received and past

negative healthcare experiences color their expectations. By providing non-judgmental care in a

culturally sensitive manner, nurses can have direct impact on how these patients seek and receive

care.

Adequate education cannot be provided to patients if nurses are not educated on the

needs of this sexual minority. Education on the language used within the LGBT community can

help improve communication with these patients. Inadequate knowledge and lack of

acknowledgement of the barriers the LGBT community face results in nurses perpetuating and

reinforcing those barriers to these patients.

LGBT patients can have different social support networks, that may not include family,

which can leave them feeling isolated and at higher risk for mental health issues and suicide.

Having their partner involved in their care is important to this population, but the complex laws

in the U.S. can make this challenging. Recent political changes are continuing to affect this

population by requiring changes in policy on allowing same-sex partners involvement in medical

information and rights to making medical decisions for their loved ones.
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By assuming all patients are heterosexual, patients can be alienated before they have left

the waiting room. Rather than LGBT patients asking themselves whether or not they will be

judged by their provider, changes to intake forms can create a safe place for patients to disclose

their sexual orientation and gender identity without fear of reprisal or discrimination. If holistic,

patient centered care is the goal, then there needs to be a willingness to have the difficult

conversations and open the dialogue to meet the physical, mental, emotional, spiritual, and social

health needs of LGBT patients while being inclusive of their partners in the patient care

decisions.
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Capriotti, T., & Gillespie, A. (2016). Healthcare issues in the LGBT community. Clinical

Advisor, 19(8), 2243.

Carabez, R., Pellegrini, M., Mankovitz, A., Eliason, M., & Scott, M. (2015). Does your

organization use gender inclusive forms? Nurses confusion about trans* terminology.

Journal of Clinical Nursing, 24(21/22), 33063317. https://doi.org/10.1111/jocn.12942

Dahlhamer, J. M., Galinsky, A. M., Joestl, S. S., & Ward, B. W. (2016). Barriers to health care

among adults identifying as sexual minorities: A US national study. American Journal of

Public Health, 106(6), 11161122. https://doi.org/10.2105/AJPH.2016.303049

Harding, R., Epiphaniou, E., & Chidgey-Clark, J. (2012). Needs, experiences, and preferences of

sexual minorities for end-of-life care and palliative care: A systematic review. Journal of

Palliative Medicine, 15(5), 602611. https://doi.org/10.1089/jpm.2011.0279

Khalili, J., Leung, L. B., & Diamant, A. L. (2015). Finding the perfect doctor: Identifying

lesiban, gay, bisexual, and transgender-competent physicians. American Journal of

Public Health, 105, 11141119. https://doi.org/10.2105/APJH.2014.302448

Nguyen, G. T., & Yehia, B. R. (2015). Documentation of sexual partner gender is low in

electronic health records: Observations, predictors, and recommendations to improve

population health management in primary care. Population Health Management, 18(3),

217222. https://doi.org/10.1089/pop.2014.0075

Obergefell v. Hodges, 135 S. Ct. 2071 (2015)

Skerle, J., & Lawler, K. (2015). Nursing care needs of lesbian, gay, bisexual and transgender

persons. Pennsylvania Nurse, 70(2), 2427.