Is there a "don't ask, don't tell" policy in nursing? In a 2010 article in Advances in Nursing Science, Eliason and colleagues described a "silence" among nurses regarding lesbian, gay, bisexual, and transgender (LGBT) health. They reviewed the top 10 nursing journals from 2005 to 2009 and found only eight articles (out of nearly 5,000) that focused on LGBT issues. Seven of the journals contained no articles at all on this topic.
We agree with Eliason and colleagues that nurses have been slow to initiate research and policy changes on LGBT concerns, and professional nursing organizations have remained silent while the American Medical Association and the American Psychological Association have issued statements on topics such as same-sex marriage and so-called "reparative therapies." It's imperative that nursing educators, researchers, and RNs better address the health needs of this patient population.
Surveys show that lesbian, gay, and bisexual people make up anywhere from 5% to 10% of the U.S. population. Exact statistics are elusive, partly because sexual orientation and gender identity questions aren't asked on most national and state health surveys or on hospital and health clinic registration forms. Moreover, many people may not openly identify with any one of these groups, and stigma almost certainly leads to underreporting.
The U.S. Department of Health and Human Services (DHHS) HealthyPeople.gov site (http://1.usa.gov/koiWZH) summarizes the many health challenges faced by these patients: lesbians are less likely to access preventive cancer services, gay men have high rates of HIV and other sexually transmitted diseases (STDs), and elderly LGBT patients often lack access to appropriate social services and providers. Transgender individuals are particularly at risk—of contracting HIV and STDs, of being victims of violence, and of suicide.
That the DHHS has included LGBT health in its Healthy People 2020 initiative is encouraging. Unfortunately, nursing school curricula lack such a focus, no doubt contributing to the insensitive, uninformed care some patients receive. Case studies, clinical scenarios, and cultural competency modules must include a focus on the LGBT population. Currently, simulation training—a popular teaching method in nursing schools that involves manikins, role playing, or both—almost exclusively depicts standardized generic or heterosexual "patients."
Since manikins don't portray the facial nuances and tonal qualities of humans, specially trained people should portray standardized LGBT patients, ensuring that students learn how best to serve the needs of this community.
Breaking the silence requires a scholarly discourse—in the class-room, in the curriculum, in research, at the bedside. We can begin by acknowledging the Institute of Medicine's groundbreaking consensus report, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding, published earlier this year. It identifies gaps in research and calls for increased knowledge and understanding of LGBT health, particularly regarding this population's social influences and health care inequalities. A few months after its publication, the New York City Health and Hospitals Corporation—the largest municipal health care organization in the country—announced it would require cultural competency training. The goal is to make it easier for LGBT patients to access quality care in the city's public hospitals.
Homophobia, stigma, and discrimination lead to health disparities and reduced access to care. If we are to remain faithful to our profession's mission and the public's trust, we must take a proactive approach to addressing the health needs and safety of LGBT patients, some of whom are nurses themselves.