The nurse headed down the hall to meet Ms. G, a new patient admitted for surgery. She'd received little information from report and the patient's medical record, and knew only that Ms. G was 62 and single. A woman sat by the bed, holding Ms. G's hand and crying. The nurse said gently, “I need to talk to you about preparations for surgery. Perhaps your friend can wait outside?” The crying woman said angrily, “You nurses have been trying to get rid of me all day. I showed you the legal documents that prove I have a right to stay with my partner. Why don't you respect them?”
This story illustrates two major problems with healthcare for lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) patients. First, some nurses make assumptions that all people are heterosexual and don't recognize same-sex partners; second, hospitals and clinics often lack places to record information about same-sex relationships and families. In states without same-sex marriage laws, a person in a long-term committed relationship would be noted as “single” on official forms.
Unfortunately, sometimes even patients with legal documents such as power of attorney for healthcare find that hospital staff won't honor them.1 But the nurse in this scenario wasn't intentionally discriminating against the couple; she simply didn't know about their relationship. She made an assumption about the patient's sexual orientation based on the lack of information about her relationship in the medical records.
Too often, LGBTQ patients, families, and healthcare workers experience discriminatory treatment, neglect, mistrust, and harassment.2 Diversity efforts in healthcare have expanded to address racial/ethnic diversity, age, social class, and disability status, but have only rarely considered the needs of LGBTQ people and communities.2
When nurses aren't knowledgeable about LGBTQ issues, they may render their patients invisible, dismiss their same-sex partners as “friends” rather than life partners, operate based on the stereotypes about LGBTQ people they learned as youth, and provide inappropriate care.2 Many nurses aren't familiar with the terminology used to refer to LGBTQ individuals and community, so the first step is knowing the right terms to use. This article offers practical information on terminology related to LGBTQ issues and provides nurses with key resources to facilitate continuing education.
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Figure: The concept of sexuality
From “homosexual” to alphabet soup
The term homosexuality was introduced in the late 1860s to define people attracted to others of the same sex. Ironically, no corresponding term identified people with other-sex attractions until the 1890s, when the word heterosexual first appeared in the literature.3
Although same-sex behaviors have been reported throughout history, they weren't labeled as a characteristic of a type of person until sexologists created the term homosexual. The presence of a term allowed people to organize into social and political communities around the identity. The “homosexual community” was pathologized by the medical and psychiatric professions until the 1970s, and homosexual activity was a crime in many states until a Supreme Court decision decriminalized homosexuality in 2003.4 Because the term homosexual was created by the psychiatric establishment, activists started to refer to the gay community as a term of their own choosing.
In the 1970s, women in the gay community began to organize and demand representation, and organizations began to use the terms gay and lesbian. Similarly, people with bisexual identities in the 1980s, and then transgender activists in the 1990s, demanded inclusion, leading to use of LGBTQ communities.4
We use LGBTQ as a shorthand to reflect the most common sexual and gender identities used in the United States, as well as keeping the more ambiguous and broad terms of queer and questioning to capture those who don't use labels. Others use the term sexual minorities or sexual and gender minorities to describe this population. In some contexts, where it's important to be as inclusive as possible, the alphabet soup can be quite thick. Many communities use particular terms, such as two spirit, which is used by many American Indians, and same-gender loving, which is used by many in the Black community.5,6 Young people are more likely to use the term queer, and by using it as a personal identification, turn it from a negative into a positive.
What is sexuality?
Sexuality refers to the biological, psychological, social, and cultural factors that make up human reproduction and pair bonding. It includes sexual orientation, sex, and gender (see The concept of sexuality).
Sex has a dual meaning, including the biological aspects of male and female as well as a set of behaviors associated with reproduction and/or pleasures and intimacy. In reality, biological sex is on a continuum rather than only two “opposite” sexes.7 Some people are born with one of the many intersex conditions, also called disorders of sexual development, which put them in between our binary categories of male and female in terms of their genitals, internal reproductive organs, or hormones.8 Most people with intersex conditions identify as heterosexual, but some identify as lesbian, gay, or bisexual. Some identify as male or female, and a few as transgender.2
Sexual orientation has at least three components, including sexual identities, sexual behaviors, and sexual attraction patterns.7 No strong evidence indicates that sexual orientation is a purely biological or genetic factor; it's probably related to a gene-environment interaction like most complex human behavior.2
Sexual identities are the labels people use to describe themselves to others. The most common are lesbian, gay, bisexual, and heterosexual, although some specific subsets of the population may use other terms such as two spirit, same-gender loving, queer, or euphemisms such as “family” and “that way.”2
Sexual behaviors refer to the gender of the sexual partners regardless of the label the person uses. A significant number of people who identify as heterosexual have had a same-sex experience in the past or present.
Sexual attraction patterns refer to the nature of a person's sexual fantasies and desires, whether the attraction is acted upon or not. Population studies report that about 4% of the U.S. population uses one of the sexual minority labels, 8% report same-sex behavior, and 11% acknowledge same-sex attraction.9
Some opponents of LGBTQ rights use the term sexual preference to suggest LGBTQ people could easily change their sexuality or gender. There's no evidence that LGBT orientations or identities can be changed without causing considerable harm.10
Gender is what a particular group of people in a specific cultural and historical time period believe that men and women, or boys and girls, should be like in terms of their personalities, communication styles, adornments, style of dress, choice of occupations or interests, play activities, and so on.2 Most of us have a gender identity that's consistent with our physical bodies. If we have a woman's body, we think of ourselves as female.
For a small subset of the population, however, gender identity isn't consistent with their physical bodies. We refer to them as having a transgender identity. Transgender women are born with male bodies and transition to women's roles, and transgender men were born in female bodies and transitions to men's roles. Transitioning refers to changing one's appearance and behavior to fit in as the gender with which the person identifies, and can include taking hormones and having cosmetic surgery, electrolysis, or voice training. The way a person looks is referred to as gender expression or gender presentation.2
Defining stigma
There would be little or no need for an article about LGBTQ healthcare issues if not for stigma: the process of labeling a person or group of people as deviant resulting in oppression, including invalidation, rejection, harassment, discrimination, and violence.11Heterosexism refers to stigma and discrimination based on sexual orientation, and gender normativity refers to a system that allows only two genders that can't be changed.2 LGBTQ people may experience other forms of oppression because they may represent every other form of human diversity in addition to sexual orientation and/or gender identity differences.12
Coming to terms with your patients
Most of the time, we don't need to use sexuality or gender terms in our conversations with patients; we use their names. When it's necessary to use terms when talking to individuals, however, avoid homosexual, queer, and sexual preference, as they're considered offensive to many in LGBTQ communities. Instead, use sexual orientation, sexual identity, or LGBTQ. LGBTQ refers to communities rather than individuals, and the queer/questioning part is not considered offensive when used in the abstract like this. Refer to significant others as partners.
When taking a health history, ask broad questions such as:
- Are you sexually active with men, women, both, or neither?
- What was your sex assigned at birth? What's your gender identity now? (It takes at least these two questions to identify a transgender person.)
- Do you currently have a partner? Is your partner male, female, or transgender?
- Is there anything related to your sexuality or gender that might be relevant to your healthcare at this time?
Changing healthcare
In 2011, two important reports were released. The Institute of Medicine (IOM) issued The Health of LGBT People, and The Joint Commission released a report about improving healthcare experiences for LGBTQ patients, families, and communities.13,14 (See Recommendations from The Joint Commission on LGBTQ health, which outlines the five main areas of the report and offers suggestions relevant to nursing practice.) The Joint Commission report focuses on making the healthcare environment more welcoming and inclusive of LGBTQ patients and professionals.
A commitment to LGBTQ inclusion needs to come from nursing leadership, who should review all nursing policies and procedures to make sure they're inclusive. These policies include patient rights statements, sexual harassment policies, employee benefits, and policies about professional conduct. All practicing nurses need education about the broad diversity of patients and coworkers so all nursing practice is respectful and inclusive. All LGBTQ healthcare providers should feel safe and included in the workplace; currently, many don't.15,16
In terms of data collection, all healthcare-related forms need to gather information about sexual and gender identities of patients, as well as their family structures. Community education and outreach must include LGBTQ communities.2
Table: Recommendations from The Joint Commission on LGBTQ health
14In September 2011, the Centers for Medicare & Medicaid Services issued new rules requiring that hospitals respect the right of all patients to choose who may visit them in the hospital and to name who can make medical decisions for them, thus protecting same-sex couples.17 The following resources provide up-to-date information and the newest guidelines on LGBTQ issues in healthcare.
LGBTQ resources
Nurses who wish to learn more about LGBTQ issues can draw on various sources of information. A few books were directed to nurses in the past; for example, Keys to Caring: Assisting Your Gay and Lesbian Patients (1990) and Who Cares? Institutional Barriers to Healthcare for Lesbian, Gay, and Bisexual Persons (1996). These books were written before much empirical data had been collected on LGBTQ populations. Since then, two reports from the IOM and several textbooks are available that focus on LGBTQ healthcare.13,18–25
Additionally, nurses can explore various Internet sources about LGBTQ healthcare, but finding sound information about LGBTQ health can be challenging because of the persistence of myths, stereotypes, and stigma. When searching for information on the Internet, check that the website:
- is sponsored or authored by a defined group or individual and has links to information about the qualifications and contact information for the group or individuals responsible for the site.
- includes a clear explanation of policies and positions on issues related to LGBTQ health reflecting respect, acceptance, and advocacy.
- is likely to remain; the affiliations related to the site should have a stable identity.
- provides reliable evidence to support the information provided; that is, citations to scholarly publications or government documents back up any claims.
See On the Web for several online resources that meet these guidelines and provide examples of some important LGBTQ resources. Several of these sites include video presentations to share with colleagues and patients.
Websites that don't meet the guidelines should be considered with suspicion. If a website advocates negative religious or policy positions or promotes programs to change a person's sexual orientation or gender identity, this information isn't based on the latest research about sexual orientation or gender identity.
Additional issues
Despite access to resources to support their care of LGBTQ patients, nurses may confront additional issues while providing clinical care. One critical issue is the individual nurse's own beliefs about sexual orientation and gender identity. Those beliefs may or may not be affected by research findings and new facts.
Additionally, nurses may be hampered by the lack of information about LGBTQ individuals and issues provided in basic nursing education. When information is provided in an educational setting, most nurses realize that they need to continually update that basic information, especially in their specific area of practice. Nursing education has a responsibility to educate nurses about cultural diversity in all the groups they serve.
Another issue is the “climate” in which nurses practice. People in certain locales and settings, such as cities with larger LGBTQ populations and legal protections for LGBTQ people, may be more open to variation in sexual orientation or gender identity, more knowledgeable about forms of oppression, and more likely to follow policies and procedures that encourage culturally appropriate care.
Regulations meant to protect patients can pose some legal roadblocks to inclusion. For example, Health Insurance Portability and Accountability Act regulations limit those who can have access to a patient or that patient's information. If patients don't have the proper documentation about who may visit them or have access to their personal information, hospital personnel may feel constrained about permitting access if patients are unable to speak for themselves. Hospital systems also serve as a barrier if their printed forms ask no questions about legal documents that may protect same-sex relationships in states where marriage isn't an option.
Best resources
Many resources are available to support nurses as they care for LGBTQ patients. As in any clinical encounter, however, perhaps the best resource is the patient, and the most important nursing skill is to listen.
On the Web
- Gay and Lesbian Medical Association (GLMA)
Welcomes nurses as members and has an annual conference offering nursing CE credits. The Guidelines for LGBTQ healthcare providers is particularly useful (click on Publications).
http://glma.org
Directory of inclusive Christian churches and information about LGBTQ and the Bible.
www.gaychurch.org
A comprehensive resource for information related to LGBTQ retirement.
www.gayretirementguide.com
A social networking site for gay teens to network and share information.
www.facebook.com/pages/Gay-Teens/123423037695826
- Hillary Rodham Clinton Human Rights Speech
Historic speech by Secretary of State Clinton in December 2012 in recognition of International Human Rights Day.
www.youtube.com/watch?v=WIqynW5EbIQ
Rates hospitals on the Healthcare Equality Index for their inclusion of LGBTQ-friendly policies and procedures.
www.hrc.org/issues/health
A project dedicated to giving hope to LGBTQ teens; includes links to videos on YouTube.
www.itgetsbetter.org
This site includes materials for presentations on LGBTQ health to nursing audiences.
www.lavenderhealth.org/index.html
Video showing a day in the life of a young gay man in Australia.
www.youtube.com/watch?feature=player_embedded&v=_TBd-UCwVAY
- National Center for Lesbian Rights
Legal information and support for LGBTQ people and their families.
www.nclrights.org/site/PageServer
- National Coalition for LGBT Health
Contains fact sheets and reports on many health concerns of LGBTQ populations.
http://lgbthealth.webolutionary.com/content/resources
- National Gay and Lesbian Task Force
Provides the latest information on changes in federal and state laws regarding LGBT people.
www.thetaskforce.org
- National Resource Center on LGBT Aging
Provides print and video resources about older LGBTQ people.
www.lgbtagingcenter.org
Services and advocacy for LGBTQ seniors.
www.sageusa.org/index.cfm
- Stop Bullying Campaign of the Federal Health and Human Services Agency
Has a section dedicated to LGBTQ youth.
www.StopBullying.gov
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