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Culturally competent care for older LGBTQ patients

Kraus, Shaina, MSN, RN, ATC; Duhamel, Karen V., MSN, MS, RN

doi: 10.1097/01.NURSE.0000534092.48992.7a

Discrimination and abuse force many older adults in the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community to avoid or delay seeking healthcare. Use the simple tips and strategies outlined here to make these patients feel safe and comfortable.

Shaina Kraus is an assistant director of nurses and infection control practitioner at Douglas Manor in Windham, Conn., and Karen V. Duhamel is an assistant professor of nursing at the University of Hartford in West Hartford, Conn.

The authors have disclosed no financial relationships related to this article.



PATIENTS WHO IDENTIFY as lesbian, gay, bisexual, transgender, or queer (LGBTQ) have endured a long history of stigmatization and discrimination that has only recently started to ease. Dedicated activists and the community at large have made gradual progress, but the work isn't finished. These patients still sometimes experience discrimination from frontline healthcare personnel either intentionally or, more commonly, unintentionally through ignorance or misunderstanding. This article explores the varied needs of older LGBTQ adults and examines how nurses working in all settings, including long-term care, can take practical steps to prevent discrimination based on sexual orientation or gender identity.

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Patients at risk

Research has shown that older LGBTQ adults are at greater risk for mental distress, poor general health, and disability than heterosexuals in the same age-group. They're also at greater risk for unhealthy behaviors, such as smoking and excessive drinking, which can lead to an earlier need for long-term care.1 Ageism and sexual stigmatization can worsen the burden of disease on an older member of the LGBTQ community.2

The risks of needing long-term care can vary by sexual orientation and gender. In one study, researchers found that women living with female partners were more likely to need help bathing or dressing than married women and women living with male partners. Similarly, men living with male partners were more likely to need help with errands compared with men married to women or living with female partners.3 Consequently, compared with heterosexual counterparts, older LGBTQ adults may face a higher risk of needing long-term care as they age.

To complicate matters, many LGBTQ adults aren't on speaking terms with their biological families due to philosophical differences in their views on gender and sexual identity.1 This can force them to rely on friends and peer social groups, who may themselves be in similar situations and unable to help. Because these patients are also less likely to be married or partnered, they're vulnerable to social isolation.4



As people feel increasingly isolated socially, they're less able, and less likely, to ask for and receive proper assistance. This, combined with the stigma and discrimination that people who identify as LGBTQ face in healthcare, also makes them less likely to disclose their sexual or gender identity, which undermines optimal care.1,4

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Trusting their caregivers

Patients in a long-term care facility need to trust the care being given to them as well as those providing that care. Older LGBTQ adults have expressed significant fears regarding staff mistreatment, discrimination, and purposeful isolation by other patients if their sexual or gender identity is made known.5 Concerns about the risk of abuse or neglect lead some older adults who identify as LGBTQ to avoid long-term care facilities despite their need for nursing care. Other concerns include a reluctance to “go back into the closet” or to be separated from their partners and/or the LGBTQ community.6

The American Geriatrics Society has recognized that subtle forms of discrimination in healthcare facilities can include denying patients' families of choice access to visitation.7 The society recommends that organizations develop policies and procedures that ensure the inclusion of patients' partners and families of choice. In a 2011 field guide, The Joint Commission also recommends that facilities and providers develop nondiscriminatory policies that include sexuality and gender in their wording as well as a broader definition of the word family to include family of choice, which can encompass anyone the individual sees as significant in his or her life.8 (See Recommendations from The Joint Commission on LGBTQ health.) These policies and procedures explicitly protect patients' already established right to choose their own supporters and their right to equal visitation.2

In some states, healthcare decisions at end-of-life default to next of kin in the absence of an advance directive.9 This practice can have significant consequences when same-sex or domestic partners have a better understanding of the patient's health history and values, goals, and preferences for healthcare than the patient's blood relatives.9 Encourage patients to identify a healthcare surrogate, discuss preferences for healthcare with the surrogate, document their preferences, review those preferences on a regular basis, and update documentation when those preferences change.

In 2015, Sabin et al. found a widespread bias in favor of heterosexual over lesbian or gay people among nurses. Nurse educators agree on the importance of teaching nursing students about patient care of sexual minorities, but they feel unprepared to do so.10 Implicit or explicit gender or sexual bias perpetuates stereotypes and disparities in healthcare.

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What nurses can do

Simply being more aware of the subtle forms of discrimination and eliminating them within a nurse's own practice can help. Look for signs of subtle bias in the oral and written questions that are part of any standard admission assessment. For example, many paper forms and electronic medical records (EMR) allow only male or female options for patient sex, and EMR systems may not be configured to allow a change in sex or name after a patient transitions from one sex to another.7 Ensure that admission forms include questions about sexual orientation, gender identity, and family structures.

A nurse can word questions in a way that doesn't assume the patient is heterosexual. For example, adding the word “partnered” under relationship status can supplement the more commonly present “married/single/divorced.” In addition, the nurse can add comments to the EMR if configuration doesn't allow for changes. These actions signal to patients that the nurse is supportive of their personal identity and right to dignity.

Nurses can advocate for LGBTQ patients in their facility in many ways. Nurses are taught in school that even a short but positive interaction with patients can be a turning point in their day. Nurses can show patients that they're safe, which is the guiding principle of culturally competent care.

The Affordable Care Act mandates culturally competent care, but not many facilities are educating staff on gender identity and sexual orientation.4 Truly culturally competent training must include information on the diversity of the LGBTQ community.4

Culture change takes time, commitment, and education. (See Healthcare resources for older LGBTQ adults and their caregivers.) One way to educate nurses and help create an LGBTQ-friendly environment for patients is through intentional education in a way that best benefits the needs of the institution. Adding an LGBTQ-focused program, such as the Nurses Health Education about LGBT Elders curriculum, has been shown to help. In one study published by Hardacker et al., nurses who completed the 6-week program gained knowledge and confidence in the care of LGBTQ older adults.11 The program included information on terminology, barriers to care and health disparities, unique health concerns, ways to create positive environments, and common legal concerns for older LGBTQ adults. This was anecdotally connected to increased feelings of empathy and understanding for LGBTQ patients as well as self-reported positive attitudinal changes. The implications for nurses using a specific LGBTQ education curriculum are clear: Education can help to remove both internal and external barriers, resulting in unbiased and safer care.

The Hardacker et al. study found that younger nurses were much more accepting of LGBTQ health information than older nurses, and that some nurses didn't even want to finish the course, citing religious or ethical reasons.11 While the implications of religion and working with the LGBTQ population are outside the scope of this article, responding to questions and objections brought up when working with this population speaks to shifting societal views. The study stated that to provide the best possible healthcare, providers should leave personal biases out of healthcare encounters.11 The American Nurses Association's Code of Ethics for Nurses with Interpretive Statements strongly endorses this approach.12

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Changing the atmosphere opens doors

Discrimination is real. Stigmatization is real. Fear of discrimination, abuse, neglect, and isolation keeps many members of the LGBTQ community from seeking and obtaining necessary healthcare. Nurses, as frontline care providers, are often their most influential providers. Open-minded and accepting nurses can help to change the atmosphere of a whole facility if they advocate for their patients and work to be more culturally competent in their encounters. Nurses, through actions and attitudes that focus on helping LGBTQ patients, can make the difference.

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Healthcare resources for older LGBTQ adults and their caregivers

  • Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE)
  • SAGE is the country's largest and oldest organization dedicated to improving the lives of older LGBTQ adults. It offers services, advocacy for public policy changes, and resources for LGBTQ seniors and their caregivers. SAGE also created the National Resource Center on LGBT Aging through a federal grant in 2010.
  • National Gay and Lesbian Task Force
  • This organization provides the latest information on changes in federal and state laws regarding the LGBTQ community.
  • GLMA: Health Professionals Advancing LGBT Equality
  • Called simply the Gay and Lesbian Medical Association before introducing its current tag line in 2012, GLMA advocates equality in healthcare for LGBTQ patients and their families, as well as healthcare professionals who identify as LGBTQ.
  • Lavender Health
  • This resource includes various resources and materials for presentations on LGBTQ health to nursing audiences.
  • National Coalition for LGBT Health
  • This coalition provides fact sheets and reports on health concerns of LGBTQ populations on its website.
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1. Alpert J. Out, proud and old: LGBT seniors more likely to age alone. 2015.
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8. The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. Oak Brook, IL: Joint Commission Resources; 2011.
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12. American Nurses Association. Code of ethics for nurses with interpretive statements. 2015.
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