Public acceptance of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community is steadily increasing; 64% of Americans agree that gay marriage should be legal, and 72% are accepting of same-gender relations.1 In July 2017, the American Nurses Association issued a statement supporting equality and human rights for the LGBTQ community.2 Although some positive policy changes in LGBTQ equality have taken place, the historic and lingering stigma this patient population experiences is still a major contributor to greater health risks.3 This article discusses the unique health challenges faced by LGBTQ individuals and offers suggestions for best practices in the critical care setting.
LGBTQ individuals share the same social determinants of health that affect the rest of society. However, the additional burdens of stigma, prejudice, and homophobia have led to unique health risks, including premature death.4 One study found that sexual minorities living in high-prejudiced communities have on average a shorter life expectancy of approximately 12 years compared with sexual minorities living in nonprejudiced communities.5 Analysis of specific causes of death revealed that suicide, homicide/violence, and cardiovascular diseases were substantially elevated among sexual minorities in high-prejudiced communities. These findings potentially affect ICU use because cardiac disorders account for 8 of the 18 conditions with high ICU use.6 As ICU use continues to rise, critical care nurses are expected to interface more with LGBTQ patients and their families.
Many LGBTQ cultural competency trainings use the educational video “To treat me, you have to know who I am” to underscore the fundamental connection of sexuality and gender identity with health. (See LGBTQ health resources.) Although identifying as LGBTQ is not biologically hazardous to health, enduring social stigma and homophobia is.7 Sexual identity is not the cause of any disease or disorder. For example, there is evidence that lesbians may be at higher risk for breast cancer, not because they are lesbians, but because they may have given birth to fewer children and receive less routine healthcare than their heterosexual counterparts.8,9
LGBTQ health disparities
The healthcare issues of the LGBTQ population were addressed broadly and explicitly for the first time in 2008 in the U.S. Department of Health and Human Services (HHS) Healthy People 2020 report.10 To appreciate the complexity of LGBTQ healthcare issues, it is necessary to have an understanding of the concepts of health disparity unique to these populations. (See HHS health disparity definition.)
Addressing LGBTQ health disparities means upholding social justice in health policies, as these institutions are inextricably linked.11 Some of the most notable health disparities affecting LGBTQ patients include:
- Between 19% and 40% of all homeless youth identify as LGBTQ.12
- Young gay and bisexual men show significant elevations in biomarkers of cardiovascular disease compared with heterosexual men.13
- Gay and bisexual men accounted for 82% of new HIV diagnoses among males and 67% of all diagnoses in 2015. Black gay and bisexual men accounted for the largest number of HIV diagnoses.14
- There is a high prevalence of bullying among sexual minority children and adolescents based on their perceived sexual orientation or gender.4
- Smoking prevalence is higher in the LGBTQ community than the general population.15
- Lesbian, gay, and bisexual adults have 1.5 times the risk of asthma compared with heterosexual adults.16
- Nearly 4 out of 10 LGBTQ older adults have contemplated suicide at some point during their lives.17
The confluence of these factors affects the mental health, resiliency, risks, and protective behaviors of LGBTQ people. Critical care nurses can advocate for screening and testing for specific diseases when risks are identified during assessment.18
The Synergy Model
The National Academy of Medicine, formerly called the Institute of Medicine, proposed four conceptual perspectives to guide the meaningful understanding of LGBTQ health. The four perspectives include minority stress (chronic stress experienced by sexual and gender minorities due to stigmatization), life course (how events at each life stage influence subsequent stages), intersectionality (the ways in which an individual's multiple identities interact), and social ecology (the notion that people are surrounded by spheres of influence, such as families, communities, and societies).3 The American Association of Critical Care Nurses (AACN) Synergy Model for Patient Care, specifically the Response to Diversity component of the model, is one framework for providing LGBTQ-sensitive care. The Model has two components: patient characteristics and nursing competencies. The basic premise of the model is that the needs or characteristics of patients and families influence and drive the characteristics or competencies of nurses. Synergy results when the needs and characteristics of a patient, clinical unit, or healthcare system are matched with a nurse's competencies.19
Patient characteristics are attributes that describe the current state, capacity, and needs of the patient. Each attribute is assigned a numeric value from 1 (low) to 5 (high), based on the patient's status in the health–illness continuum. The nursing competencies reflect the knowledge, skills, and attitudes needed to meet the needs of the patient and their families. Each nursing competency is also assigned a numeric value based on the nurse's competency level from 1 (competent) to 5 (expert). When aligned, these two components improve patient outcomes. As part of best practices, competencies require validation and evaluation.19
Patient-centered communication. The heart of patient-centered care is sensitive face-to-face communication. A rainbow flag sticker in the visitors' lounge does not mean much if the staff's language does not convey respect and validation of LGBTQ experiences. Nonjudgmental verbal and nonverbal communication remains the most explicit and enduring test of how staff value the inherent dignity of LGBTQ patients. It is a vital first step in establishing trust. (See Sample scripts for LGBTQ-sensitive communication.) Depending on staff's competency levels, sample scripts should be posted in high-traffic staff areas and near unit telephones or call-answering stations to provide visual cues during patient and family interactions. All patient interactions should be grounded in care rather than in indulging in questions asked out of curiosity.20
Visitation. Since December 2011, the Centers for Medicare and Medicaid Services has required hospitals to explain to all patients their right to choose who may visit them during their inpatient stay.21 The rule aims to prohibit hospitals from denying visitation privileges based on race, color, national origin, religion, sexual orientation, gender identity, or disability. This is of particular importance to LGBTQ patients who may be estranged or alienated from their family of origin but rely on their family of choice during a health crisis.22
The AACN supports unrestricted visitation by the patient's chosen support person.23 Open visitation and participation of a support person not only enhances family satisfaction and improves communication, but is also an opportunity to gain valuable patient information from those who may know the patient best.21
Handoff. Handoff between care providers is an important time to address active issues the patient is experiencing.24 For transgender patients, this is an opportunity for staff nurses to communicate salient information that relates to the patient's gender identity, sexual orientation, and other clinically relevant information, such as sex hormones the patient might be taking. It is also important here to highlight the patient's preferred name and gender pronoun, history of gender reassignment surgery and relevant complications (if applicable), and whether the patient is in a significant relationship. Handoff with the patient and family present may be an opportune time to demonstrate inclusive caring competencies that exemplify cultural sensitivity and validate the patient's gender identity.
Best practice considerations during handoff that are of particular importance to LGBTQ patients include keeping the conversation clinical, being sensitive with shared spaces (for example, a semiprivate hospital room or open spaces separated only by curtains), and leading by example.25 In states where the Caregiver Advise, Record, Enable (CARE) Act applies, bedside handoff is an appropriate time for nurses to confirm or update the record of the designated caregiver; inform the patient and family of possible discharge date; and provide the caregiver with education about the medical tasks to be performed at home by the caregiver.26
Promoting a welcoming environment
The patient-care environment is one of the items rated in the Hospital Consumer Assessment of Healthcare Providers and Systems. LGBTQ patients may have particular sensitivity to physical cues that affirm LGBTQ sexuality and identities, due to historically contentious relationships with healthcare establishments. (See Institutional checklist for an LGBTQ welcoming environment.) Healthcare stakeholders are advised to create an environment of accountability. Staff are encouraged to politely correct colleagues who use the wrong pronoun or make insensitive comments.27
Doing your part
The AACN Synergy Model for Patient Care identifies three levels of outcomes: those derived from patients, nurses, and healthcare systems. Critical care nurses are expected to engage in designing systems thinking solutions to address LGBTQ health disparities. Nurses can advocate for:27
- Annual LGBTQ cultural competency training for all staff, including new hires.
- Procedures that hold staff accountable for making negative or discriminatory comments or actions against LGBTQ people.
- Clear lines of referral for complaints and questions for both staff and patients.
- Appointment of a staff person for providing guidance, assisting with procedures, offering referrals, and fielding complaints.
- Assessment of patient satisfaction or feedback from LGBTQ patients and families and the surrounding LGBTQ community.
As empirical evidence of emerging health-illness patterns among LGBTQ populations evolves, it is important for critical care nurses to continue to inform themselves of practice, education, research, and healthcare policy developments. Stakeholders should anticipate trends in critical care, such as specialties in gender reassignment surgery and managing potential complications.28 (See LGBTQ health resources for more information.)
LGBTQ patient care remains a challenge, even as social acceptance continues to increase. Critical care nurses must be aware of their own biases, provide patient-centered care, and inform their practice with the best-available evidence.
HHS health disparity definition10
Health disparity: A particular type of health difference that is closely linked with economic, social, or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, or age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.
LGBTQ health resources
YouTube: “To treat me, you have to know who I am”
GLMA Health Professionals Advancing LGBT Equality
The Joint Commission
Transgender Law Center
3. Institute of Medicine. Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender people: Building a Foundation for Better Understanding
. Washington, DC: National Academies Press; 2011.
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7. Martos AJ, Wilson PA, Meyer IH. Lesbian, gay, bisexual, and transgender (LGBT) health services in the United States: origins, evolution, and contemporary landscape. PLoS ONE
8. Dibble SL, Roberts SA, Nussey B. Comparing breast cancer risk between lesbians and their heterosexual sisters. Womens Health Issues
10. Department of Health and Human Services. The Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, Phase I report: recommendations for the framework and format of Healthy People 2020, Section IV: Advisory Committee findings and recommendations. 2008. www.healthypeople.gov/sites/default/files/PhaseI_0.pdf
11. Braveman P. What are health disparities and health equity? We need to be clear. Public Health Rep
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12. Wilson BDM, Kastanis A. Sexual and gender minority disproportionality and disparities in child welfare: a population-based study. Child Youth Serv Rev
13. Hatzenbuehler ML, McLaughlin KA, Slopen N. Sexual orientation disparities in cardiovascular biomarkers among young adults. Am J Prev Med
14. Centers for Diseases Control and Prevention. HIV in the United States: at a glance. 2017. www.cdc.gov/hiv/statistics/overview/ataglance.html
15. Lee JG, Blosnich JR, Melvin CL. Up in smoke: vanishing evidence of tobacco disparities in the Institute of Medicine's report on sexual and gender minority health. Am J Public Health
16. Conron KJ, Mimiaga MJ, Landers SJ. A population-based study of sexual orientation identity and gender differences in adult health. Am J Public Health
17. Fredriksen-Goldsen KI, Kim HJ, Barkan SE, Muraco A, Hoy-Ellis CP. Health disparities among lesbian, gay, and bisexual older adults: results from a population-based study. Am J Public Health
18. Lim FA, Brown DV Jr, Justin Kim SM. Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: a review of best practices. Am J Nurs
19. American Association of Critical-Care Nurses. Synergy model. www.aacn.org/nursing-excellence/aacn-standards/synergy-model
20. Transgender Law Center. 10 Tips for working with transgender patients. 2016. https://transgenderlawcenter.org/resources/health/10tips
21. Centers for Medicare and Medicaid Services. CMS Manual System Pub. 100-07 State Operations Provider Certification. 2011. www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R75SOMA.pdf
22. Griebling TL. Sexuality and aging: a focus on lesbian, gay, bisexual, and transgender (LGBT) needs in palliative and end of life care. Curr Opin Support Palliat Care
23. American Association of Critical-Care Nurses. Family presence: visitation in the adult ICU. 2016. www.aacn.org/clinical-resources/practice-alerts/family-presence-visitation-in-the-adult-icu
24. Anderson J, Malone L, Shanahan K, Manning J. Nursing bedside clinical handover: an integrated review of issues and tools. J Clin Nurs
25. Cicero EC, Perry Black B. “I was a spectacle... a freak show at the circus”: a transgender person's ED experience and implications for nursing practice. J Emerg Nurs
27. The National LGBT Health Education Center. Providing welcoming services and care for LGBT People: a learning guide for health care staff. 2015. www.lgbthealtheducation.org/wp-content/uploads/Learning-Guide.pdf
28. American Society of Plastic Surgeons. Gender confirmation surgeries rise 20% in first ever report. 2017. www.plasticsurgery.org/news/press-releases/gender-confirmation-surgeries-rise-20-percent-in-first-ever-report