Incredibly Easy blog

The Incredibly Easy blog will expand on selected topics presented in the print journal.

Monday, February 13, 2012

Welcoming LGBTQ patients

Terry Pless*, RN, only has another hour in the ED until the night shift takes over. It has been a quiet night, but now there’s a woman coming in with severe abdominal pain. “This won’t be hard,” she thinks to herself. She glances at the chart from the admitting desk and notices that the patient is Shari Silverstein*, who’s married, 58 years old, and here at the beach for a holiday from New York City. She has good insurance coverage and her primary is Pat Morris.*


Terry goes into the exam room to start an assessment. Shari is on the exam table, grimacing, holding her abdomen, uttering an occasional groan, and doubling over. A grey-haired woman who appears to be about 10 years older than Shari is standing by the table with her arm around Shari’s shoulder.


“Hi, Shari. I’m Terry. I’ll get your vital signs and ask a few questions, and the doctor will be in very soon so we can get you started with something for your pain, and figure out what’s going on.”


“Thanks,” mutters Shari.


“You should know she’s allergic to penicillin,” says the grey-haired woman.


Terry replies, “Thanks, but we’ll have to ask you to step outside. When her husband gets back from the parking lot, he can join us here if Shari wishes.”


The grey-haired woman tightens her arm around Shari’s shoulder, and Shari starts groaning louder. “She doesn’t have a husband, and I’m going to stay with her. We want to be together.” Shari nods forcefully as her groans start to ease up.


Terry responds, “Well, let’s get your vitals going and get you some relief. Where’s your husband?”


Again the older woman speaks up, “She doesn’t have a husband. I’ll be staying with her.”


Terry sighs and proceeds to take Shari’s vital signs. She usually spends a bit more time with the initial nursing assessment but since Shari is clearly very uncomfortable, she does the minimum and goes to get the physician. Besides, she’s now quite confused about what’s going on and is concerned that the woman with Shari could be putting her in an awkward position of violating patient confidentiality.

Terry finds the physician at the nurses’ station, along with the unit clerk.


“What’s with the woman who’s with the abdominal pain patient who was just admitted?” she asks.


The physician shrugs his shoulders; the clerk responds that she isn’t sure but she’s the primary on Shari’s insurance, Pat Morris. This gets the attention of both Terry and the physician.


“How can that be?” Terry asks.


“I have no idea,” the clerk responds, “but they came in together and the insurance information is legitimate. It’s associated with a New York company that Pat says she works for.”


The physician offers this bit of information: “I know that some companies are giving ‘domestic partner’ benefits, and I think that New York also just made gay marriage legal.”


The clerk looks shocked and says, “Yes, the form says they’re married.” Terry reacts, “I can’t believe it. Now what do we do? I’ve never had to take care of a gay couple before. What if I do something to offend them? I wouldn’t know what to say.”


For many healthcare providers, one thing isn’t incredibly easy — understanding and caring for patients who are lesbian, gay, bisexual, transgendered or queer/questioning (LGBTQ). Even for employees who are LGBT or Q, because of widespread stigmatization, there are many barriers to providing the kind of compassionate care that all people deserve.


But there’s hope and help! In the story above, which covers about 2 minutes of an initial nurse-patient interaction, Terry faced a challenge that could’ve been easily avoided if she had been prepared for such a situation. If Terry had initiated an introduction with the grey-haired woman, she would’ve discovered that this was Pat, the primary on Shari’s insurance. Terry had assumed that “Pat” was a male husband, and that the older woman wasn’t related in any way to Shari. Therefore, Terry assumed Pat wasn’t eligible to be involved in Shari’s care.


Terry and the other staff members were uncertain about how to care for LGBTQ patients, and that led to a feeling of discomfort that would probably be evident to the couple. One of the ways that Terry and the other staff members could’ve approached this situation differently is by broadening their understandings of family.


For LGBTQ individuals, the meaning of “family” can be very different from what has been traditionally expected, and in many places it’s now taken to mean whomever patients claim are their family. LGBTQ individuals may have intimate partners who are same-sex or other-sex, and they may be male, female, transgender, or differently gendered. LGBTQ individuals may or may not be in “legal” marriage or domestic partner relationships with their intimate partner, even where this is now legal.


In LGBTQ communities, “family” is a word often used as code for other people who are also LGBT or Q. However, if you refer to an LGBTQ patient’s family, most LGBTQ individuals will assume you’re asking about their family of origin. They also know that their intimate partner and/or children may not be recognized as “legitimate” even if they are. Because many LGBTQ people have very uneasy relationships with some or all of the people in their family of origin, and their intimate partner is often considered not legitimate, asking about their family may not be who you need to know about at all.


Consider alternative ways to ask about those who are commonly referred to as family. Even for patients whose sexual or gender identity you don’t know for sure, consider asking about someone’s significant others or the “people who mean the most to you.” Alternatively, what you really need to know is who’ll be participating in the decisions about healthcare and helping with care at home.


There are several things that we recommend for all healthcare providers to avoid a situation like the one that Terry faced. For example, we suggest a number of ways to conduct a verbal health history and adjust written forms so that all people, regardless of sexual or gender identity, can comfortably respond. Second, we have a number of “exercises” for all healthcare professionals to help understand how people like Shari and Pat feel when they encounter the healthcare system. Here are few suggestions to get you started.


To make your environment LGBTQ friendly:

Display a rainbow symbol in your reception area. The rainbow has been adopted in the LGBTQ community as a symbol of the diversities that exist within the community, including all ethnicities, cultures, religions, and political affiliations.

Include same-sex couples in photographs that appear in brochures or posters.

Change the terms “husband” and “wife” to “spouse” or “intimate partner” on intake forms.

Create policies and practices that provide an open and welcoming message during the first 2 minutes with any new patient so that if patients want to let you know they’re LGBT or Q, they can do so comfortably.


To better understand how it feels to be LGBTQ in a place where most everyone else isn’t:

Notice how often you refer to your heterosexual husband, wife, girlfriend, or boyfriend in a day.

Consider how you would feel if your significant other wasn’t included in an event where everyone else brings a heterosexual husband, wife, girlfriend, or boyfriend.

To learn about organizations and groups that provide LGBTQ support services in your community:

Ask someone you know who’s LGBT or Q. If you think you don’t know anyone who is, ask your friends; chances are you do know folks who are LGBT or Q and some of your other friends are likely to know.

Find a Metropolitan Community Church or Parents, Families, and Friends of Lesbians and Gays (PFLAG) in your area. Even if one of these groups is many miles away, you can contact them to find out more about local support groups in your area.

Check out websites of LGBTQ healthcare and human rights organizations for more information, including Lavender Health and the Gay and Lesbian Medical Association.


Finally, here are some additional resources that we recommend that provide accurate and helpful information on a broad range of health-related issues:

LGBTQ Cultures: What Health Care Professionals Need to Know about Sexual and Gender Diversity

Lesbian Health 101: A Clinician’s Guide

Fenway Health provides direct services to LGBTQ people in the Boston area, but also provides extensive resources to support LGBTQ healthcare throughout the United States and internationally.


*The names of the RN and patients are fictional and used for illustrative purposes only.


By Peggy L. Chinn, PhD, RN, FAAN

Professor Emerita School of Nursing University of Connecticut Hartford, Conn.


Suzanne L. Dibble, DNSc, RN

Professor Emerita Institute for Health & Aging, School of Nursing University of California, San Francisco San Francisco, Calif.


Michele J. Eliason, PhD

Associate Professor Department of Health Education San Francisco State University San Francisco, Calif. 


Jeanne DeJoseph, PhD

Professor Emerita School of Nursing University of California, San Francisco San Francisco, Calif.