Gay and Lesbian Cultural Competencies and Healthcare

Definitions and Identity Issues

Historical and anthropological research shows that people whose primary identity is homosexual have not always existed in every society or historical period. However, research does show that homosexual behavior occurs in virtually every society and historical period. Thus any attempt to assess the size of the homosexual population raises a question about the definition of what is being measured; identities or behavior; since not everyone who engages in homosexual activity self-identifies as a "homosexual".

Results from the largest recent national probability survey on sexual behavior among 3,423 adults demonstrates a disparity between self-identity and sexual behavior. The survey showed that whereas 7.6 percent of white men reported ever having same-sex sexual partners, only 3.0 percent identified as "homosexual" or "bisexual". The corresponding proportions for white women were 4.0 and 1.7 percent; for black men, 5.8 and 1.5 percent; and for black women, 3.5 and 0.6 percent. (Diamond, p. 305) The boundaries of these definitions are clearly quite sketchy and deeply personal.

While one person might equate desire for another of the same sex with homosexuality, another person might think that one has to act on these desires to be homosexual. And, what about the individual who considers himself a homosexual but has never had sex with another person of the same sex? The more commonly described disparity between self-identity and behavior involves people who self-identify as heterosexual, but have sex with partners of the same sex. Some such people are actually partnered or married to opposite sex partners, while others are not.

Mental Health

Lesbian and gay men have a wide range of mental health needs. While there is no intrinsic relationship between sexual orientation and psychopathology, the effects of homophobia and prejudice have adversely affected many gay and lesbian individuals. Thus, while many mental health issues for lesbians and gay men parallel those in the heterosexual community, others relate to their distinctive experiences: estrangement from families, the challenge of adjusting to a minority sexual orientation, the hostility or abuse that many lesbians and gay men experience throughout their lives, the lack of social support for gay relationships or family structures, or other factors.

Gonsiorek explains that while homosexual individuals present a full spectrum of psychological adjustment from the well adjusted to the severely disturbed, the effects of homophobia and prejudice have adversely affected many gay and lesbian individuals. (Gonsiorek 1988) He describes one of the greatest impediments to the mental health of gay and lesbian individuals as "internalized homophobia." Internalized homophobia refers to negative feelings one incorporates into one's self-image as the result of being raised with culturally sanctioned anti-homosexual biases. Gonsiorek states that symptoms may range from a tendency toward self-doubt in the face of prejudice to unmistakable, overt self hatred. (Gonsiorek, 1988)

Violence

Gay males and lesbians are routinely the victims of violence. A survey of nearly 2,100 lesbians and gay men nationwide by the National Gay Task Force found that more than 90 percent had been victims of verbal and physical assault because of their sexual orientation. (Gibson, 1989) Indeed, a report on bias crime sponsored by the National Institute of Justice found that 'homosexuals are probably the most frequent victims.' In a nine-city study of anti-gay violence, "nearly half of lesbians and gay men had been threatened with violence and modified their lives to reduce the likelihood of attack. Two out of three feared for their safety." A 1999 report by the National Coalition of Anti-Violence Programs (NCAVP) found that hate crimes committed against lesbians, gay men, bisexual and transgender people (LGBT) continue to rise throughout the United States, despite reported decrease in crime generally. These figures probably represent only a fraction of the actual crimes committed, as studies of gay men and lesbians victims indicate that there is vast underreporting of hate crimes.

To literally add insult to injury, "physicians tend to be especially insensitive to gay men and lesbians in cases of sexual assault. There's an unwillingness to believe that a man, especially a gay man, can be sexually assaulted." (Cotton, p. 2999) Lesbian victims of sexual assault may have compounded problems. "When a rape is a lesbian's first sexual contact of any kind with a man, it 'can create a lot of psychological problems beyond what other women who have been raped would face.'" (Cotton, p. 3000)

Gay men and lesbians also experience domestic violence, as in heterosexual relationships. And, "according to Women Inc., a San Francisco-based organization serving battered women, domestic violence occurs in 1 in 4 lesbian relationships-roughly the same percentage as in heterosexual relationships."

Lack of Recognition of Relationships

In general, the laws governing health care, property distribution and personal medical decision making reflect distinctions between gay and straight relationships and families that have been characterized as heterosexist. (Peterson, 1996)

A health provider's role in culturally competent care

In order to gain trust, you will need to create an atmosphere of openness and affirmation with all patients. There are many different components to creating an environment welcoming to Gay, Lesbian, Bisexual, Transgendered [GLBT] patients, including outreach, office space, intake forms, confidentiality policies, staff training, and the patient interview. Small changes you make in these areas can have a big effect on the comfort felt by your GLBT patients, and this will translate into a more satisfying patient-provider relationship and better health outcomes.

Discrimination in healthcare

Unfortunately, gay, lesbian, bisexual and transgendered people have reasonable fears of discrimination when seeking health care:

• A 1998 survey of nursing students showed that 8 to 12% (depending on whether the respondent rated gay, lesbian or bisexual) despised lesbian, gay and bisexual people, 5-12% found lesbian, gay and bisexual people disgusting and 40-43% believed that lesbian, gay and bisexual people should keep their sexuality private.
• In a 1996 survey of 1,027 New Mexico physicians, 4.3% indicated that they would deny gay and lesbian people acceptance to medical schools and 10.1% believed that gay and lesbian physicians should be discouraged from seeking obstetrics/gynecology training. In the same study, over 20% of the general practitioners, 9.3% of family practice physicians and 4% of pediatricians reported that they would discontinue patient referrals to gay or lesbian surgeons. (The good news is that provider attitudes have improved since a 1986 California study in which 40% of MDs said they were uncomfortable with treating gays and lesbians, 30% opposed admitting gays and lesbians to medical schools, and 40% would not refer clients to gay or lesbian colleagues.)
• A 1991 Midwest study of nursing students' attitudes toward lesbians reported that 50% of nursing students felt that lesbianism was "unacceptable," 28% believed that "lesbians transmit AIDS," and 15% believed that lesbianism was "illegal."
• In survey published in 1988, 84% of lesbians surveyed had experienced a general reluctance to seek health care, finding it non empathic. This study revealed that 96% of lesbians "anticipated situations in which it could be harmful to them if their health care provider knew they were lesbian."

Basic tips for culturally competent care

Approximately 5 to 10% of your patient population may be lesbian, gay and bisexual and approximately 1 to 10% may be transgendered (not all will be transsexual, though). If these numbers sound high to you, it may be that you are not asking the right questions, or that patients are not comfortable disclosing. Begin with self-evaluation and reflection. What expectations and assumptions do you bring to the patient encounter? What values, biases and beliefs?

• Sexual behavior may change over time, and sexual orientation is not synonymous with sexual behavior. For example, a woman may state that she is a lesbian, but engages in occasional sex with men.
• Negative past experiences, provider-patient power dynamics, and societal pressures may make it very difficult for patients to disclose same-sex behavior in a health care setting. Be sensitive to your verbal and your body language to create an atmosphere of care, openness and non-judgment.
• GLBT patients are likely to be especially conscious of protecting their privacy in medical records, and the potential disclosure of their sexual orientation on medical records may be a factor in their willingness to discuss it openly with you. Be explicit with patients about how and whether you will document of sexual orientation in the medical record and obtain the patient's permission before doing so.
• Be familiar with appropriate GLBT community referrals. Referring GLBT patients to health resources in their community is analogous to referring an older client to services targeting elderly people or a person with diabetes to the American Diabetes Association. GLBT organizations in your area will be happy to provide you with brochures to hand out to patients.
• Again, remember that cultural competence is a learnable skill. GLBT patients will notice your attempts to be welcoming and will respond very positively.

Tips for creating a welcoming healthcare culture

• Post a sign in waiting areas that says "We do not discriminate on the basis of age, race, sex, sexual orientation, gender identity, religion, language, or disability." GLBT people notice when sexual orientation and gender identity are included in non-discrimination policies, because they often are not.
• Have an affirmative action policy for hiring "out" GLBT people. This will go a long way towards making GLBT patients more comfortable.
• Waiting area reading materials and bulletin boards should include positive items about the GLBT community and materials of interest to the GLBT community.
• Provide in-depth training for staff members on homophobia and GLBT health concerns. All staff dealing directly with clients should be able to talk comfortably about all forms of sexuality and all gender identities. Have staff practice with each other until they are comfortable.
• Friends and partners of GLBT patients should be given the respect and privileges usually given to a spouse or relative.

History and physical intake form

• Patient intake forms should be free of heterosexual assumptions. Include options such as "Living with domestic partner" as well as standard options such as married and single. Instead of "husband/wife" use gender neutral terms such as, "partner."
• Whenever there is a sex or gender question, add a third category for transgendered with space that people can elaborate. Do not list transgendered as an alternate sexual orientation (like lesbian, bisexual, or heterosexual). Gender identity and sexual orientation are distinct.
• Questions about families should allow for alternative families including two parents of the same sex and more than two parents.
• Intake forms need to include an explanation about how confidentiality will be protected and who has access to medical records. Offer the patient the right to refuse to answer a question on the intake form if they are concerned--you can discuss it in your office.
  

Patient interview

Remember that any person who walks into your office could self-identify as gay, lesbian, or bisexual and/or have a history of relationships with members of the same sex. Similarly, they may have been born the other sex than they appear. If a patient has left blanks on the intake form, this may be an indication that they felt uncomfortable being open in writing. You have another, better chance to create trust with the GLBT patient during the initial interview.

• Ensure that questions you ask are open-ended and apply to all patients.
• It is important to take a complete sexual history in a non-judgmental manner. Revisit the sexual history each time you see the patient as practices and partners may change (this is true, of course, for heterosexual/non-transgender patients, too). It is important when discussing sexuality to focus on behavior and not just sexual orientation or identity, as not all people with homosexual behaviors identify as such.
• If a patient seems offended by something you've said, you may simply apologize and offer a brief explanation about why information is necessary to provide the best care possible. Ask what terminology the patient prefers.
• Seek out colleagues who have experience in gay, lesbian, bisexual, and transgender healthcare (many more providers are experienced with GLB health than with transgender health). You may use these colleagues for advice and for referrals.
• Explain how the patient's confidentiality will be protected, and who will have access to the information. Give the patient the option of refusing to answer a question. If the patient's confidentiality cannot be protected, it may be to the patient's disadvantage to provide specific information if it is recorded in the medical chart.
• If a teenager or young person does disclose their lesbian, gay, bisexual, or transgendered identity to you, you must treat this information with great privacy and respect. You may be the first person he or she has told. As sexual minority young people are at increased risk for both suicide and abuse, pay special attention to the mental health of this patient. Ask about the patient's access to support. Isolation from peers and rejection by family are very real risk factors for some sexual minority youth.
• Ask GLBT patients about a personal history of hate crimes/violence. Victims of violence are at increased risk of post-traumatic stress disorder.
• If you are a pediatrician seeing a child with same-sex parents, include both in discussions about the child's health care even if both do not have legal custody. Health care is compromised when any primary caregiver is excluded.