The Value of Identity: Providing Culturally-Responsive Care for LGBTQ+ Patients Through Inclusive Language and Practices

Introduction

The lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) people living in the United States are as diverse as the country itself. These individuals and their families represent every race, ethnicity, faith-based group, physical ability/disability, age and socioeconomic level.¹ In 2018, Gallop reported that 4.5% of American adults identify as lesbian, gay, bisexual or transgender.² Like many at-risk populations, LGBTQ people experience disparities in both the occurrence of certain physical/mental health issues, but also in the manner in which they receive care. The 2011 report, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender Community published by The Joint Commission, illustrates these disparities for LGBTQ individuals with experiences including: lower overall health status; higher rates of smoking, alcohol, and substance abuse; higher risk for mental health illnesses, such as anxiety and depression; and higher rates of sexually transmitted diseases, including HIV infection.

To complicate this, LGBTQ people face challenges in receiving culturally appropriate healthcare. This may be due to providers and staff not receiving adequate education and training to override any bias or stigma and meet each person’s unique needs.¹ The common gaps in training include best practice approaches, identifying needs, providing care for minority and vulnerable populations, and building professional competency around language. This all comes at a critical juncture, where identifying and addressing the healthcare needs of LGBTQ individuals has received increased attention from the Institute for Medicine, Healthy People 2020 and the Agency for Healthcare Research.³ As the landscape of healthcare evolves, so do definitions of gender and orientation; both of which grown well beyond just male/female and straight/gay. It was only a matter of time before this expansion of language would intersect healthcare.

Evolution of Language and LGBTQ Terms

Near the third decade of the twenty-first century, a number of advancements have had an impact on healthcare, from technology to pharmaceuticals. Social advancements, too, have had impacts, especially as it relates to LGBTQ persons. Since the 1990s, those 5 letters have evolved in tandem with the progress this community has experienced regarding legal rights and societal acceptance. These letters are meant as an expression of inclusion.⁴ There isn’t standard agreement, though, for a definitive list. For example, the “Q” was added around the millennium: some choose to define it as “questioning,” representing people who were undecided, or unsure of their orientation. However, others have declared it was for “queer,” an umbrella term, repurposed from a pejorative, to represent a segment of this community.⁴ This lack of consensus poses a challenge, as anyone looking for greater understanding may not be able to determine a clear answer on what is currently acceptable. It is important to note, though, that the variance in terms and identities should not be viewed as “right” or “wrong.” Rather, it is important, as Medium.com writer Jeffry J. Iovannone notes, “to encourage critical thinking around language as a vehicle of social change, and to recognize that people do not have to agree on all things to work communally.” Language, especially in this context, should not be used to exclude others. One should think critically about the words used to see if they are serving the intended purpose, or creating additional problems.⁵

Implications on Healthcare Delivery

Addressing the health needs of any underrepresented population can present challenges for healthcare providers and systems of care — from messaging and access to staff/provider education and cultural competency. These topics are especially relevant as they have the potential for being barriers to care. Patients who identify as LGBTQ face “delayed or substandard care, mistreatment, inequitable policies and practices, little or no inclusion in health outreach or education, and inappropriate restrictions or limits on visitation.⁶” These inequalities are likely to be more prevalent for LGBTQ persons from racial/ethnic minorities or in relation to “education level, income, geographic location, language, immigration status, and cultural beliefs.⁷” LGBTQ persons who experience discrimination and mistreatment are more likely to not trust health care systems and be less likely to seek treatment for medical issues.⁸ The key in building equity in healthcare starts with education around language, making all of this work education. The most cited barrier [to introducing LGBT education for staff] was perceived lack of need.⁹ One of the rewards of cultural competence in health care is physician [or staff] self-reported increases in confidence and comfort in delivering care for LGBTQ patients.¹⁰

By embracing the truth that there is always room to grow and improve, we have the opportunity to build a greater capacity to educate — both staff and clinicians, as well as our patients. The yield from increased education could be immeasurable.

Best Practice Care

Key aspects of best practice care must reach well beyond healthcare provider skills. Due to lack of readiness for the nation’s LGBTQ+ citizens, medical providers serving this population must work to remove existing barriers to healthcare; these include not just fear of discrimination resulting in delayed healthcare but actual discrimination, including but not limited to provider bias, lack of inclusiveness of body or gender representation, mis-diagnosis, and reliance on prevailing stereotypes or myths about LGBTQ+ patients.¹¹

Welcoming-Environment Language

What do our patients see and read upon walking in? How do they experience their healthcare provider on the phone? Through their website text? What is their experience during the first office interaction with scheduling and asking questions? Are there inclusive bathrooms with signage posted? Checking the language related to these areas with an LGBTQ+ lens is a critical piece to assess when striving to make LGBTQ+ patients feel welcome and safe.

Who are the best consultants to give that guidance? LGBTQ+ community members themselves. Thoughtful inclusion of community members to guide the welcoming language process is critical, and paying them for their time and expertise is a baseline of respect. Showing that their work is valued will truly allow more patients to come through the door. Key areas to review in this venture are websites; internally and externally (community / vendor) displayed information, magazines and brochures; pictures; bathrooms and bathroom signage; and non-discrimination policies with language inclusive of LGBTQ+ displayed prominently. Other aspects of creating a welcoming environment regarding wording certainly involve provider knowledge and skills but those aspects will be covered in the next section. Providers who truly want to make their offices and practices “welcoming” need to consult with and pay for the expertise of those they want to serve.^11,12

Language Guidelines for Forms & Patient-Provider Interactions (GLMA)

When LGTBQ+ individuals come in to a practice for the first time, an intake form can often give them a good picture of how inclusive and safe the medical practice is. Forms need to allow for the flexibility of human gender identity and expression, and allow for a great diversity of relationships and experiences. Some examples include using “gender____ (write in)” instead of “male ____ female___” and “parent 1_______ parent 2 _____ “ etc. instead of “mother / father.¹¹”

Sample language guidelines for forms include:

• “You” or “They” instead of “him/her,”

• “Transgender” gender boxes on a form as well as “male/female,” or using a fill-in-the-blank,

• “Relationship status” instead of “marital status.” Add options like “partnered” and change “husband / wife” to “spouse,”

• For sexual and/or romantic relations use terms like “partner” or “significant other” instead of boyfriend, girlfriend, husband, wife.

For patient-provider interactions, create a safe and inclusive space to discuss sexual history and health by assuring all patients of confidentiality, and also explaining the rationale for the questions being asked.

More tips about patient-provider interactions include:

• Use correct affirming pronouns and names¹³

• Check the form and/or please ask. Those who have usually been marginalized or excluded will notice the effort.

• Mistakes: Were the wrong pronouns used? Apologize with a quick sincere apology meant to address the mistake. Invest in a culture where making mistakes and learning from them is welcome.

• Do not use language which assumes or stereotypes which sexual behaviors go with which bodies and identities. Not all gay men have anal sex. Not all lesbians use phallic sex toys.

• When discussing condoms, barriers, and/or birth control, avoid language which assumes heterosexuality or which may be irrelevant. Asking about partners and bodies will lead to better, more accurate information. Using open-ended questions may avoid accidents

• What if name and gender do not match in the records? For some LGBTQ+ patients who have changed their names and/or may be transgender, some issues with insurance and payment of services can get complicated. Some essential procedures may even be denied (i.e. prostate exams for a patient listed as female). Show empathy by doing everything possible to resolve this issue. In cases where a patient’s name does not match between documents, inquire with open questions like “could the insurance perhaps be listed under a different name?” Avoid asking a person what their “real name” is: “This could imply that you do not acknowledge their [affirming] name as “real.¹³”

• Avoid asking unnecessary questions¹³

• Use the patient’s language and terminology when discussing behaviors and partners during sexual-history taking. Clarify and definitions or meanings to avoid assumptions.

• Do not label a patient based on their stated behaviors. Just because a patient has noted they have sex with men and women does not mean that they identify as bisexual, gay or even straight. Behavior is not the same thing as identity.

Language Skills - Training

Training is fundamental. But a “one and done” approach will not suffice. Training for language to better serve LGBTQ+ individuals requires time and engagement. Initial training, ongoing training, booster trainings and meaningful assessment of training skills and concepts are critical pieces of the training process if a provider or practice wants to make good on its promise to be a welcoming place for LGBTQ+ patients. Further, training every level of the organization in the concepts, knowledge, empathy, and sensitivity towards this group of people is essential to an organization that promotes itself as an LGBTQ+ welcome practice.¹³ Front line staff must have training in using the proper language, pronouns and terms, showing empathy, and avoiding stereotypes.¹¹

All clinical staff, including front line and phone support staff, should use scripts and questions in a way that does not assume gender identity or orientation (e.g. even if a voice sounds feminine or masculine on the phone, female or male pronouns should not be used, and stereotypes should not be assumed). As previously noted, the LGBTQ+ community has experienced significant barriers to accessing welcoming comprehensive medical care. The training aspect of a program must be emphasized, and delivered in a quality manner. A one-hour LGBTQ+ 101, once or twice a year, will in no way suffice. With employee turnover and the constant evolution of affirming and accurate LGBTQ language, providers must commit to consistent quality training evaluation and adaptation in order to be current, relevant and effective. A provider’s medical care skills for the LGBTQ+ population will be measured by the quality of care given by the least-trained staff person. If quality LGBTQ training is not available within an organization, providers can reach out to sexuality training experts in their community to create a robust program.

Conclusion

There is significant value in understanding the impact of language regarding sexual and gender identity and orientation. It is critical to provide accurate, up-to-date education for all members of the healthcare community in order to understand importance of adopting nuanced language to affirm an individual’s gender, or sexuality. Doing so builds equity, and provides a safe space for LGBTQ patients to receive the quality care they deserve.