Depression 

Dealing with LGBTQ Patients: The significance of Increasing Cultural Competency – Part 2

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Naturopathic Perspective

This is the second part of a 2-part article discussing competent care for LGBTQ patients. Part 1 discussed the recent National Institutes of Health determination of sexual and gender minorities as any adverse health disparity group associated with the variety of increased risk factors faced with this demographic – risk factors that report, at least partly, to social stigma and lack of providers informed on LGBTQ healthcare needs. The statistics suggest that this less-than-optimal care can especially impact teens and seniors who identify as sexual or gender minorities. Recent studies highlighting practitioner bias reveal the necessity to improve our understanding of the proper way to support our patients who are part of this minority group.

Negative Experiences Seeking Care

While the bond between your health from the LGBT population and also the biases inside the medical profession have not been fully sussed out in research, one can easily see the link between delayed care and the possibility of facing discrimination or ignorance. In a survey of nearly 5000 LGBT individuals and people coping with HIV, over fifty percent had experienced healthcare discrimination, such as being refused treatment or healthcare providers refusing to the touch them.One in a 2009 report through the Center for American Progress, 29% of LGBT individuals reported delaying necessary visits to a doctor, as compared with 15% of people who identified as straight.2 An identical number of transgender patients report delaying care because of discrimination.3 One fourth of transgender people surveyed reported that they been harassed or disrespected in a hospital or doctor's office.3 Up to 50 % of transgender men reported “harassment, physical assault or denial of equal treatment inside a doctor's office or hospital,” based on a 2023 survey.4

With the recent proposed repeal from the Affordable Care Act , protections afforded to the LGBT community through the non-discrimination clause5 are in risk of being rescinded. A paper released by Fenway Health outlines the possible impacts on the LGBT community and also on those living with HIV.6 A finish towards the ACA could jeopardize or eliminate federal programs that deliver choose to a greater percentage of LGBT people.5 Programs such as the ones that provide medications to low-income HIV individuals could be slashed, further complicating the use of quality and competent care.7

Matthew Kavanaugh, a policy analyst for that organization Health Gap Global Access Project, was quoted as saying, “One of the most basic stuff that happened with Medicaid expansion is the fact that people were able to move off of ADAP and not just get HIV drugs but full [health] insurance. In the event that rolls back, it's likely we will see huge issues with ADAP. That in turn could hurt the US effort to control HIV.”8

Policy aside, navigating a healthcare system which has traditionally not considered the easiest method to take care of this population could be daunting for LGBTQ individuals. Along with potentially facing discrimination, the patients themselves often end up educating their providers on SGM health problems, an obligation which should rest using the provider.

Finding & Training Competent Providers

A study published in the American Journal of Public Health described the problem of finding a doctor who is competent in the proper care of LGBT patients.9 Only 15% training hospitals surveyed had a list of LGBT-competent doctors, and just 16% reported offering what was referred to as “full” LGBT competency training at their institution; 52% of teaching hospitals surveyed didn't have training whatsoever.9

The amount of SGM competency of current doctors may be easily attributed to insufficient training. A white paper published in 2023 reported that medical schools spend, on average, 5 hours covering topics related to LGBT health insurance and that little to none of the training covers the healthiness of transgender people.10 Within the same year, however, the Association of American Medical Colleges developed and published competencies meant for medical schools to ensure that physicians are educated to provide equitable take care of LGBTQ, gender non-conforming, and DSD individuals.11 University of Louisville's Med school was the first one to incorporate these competences, and it has done this thoroughly and comprehensively by integrating information about LGBTQ health throughout their curriculum and spreading it over the 4 years; by doing so, it is becoming one to other medical colleges.12 Recently, the District of Columbia expanded around the concept of competencies by passing legislation requiring cultural competency training for all healthcare providers around the care of LGBT patients.13

Improvements

While competency training implies competence, the truth is that with respect to the duration and quality of the education, the requirement of a course does not necessarily equate with expertise or proficiency. To higher care for this growing demographic, doctors must notice their own internal biases regarding gender and sexual orientation and should stay up to date on the latest standards of take care of this patient population.

An example of failure to remain current with SGM-related healthcare is evidenced by the use of the HIV medication, emtricitabine/tenofovir disoproxil, which has been approved for pre-exposure prophylaxis of HIV since July of 2012. While it has been discovered to effectively prevent contraction from the HIV virus by a lot more than 90% when used consistently, a 2023 survey of primary-care providers found that only 1 in 3 primary-care doctors and nurses even knew of the information on PrEP.14

Considering our own biases when controling these patients is not only best practice but is also in line with naturopathic medical philosophy. “Obstacles to cure” inside a LGBTQ patient might be more significantly affected by social determinants of health which are incompatible with this patient's individual identity. Shared decision-making may help to enhance the doctor-patient relationship when you have had previous negative experiences and could help decrease the impact of practitioner biases.15-17

Approach

Beyond bringing awareness to biases and understanding standards of take care of LGBTQ patients, providers must consider inclusivity in their office practices, policies, and communications.

Creating an inviting and affirming practice and approach may necessitate some changes if you haven't treated many SGM patients to-date. When considering the provision of better choose to the LGBTQ patient population, here are a few factors to bear in mind:

  • Do not automatically assume that a patient is heterosexual. By accepting patients who come out to you like a SGM, you not have only the opportunity to give them better care, however this positive healthcare experience may also potentially impact any internalized homophobia and enable them to continue to create a positive identity.
  • Remember that some patients have experienced prior negative experiences also it may take them several visits before they trust the connection enough to show information about their sexuality or gender identity
  • Remember questions for example “Are you having sexual contact with other individuals which involves the exchange of body fluids?” If the response is yes, ask them how many partners they've had in the past 6 months, and then in the past year. Ask if their partners are men, women, or both. If your patient is offended by these questions, remind them that the practice is one that is available to everyone where all people should feel comfortable regardless of who they're.
  • Discuss the risk factors that change up the LGBTQ population in greater numbers, for example tobacco, alcohol, and drug abuse. Screen for depression and suicide risk in all LGBTQ patients, regardless of how they present. Related risk factors include HPV-associated cancers and breast cancer in lesbian women .18
  • Discuss relevant sexually-transmitted infection and cancer screenings, and be mindful of language in addition. While a trans man could have a cervix that needs to be screened, discussion about anatomy they might feel negatively about should be conducted thoughtfully and tactfully. Be familiar with cancers that LGBTQ patients are at and the higher chances. For instance, screen for anal cancers by Pap smear in MSM. Your emr program might be able to help prompt you to consider the relevant risk factors and necessary screenings based on a patient's identity – something referred to as decision support. For example, while some EMR programs may remind clinicians that everyone between the ages of 15-65 should have an HIV test, men who have sex with men may need to be tested more frequently.
  • Follow the 2023 PrEP Clinical Practice Guidelines19 to do recommended tests, and prescribe PrEP to patients without HIV who could benefit
  • For trans patients on hormone therapy, there is still much research that must be done to better comprehend the long-term impact of hormone use. Screening for that risk factors that we are conscious of, however, such as heart health, is an important part of comprehensive trans care.
  • Inclusive communication can help identify a patient's support system, which will consequently have positive effects on their compliance. Ask whom they include in their family, whom they accept, and whether they have a partner or spouse. Because the LGBTQ population handles a larger incidence of suicidal ideation, building family support is also an important suicide prevention strategy.20
  • Ask in regards to a patient's family-planning ideas. An increasing number of LGBT individuals are starting families, and initiating this inquiry is a good method to demonstrate inclusivity while getting to better know your patient.21
  • Know the social determinants of health that many impact minorities in your town. For instance, if gun violence is an issue, this is usually a discussion you initiate with SGM patients who're at greater risk of harassment and victimization.
  • Consider how you can help make your practice as inclusive and welcoming as possible. For instance, post LGBT “SafeZone” signs inside your office; have images of same-sex couples in your website or blog; have referrals and directions to local suppliers that are LGBT-friendly.
  • Train all your staff in LGBT sensitivity, nondiscrimination policies, and inclusive communication22
  • Trans people have reported providers conflating their gender identity with health issues not associated with gender-confirming hormone therapy. Be mindful and informed when relating gender and hormone therapy to health issues that may seem unrelated towards the patient.

It is interesting to note that regardless of the suboptimal care that lots of SGM patients have received, certain LGBT populations demonstrate resilience so that health recommendations and support around healthy lifestyle changes may be well received. For instance, despite being statistically more overweight than heterosexual women, a nationwide study found that lesbian and bisexual women actually have higher-quality diets than their heterosexual counterparts.23 This means that LGBTQ patients might be particularly well-suited to naturopathic care and that exploring the foundations of health with one of these patients might be of significant help to their well-being.

In the survey of seniors through the National Institute on Aging that was mentioned earlier in this paper,24 82% of LGBTQ quickly 50 years old put together to take part in moderate physical activity, and 91% were found to engage in wellness activities. In light of the elevated incidence of disability and disease revealed in the survey, in comparison to heterosexual older Americans, these health-focused findings suggest that this population may be motivated as patients to remain healthy and “beat” the chances with support and patient education. Ninety-percent of those surveyed expressed feeling positive about belonging to their LGBT communities.24

Supporting Further Research

While recent research has certainly expanded upon our knowledge of how you can better care for our SGM patients, continued work in el born area is essential. To support these research efforts, you are able to help by telling patients in regards to a long-term study being conducted through the University of California at San Francisco. The UCSF PRIDE study aims to be the queer form of the Framingham Health Study in terms of its breadth and duration.25 Encourage your LGBTQ patients to download the Pride app and to have fun playing the data collection. Participants will complete a yearly health questionnaire that takes approximately Half an hour annually.

Additional Resources

  • Gay and Lesbian Medical Association 's online provider directory: Helps patients locate LGBT-friendly health care professionals. You are able to sign up for free to be considered a listed provider.
    • glma.org
  • Human Rights Campaign: Includes a Healthcare Equality Index that has evaluated a large number of healthcare facilities nationwide and can be a valuable resource for finding LGBTQ-supportive providers
    • hrc.org/hei
  • TransLine: Something that allows doctors nationwide to inquire about clinical experts for help with trans patients
    • project-health.org/transline
  • American Medical Association's “Physician Helpful information on an LGBTQ-inclusive practice”
    • ama-assn.org/delivering-care/physician -resources-lgbtq-inclusive-practice
  • World Professional Association for Transgender Health
    • wpath.org
  • LGBT Health Workforce Conference
    • http://bngap.org/lgbthwfconf/
  • The book Fenway Guide to Lesbian, Gay, Bisexual and Transgender Health
  • Fenway Institute's National LGBT Health Education Center has lots of online resources, including free, online learning modules that provide CME credit
    • lgbthealtheducation.org/lgbt-education/learning-modules/
  • org: Aims to help doctors, nurses and medical professionals unlearn racial bias and elevate the quality of healthcare for black SGMs
    • hishealth.org/trainings
  • Resources for your LGBTQ patients
    • Patient Toolkit : www.rainbowhealth.org/resources-for-you/patient-toolkit/
    • Human Rights Campaign's Safer Sex for Trans Bodies Guide: www.hrc.org/resources/safer-sex-for-trans-bodies
  • Resources for LGBT cancer patients
    • http://cancer-network.org
    • lbbc.org/lgbt-breast-cancer/lbbc-resources

Videos

  • YouTube: “Vanessa Goes to the Doctor”

Refs:

  1. Lambda Legal. When Health Care Isn't Caring: Lambda Legal's Survey of Discrimination Against LGBT People and individuals with HIV. 2010. Offered at: https://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf. Accessed April 15, 2023.
  2. Krehely J. How you can Close the LGBT Health Disparities Gap. December 21, 2009. Center for American Progress. Offered at: https://www.americanprogress.org/issues/lgbt/reports/2009/12/21/7048/how-to-close-the-lgbt-health-disparities-gap/. Accessed April 15, 2023.
  3. Grant JM, Mottet LA, Tanis J. Injustice at each Turn: A study from the National Transgender Discrimination Survey; 2011. National Center for Transgender Equality. Available at: http://www.thetaskforce.org/static_html/downloads/reports/reports/ntds_full.pdf. Accessed April 20, 2023.
  4. Shires DA, Jaffee K. Factors associated with health care discrimination experiences among a national sample of female-to-male transgender individuals. Health Soc Work. 2023;40:134-141.
  5. Wang T, Kelman E, Cahill S. Exactly what the New Affordable Care Act Nondiscrimination Rule Means for Providers and LGBT patients. September, 2023. The Fenway Institute. Offered at: http://fenwayhealth.org/wp-content/uploads/ACA-1557-Non-Discrimination-LGBTs-Brief-v2.pdf. Accessed April 20, 2023.
  6. Wang T, Cahill S. Exactly what the American Health Care Act method for LGBT People and People Living with HIV. 2023. The Fenway Institute. Available at: http://fenwayhealth.org/wp-content/uploads/2023/03/Policy-Brief-What-AHCA-means-for-LGBT-PLWH-final.pdf. Accessed April 20, 2023.
  7. Macsata BM. Despite Trump's Troublesome Policies, HIV Advocacy Must Remain in Motion. March 22, 2023. AIDS Drug Assistance Program. Offered at: http://adapadvocacyassociation.blogspot.com/2023/03/despite-trumps-troublesome-policies-hiv.html. Accessed April 20, 2023.
  8. Health Gap in media. Posted on Press by Brittany Herrick. December 17, 2023. Health Gap Global Access Project. Offered at: http://www.healthgap.org/tags/global_health. Accessed April 20, 2023.
  9. Khalili J, Leung LB, Diamant AL. Locating the perfect doctor: identifying lesbian, gay, bisexual, and transgender-competent physicians. Am J Public Health. 2023;105:1114-1119.
  10. Burkhalter JE, Margolies L, Sigurdsson LM, et al. The National LGBT Cancer Plan of action: A White Paper of the 2023 National Summit on Cancer in the LGBT Communities. LGBT Health. 2023;3:19-31.
  11. Association of yankee Medical Colleges. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born with DSD: A Resource for Medical Educators. 2023. AAMC Web site. https://members.aamc.org/eweb/upload/LGBTDSD%20Publication.pdf. Accessed April 20, 2023.
  12. LGBT Health and Wellness Competency Certificate. 2023-2023 LGBT Overall health Competency Series. University of Louisville Site. http://louisville.edu/lgbt/lgbt-hsc/lgbt-health-and-wellness-competency-certificate-1. Accessed April 20, 2023.
  13. LGBTQ Cultural Competency Continuing Education Amendment Act. 2023. [enacted]. Bill offered at: http://lims.dccouncil.us/Download/33671/B21-0168-Introduction.pdf. Accessed April 20, 2023.
  14. Centers for Disease Control and Prevention. Daily Pill Can Prevent HIV. Last updated November 24, 2023. CDC Site. https://www.cdc.gov/vitalsigns/hivprep/index.html. Accessed April 15, 2023.
  15. Peek ME, Lopez FY, Williams HS, et al. Growth and development of a Conceptual Framework for Understanding Shared Decision making Among African-American LGBT Patients as well as their Clinicians. J Gen Intern Med. 2023;31:677-687.
  16. DeMeester RH, Lopez RY, Moore JE, et al. A Model of Organizational Context and Shared Decision Making: Application to LGBT Racial and Ethnic Minority Patients. J Gen Intern Med. 2023;31:651-662.
  17. Nathan AG, Marshall IM, Cooper JM, et al. Use of Decision Aids with Minority Patients: An organized Review. J Gen Intern Med. 2023;31:663-676.
  18. Quinn GP, Sanchez JA, Sutton SK, et al. Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning populations. CA Cancer J Clin. 2023;65:384-400.
  19. Centers for Disease Control and Prevention. Preexposure Prophylaxis for the Prevention of HIV Infection in the usa – 2023. A Clinical Practice Guideline. CDC Web site. https://www.cdc.gov/hiv/pdf/guidelines/PrEPguidelines2023.pdf. Accessed April 15, 2023.
  20. O'Brien KH, Putney JM, Hebert NW, et al. Sexual and Gender Minority Youth Suicide: Understanding Subgroup Differences to Inform Interventions. LGBT Health. 2023;3:248-251.
  21. Pathways to Parenthood for LGBT People. 2023. National LGBT Health Education Center: A Program of the Fenway Institute. Offered at: https://www.lgbthealtheducation.org/publication/pathways-parenthood-lgbt-people/. Accessed April 20, 2023.
  22. Healthcare Equality Index 2023. Human Rights Campaign Foundation Site. http://www.hrc.org/hei. Accessed April 20, 2023.
  23. VanKim NA, Austin SB, Jun HJ, et al. Dietary Patterns during Adulthood among Lesbian, Bisexual, and Heterosexual Women in the Nurses' Health Study II. J Acad Nutr Diet. 2023;117:386-395.
  24. Fredriksen-Goldsen KI, Kim HJ, Emlet C, et al. The maturing and Health Report: Disparities and Resilience among Lesbian, Gay, Bisexual, and Transgender Older Adults. Seattle, WA: Institute for Multigenerational Health; 2011. Offered at: http://age-pride.org/wordpress/wp-content/uploads/2012/10/Executive_Summary10-25-12.pdf. Accessed April 20, 2023.
  25. The Pride Study. Your Story. Your Health. 2023. Offered at: https://www.pridestudy.org/. Accessed April 20, 2023.
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