How NPs Can Create Welcoming Environments for LGBTQIA+ Patients
Dr. Vanessa Pomarico-Denino, Ed.D, APRN, FNP-BC, FAANP
Why is it important for NPs to learn about LGBTQIA+ identities?
It is not enough for healthcare providers to be just “LGBTQIA+-friendly” or “accepting.” It is essential to be educated on the issues that face these populations, to know how to appropriately discuss them with patients, and to proactively create a welcoming space for all patients.
The majority of providers today have not been well educated on LGBTQIA+ identities and the ways to be welcoming to LGBTQIA+ patients. As a result, 56% of LGBTQIA+ people have experienced some form of healthcare discrimination, from a refusal of care to a lack of gender-inclusive language on intake forms.
LGBTQIA+ people of color are more than twice as likely to avoid care than white LGBTQIA+ individuals. Also, one study found that transgender youth whose pronouns were respected by people in their lives attempted suicide at half the rate of individuals whose pronouns were not respected. Having a supportive environment is essential for LGBTQIA+ people to feel seen and comfortable when seeking care.
What does it mean to be transgender?
Transgender individuals are people who are living as a different gender from their sex assigned at birth. People who identify as transgender may or may not have had gender-affirming surgery, may or may not use hormones, and may or may not have plans to alter their bodies at all. Gender dysphoria is persistent discomfort or distress when there is a discrepancy between gender identity and the sex assigned at birth.
What does it mean to be non-binary?
A non-binary person is someone whose gender identity is not strictly male or female. It is important for intake forms to have inclusive language so a patient can tell you what pronouns they use. This helps to prevent misgendering patients with common terms of respect like “sir” or “ma’am.”
What is misgendering?
Misgendering is intentionally or unintentionally using language that does not align with someone’s affirmed gender. This may include using the wrong pronouns, using someone’s name assigned a birth when they have provided a different name, or using gendered language like “sir” or “madam.”
Misgendering patients is a serious matter as it can make patients feel uncomfortable and unwelcome. It may take time to reestablish trust with patients after misgendering them, and some patients will avoid seeking care until they end up in the ED with an urgent issue.
If you make a mistake when talking to a gender-diverse patient, simply acknowledge it, correct yourself and move on. You do not need to make it a big deal. It is most important that a patient feels that their identity is respected.
What does the American Association of Pediatrics recommend for supportive care of transgender and gender-diverse children and adolescents?
- Provide access to care for gender-diverse youth
- Provide support to family and friends
- Electronic Health Records should reflect the preferred name and pronoun
- Support insurance plans that cover transgender-related care (medical, psychological, and surgical interventions)
- Act as advocates for policy and law promoting acceptance of gender-diverse youth
What can NPs do to be more welcoming to LGBTQIA+ patients?
- Deepen your knowledge of identities and terms
- Use inclusive and gender-neutral language
- Convey respect
- Be patient
- Remember it takes time to build trust, and it can be difficult for patients to discuss issues related to their identity, body, or sexual health
- Learn to speak their language
- Introduce yourself with your name and pronouns and ask them theirs
- Mirror the language patients use to talk about themselves and their bodies
- Some patients may find anatomical language triggering or offensive. It is better to ask what the patient prefers to call a part of their body and mirror their language.
- Ask “What can I do to help you with your journey?”
- Focus on the patient’s presenting complaint
- Do not delve into a patient’s surgical history or transition-related plans unless it is relevant to the presenting complaint.
What policies should NP offices have to be welcoming to LGBTQIA+ patients?
There are many small changes nurse practitioners can make to signal respect and affirmation to LGBTQIA+ patients. Some examples include:
- Communicate non-discrimination policies to all employees and patients on hospital websites, posted in patient waiting areas, and on patient registration forms
- Display rainbow decals or wear lapel pins; may say “safe space” or “all are welcome”
- Add “partnered” to demographic forms
What are the top health issues for LGBTQIA+ patients?
It is important to remember that LGBTQIA+ populations experience certain health concerns at higher proportions than the average population. Understanding these disparities can help NPs be more proactive and provide better care to LGBTQIA+ patients.
The top ten health issues for LGBTQIA+ patients are:
- Tobacco, substance, or alcohol abuse
- Intimate partner violence
- Transgender women of color face the highest rates of fatal intimate partner violence
- Sexual health:
- Many schools do not teach LGBTQIA+-inclusive sexual health. It is important to discuss consent, protection, and healthy relationships with LGBTQIA+ patients.
- Unfortunately, LGBTQIA+ youth face high rates of homeless in the U.S. Such individuals may turn to sex work to help them survive. It is essential to discuss sex practices and screen for STIs with LGBTQIA+ patients.
- In 2020, 40% of LGBTQIA+ individuals had contemplated suicide in the previous 12 months. It is essential to screen LGBTQ patients for mental health concerns.
- Body dysmorphia:
- While transgender individuals experience gender dysphoria, body dysphoria is also a major concern in the LGBTQIA+ community. Gay men experience body dysmorphia at higher rates than straight peers due to perceived pressures in the community and unrealistic expectations in media and pornography.
- Reproductive health/fertility/contraception:
- Do not assume that LGBTQIA+ patients have no interest in bearing or having children. Ask patients if they have fertility issues or need or want access to fertility services.
- Provide family planning information to transgender individuals who are considering hormone therapy or gender-affirming surgery.
- At the same time, being on testosterone does not offer protection against pregnancy for transgender men. Be sure to discuss contraceptive options with transmasculine patients.
- Access to insurance coverage and healthcare
- LGBTQIA+ populations have higher rates of uninsurance or under-insurance.
- There is a lack of educated providers.
- Immunizations and screenings
- All patients should be immunized against HPV, Hepatitis A, and Hepatitis B
- All patients should be screened for HIV and Hepatitis C every year or 6 months depending on the patient’s sexual history
- Risk factors for breast cancer, reproductive cancer, colon cancer
- Patients may not have had appropriate screenings in the past due to a lack of access to medical care.
- Remember that patients need to be screened based on their anatomy. For example, a transgender woman who has a prostate still needs age-appropriate prostate screenings; a transgender man who has a cervix still needs routine cervical cancer screenings.
How do you obtain a sexual history for LGBTQIA+ patients?
NPs can obtain sexual histories for LGBTQIA+ patients the same as other patients. You should consider the person’s sexual identity and ask about current activity, number of partners, and types of practices. Respectful questions regarding sexual history include:
- Are you currently sexually active?
- Do you have sex with male partners, female partners, or both?
Keep in mind that you do not need to know the specifics of someone’s sexual practices. You can simply ask if they have receptive intercourse, for example, to understand what is putting the patient at risk for contracting an STI or anal cancers. If a patient is not forthcoming with their number of partners, simply ask if they have had sex with two or more partners in the last month.
Other relevant questions include the use of shared sex toys, contraceptive use, and a history of physical or sexual abuse. Having respectful conversations with LGBTQIA+ patients will help them feel safe, be more honest with you, and ultimately allow you to provide better care.
Earn CE hours by enrolling in the course Expanding the Rainbow: Understanding the needs of the LGBTQIA patient (free with Passport Membership)!