Clinical Journal of HIV & AIDS

Providing Care to the LGBT Community: Cultural Competency and Best Practices

Abstract

Lesbian, gay, bisexual, and transgender (LGBT) refers to a diverse community from a gender, sexual, and cultural perspective. While these identities tend to be grouped under the broad heading of LGBT, the diversity and differences among and between these groups couldn't be more obvious or evident. This brief review of the literature provides important information that will help nurses and other health care providers offer more culturally competent care to this population despite gender or sexual identity.

Introduction

Lesbian, gay, bisexual, and transgender (LGBT) refers to a diverse community from a gender, sexual, and cultural perspective (please see (Table 1) for a summary of identity terminology). A 2013 Pew Research Center survey of LGBT adults found that while an overwhelming majority of participants reported perceiving society as more accepting (92%), 43% also reported having been the victim of stigma or discrimination as a result of their sexual orientation over the past year [1]. While these communities tend to be grouped under the broad heading of LGBT, the diversity and differences among these groups is obvious and the diversity and distinction between each group can be increasingly individualized. Adding to this complexity are the other variant characteristics of culture with which these individuals may identify. Variant characteristics of culture may change or remain stable over a lifetime such as nationality, race, ethnicity, religious affiliation, socioeconomic status, educational status, political affiliation, immigration status, etc. [2,3]. In light of these various cultural influences, and in an effort to provide the most comprehensively competent care for all of their patients, including members of the LGBT communities, it is imperative that nurses have a sound understanding of cultural competence and the health related issues that may impact LGBT persons.

Cultural Competence

Cultural competence has been previously defined as the explicit use of culturally based care and health knowledge that is used in meaningful ways to be congruent with the needs of individuals or groups [4], the ongoing process in which the healthcare provider continuously strives to effectively work within the cultural context of the client [5], self-cultural awareness, knowledge, and understanding of the client's culture and adaptation of care to be congruent with the client's culture [2,3] and a dynamic, fluid, continuous process whereby an individual, system, or healthcare organization's meaningful and useful care delivery strategies are based on knowledge of the cultural heritage, beliefs, attitudes, behaviors, and worldview of those to whom they provide care [6]. While these models have been primarily focused on cultural competence with regards to racial and ethnic diversity, they can provide a loose framework for understanding the subcultures that underlie prevailing cultural influences such as those found among LGBT individuals and communities. Purnell's model consists of twelve cultural domains and their concepts. The twelve domains are overview/heritage, communication, family roles and organization, workforce issues, biocultural ecology, high-risk health behaviors, nutrition, pregnancy and the childbearing family, death rituals, spirituality, healthcare practices, and healthcare providers [2,3]. Certain issues may be of particular concern when considering culturally competent care of individuals who identify, either openly or not, as members of the LGBT community, such as family role and organization, high-risk health behaviors, and health-care practices manifestated in openness of sexual identity, frequency of high risk behavior, safer-sex practices, and consistency of preventative health-care.

Institute of Medicine

The Institute of Medicine (IOM) [7] reported on the health status of lesbian, gay, bisexual, and transgender individuals and the issues related to health and wellness among the LGBT community. The report pointed to recommendations in several areas that would advance understanding of LGBT health including data collection, methodological research, research training, and policy on research participation. The authors also noted that the minority stress model as well as the life-course perspective were integral in understanding the challenges that LGBT individuals encounter over the lifespan. As in the IOM report, this report is further divided to analyze developmental stages throughout the lifespan for this selected population.

Childhood and adolescence

Nurses who specialize in childhood and adolescent health are increasingly challenged when working with individuals who may or may not be aware of their own sexual orientation or gender identity. Childhood and adolescence are often challenging for these young individuals who may be trying to understand how and why they may be different from their peers, particularly if they come from familial or community backgrounds that stigmatize differences regarding sexual or gender identification. This is precisely where the other domains of culture such as heritage/ethnicity, family roles and expectations, socioeconomic factors, education, and religion need to be considered as they may conflate the challenges of coming to terms with one's own sexuality or gender identity. Among all the challenges that may exist for young LGBT persons. Among all the challenges that may exist for young LGBT persons, depression and suicide have been identified as major risk factors for lesbian, gay, and bisexual youth and youth who report same-sex romantic attraction in comparison with their heterosexual counterparts, even when controlling for other confounding risk factors such substance misuse and depression (IOM). While the IOM reports that interventional approaches to reducing the incidence of suicide in this population have been lacking, it is important for nurses and other healthcare providers to be aware of existing resources. A popular resource utilized by healthcare professionals in particular is the Trevor Project [8]. Founded in 1998, The Trevor Project is a leading national organization providing crisis intervention and suicide prevention services to lesbian, gay, bisexual, and transgender (LGBT) youth ages 13-24 [8]. Other areas of concern that tend to have higher rates among youth and young LGBT adults include eating disorders/body image disturbances (particularly among gay men), transgender specific mental health issues, substance misuse, and sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) and human papilloma virus (HPV) [9] . Even as societal norms continue to shift toward more acceptance of LGBT individuals (especially in larger urban areas) and in light of more visible positive role-models for young LGBT persons, it is import-ant to keep in mind that risk factors for young LGBT individuals remain and still include harassment, victimization, bullying, violence and other psychological disadvantages this vulnerable population may encounter.

Early and middle adulthood

Early and middle adulthood, defined loosely as the ages 20 through 60, is another lifespan phase that can present numerous challenges to individuals who identify as LGBT.

Many of these individuals have witnessed the positive effects of the gay rights movement as well as the devastating effects of the AIDS/HIV epidemic. There is no doubt that both of these phenomena have had an influence on the LGBT community at large. Early and middle adulthood is often a time when many LGBT individuals must weigh the need for being "out" or not. How honest should one be with one's family and friends about their sexual orientation? All people want to live productive, meaningful lives, something heterosexuals, with regards to their sexuality at least, may take for granted. Marriage equality, which has been legal since 2015 in the U.S, has done much to provide LGBT persons with more legitimacy with regards to the loving, personal relationships in which they engage. Nevertheless, heteronomativity in society at large remains strong. The overwhelming nature of the dominant United States culture promotes heterosexuality while often deeming non-heterosexuality as controversial. Religion, to a great extent, is one of the reasons this may be the case. Nevertheless, nurses and other healthcare providers must be aware that many people who identify as LGBT have spiritual needs and may or may not be affiliated with an organized religion. In terms of health and illness, nurses need to be aware that certain health-related conditions may be more prevalent in LGBT populations. For example, since the IOM report on lesbian health in 1999, breast cancer rates for lesbian women have remained higher than rates for heterosexual women. Lesbian and bisexual women are also at increased risk for increased basal metabolic index (BMI), obesity, tobacco use, and other disorders related to drug and alcohol use. Nurses must assess for these conditions regularly and provide appropriate referrals. Men who have sex with men (MSM), and particularly MSM infected with HIV, have the highest rate of anal cancer among all individuals diagnosed with anal cancer [10,11] and must be evaluated and referred for anal Pap smears accordingly. With regards to HIV, healthcare providers are encouraged to look at innovative outreach programs that benefit young, at -risk populations such as minority MSM [12]. Additionally, annual assessment and screening for HIV, including the potential introduction of Pre-Exposure Prophylaxis (PreP) therapy [13], syphilis, Chlamydia, and gonorrhea should be considered for all men who have sex with men.

Later and late adulthood

Later and late adulthood is defined as those aged 60 and greater. For many people in this stage of life, this is often a time of immense health-related challenges [14]. Older lesbians, bisexual, and gay men have a higher prevalence of mental health problems, disability, and disease and physical limitations than their heterosexual counter parts [15]. Other studies have reported that individuals who identified as gay or lesbian have increased rates of substance abuse, tobacco use, alcohol abuse, and domestic violence [16]. However, much of this data was collected from study participants who may frequent gay bars and other venues that attract individuals who identify as gay or lesbian, providing reasoning that results may not be accurate in regard to these populations as a whole [17]. Transgender older adults are also at higher risk for poor physical health, disability, and depressive symptoms compared to cisgender adults [6].

Many older LGBT adults live alone, and depending on their life circumstances, may or may not have a support system to assist with the challenges older age and increased risk of illness encompass [18]. Implementation practices consist of coercing nurses to familiarize themselves with the resources available in their communities that would benefit older adults who identify as LGBT. Older adults identifying as LGBT may find support through chosen families and informal support networks such as LGBT community organizations and gay-affirmative religious networks. LGBT older adults need to be recognized by the Older Americans Act (OAA) as a "greatest social need" group, opening up important funding avenues to prioritize services for this vulnerable population (Appendix 1 and Appendix 2). Anti-discrimination legislation and the expanding the definition of "family" to include families of choice are among the policies that could improve sensitivity to LGBT elders. Additionally, effective culturally-sensitive training for service providers could improve the experiences of LGBT elders with healthcare providers. As a result of this implementation, expectations of discrimination that may contribute to a delay in care will be reduced [19].

Transgendered populations

An area of increasing concern for nurses is caring for transgendered populations following surgery and post-surgical complications. Pelvic pain and persistent menses is common in transgender men and can be a clinical challenge for nurses. However, the workup of pelvic pain in transgender men is similar to that for cis-gender women. Etiologies to consider include atrophic or infectious vaginitis, cervicitis, cystitis, STIs, adhesions, and musculoskeletal and neurogenic disorders. Behavioral etiologies include depression, history of emotional trauma (including sexual assault or abuse), and post-traumatic stress disorder. Transgender men who have pelvic pain after hysterectomy but have retained one or both ovaries/gonads should be screened for a gonadal pathology. Administering testosterone often results in estrogen deficient, atrophic vaginal tissues akin to a post-menopausal state in cis-gender women [20]. Hysterectomy with and without salpingectomy/oophorectomy is considered to be a medically necessary component of gender affirming surgical therapy for transgender men who choose this procedure; It is unknown how many transgender men obtain hysterectomy for gender affirmation or gender dysphoria. In the National Transgender Discrimination Sur-vey, 21% of trans men had undergone hysterectomy; 58% desired a hysterectomy at some time in the future, and 21% had no desire for a hysterectomy. Hysterectomy has been successfully combined with other gender affirming surgeries performed on the same day, including vaginectomy, mastectomy, and genital reconstruction [20]. Female to male (FTM) sex reassignment surgery has reported less successful results in relation to the difficulty in building a functional penis from minimal clitoral tissue.

For some, removing the breasts with top surgery is enough. Some FTMs use a prosthetic penis called a packer that is either glued or strapped on. Those who undergo FTM surgery have the option to surgically create a penis through a phalloplasty. A phalloplasty is the reconstruction of tissue that can be done a year following preliminary surgery in which the uterus and ovaries are removed. The procedure combines several surgeries during which a penis shaped structure is constructed by peeling and rolling skin from the abdomen or upper thigh and attaching it over the clitoris to preserve as much sexual stimulation as possible. Many who have undergone this procedure report unsatisfactory urination ability and, although the penis can be used for intercourse, it is often, unfortunately, less than perfect [21].

Best practices for providing care

Best practices for providing culturally competent care for the LGBT community begins with being aware that the term LGBT represents a variety of sexual identities, each having unique health-related concerns specific to their group. Research has shown that sexual identification does not necessarily align with sexual activity and that health-related risks are more related to activity vs. identification [22]. Someone may identify as a heterosexual man and routinely engage in sex with other men, putting him at greater risk for HIV and other sexually trans-mitted illnesses (STIs) while a male identifying gay may be in a monogamous relationship and at very low risk for HIV and STIs. Individuals who identify as LGBT experience significant disparities in accessing health care compared to cis-gender heterosexual people. For example, women who have sex with women are less likely to receive the human papilloma virus (HPV) vaccine, cervical cancer screenings, and mammograms, and men in same-sex relationships are twice as likely to have unmet medical needs [23,24] contributing to the increase of healthcare disparities for this selected population. McNamara and Ng point out that these disparities can be reduced by creating environments that are more welcoming to all clients. These environmental changes might include having gender neutral restrooms, avoiding signage that appears welcoming to a single gender, and altering forms to allow for the collection of information pertaining to the client's preferred name and pronoun, gender and sexual identity, gender assigned at birth, and partner status and other family [22]. To achieve the goal of providing culturally competent care, nurses must continuously strive to provide informed, congruent, client-centered care in a non-judgmental manner when interacting with clients despite their gender or sexual orientation.

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