Discussion
LGBT healthcare disparities: What progress have we made?

https://doi.org/10.1016/j.pec.2017.06.003Get rights and content

Abstract

Nearly fifteen years have passed since this author’s publication which examined the depth of education and training for medical students and practicing physicians specific to clinical competence in the care of lesbian and gay patients in the United States. Since then, there has been an explosion of research gains which have shed a steady light on the needs and disparities of lesbian and gay healthcare. This rich literature base has expanded to include bisexual and transgender (LGBT) healthcare in peer-reviewed journals. Despite these research gains underscoring a call for action, there continues to be a dearth of cultural competency education and training for healthcare professionals focused on clinical assessment and treatment of LGBT patients. This article will focus exclusively on the current status of medical and nursing education and training specific to clinical competence for LGBT healthcare. We are long overdue in closing the clinical competency gap in medical and nursing education to reduce the healthcare disparities within the LGBT community.

Introduction

There has been a surge in the literature on lesbian, gay, bisexual and transgendered (LGBT) healthcare issues since the time of our previous article published in 2003 [1]. The focus at that time was on the healthcare needs of patients who identified as lesbian or gay. While the terms “gay and lesbian” previously were used to encompass sexual minorities, an expanded abbreviation of “L.G.B.T.” was adopted to include bisexual and transgender. The term “transgender” is used to describe people who do not identify with their biologically assigned sex at birth [2]. The expansion of the nomenclature has grown to become even more broadly defined with added initials of Q and I, as in LGBTQI [3]. The ‘Q’ can mean ‘questioning’ or ‘queer’. Queer has evolved into an umbrella in-group term, formerly used in a derogatory manner to discriminate until it was re-appropriated in the 1990′s to reclaim and reflect the whole LGBTQ community. Use of the ‘Q' as “questioning” reflects someone who may be in the process of exploration and consideration of his or her sexual orientation or gender identity [4]. ‘I’ is for ‘intersex,’ someone whose anatomy is not exclusively male or female” [3]. The continual search for inclusiveness reaches far beyond the binary use of male and female, with more emphasis on a person’s gender identity which may be distinct from sexual orientation [3]. While there is no universally agreed upon abbreviation, this article will use the moniker of LGBT when referring to this growing and still medically underserved population in the United States.

The expansion of research efforts has also propelled significant attention from legislators, policy makers and community leaders in the quest for equal rights for the LGBT community, particularly within the United States. In the healthcare arena, recent reports from the Institute of Medicine [4], U.S. Department of Health and Human Services [5], and position statements from the American Association of Medical Colleges (AAMC) [6], American College of Physicians [7] and American Academy of Nursing [8] have called attention to gaps in LGBT training and education for physicians and nursing professionals that have long been overlooked.

Despite such advances and policy changes, a lack of awareness and stigma persists in our society at large and in many other areas including our healthcare system. For instance, there continues to be reports of negative experiences with health care professionals by lesbian, gay, bisexual and transgendered persons including encountering homophobia and unsatisfactory or unequal healthcare treatment [9], [10]. In an online national survey of LGBT physicians, 65% had experienced hearing derogatory comments from healthcare professionals about patients who are LGBT and 34% had witnessed discriminatory care of a LGBT patient [11]. Bearing witness to negative comments and discriminatory LGBT patient care can be profoundly disturbing, particularly for LGBT physicians. This is compounded by the experiences of self-identified gay and lesbian physicians who may also experience issues of heterosexism, homophobia, and hostility in the workplace [12], [13].

Sabin and colleagues [14] examined the implicit and explicit attitudes toward lesbian and gay people among healthcare providers that included physicians, nurses, mental health providers, and other providers and found pervasive heterosexual preferences. Another study of lesbian patients who experienced discriminatory behavior from a clinician sought subsequent health knowledge advice online rather than from a professional [15]. Acceptance by healthcare professionals has been even slower for transgender patients, who often face injustice as youth in school, the workplace, and many other sectors of society. A 2011 U.S. survey of 6450 respondents who identified as transgender or gender non-conforming found that 19% reported being refused medical care with even higher numbers among people of color in the survey [10]. The fallout from these unfair practices can be quite significant as evidenced in the unrelenting documented health disparities within the LGBT community.

Quinn et al. [16] noted that failure to elicit sexual orientation and gender identity from patients was akin to a failure to screen or diagnose. This is emphasized in Healthy People 2020, the Institute of Medicine [4], and the Joint Commission [17] which calls for the routine inclusion of sexual orientation and gender identity data within electronic health records [18]. Collection of this critical data provides a foundation for understanding the cultural needs of each patient and provides an opportunity to track and analyze health disparities at the LGBTQ population level. Further, this underscores the “professional duty of clinicians to create safe environments for disclosure of and attention to this important aspect of a patient’s social history” [19].

In the effort to reduce health disparities between specific patient populations, cultural competence and cultural humility programs have been the primary yet broadly defined approach for training interventions for clinicians and healthcare personnel. As the research evidence expands to define and understand specific disparities within the subgroups of LGBT, challenges and barriers have been identified, calling for medical educators to develop and embed a set of educational goals and competencies in the curriculum to directly address issues of sex, sexuality, and gender-related clinical care [20].

Medical educators and researchers have highlighted the ethical imperative of the medical profession to reduce healthcare disparities and practice within the healthcare values of social justice, cultural humility and humanism [6]. When physicians do not address sexual orientation openly with patients, they neglect their role in providing appropriate and effective patient education on wellness and disease prevention [21] and decreasing the likelihood of adverse health outcomes.

According to a 2011 survey [22], more than 33% of U.S. medical schools reported 0 h of LGBT-specific content in the curriculum delivered in the clinical years and 6.8% schools reported 0 h in the pre-clinical years. Those schools with specific LGBT content coverage within the curriculum reported a median of 5 h of LGBT content within the standard 4 year curriculum. Further, 43.9% of those surveyed deans and faculty rated the curricular LGBT-content as “fair” [22]. In addition to the number of LGBT curricula content specific hours, Sanchez [23] reported that medical students were more likely to positively view their ability to provide care to LGBT population if they practiced sexual history taking from patients who identified as LGBT patients. Other medical schools have included sexual history taking practice in the curriculum, recognizing that developing clinical competence in conducting an inclusive sexual history is one method lesbian, gay, bisexual, and transgender (LGBT) patients have used to gauge whether a clinician may be LGBT-friendly [24].

These recent surveys of US medical school efforts to include LGBT curricula content contrast modestly with previous ones by Wallick and colleagues in 1992 [25] who reported a national average of 3 h and 26 min across 4 years of undergraduate medical education devoted to homosexuality. Six years later, Tesar [26] reported an average of 2.5 h, with 50% of US medical school curricula containing no content at all on the topic.

Such modest gains in LGBT curricular content hours reflects the ever-present challenges and barriers in medical education despite policy documents and position statements by AAMC [6] underscoring the need for improved healthcare of LGBT patients. Such barriers include a lack of effective curricular materials in increasing learner competence, absence of trained faculty, limited instruction time, faculty perception that LGBT issues are not relevant to their specific courses, LGBT content absent on national exams, and lack of faculty and attending physician role models for discussing sexual orientation, attraction, or gender identify [21].

The extent to which LGBT specific healthcare issues are integrated within undergraduate and graduate nursing curricula is uncertain. While the American Academy of Nursing issued a policy statement in 2012 endorsing efforts to support LGBT healthcare needs, it lacked specific nursing curricular standards [8]. Furthermore, a review of the nursing literature demonstrates a general absence of LGBT-focused scholarly research in nursing journals and, more specifically, seven of the top ten nursing journals did not publish any articles on LGBT issues from 2005 to 2009 [27]. Similarly, a review of the leading nursing textbooks revealed no practical discussions on LGBT status or relationship patterns [11]. Zuzelo [28] discussed the implications of the absence of LGBT content in nursing journals and textbooks which reinforce rather than challenge students’ negative attitudes or misperceptions.

Eliason et al. [11] argued that the nursing profession has not kept up with other health professions in conducting research, issuing policies and practice guidelines, and education to address health needs of the LGBT population. Findings from a survey of nursing faculty from undergraduate schools reported 23–63% of the faculty indicated they never taught LGBT health-related topics in the past 2 years [27]. Moreover, an average of 2.12 h of classroom teaching time was devoted to LGBT health topics for the entire nursing program [27].

Similar to medicine, challenges and barriers exist in the nursing profession that has stalled the emergence of LGBT education within nursing curricula. Despite the belief that teaching nursing students about LGBT health needs and care was important, 72% of nursing educators from accredited colleges reported being unprepared to teach LGBT content [29]. In a study examining nurse discomfort with LGBT patient care, nearly 80% had not received LGBT-specific training which the researchers believed contributed to discomfort reported by 30% of the nurses when working with LGBT patients [30]. Raising faculty comfort and confidence requires faculty development programs that will increase knowledge of LGBT healthcare disparities, reinforce clinical competence for LGBT patient assessment and care, and role-model effective communication skills within the classroom and clinical setting.

Providing continuing medical education (CME) to physicians and other clinicians to fulfill the goal of providing comprehensive, compassionate and culturally-competent patient-centered care is fundamental. Accomplishing this goal also requires raising physicians’ self-awareness about assumptions, biases and values that he or she may directly or indirectly convey during patient interaction [31]. All clinicians are expected to continually update their knowledge base, skill set and behavior domains of practice as required by their respective professional bodies through continuing education. According to the Accreditation Council on Continuing Medical Education (ACCME), a non-profit organization committed to continuous improvement of CME for physicians, CME serves an important role in eliminating health disparities, and educating physicians in cultural competency and humility [32]. Additionally, the Joint commission on accreditation has urged U.S. hospitals to create a more welcoming, safe and inclusive environment that contributes to improved health care quality for LGBT through staff training and development of LGBT inclusive non-discriminating policies and procedures [17].

There are numerous LGBT training resources for physicians, nurses and other members of the allied health team [33], [34], [35], [36], [37], [38], [39]. Calls for providing LGBT competency training and resources notwithstanding, there appears to be a scarcity of such programs, policies and competency training that have reached practicing physicians and nursing professionals. In a survey of US academic practices, only 16% of practices reported having comprehensive LGBT training and 52% reportedly had no LGBT training [40]. Further, only 15% of participating practices in the survey had an available listing of those physicians who participated in LGBT competent training. The study authors [40] concluded that such low rates of LGBT training and policies “suggested a lack of awareness of existing health disparities for LGBT individuals”.

For LGBT patients who have avoided the healthcare system, emergency physicians are very often a first healthcare encounter and that experience may directly shape the likelihood of future healthcare seeking behavior for the patient. Patient experience is impacted by a multitude of factors including whether the physical space of the emergency department is conducive to patient privacy and confidentiality, if emergency team members display concern for patient physical comfort, and whether respectful, non-judgmental communication behavior is shown by the team during patient interactions [41]. LGBT patients who routinely avoid the healthcare system have a need for emergency care by physicians and teams equipped with knowledge of LGBT health disparities, and the communication skills to engage in potentially sensitive and difficult conversations surrounding these disparities. Yet, in a 2013 survey of US accredited emergency medicine programs to assess inclusion of LGBT content in residency education, 26% of programs ever presented a specific lecture on LGBT health issues [42].

As suggested earlier, lack of awareness of existing health disparities can also have a direct impact on physician communication behaviors with LGBT patients. A recent study to assess knowledge, attitudes and practice behaviors of healthcare providers in the oncology setting found that 74% did not inquire about a patient’s orientation when taking a history, explaining they did not see the relevance to cancer care [19]. This is telling given the link between sexual orientation with social relationships, mental health and the need for psychosocial support and physician-patient rapport following a cancer diagnosis [43], [44], [45], [46]. In another survey of adolescent provider assessment of knowledge, attitudes and elements of practice, a mere 29% of the physicians reported they would regularly discuss sexual orientation while taking a sexual history from a sexually active adolescent. Additional data to assess physician LGBT knowledge included responses to the following statement “there is an association between being an LGBT adolescent and suicide” with a reported 10% disagreed, 33% did not know and 57% agreed with the statement [47]. The authors concluded that lack of knowledge could provide an explanation for why physicians most often selected the reason of “it was not significant” for why they did not discuss sexual orientation with sexually active adolescent patients [47].

The literature is unclear about what constitutes best practices and acceptable measures for evaluating LGBT competency training. There are studies which have shown the benefits of cultural competency training in healthcare settings specific to provider-related outcomes (post-test competencies, knowledge, changes in attitudes), patient/client-related outcomes (physiological, patient perception of care, satisfaction and trust) and outcomes related to health service access and utilization [48]. There is limited evaluative research that has focused specifically on LGBT-content training for health professionals. One study [31], conducted on resident physicians in the Northeast, measured resident preparedness to care for lesbian and gay patients and found that 96% felt more prepared after participating in a three-hour training. However, this training did not encompass a full range of LGBT issues and limited the focus to lesbian and gay health using didactic instruction, small group discussion, videotape review, and case discussion. While this study outcome was on provider preparedness to provide care to lesbian and gay patients, effectiveness of LGBT training remains limited and mostly addresses changes in providers. This does not necessarily translate into better health outcomes for LGBTQ people.

This article has primarily focused on a review of medical, nursing and continuing education specific to LGBT healthcare competence among clinicians. Yet, the reality is that everyone on the healthcare team including non-clinical staff requires education to create and support an environment that is non-judgmental and welcoming for all patients. From the patient’s perspective, every interaction contributes to the care experience beginning with the security guard at the hospital or clinic entrance, front office staff for registration, medical assistants, nurses, technicians, physicians, and billing staff. Patient satisfaction is significantly enhanced when all members of the healthcare team communicate respectfully and sensitively with patients. When this is routinely valued and expected, LGBT patients are more willing to share their personal information including their preferred gender, name, and chosen pronoun which allows the healthcare team to address the patient accurately and identify the correct health record [49]. While seemingly basic, these initial welcoming rituals can shape and transform previous negative experiences, often faced and described by LGBT patients as distressful due to “anticipated, perceived and actually insensitivity or rejection” by members of the healthcare team [50].

In 2007, the Human Rights Campaign Foundation developed a benchmarking tool referred to as the Health Equality Index (HEI) which designates hospitals and healthcare facilities across the United States as leaders in LGBT health care equality [37]. As of 2017, 590 hospitals and healthcare facilities have participated with more than 98 percent of these facilities demonstrating that they have fully LGBTQ-inclusive patient and employment non-discrimination policies and equal visitation policies [51]. The HEI assures that the healthcare facility has the information and resources needed to ensure that the LGBTQ patient population has access to truly patient-centered care. HEI training on LGBT health issues is offered to all members of the healthcare team that includes how to effectively interact and elicit information from patients using language that makes no assumptions about sexual identity or orientation.

In healthcare, as in all human interactions, people hold ideas and feelings about others that may involve judgment, stigma and reflect bias, which is demonstrably harmful for all people, and especially for those who are most vulnerable in society such as LGBT patients [52]. Staff training provides opportunities to raise self-awareness about unconscious biases, clarify LGBT terms and definitions, share unique health needs and challenges, and practice tools and techniques for respectful and sensitive verbal and written communications [49].

Such training on culturally competent care also recognizes the importance of communicating assurance to the patient that information will be kept confidential. Acknowledging to the LGBT patient that forms and “clinic processes may not be fully developed and inclusive of LGBT patients is important” [49] while emphasizing the need for improvement to achieve inclusivity. Being open and honest about not having the most in-depth knowledge for meeting the LGBT patient’s needs is an expression of cultural humility. Such honesty emphasizes genuine interest and curiosity, trust, and mutual learning between the clinician and patient that is essential to patient care and safety.

Section snippets

Conclusion

Fourteen years have passed since this author's first review of the quantity and quality of education that future and practicing healthcare providers receive in caring for lesbian, gay, transgendered and bisexual individuals in the United States. While there has been an explosion of research specific to LGBT healthcare in peer-reviewed journals in the last two decades, there continues to be a deficiency of cultural competency education training specific to treatment of LGBT patients for members

References (52)

  • H. Daniel et al.

    Lesbian, gay, bisexual, and transgender health disparities: executive summary of a policy position paper from the American College of Physicians

    Ann. Intern. Med.

    (2015)
  • American Academy of Nursing, Position Statement on Health Care for Sexual Minority and Gender-Diverse Populations

    (2012)
  • R. Chapman et al.

    Nursing and medical students’ attitude, knowledge and beliefs regarding lesbian, gay, bisexual and transgender parents seeking health care for their children

    J. Clin. Nurs.

    (2012)
  • J.M. Grant et al.

    Injustice at every turn

    Natl. Center Transgender

    (2010)
  • M.J. Eliason et al.

    Nursing’s silence on lesbian, gay, bisexual, and transgender issues: the need for emancipatory efforts

    ANS: Adv. Nurs. Sci.

    (2010)
  • N.B. Peterson et al.

    Faculty self-reported experience with racial and ethnic discrimination in academic medicine

    J. Gen. Intern. Med.

    (2004)
  • J.A. Sabin et al.

    Health care providers’ implicit and explicit attitudes toward lesbian women and gay men

    Am. J. Publ. Health

    (2015)
  • G.P. Quinn et al.

    Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations, CA

    Cancer J. Clin.

    (2015)
  • The Joint Commission, Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide

    (2011)
  • Office of Disease Prevention and Health Promotion, Lesbian, Gay, Bisexual, and Transgender Health | Healthy People 2020, Heal. People 2020

    (2017)
  • Agency for Healthcare Research Quality (AHRQ)

    Evidence-based practice center systematic review protocol project title: improving cultural competence to reduce health disparities for priority populations, AHRQ

    Eff. Health Care Progr.

    (2014)
  • R.L. Tamas et al.

    Addressing patient sexual orientation in the undergraduate medical education curriculum

    Acad. Psychiatry

    (2010)
  • J. Obedin-Maliver et al.

    Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education

    JAMA

    (2011)
  • N.F. Sanchez et al.

    Medical students’ ability to care for lesbian, gay, bisexual, and transgendered patients

    Fam. Med.

    (2006)
  • R. Lee et al.

    Sexual history taking curriculum: lecture and standardized patient cases

    MedEdPORTAL Publ.

    (2014)
  • M.M. Wallick et al.

    How the topic of homosexuality is taught at U.S. medical schools

    Acad. Med.

    (1992)
  • Cited by (125)

    • Using Simulation to Improve Communication Skills

      2024, Nursing Clinics of North America
    View all citing articles on Scopus
    View full text