Cultural Competence in LGBTQIA+ Community Healthcare

LGBTQIA…xyz

The Alphabet Soup of Community Healthcare

Andrew Appello

MSOM, L.Ac., RH(AHG), BSN, RN

HealthyLivingAcupuncture@gmail.com

NJSNA/IFN Convention

Atlantic City, NJ – 

October 12, 2017

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:

Nurses will:

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Note disparity of the LGBTQIA community

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Learn terminology and be introduced to LQBTQIA

culture

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Discover the unique biopsychosocial health needs

of the LGBTQIA community

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Improve culturally competent nursing care to the

LGBTQIA community

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October 6, 2016 -The director of the

National Institute on Minority Health and

Health Disparities announces (Perez-

Stable, 2016):

Sexual and Gender Minorities Formally

Designated as a Health Disparity Population

for Research Purposes

n

Less access to care

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Higher burden of disease

n

Stigma, hate-violence, discrimination

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Stigma

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Discrimination

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Violence

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Rejection by families and communities

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Inequality in the workplace

n

Inequality in health insurance sectors

n

Provision of substandard care

n

Denial of care because of an individual’s sexual

orientation or gender identity

(Ranji, Beamesderfer, Kates, & Salganicoff, 2014)

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Definition:

“Having the knowledge, abilities, and

skills to deliver care congruent with

the patient’s cultural belief and

practices” (Purnell, 2013, p. 7)

W

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N

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Implementing the American Nurses Association

Standards of Care 8: Culturally Congruent Practice

(Marion et al., 2017)

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Show RESPECT, EMPATHY, and EQUITY

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Self Assessment and Reflection

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Teach nursing colleagues

(+ many others)

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Higher-Order concept that involves

overcoming barriers of cognition

and affect (de Chesnay, Hart, &

Brannan, 2016)

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How do YOU feel?

M

y

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t

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r

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:

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A girl walks into the bar…

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Labels, labels, labels….

OR

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Fluidity

*NOTE: Identity is not equal to culture and

culture is not equal to identity but both inform

LGBTQIA community nursing care!

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“It is critical for practitioners to

keep in mind that groups are

composed of individuals – we

should not stereotype individuals in

terms of group characteristics” (de

Chesnay, 2016, p. 4)

A

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Stereotypes:

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Gay men are not handy or sporty

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Gay men are fabulous (sequins

and glitter implied)

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!

(

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How do you identify?

T

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Lesbian

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Gay

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Bisexual

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Transgender

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Q

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Lesbian

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Gay

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Bisexual

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Transgender

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Queer

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Intersex

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Asexual

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

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Lesbian

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Gay

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Bisexual

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Transgender

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Queer

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Questioning

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Intersex

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Ally

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Asexual

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Pansexual

S

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a

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Three components (Fredriksen-

Goldsen et al., 2014):

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Sexual identity

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Sexual attraction

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Sexual behavior

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L

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MSM (Men who have Sex with Men)

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WSW (Women who have Sex with Women)

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MSMW, MSWM and WSMW, WSWM

u

Terms introduced especially in research to

convey that sexuality is a broad concept where

behavior, desire, and identity do not always

coincide (Young & Meyer, 2005-seminal source)

u

The terms Gay and Lesbian often refer to

Caucasians while MSM/WSW are more

inclusive of people of color (Young & Meyer,

2005-seminal source)

u

Gay/Lesbian etc. imply identity and community

u

MSM/WSW speak to behavior

C

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O

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Can be:

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A celebration and liberating

OR

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Painful and terrifying

But definitely life changing

RN interventions:

n

Be supportive

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Listen

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Allow the client to come out when ready

L

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WSW

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There are many types of Lesbians!

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Baby dyke

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The butch-fem divide

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Girl next door

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Lipstick lesbian

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Ursula

*Note: “Dyke” can be used as a terrible insult or a

reclaimed identity of empowerment. RN: Don’t use!

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Stereotype joke: What is a lesbian couple’s second

date?

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 Renting a U-Haul to move in together (U-Haulin’ it)

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Opening a book store together

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Adopting a cat

L

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Lesbians and bisexual women are at an increased risk for:

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Obesity, smoking, stress.

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Breast, endometrial, and ovarian cancer

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Polycystic ovary syndrome

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Depression and anxiety

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Bacterial vaginosis

n

Lesbians are less likely to get:

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Mammograms and clinical breast exams

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Cancer screening

n

RN Interventions:

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Screen for all above risks

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Screening for heart disease, lung cancer

R

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Be sensitive!

n

Don’t ask me about my donor

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You go broke or into debt because insurance does

not cover it

n

Nurse: “Why doesn’t your wife carry? She is

younger and thinner”

n

Patient: “Because carrying a child does not match

her gender identity”

G

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C

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MSM

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So many types of gay men!

u

Bears

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Wolves

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Otters

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Twinks

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Jocks

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Cubs

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Boy next door

K

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Y

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P

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Relevant to STD screening and risk

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Top = prefers insertive anal intercourse

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Bottom = prefers anal receptive intercourse

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Versatile (Vers) = enjoys topping and bottoming

H

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Gay and bisexual men represent the most

vulnerable group in the US

u

55% of the HIV infected population

n

Risk of being diagnosed with HIV in a MSM man’s

lifetime:

u

1 in 6 All races

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1 in 2 African-Americans

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1 in 4 Hispanics/Latinos

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1 in 11 Caucasians

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In 2014:

n

92% of new HIV diagnoses in the 18-24 age range

were gay/bi men

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27% of new HIV diagnoses in the gay/bi population

were men age 18-24

S

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Questions:

u

Have you performed oral sex?

u

Have you received anal receptive intercourse

(bottomed)?

u

Have you had multiple sexual partners?

u

Has your sexual partner had multiple sexual

partners?

n

Assess for risky behavior and condom use.

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Is he knowledgeable about what constitutes risk?

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n

Chlamydia:

u

At least annual screening; every 3-6 months if at

high risk

u

Screen at site of contact regardless of condom use

– urethra or rectum

n

Gonorrhea:

u

At least annual screening; every 3-6 months if at

high risk

u

Screen at site of contact regardless of condom use

– urethra, rectum, or pharynx

*High risk = 1. Those with HIV + persistent risky behavior or 2. Patients or

their sexual partners with multiple partners

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Syphilis:

u

At least annual screening; every 3-6 months if at

high risk

n

Herpes:

u

Type-specific serological test if status unknown or

previously undiagnosed genital infection

n

HIV:

u

At least annually if status unknown or negative and

patient or patient’s sexual partner has had multiple

partners since last test

*High risk = 1. Those with HIV + persistent risky behavior or, 2. Patients or

their sexual partners with multiple partners

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Hepatitis B:

u

Test all for HBsAg

n

Hepatitis C:

u

Test those born between 1945-1965

u

Test those with other risk factors: injection drug use,

blood transfusion before 1992, long term

hemodialysis, born to mother with Hep. C, intranasal

drug use, receipt of an unregulated tattoo, and other

percutaneous exposures

u

Test annually + HIV infection

P

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n

Pre-Exposure Prophylaxis

n

Truvada (tenofovir and emtricitabine)

n

Taken daily to 

reduce 

the likelihood contracting HIV

by more than 90%

n

Much less effective when not taken daily and

consistently and more effective when used with

condoms and other safe sex methods

A

P

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P

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My story: The lawyer…

A

P

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P

P

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b

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MSM focus groups:

u

Majority of men feel that PrEP use means they do

not need to use condoms (Taylor et al., 2014)

n

RN Interventions:

u

Reinforce need for safe sex and that PrEP does not

prevent other infection!

B

i

s

e

x

u

a

l

n

MSMW or WSMW

n

Identify as having sexual and

romantic attraction to both genders

n

Degree of attraction to each

gender can vary

n

Common misconception/stigma:

“You are just on your way to figuring

out if you are gay or straight”

B

i

s

e

x

u

a

l

n

Bisexual women have higher rates of depression

as compared to lesbians and heterosexual women

(Bostwick, 2012)

Q

u

e

e

r

n

“Dictionary” definition: Abnormal or strange

n

History of use as a word showing hate toward those

who do not conform to dominant norms of gender

and sexuality

n

For LGBTQIA community:

u

A reclaimed term of empowerment (inside of the

community)

u

The pride involved in not conforming to gender or

sexuality expectations

u

An identity

u

Often has socio-political connotations

n

RN recommendation: Do not use unless the client

uses first!

Q

u

e

s

t

i

o

n

i

n

g

n

Exploring one’s gender identity and expression

and/or

n

Exploring one’s sexual orientation

n

Interventions:

u

Provide a supportive and open environment

u

Create a school-based or web-based LGBTQIA

inclusive sex education program for all youth

(Pingel, Thomas, Harmell, & Bauermeister, 2013)

I

n

t

e

r

s

e

x

n

Those who have primary and/or secondary sex

traits of both male and female genders

n

It is not socially acceptable to use the term

hermaphrodite

n

Disorders of Sex Development (DSD) – A

controversial term

n

Research is insufficient concerning the benefit of

early gender assignment surgery (Diamond &

Garland, 2014)

n

Recommendation is to delay cosmetic surgery until

the patient can appropriately consent (Diamond &

Garland, 2014)

A

l

l

y

n

A cisgender, heterosexual person who supports

LGBTQIA social equality

(Cisgender: Gender identity = socially recognized

sex)

A

s

e

x

u

a

l

n

A sexual orientation

n

One who feels lack of attraction or

desire for a sexual partner

n

Differs from the practice of celibacy

P

a

n

s

e

x

u

a

l

n

AKA omnisexual

n

Those who have romantic or sexual desire for

others of all genders and sexuality

D

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…

T

r

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a

?

n

Research by Hatzenbuehler and McLaughlin

(2014)

n

Tested LGB youth exposed to structural stigma

u

Structural stigma = stigma encoded into state

legislation.

u

Example: no marriage equality laws

n

Conclusion: LBP youth living in states with

structural stigma experience cortisol blunting

reminiscent of post-traumatic stress

H

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n

Increased rate of suicide and homelessness

(LGBT youth)

n

Increased rate of HIV infection (gay men)

u

Especially men of color

n

Increased risk of obesity (lesbian and bisexual

females)

n

Less likely to have preventative cancer services

(lesbians)

n

Increased use of tobacco, alcohol, and drugs (all

LGBT)

H

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2

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n

Increased HIV/STD, victimization, mental health

issues, suicide (transgendered people)

n

Less likely to have health insurance (transgendered

people)

n

Increased isolation, lack of social services,

culturally competent providers (elderly LGBT)

W

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)

n

Increased risk for suicide, anxiety, depression,

substance abuse, HIV/AIDS

n

Youth: bullying and harassment in school leading to

poor academic outcomes and drop-out

n

Trans* people of color: Increased homelessness,

job discrimination, and mental health issues

G

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y

,

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)

n

Hormone prescribing: The Endocrine Society

n

Overall care guidelines: WPATH

I

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)

n

World Professional Association for Transgender

Health

n

Interdisciplinary

n

Mission: To promote evidence based care,

education, research, advocacy, public policy, and

respect in transgender health

n

Annual conferences

n

Clinical training program

T

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a

,

2

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7

)

n

Transsexual – Lives opposite gender as birth. Often

refers to a trans* person pursuing gender

confirmation (sex reassignment)

n

Transgender

1.

A person whose gender expression does not match

society’s birth sex expectation

2.

Outside of the binary male/female

3.

No or multiple genders

n

Gender queer/gender non-conforming – gender

identity or expression outside of dominant society

norms

T

r

a

n

s

g

e

n

d

e

r

T

e

r

m

s

n

Trans* man = FtM (female to male) or F2M

n

Trans* woman = MtF (male to female) or M2F

n

Please do not use the term “tranny”!

u

Inappropriate slang

u

Term of hate and oppression

n

Transitioning – the process of changing from one

gender to another (University of California, 2017)

u

Medical – hormones, surgery, speech therapy

u

Social – pronoun use, name use

u

Legal – name change, gender change on documents

N

o

t

R

e

l

a

t

e

d

t

o

G

e

n

d

e

r

I

d

e

n

t

i

t

y

n

Cross-dresser

u

Transvestite has a negative connotation as

a former mental health diagnosis term.

Please do not use.

n

Drag king

n

Drag queen

T

r

a

n

s

*

T

e

r

m

s

n

Gender non-conforming – Gender identity outside of

dominant social norm

Vs.

n

Gender dysphoria – Refers to the distress caused

by gender non-conformity

T

h

e

T

r

a

n

s

*

H

e

a

l

t

h

c

a

r

e

P

a

r

a

d

o

x

n

Diagnosis: Gender dysphoric disorder

A trans* person must be diagnosed as “disordered”

in order to receive medical treatment.  Does this

concept further stigmatize the transgendered

population?

**Stigma of pathologizing of trans* people is a

barrier to care (Singh & Dickey, 2016)

Solution??

G

e

n

d

e

r

D

y

s

p

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o

r

i

a

a

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d

O

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s

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o

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)

T

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p

e

o

p

l

e

c

a

n

e

x

p

e

r

i

e

n

c

e

:

n

Substance abuse

n

Chronic minority stress

n

Anxiety

n

Depression

n

Self-harm

n

History of abuse and

neglect

n

Compulsivity

n

Sexual concerns

n

Personality disorders

n

Eating disorders

n

Psychotic disorders

n

Autistic spectrum

disorders

A

d

o

l

e

s

c

e

n

t

s

(

W

P

A

T

H

,

2

0

1

1

-

c

u

r

r

e

n

t

r

e

v

i

s

i

o

n

)

n

Gender dysphoria can be confused with psychosis

n

Comorbidities often found: anxiety, depression,

oppositional defiant, autistic spectrum disorders

n

Family needs psychosocial support

n

Interventions may include puberty suppressing

hormones

n

Educate the community (schools, camps, courts,

teachers etc.)

n

Peer support groups

n

Do not impose a male/female binary view on

gender

n

Encourage role change exploration first

T

r

a

n

s

*

T

h

e

r

a

p

e

u

t

i

c

M

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2

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-

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r

r

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n

t

r

e

v

i

s

i

o

n

)

n

Surgery

n

Hormone therapy

u

Average transition takes 2 years

u

Highly individual in duration and extent to

transition

n

Voice and speech therapy

n

Change in gender role – living in role consistent

with gender identity

T

r

a

n

s

*

T

h

e

r

a

p

e

u

t

i

c

M

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2

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-

c

u

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r

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v

i

s

i

o

n

)

n

Mental health counseling helps to:

u

Explore gender identity, role, expression

u

Work on consequences of stigma and dysphoria

u

Minimize internalized transphobia

u

Enhance social support

u

Improving body image

u

Promote resilience

N

o

t

e

…

Treatment to alleviate “dysphoria” is individualized

u

Therapy may consist of any combination of

modalities or all of the above

H

o

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m

o

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v

i

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i

o

n

)

M

t

F

n

Estrogens (transdermal)

n

Anti-androgens

u

Sprionolactone

u

Cyproterone acetate (not in

US)

u

GnRH (Gonadotropin

Releasing Hormone)

agonists

F

Block gonadotropin

releasing hormone

receptors

u

5-alpha-reductase

inhibitors

F

Prevent DHT conversion

u

Progestins

F

t

M

n

Testosterone

n

Progestins

u

Used to stop menses

H

o

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o

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n

)

*Ratings for increased risk: Likely, possible, and no

/inconclusive

n

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)

M

t

F

n

Cardiovascular

impairment

n

Venous

thromboembolism

u

Blood pressure

u

Weight

u

Pulse

u

Tobacco use***

n

Heart and lung exam

n

Extremity evaluation

u

Peripheral edema, local

swelling, pain

F

t

M

n

Excessive weight gain

n

Acne

n

Uterine breakthrough

bleeding

n

Cardiovascular issues

n

Psychiatric symptoms

n

Blood pressure, pulse,

weight

n

Heart and lung exam

n

PCOS

n

Pregnancy

S

u

r

g

i

c

a

l

I

n

t

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r

v

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r

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n

t

r

e

v

i

s

i

o

n

)

M

t

F

n

Upper:

u

Breast augmentation

/mammoplasty

n

Lower:

u

Penectomy, orchiectomy

u

Vaginoplasty, clitoroplasty,

vulvoplasty

n

Other:

u

Facial feminization,

liposuction, lipofilling, voice

surgery, thyroid cartilage

reduction, gluteal

augmentation, hair

reconstruction

F

t

M

n

Upper:

u

Subcutaneous

mastectomy, male chest

creation

n

Lower:

u

Hysterectomy,

ovariectomy, vaginectomy

u

Metoidioplasy/phalloplasty,

scrotoplasty, erecion and

testicular prostheses

n

Other:

u

Voice surgery, lipofilling,

liposuction, pectoral

implants

C

a

l

l

t

o

P

r

o

v

i

d

e

r

s

(

S

i

n

g

h

&

D

i

c

k

e

y

,

2

0

1

6

)

n

Make sure the client’s voice is heard

n

Pursue training in trauma, resilience, and minority

stress

n

Be aware of potential violence and hate crime

n

Work with a trans-affirmative mentor

n

Use cisgender privilege to speak out about

oppression

n

Clarify that trans* is not a pathology

P

r

a

y

t

h

e

G

a

y

A

w

a

y

…

In NJ conversion psychotherapy of minors is illegal

and is thought to cause damage (Singh & Dickey,

2016)

n

NJ bill 2012-2013 A3371

“

J

a

s

m

i

n

e

”

–

O

n

e

W

o

m

a

n

’

s

E

x

p

e

r

i

e

n

c

e

n

60 year old MtF

n

“I’ve had my heart broken so many times I just had

to stop working as a youth role model”

u

Generations of girls before me got their hormones on

the street and got sick

n

Prostitution is a big issue (especially MtF)

u

Surgery in Mexico or Thailand, only a few in North

America of reputation – how to finance?

n

“When you are an ‘other’ you find ways to isolate”

u

Her rationale for working in night clubs, a way to

avoid society

u

“There is no one to say I can connect you to

something… so they just vanish”

“

J

a

s

m

i

n

e

”

–

O

n

e

W

o

m

a

n

’

s

E

x

p

e

r

i

e

n

c

e

n

Passing vs. not passing – different levels of stigma

n

One surgeon said “you are a man, why don’t you

just be a man?”

n

“Respect is really the issue!”

n

“It’s okay to ask- don’t play the pronoun game”

n

“It can be very empowering for a trans person to tell

you how they identify… if they do not feel judged”

n

Post breast surgery bleed. Went to a Catholic

hospital the next day and was turned away

P

r

o

n

o

u

n

s

,

P

r

o

n

o

u

n

s

,

P

r

o

n

o

u

n

s

…

Standard English Pronouns:

n

I

n

You

n

He, She

n

We

n

You (all)

n

They

**What pronouns do you use?

G

e

n

d

e

r

N

e

u

t

r

a

l

P

r

o

n

o

u

n

s

…

…

n

He

n

She

n

Ey

n

Ve

n

Fae

n

Per

n

They

n

Xe

n

Ze/zie

P

r

a

c

t

i

c

e

s

e

n

t

e

n

c

e

:

_

_

_

_

_

w

a

s

v

e

r

y

p

r

o

u

d

o

f

_

_

_

_

_

.

n

Himself

n

Herself

n

Eirself

n

Verself

n

Faerself

n

Perself

n

Themself

n

Xemself

n

Hirself

“

R

o

s

e

l

y

n

’

s

”

B

r

e

a

s

t

s

…

n

RN: You haven’t had a mammogram in

how long?!?!

R

N

I

n

t

e

r

v

e

n

t

i

o

n

s

n

Consider your own beliefs, feelings, and

judgments on sexuality and gender

n

Support, listen, and suspend judgment

n

Educate others and advocate for the LGBTQIA

community

n

Develop a referral network of LGBTQIA

affirmative practitioners

u

Primary care practitioners

u

Mental health providers

R

N

I

n

t

e

r

v

e

n

t

i

o

n

s

n

Provide resources as appropriate

u

The Pride Center of New Jersey

F

www.pridecenter.org

u

WPATH “find a provider”

F

www.wpath.org

u

Human Rights Campaign

F

www.hrc.org

u

NJ Department of Children and Families

F

http://www.nj.gov/dcf/adolescent/lgbtqi/

u

Community and LGBT Culture

F

https://outinjersey.net/

A

n

t

i

-

B

u

l

l

y

i

n

g

C

a

m

p

a

i

g

n

n

School Nurses Can Help!

u

On-line support group

u

Student organizations

u

LGBT affirmative/inclusive sex-ed

W

e

l

c

o

m

e

t

h

e

C

o

m

m

u

n

i

t

y

!

R

e

f

e

r

e

n

c

e

s

:

n

Bostwick, W. (2012). Assessing bisexual stigma and mental health status: A brief report. 

Journal of Bisexuality

, 

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(2),

214–222. http://doi.org/10.1080/15299716.2012.674860

n

Centers for Disease Control and Prevention. (2017a). 

HIV among gay and bisexual men

. Retrieved from

https://www.cdc.gov/hiv/group/msm/index.html

n

Centers for Disease Control and Prevention. (2017b). 

PrEP

. Retrieved from https://www.cdc.gov/hiv/basics/prep.html

n

Centers for Disease Control and Prevention. (2017c). 

Screening recommendations and considerations referenced in

treatment guidelines and original sources

. Retrieved from https://www.cdc.gov/std/tg2015/screening-

recommendations.htm

n

De Chesnay, M. (2016). Vulnerable populations: Vulnerable people. In M. de Chesnay & B.A. Anderson (Eds.), 

Caring

for the vulnerable: Perspectives in nursing theory, practice, and research

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th

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Jones & Bartlett Learning.

n

De Chesnay, M., Hart, P., & Brannan, J. (2016). Cultural competence and resilience. In M. de Chesnay & B.A.

Anderson (Eds.), 

Caring for the vulnerable: Perspectives in nursing theory, practice, and research

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n

Diamond, M., & Garland, J. (2014). Evidence regarding cosmetic and medically unnecessary surgery on infants.

Journal of Pediatric Urology, 10(1), 2-6. 

DOI: http://dx.doi.org/10.1016/j.jpurol.2013.10.021

n

Fredriksen-Goldsen, K. I., Simoni, J. M., Kim, H.J., Lehavot, K., Walters, K. L., Yang, J., & Hoy-Ellis, C. P. (2014). The

health equity promotion model: Reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health

disparities. 

The American Journal of Orthopsychiatry

, 

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n

Hatzenbuehler, M. L., & McLaughlin, K. A. (2014). Structural stigma and hypothalamic-pituitary-adrenocortical axis

reactivity in lesbian, gay, and bisexual young adults. 

Annals of Behavioral Medicine : A Publication of the

Society of Behavioral Medicine

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Marion, D., Douglas, M., Lavin, M., Barr, N., Gazaway, S., Thomas, E., & Bickford, C. (2017). Implementing the new

ANA standard 8: Culturally congruent practice. 

OJIN: The Online Journal of Issues in Nursing, 22

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n

Office on Women’s Health. (2017). Lesbian and bisexual health. Retrieved from https://www.womenshealth.gov/a-z-

topics/lesbian-and-bisexual-health

R

e

f

e

r

e

n

c

e

s

:

n

Perez-Stable, E. (2016). Director’s message: Sexual and gender minorities formally designated as a health disparity

population for research purposes. Retrieved from https://www.nimhd.nih.gov/about/ directors-

corner/message.html

n

Pingel, E. S., Thomas, L., Harmell, C., & Bauermeister, J. (2013). Creating comprehensive, youth centered, culturally

appropriate sex education: What do young gay, bisexual and questioning men want? 

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n

Purnell, L.D. (2013). 

Transcultural health care: A culturally competent approach

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Ranji, U., Beamesdurfer, A., Kates, J., & Salganicoff, A., (2014). 

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gay, bisexual, and transgender individuals in the U.S. 

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n

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n

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n

University of California. (2017). 

LGBTQIA resource center glossary

. Retrieved

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n

U.S. Department of Health and Human Services. (2017). 

Lesbian, gay, bisexual, and transgender health. 

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th

ed.) Retrieved from

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Young, R. M., & Meyer, I. H. (2005). The trouble with “MSM” and “WSW”: Erasure of the sexual-minority person in

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95

(7), 1144–1149.

http://doi.org/10.2105/AJPH.2004.046714