Providing Culturally Competent Care for LGBT+ Patients

Laura M. Cascella, MA, CPHRM

Diversity is a cornerstone of American culture that is reflected in our national institutions and endeavors, including healthcare. Healthcare providers and staff members interact on a daily basis with people of varying backgrounds and experiences. Although patient populations might differ based on geographic location or type of facility, the need for culturally competent care never diminishes.

One facet of our diverse society is the lesbian, gay, bisexual, and transgender (LGBT) community. People who identify as LGBT make up 5.6 percent of the U.S. population, and the number continues to grow.¹ Although each group within this community is unique, the term "LGBT" often is used as an umbrella term to discuss overarching issues — such as access and barriers to healthcare — that affect various individuals and groups within this community.

The Joint Commission's field guide, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community, explains that "LGBT individuals experience disparities not only in the prevalence of certain physical and mental health concerns, but also in care due to a variety of factors, including experiences of stigma, lack of awareness, and insensitivity to their unique needs."²

The guide also lists other potential barriers to care that LGBT individuals might face, such as "refusals of care, delayed or substandard care, mistreatment, inequitable policies and practices, little or no inclusion in health outreach or education, and inappropriate restrictions or limits on visitation."³

In an attempt to overcome these numerous issues and align with the ideals of health equity and patient-centeredness, the healthcare community has made strides in recent years to address cultural competence for LGBT+ patients. ECRI notes that "The end result from LGBT-inclusive approaches is not only the delivery of appropriate care but also improved patient and family satisfaction."⁴

As with most quality improvement initiatives, more work remains in determining and adopting best practices for providing culturally competent care to the diverse LGBT+ population. However, as a result of the work that has already been done, various strategies have emerged that provide a path for healthcare organizations to follow in the pursuit of this goal.

Below are a number of recommendations for healthcare leaders, providers, and staff to consider in the areas of organizational policies/practices, patient care, and education/training.⁵

• Organizational policies/practices:
  • Assess current organizational practices to identify potential gaps in policies and services related to LGBT+-inclusive care. Make sure policies comply with all federal and state regulations.
  • Depending on the size of your organization, designate a point person, office, or advisory group to oversee LGBT+-related issues as part of your organization's overall health equity strategy.
  • Include language on your facility's website and in its marketing materials that describes the organization's commitment to high-quality, culturally competent, patient-centered care. Make sure that marketing, advertising, and informational materials reflect diverse populations.
  • Consider creating a webpage or portal for information and resources related to LGBT+ care. As part of this information, offer an easily accessible directory of LGBT+-welcoming providers within the organization.
  • Review codes of conduct and ethics to ensure they include expectations for respectful, courteous communication with all patients, visitors, and staff members. Organizational policies also should specify consequences for code violations.
  • Make patients, providers, and staff aware of your organization's nondiscrimination, anti-harassment, and confidentiality policies. Post these policies in visible locations.
  • Evaluate environmental factors that might present issues for LGBT+ patients, such as bathroom designations, rooming policies, etc. Discuss ways to adopt approaches that will create the greatest level of comfort for all patients.
  • Consider revising your patient forms to include (a) an option for chosen name in addition to legal name, (b) an extra blank box for gender, which will give patients the flexibility to identify in the way that makes them most comfortable, (c) a partnership option under relationships, and (d) general wording such as "parents/guardians" rather than "mother" and "father" to accommodate same-sex parents.
  • Consider your documentation systems and policies, and determine how best to document care for transgender patients.
  • Review visitation policies (for inpatient facilities) to ensure that they empower patients to decide who can visit them and act on their behalf.
• Patient care:
  • When providing care, do not make assumptions about patients' sexual orientations, gender identities, beliefs, or concerns based on physical characteristics, such as clothing, tone of voice, perceived femininity/masculinity, etc.
  • Politely ask for clarification if it is unclear what a patient would like to be called or how the patient would like to be addressed. Apologize if you mistakenly refer to a patient in a way that causes offense.
  • Do not ask patients questions about sexual orientation or gender identity that are not material to their care or treatment.
  • Do not disclose patients' sexual orientations or gender identities to individuals who do not explicitly need the information as part of the patients' care.
  • Implement strategies to promote patient dignity throughout the course of patient care and treatment.
  • Stay current on health issues affecting the LGBT+ community, and be aware that the various subgroups within this community may have different and unique healthcare needs.
  • Be prepared to provide appropriate referrals for LGBT+ patients, and consider participating in referral programs through LGBT+ organizations.
• Education/training:
  • Build awareness within your organization about the LGBT+ community and considerations for care. For example, discuss with healthcare providers and staff the difference between sexual orientation and gender identity, which might be confusing to people who are not familiar with these concepts.
  • Help providers and staff members understand that sexual orientation and gender identity are just two factors that contribute to an individual's overall identity. Other factors — such as race, ethnicity, religion, socioeconomic status, education level, income, etc. — also contribute to a person's overall experience, perceptions of healthcare, and potential barriers to care.
  • Provide training to healthcare providers and staff on culturally competent care and organizational policies related to conduct, ethics, privacy, and communication. Training should occur at orientation and periodically thereafter to reinforce expectations and standards.
  • Train providers and staff members to use patients' preferred names and pronouns, and make sure this information is clearly indicated in patients' health records.
  • Educate providers and staff members about the principles of trauma-informed care, and how this approach can support patient engagement and help patients build resilience and cope with adversity.
  • Train providers and staff members on inclusive communication principles and language that promotes health equity.

In Summary

Providing high-quality, culturally competent, patient-centered care is a complex process that requires ongoing learning and awareness of factors affecting diverse populations. Opportunities for growth and knowledge-building among healthcare leaders, providers, and staff members should be viewed as educational and quality improvement opportunities rather than as organizational or individual weaknesses. Even healthcare organizations that have taken leaps toward improving cultural competence for LGBT+ patients can find new ways to address barriers to care and engage staff in improvement initiatives.

For more information about addressing cultural competence in the care of LGBT+ patients, see Risk Resources: LGBT+-Inclusive Care for links to a variety of informative publications and materials.

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¹ Jones, J. (2021, February 24). LGBT identification rises to 5.6% in latest U.S. estimate. GALLUP News. Retrieved from https://news.gallup.com/poll/329708/lgbt-identification-rises-latest-estimate.aspx

² The Joint Commission. (2011). Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. Retrieved from www.jointcommission.org/lgbt/

³ Ibid.

⁴ ECRI Institute. (2015, October). Are LGBT-inclusive approaches for patients and staff on your radar screen? Risk Management Reporter, 34(5), 6.

⁵ AHIMA. (2017, March). Improved patient engagement for LGBT populations: Addressing factors related to sexual orientation/gender identity for effective health information management. Journal of AHIMA, 88(3): extended online version. Retrieved from http://bok.ahima.org/doc?oid=302067; Deutsch, M. B., ed. (2016, June). Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people (2nd edition). Center of Excellence for Transgender Health, Department of Family and Community Medicine. University of California San Francisco. Retrieved from www.transhealth.ucsf.edu/guidelines; ECRI Institute, Are LGBT-inclusive approaches for patients and staff on your radar screen?; Hollenbach, A. D., Eckstrand, K. L., & Dreger A., eds. (2014). Implementing curricular and institutional climate changes to improve health care for individuals who are LGBT, gender nonconforming, or born with DSD. Association of American Medical Colleges. Retrieved from https://store.aamc.org/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.html; 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; Transgender Law Center. (2011). 10 tips for working with transgender patients. Retrieved from https://transgenderlawcenter.org/resources/health/10tips; Gay & Lesbian Medical Association. (2014). Guidelines for care of lesbian, gay, bisexual, and transgender patients. Retrieved from https://npin.cdc.gov/publication/guidelines-care-lesbian-gay-bisexual-and-transgender-patients

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