Creating a Safe Place for LGBTQIA+

Healthcare professionals wanting to improve their practice know the importance of understanding the needs and expectations of LGBTQIA+ communities (Moreno et al., 2017).

Cultural safety goals go beyond recognizing disparities and instead challenge systems that create inequality by focusing on provider-patient power dynamics as a source of this inequality. Mukherjee et al. (2021) describes cultural safety for LGBTQIA+ people using five central tenets adapted from the broader cultural safety literature. These five tenets are partnerships, personal activities of daily living (ADLs), harm prevention, patient centering, and purposeful self-reflection. More specifically, cultural safety seeks to form partnerships with patients to transfer power from the provider to the patient. It seeks to understand the patient’s ADLs or everyday norms and experiences to incorporate them into clinical care. Prevention of harm is based on understanding what the patient needs to stay safe, with frequent clinician check-ins about whether the interactions or care plan might inadvertently cause further harm. Also imperative for clinicians is to demonstrate patient centering by listening and providing meaningful care that fits into patients’ lives. Finally, purposeful self-reflection is a process of uncovering one’s biases and beliefs that may lead to stigmatization or judgment and transforming them to create a nonjudgmental environment. Comprehending clinical care through a cultural safety framework will deliver a comprehensive approach to managing the whole patient.

According to Mukherjee et al. (2021), Irihapeti Ramsden originally defined cultural safety as a Maori Nursing Scholar working to ensure indigenous/aboriginal health equity. Ramsden defined five essential principles of cultural safety as partnerships, protocols, processes, positive purpose, and personal knowledge. Overt, deliberate, and systemic change must be targeted. Healthcare access and delivery must be improved for marginalized populations to create a culturally safe space for historically oppressed populations such as LGBTQIA+ individuals. Further, according to Ramsden, personal knowledge must include ongoing provider action shaped by self-reflection, and engagement and/ or support of advocacy work those challenges and dismantles the provider’s biases. Finally, understanding historical and present-day experiences of oppression is also crucial for enacting cultural safety.

Cultural Safety and LGBTQIA+ Populations

Cultural safety is essential to closely examine the experiences of LGBTQIA+ people in healthcare today. According to the Healthcare Equality Index (the national benchmarking tool for LGBTQIA+ healthcare equality, LGBTQIA+ patients are often unhappy with the care they receive from their providers due to stigma and bias. LGBTQIA+ patients avoid seeking healthcare services or providing full disclosure about their sexual orientation or gender identity rather than face the possibility of misunderstanding, discrimination, or even maltreatment by a healthcare provider. Of those surveyed for the Health Equality Index in 2014, 70% of transgender and gender-nonconforming respondents and almost 56% of lesbian, gay, or bisexual respondents had at least one of the following adverse experiences:

• Healthcare providers using harsh or abusive language

• Healthcare providers refusing to touch them or using excessive precautions

• Being blamed for their health status

• Healthcare providers being physically rough or abusive

• Patients being refused needed care

The healthcare provider care that LGBTQIA+ patients want and deserve must not be prohibited by a healthcare provider’s or institutional bias, cost of care, or lack of provider knowledge. LGBTQIA+ patients deserve to receive healthcare that supports and decreases harm. End of story. Research suggests that many clinicians have little experience caring for LGBTQIA+ population. This lack of experience impacts provider confidence to adequately care for patients identifying as LGBTQIA+, which leads to increased health disparities. Care must reach beyond the low expectation of competency in order to best serve the needs of LGBTQIA+ patients. Cultural knowledge is paramount, but knowledge about how populations are marginalized is vital.

Cultural Safety for LGBTQIA+ Populations

Partnerships Partnering with the patient and community delivers coordinated care and respect and comprises patient knowledge and experiences as vital. When partnering with patients to acquire cultural safety, providers should unite with patients and the community to provide collaborative care and transfer power to patients while respecting and incorporating patient knowledge and experiences. With LGBTQIA+ communities, this implies delivering care for patients as partners in their care.

Personal Activities of Daily Living (ADLs) include an understanding of the daily activities of life and survival that LGBTQIA

A+ individuals encounter as they face marginalization, stigma, and discrimination within society. Providers must explore and understand these experiences and the daily tasks that help people to resist and survive these challenges. In order to provide culturally safe care, clinicians must avoid asking patients to explain themselves, their practices, and their identities in a way that resonates as invasive, ignorantly curious, or unnecessary. Researching the various daily struggles that LGBTQIA+ people face, and respecting ADLs is crucial. Avoid asking unneeded, not-overly-curious questions about these practices helps create trust between providers and patients. When working with patients whose gender identities or sexual practices may be unfamiliar to clinicians, be aware that various personal ADLs may be important to understand and discuss in a nonjudgmental way. For example, a norm for many trans men is chest-binding either before or instead of a double mastectomy. Chest binding can cause chest pain, muscle atrophy, or other musculoskeletal complications. Clinicians who are working toward cultural safety would support patients to achieve their desired gender presentation through this personal ADL of chest-binding, despite the risk of clinical complications.

Prevention of Harm is patient-driven engagement that supports a patient’s journey toward health. Providers should engage in mutual learning with frequent check-ins to ensure the care plan is safe and appropriate for the patient’s lifestyle. This means, for example, supporting LGBTQIA+ patients who may be engaged in underground economy jobs, such as sex work, and help to decrease harm in patients’ lives by offering more routine STI testing, prophylaxis medication such as PrEP, or expedited treatment. Alternatively, regarding the previous example of trans men doing daily chest-binding, clinicians can recommend stretching or massage to decrease muscular atrophy and pain from this practice. In each case, the priority should and must be the patient’s priorities, even though clinicians acknowledge that there may be complications due to these goals.

Patient Centering is when the healthcare provider provides the means to achieve healthcare goals as decided by the patient, and then helps the patient move toward goals. When the healthcare provider has aligned purposes with patients, to providing the means to achieve the goals that the patient wants and/or needs, this solidifies clinicians as part of the patients’ positive moves toward their goals. Completing prior authorizations with insurance companies is an example of a simple way to help trans and gender expansive patients access gender affirming care. Supporting patients without judgment when they are in difficult relationships is another example of patient centering.

Purposeful self-reflection is when the healthcare provider becomes aware of their cultural beliefs, including reflecting on their blind spots and internal biases. This requires self-reflection and accountability processes to deal responsibly with these internal processes, so they do not interfere with the provider-patient relationship. Healthcare provider should practice self-reflexivity to develop an awareness of innate, tacit, and biased cultural beliefs to address them. In the context of the powered provider-patient relationships, the onus of understanding cultural biases falls on the provider rather than the patient. With LGBTQIA+ patients, as with most patients, it may not be appropriate to speak these biases out loud but instead to eradicate their impact on the patient experience.

Initially, it may be easier to recognize the lack of cultural safety rather than the presence of cultural safety. A lack of cultural safety exists when practices demean, devalue, or disempower LGBTQIA+ patients' identities (Mukherjee et al.,2021). A typical example is the leveraging of hormone prescriptions to reward HIV+ trans patients for taking their HIV treatment medications, thereby devaluing the trans identity of the patient (Mukherjee et al.,2021). Additionally, many clinicians working with asexual patients may create a goal of having healthy sex for their patients, even though this might not be the patient's goal (Mukherjee et al.,2021). This can disempower the patient from choosing their progress and goals.

Cultural safety is defined as an outcome wherein LGBTQIA+ individuals' historical and personal narratives are recognized and valued by clinicians. Cultural safety is an outcome for patients produced primarily through applying cultural competence in the clinical setting and providers' diligent work to decrease barriers outside the patient-provider setting Mukherjee et al.,2021). Cultural safety does not end with the patient visit. Providers and staff must create avenues for increased access to safe and legal employment options when the healthcare provider becomes aware of their cultural beliefs, including reflecting on their blind spots and internal biases (Mukherjee et al.,2021). To promote culturally safe care, clinicians must be leaders. One must educate current and future healthcare providers and public and private insurers about the medical and economic needs of LGBTQIA+ patients (Mukherjee et al.,2021). The healthcare provider is an active tool in decreasing the harm of ongoing stigma when working with LGBTQIA+ patients, via equalizing the power dynamic within the provider-patient relationship (Mukherjee et al.,2021).

The Vice Practices’ healthcare team is an advocate for the LGBTQIA+ community. Individuals who are Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and Plus are respected and acknowledged that they are part of the community as a whole. Also, as the Healthcare Director of V Health Center, I understand that one community comes from all walks of life and includes people of all races, ethnicities, ages, socioeconomic statuses, sexual orientations, gender identities and from various parts of the country (Center for Disease Control and Prevention [CDC], 2022) The perspectives and needs of LGBTQIA+ people should be routinely considered in public health efforts to improve the overall health of every person and eliminate health disparities. Over the years of being a healthcare provider, I have experienced, emphasized, acknowledged, and understood the needs of the LGBTQIA+ community. I listened to and had full comprehension of their healthcare concerns, empowering preventive measures to mitigate the healthcare disparities in this community. The Vice Practice can improve the health of entire communities, and I am culturally competent in medical care and prevention services specific to the LGBTQIA+ population. The Vice Practice enables cultural awareness and safety towards the LGBTQIA+ community because Vice Practice Cares!

References

Center for Disease Control and Prevention. (2022, November 3). Lesbian, Gay, Bisexual, and Transgender Health. https://www.cdc.gov/lgbthealth/index.htm

Moreno, A., Laoch, A., & Zasler, N. D. (2017). Changing the culture of neurodisability through language and sensitivity of providers: Creating a safe place for LGBTQIA+ people. NeuroRehabiliatation, 41(2), 375-393. https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=125767221&site=ehost-live&scope=site

Murkerjee, R., Wesp, L., Singer, R., & Menkin, D. (2021). Clinician’s guide to LGBTQIA+ care: Cultural safety and social justice in primary sexual, and reproductive healthcare(1st ed.). ProQuest. https://chamberlain.primo.exlibrisgroup.com/permalink/01CUCON_INST/f6kb8f/cdi_askewsholts_vlebooks_9780826169211