On June 26, 2015, the U.S. Supreme Court legalized same-sex marriage in all 50 states. Connecticut joined the ranks of other states with the signing of House Bill 7006-an act giving transgender individuals the ability to change their birth certificates without requiring sexual reassignment surgery, which became effective on October 1, 2015. And on March 7, 2016, New York City Mayor Bill de Blasio signed an executive order allowing people the right to use city bathroom facilities consistent with their gender identity.
Although the lesbian, gay, bisexual, and transgender (LGBT) community is making strides in societal recognition, barriers still exist in legislation, healthcare, and nursing/medical education. It's imperative that we provide effective care for this population, starting with identifying the barriers to teaching LGBT health.
Stigma and discrimination
According to a Gallup poll conducted in 2012, approximately 3.5% of the population identify as LGBT. In a 2015 survey conducted by You.Gov, 31% of those age 18 to 29 stated that they aren't 100% heterosexual. "Societal stigma, discrimination, and denial of civil and human rights" often discourage LGBT patients from receiving or seeking healthcare. Why does this population face societal stigma and discrimination? Remember, it was only in 1973 that homosexuality was taken off the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) list of mental disorders. The current DSM-5 lists gender dysphoria as a mental health disorder. It's speculated that without a diagnosis, an individual may potentially be denied appropriate healthcare; however, a diagnosis risks further stigmatization.
Civil and human rights for the LGBT community are still questionable. North Carolina's House Bill 2-known as the Public Facilities Privacy and Security Act-signed on March 23, 2016, by Governor Pat McCrory, states that the use of "multiple occupancy bathroom and changing facilities in schools and public agencies" is restricted to one's biological sex. Similar bills were proposed in Kansas: Senate Bill 513 and House Bill 2737, both known as the Student Physical Privacy Act. With passage of these bills, an institution, such as a school, could be fined a minimum of $2,500 if it didn't try to restrict single-sex bathrooms, locker rooms, and/or showers to the designated sex. In this case, sex is defined as one's "chromosomes and anatomy at birth." Senate Bill 513 and House Bill 2737 both "died in committee."
Mississippi's House Bill 1523 was signed by Governor Phil Bryant on April 5, 2016. Known as the Protecting Freedom of Conscience from Government Discrimination Act, the bill allows, in part, "persons, religious organizations, and private associations" the lawful ability to withhold, for example, healthcare, from those who conflict with their "religious belief or moral conviction." House Bill 1523 was blocked by U.S. District Court Judge Carlton Reeves on June 30, 2016, hours before it was to take effect on July 1, 2016.
These discriminatory laws aren't limited to North Carolina, Kansas, and Mississippi. And the blocked laws may potentially be resurrected. On June 30, 2016, the North Carolina legislature allotted $500,000 for litigation purposes to protect its House Bill 2.
Unique health concerns
This continuing stigmatization and discrimination can contribute to increased mental health issues; higher rates of tobacco, alcohol, and other substance use; and older LGBT individuals being at increased risk for social isolation. The average attempted suicide rate in the United States is 4.6%; within the LGBT community, this is substantially higher: 10% to 20% for lesbian, gay, or bisexual individuals and 41% for transgender individuals. The rate increases when disabilities, discrimination, or homelessness (69%) are added. And refusal of care by a healthcare provider increases the rate of attempted suicide for this population to 60%. Take note, Mississippi's House Bill 1523 would've allowed healthcare providers the opportunity to lawfully deny care to someone whose lifestyle goes against their moral or religious beliefs.
LGBT patients experience barriers to healthcare, including insensitivity among healthcare providers and ignorance or lack of knowledge about LGBT-specific health concerns. Healthcare providers may not be linguistically proficient; for example, using inappropriate pronouns for those who identify as transgender.
Lack of scholarly information
In 2010, the Gay and Lesbian Medical Association and Healthy People 2020 identified LGBT cultural competence training to be "an integral part of all medical and nursing school curricula." The Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration reviewed continuing-education curricula for those already in the workforce and found the curricula to be lacking.
So what information is available for nurses? According to research in 2010, "between 2005 and 2009, the top 10 nursing journals [by 5-year impact factor] published only eight articles focused on LGBT health issues of almost 5,000 total articles." This lack of scholarship is indicative of a dearth of LGBT topics in nursing curricula. Although medical curricula include 5 hours of teaching, research hasn't been done examining nursing curricula for inclusion of LGBT topics.
With this lack of information and nursing curricula models, how will instructors teach future nurses about LGBT health? Will nursing students receive accurate information and be responsive to this population's unique healthcare concerns?
What can we do?
As an LPN instructor, I wondered what the perceived barriers to teaching with respect to the LGBT community were in a Northeast program. In March 2016, I conducted a qualitative online poll. The participants were 24 full-time LPN instructors teaching theory in the classroom and clinical at selected sites. Only those who chose not to participate (9) were excluded. It was explained that willingness to participate and answers to the questions wouldn't affect the respondents' positions as instructors, and confidentiality was offered.
The following barriers were identified:
* didn't realize unique health concerns existed: 13%
* didn't think of teaching with respect to the LGBT community: 40%
* isn't in the curriculum: 40%
* the LGBT lifestyle doesn't mesh with my personal beliefs (such as religious beliefs): 0%
* don't feel qualified: 20%
* don't know anyone in the LGBT community: 7%
* don't have appropriate resources: 7%.
Based on the poll findings, the barriers to teaching have more to do with lack of awareness and an unspecified curriculum rather than personal beliefs. Inclusion of LGBT health complies with Healthy People 2020, yet curriculum revision can be a lengthy process. What can be initiated now?
First, determine whether barriers exist in your nursing program and, if so, what are they? This can be done informally or through a more formal survey. Is one of your barriers not knowing what resources are available as in my poll's findings of 7%?
Next, consider these classroom activities. Ensure that the classroom is a respectful, safe environment for all students to feel comfortable with their own gender identity and when asking questions. What barriers or concerns do students have with respect to the LGBT population? I like to introduce the topic to my class with a short video in which people are asked when they chose to be straight (see On the web). This opens a nonconfrontational dialogue. A second video I utilize is "What Transgender People Want You to Know" (see On the web). Because healthcare providers may not be linguistically proficient, this video also introduces proper vocabulary. Another video that explains terminology is Sam Killermann's TEDx talk "Understanding the Complexities of Gender" (see On the web).
Some instructors will question how we can introduce LGBT health topics into already time-constrained courses. The answer is that it's quite simple. Concerns with linguistics can be addressed in Fundamentals. As students learn the basics of introducing themselves to patients, they can learn from the start to refer to patients and their support person(s) by their preferred names and pronouns. As students practice on binary (male or female) manikins, explain that some individuals have combined anatomies.
When teaching the cardiovascular system, the instructor can discuss that an individual who's taking estrogen may have an increased risk of cardiac issues. How might this affect someone transitioning from male to female? When teaching oncology, the instructor can address that lesbians obtain less cancer screening and possible ways to promote screening.
Ethics conversations can include current legislation, such as North Carolina's House Bill 2 or Mississippi's House Bill 1523. Is it morally acceptable to allow healthcare providers to deny care? Would students risk discrimination to obtain healthcare? How can we ensure that LGBT patients feel cared for and safe?
Additional resources can be located on the Internet. One such resource is http://LavenderHealth.org, which offers a wealth of information on LGBT education for students and healthcare providers, and assistance with locating resources such as available speakers.
Minds wide open
Scholarly information will increase as future educators pursuing graduate degrees choose research topics that address LGBT health issues. We must promote the "normalization of sexual diversity in nursing education." As opportunities are presented for staff and students alike to think critically with respect to this patient population, minds will likely open and healthcare for LGBT individuals will improve.
did you know?
Additional unique health concerns for LGBT individuals include:
* Gay men and transgender individuals have a higher risk of contracting HIV and other sexually transmitted infections.
* Some individuals may choose hormonal therapy with or without sex reassignment surgery. A person on estrogen transitioning to female, for example, may be reluctant to discuss cardiac issues-a potential risk-for fear of stopping hormonal therapy.
* Some individuals will avoid healthcare; for example, lesbians obtain less cancer screening.
on the web
"Understanding the Complexities of Gender: Sam Killermann at TEDxUofIChicago":https://www.youtube.com/watch?v=NRcPXtqdKjE
"What Transgender People Want You to Know":http://www.cbsnews.com/news/what-transgender-people-want-you-to-know/
"When Did You Choose to Be Straight?":https://www.youtube.com/watch?v=QJtjqLUHYoY
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