Rehabilitation terminology may appear to some outside the specialty practice as "alphabet soup." Consider the terms that are commonly used in daily practice: IRF-PAI, CMG, CMS, PT, OT, ST, CRRN, and PPS, among dozens of others. Although these acronyms are second nature to those of us in rehabilitation, it can be confusing to individuals on the periphery of rehabilitation practice. Similarly, one may be confused when it comes to terms describing the LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual plus) population. As with all of the patients we care for, it is important that we use appropriate language in caring for patients in a respectful, inclusive manner.
According to the LGBT Demographic Data Interactive at the University of California Los Angeles School of Law (2019), roughly 4.5% of individuals surveyed, ages 13 years and older, publicly identify as members of the LGBTQIA+ community. Among national surveys of high school youth, higher percentages are suggested by the 2019 Centers for Disease Control and Prevention Youth Risk Behaviors Surveillance System, with 11.2% identifying as gay, lesbian, or bisexual and 4.5% indicating they were "unsure" (Centers for Disease Control and Prevention, 2020). Factors related to changing social acceptance and peer inclusion from Millennial and Generation Z cohorts suggest more openness and perceived safety of community identification among youth and young adult age groups. For rehabilitation nurses, roughly 1 in 20 patients under our care could be a part of this population, with higher numbers possible considering there are those who may not share their experience openly because of fear of rejection, stigma, or privacy.
An important caveat to note in describing the lesbian, gay, bisexual, transgender, queer, intersex, asexual and other gender and orientation (LGBTQIA+) communities is that not all individuals ascribe to commonly accepted conventions; in fact, terms in Western society have been evolving to be more inclusive of a greater number of individuals and representation. The authors have been in many thoughtful discussions about the appropriate use of the "LGBTQIA+" acronym, as well as challenges with that term when applied in a blanket manner. Some of these challenges include: a) The acronym doesn't include every diverse experience of the patients who may need our services, just the most socially prevalent and commonly understood categories (e.g., gender non-binary identities are not explicitly named in the acronym); (b) The acronym can cause reaction and automatic assumptions about a patient because of stereotype threat (Steele, 2010), instances of unconscious bias (Bellack, 2015), or unwanted attention to patients who require or want privacy. Ultimately, the most appropriate term to use is one that the patient uses or requests, if they disclose to medical providers, should they choose to identify with a label or term.
Several documents by leading authorities on gender and orientation diverse populations provide guidance for nurses. The pioneering 2011 Institute of Medicine report on the health of the LGBTQIA+ population, the LGBT cultural competence field guide proposed by the Joint Commission (2011), and the recent Healthy People 2030 (2021) initiative are just a few of the policy and position papers to highlight the stigmatization of LGBTQIA+ individuals and the need for research and training specific to this population. All of these recommendations share some common themes, namely promoting awareness among healthcare providers about sexual and gender diverse population health disparities, building inclusive environments, and tailoring care with sexual and gender diverse populations (Healthy People 2030, 2021; Institute of Medicine, 2011; Joint Commission, 2011). Other practices include the following:
Individual level: Schedule continuing education (CE) workshops or seek CE on gender and orientation inclusion for both clinical and patient care population knowledge and explore readings and articles about patient experiences.
Unit level: Have a guest speaker present on these topics (video conference or live presentation post-COVID-19 pandemic).
Institutional level: Create a workgroup team with leadership to assess intake forms, bed placement policies, and electronic health records for inclusion of additional options of family structure, sex and gender status, and affirmed name and pronoun, which could differ from current legal and insurance designations. Consider also signage, for example, providing a gender-neutral or family restroom.
All levels: Seek to forward consciousness and actions in alignment with gender and orientation affirmative practice while recognizing one can hold their own authentic personal religious and cultural views toward this community.
Affirm that patient-centered care practices address the following tenets;
Diverse gender and orientation experiences are not disordered.
Gender expression and norms are diverse across cultures and all periods of human history.
Gender and orientation experiences are fluid and can be described on a continuum that may change over time through their individual developmental process.
Related pathology and health outcome disparities are more often because of societal reactions and rejection of gender diversity (Hidalgo et al., 2013) rather than manifestations endemic to this community.
As nurses, we must be aware of our own biases and preconceived notions about this community. With every patient we care for, it is our duty to provide care to the individual who presents to us. Ultimately, self-education, patient-centered care and language, and examining policies and procedures of your institution for inclusiveness, all contribute to creating a welcoming environment for all patients.
Conflict of Interest
The authors declare no conflict of interest.
Evan McEwing, DNP, PHNA-BC, RN, CCRP, CHSE
School of Nursing and Health Studies
University of Miami
Coral Gables, FL, USA
Joseph Zolobczuk, MS Ed
Umut Dursun, MA
YES Institute, Miami, FL, USA
Terrie Black, DNP, MBA, CRRN, FAHA, FAAN
College of Nursing
University of Massachusetts Amherst
Amherst MA, USA
References