👨‍⚕️Nursing Care of Vulnerable Populations Unit 7 – LGBTQ+ Health in Vulnerable Populations

Key Concepts and Terminology

• LGBTQ+ is an acronym that stands for lesbian, gay, bisexual, transgender, queer or questioning, and others
  • Lesbian refers to women who are attracted to other women
  • Gay refers to men who are attracted to other men
  • Bisexual refers to individuals attracted to both men and women
  • Transgender refers to individuals whose gender identity differs from their sex assigned at birth
  • Queer is an umbrella term for sexual and gender minorities not exclusively heterosexual or cisgender
  • The + symbol represents other sexual and gender identities (pansexual, asexual, non-binary)
• Sexual orientation describes an individual's enduring physical, romantic, and/or emotional attraction to another person
• Gender identity is a person's inner sense of being male, female, neither, or other gender(s)
• Gender expression refers to the way a person communicates their gender identity through behavior, clothing, hairstyle, or voice
• Cisgender describes individuals whose gender identity aligns with their sex assigned at birth
• Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health experienced by socially disadvantaged populations

Historical Context and Health Disparities

• LGBTQ+ individuals have faced a long history of discrimination, stigma, and marginalization
  • Same-sex sexual activity was considered a mental disorder until 1973 when the American Psychiatric Association removed it from the Diagnostic and Statistical Manual of Mental Disorders (DSM)
  • The HIV/AIDS epidemic in the 1980s disproportionately affected the LGBTQ+ community and led to increased stigma and discrimination
• Health disparities among LGBTQ+ individuals are rooted in societal stigma, discrimination, and denial of civil and human rights
• LGBTQ+ individuals experience higher rates of poverty, unemployment, and homelessness compared to the general population
• Minority stress, the chronic stress faced by members of stigmatized minority groups, contributes to health disparities
  • Minority stress includes experiences of prejudice, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes
• LGBTQ+ individuals are more likely to experience violence, including hate crimes, intimate partner violence, and sexual assault
• Historical lack of legal protections (employment discrimination, housing discrimination, marriage inequality) has contributed to health disparities

Unique Health Challenges

• LGBTQ+ individuals have higher rates of certain mental health conditions, including depression, anxiety, and substance use disorders
  • Minority stress and experiences of discrimination contribute to these disparities
• Transgender individuals may seek gender-affirming treatments, such as hormone therapy or surgery
  • Access to gender-affirming care can be limited by lack of provider knowledge, insurance coverage, and discrimination
• LGBTQ+ individuals, particularly men who have sex with men, have higher rates of HIV and other sexually transmitted infections (STIs)
  • Stigma and discrimination can be barriers to HIV/STI testing and treatment
• Lesbian and bisexual women are less likely to receive preventive services for cancer, such as mammograms and Pap tests
• LGBTQ+ individuals have higher rates of tobacco use, which can lead to various health problems (lung cancer, heart disease, respiratory issues)
• Older LGBTQ+ adults may face additional challenges, such as social isolation and lack of family support
• LGBTQ+ youth are at increased risk for bullying, harassment, and family rejection, which can negatively impact mental health

Cultural Competence and Inclusive Care

• Cultural competence in healthcare refers to the ability to provide care to patients with diverse values, beliefs, and behaviors
  • Includes tailoring delivery to meet patients' social, cultural, and linguistic needs
• Providing inclusive care for LGBTQ+ patients involves creating a welcoming environment, using inclusive language, and respecting patient privacy and confidentiality
  • Examples of inclusive language include using patients' preferred names and pronouns and avoiding assumptions about sexual orientation or gender identity
• Healthcare providers should receive training on LGBTQ+ health issues and cultural competence
• Inclusive intake forms and electronic health records (EHRs) should include options for sexual orientation, gender identity, and preferred name and pronouns
• Displaying visual cues of LGBTQ+ inclusion (rainbow flags, non-discrimination statements) can help create a welcoming environment
• Providing gender-neutral restrooms and facilities can create a more inclusive space for transgender and non-binary individuals
• Partnering with local LGBTQ+ organizations can help providers better understand and serve the community

Access to Healthcare and Barriers

• LGBTQ+ individuals face various barriers to accessing healthcare, including discrimination, lack of insurance coverage, and lack of culturally competent providers
  • Discrimination can occur at individual (provider bias) and institutional (policies, practices) levels
• Lack of insurance coverage is a significant barrier, particularly for transgender individuals seeking gender-affirming care
  • Many insurance plans have exclusions for transition-related care or require a medical necessity determination
• LGBTQ+ individuals, particularly those in rural areas, may have difficulty finding providers who are knowledgeable about and sensitive to their unique health needs
• Fear of discrimination or negative experiences with healthcare providers can lead LGBTQ+ individuals to delay or avoid seeking care
• Language barriers can be a challenge for LGBTQ+ individuals with limited English proficiency
• Transportation and cost can also be barriers, particularly for low-income LGBTQ+ individuals
• Telemedicine and mobile health services may help improve access to care for LGBTQ+ individuals

Mental Health and Substance Use

• LGBTQ+ individuals have higher rates of mental health conditions, including depression, anxiety, and substance use disorders
  • Minority stress, discrimination, and lack of social support contribute to these disparities
• Lesbian, gay, and bisexual adults are more than twice as likely as heterosexual adults to experience a mental health condition
• Transgender individuals have even higher rates of mental health conditions, with an estimated 40% experiencing depression and/or anxiety
• LGBTQ+ youth are at increased risk for suicide, with lesbian, gay, and bisexual youth being four times more likely to attempt suicide than their heterosexual peers
• Substance use disorders are also more prevalent among LGBTQ+ individuals
  • Lesbian, gay, and bisexual adults have higher rates of alcohol and tobacco use compared to heterosexual adults
  • Transgender individuals have higher rates of illicit drug use compared to cisgender individuals
• Minority stress and discrimination can lead to coping behaviors, such as substance use
• Lack of culturally competent mental health and substance use treatment services can be a barrier to care for LGBTQ+ individuals

Preventive Care and Screening

• LGBTQ+ individuals may have unique preventive care and screening needs based on their sexual orientation and gender identity
• Men who have sex with men should be screened regularly for HIV and other STIs
  • Pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy for high-risk individuals
• Transgender individuals taking hormone therapy may need regular monitoring for potential side effects (liver function tests, blood clotting tests)
• Lesbian and bisexual women should receive regular cervical cancer screening with Pap tests
  • HPV vaccination is also recommended for all individuals up to age 26, regardless of sexual orientation or gender identity
• Breast cancer screening recommendations for transgender individuals depend on their hormone use and surgical history
• Prostate cancer screening recommendations for transgender women depend on their surgical history and hormone use
• LGBTQ+ individuals should receive regular preventive care, such as immunizations and cardiovascular risk assessments
• Providers should discuss sexual health and risk reduction strategies with LGBTQ+ patients in a non-judgmental manner

Advocacy and Policy

• Advocacy efforts aim to improve the health and well-being of LGBTQ+ individuals through policy change, education, and community engagement
• Non-discrimination policies in healthcare settings protect LGBTQ+ individuals from discrimination based on sexual orientation and gender identity
  • Examples include the Affordable Care Act's Section 1557, which prohibits discrimination in healthcare settings
• Inclusive insurance coverage policies ensure that LGBTQ+ individuals have access to necessary healthcare services, including gender-affirming care
• Training and education for healthcare providers on LGBTQ+ health issues can improve cultural competence and quality of care
• Research on LGBTQ+ health is essential for understanding and addressing health disparities
  • The National Institutes of Health (NIH) has designated sexual and gender minorities as a health disparity population for research purposes
• Community engagement and partnerships with LGBTQ+ organizations can help inform advocacy efforts and improve health outcomes
• Policies that protect LGBTQ+ individuals from discrimination in employment, housing, and public accommodations can also positively impact health outcomes
  • Examples include the Supreme Court's 2020 decision in Bostock v. Clayton County, which held that Title VII of the Civil Rights Act protects individuals from discrimination based on sexual orientation and gender identity