Hawaii Nurse - May 2021

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Barriers to Competent Care of LGBTQIA+ Patients
Menjam Tamang
Department of Nursing, Hawai’i Pacific University
The lesbian, gay, bisexual,
transgender, queer, intersex,
asexual, and others (LGBTQIA+)
community are a patient
population that requires
culturally competent care
and understanding from
healthcare providers. Despite
this knowledge, LGBTQIA+
patients still face disparities
in healthcare as well as
Menjam Tamang
discrimination that often causes
them to avoid necessary care.
As patient advocates, it is the responsibility of nurses
to ensure a patient-centered care approach. However,
a lack of knowledge, skill confidence, or attitudes from
nurses can lead to insensitive care (Carabez & Scott,
2016). Therefore, the purpose of this paper was to
explore barriers that hinder LGBTQIA+ patients from
receiving equitable care and to present evidencebased
recommendations to improve their quality of
care.
In order to understand the LGBTQIA+ community,
it is essential to identify the differences between
the terms “sexual orientation” and “gender identity.”
Sexual orientation describes the sex that one is
emotionally, romantically, or sexually attracted to,
and is described with terms such as gay, lesbian,
bisexual, or pansexual. Gender identity explains the
perception of one’s self in regard to gender, such
as male, female, or non-binary. However, one’s sex
assignment at birth does not limit the gender identity
a person might adopt (HRC, 2020). Individuals
may also have pronoun preferences (she/her, he/
him, they/them) for how they wish to be addressed
(UWM, 2020). For example, someone considered
a female at birth due to anatomical features, may
identify as non-binary and utilize the pronouns
they/them, instead of gendered terms. It is also
important to note that sexual orientation cannot
be used to infer one’s gender identity. Although
transgender people identify as the opposite sex
from their birth assignment, it does not imply that
they have a specific sexual preference. For instance,
a transgender man (female assignment at birth)
may describe himself as homosexual due to his
preference towards other men (Margolies & Brown,
2019).
Evidence Findings
Peer-reviewed scholarly literature was explored to
uncover research findings on barriers to competent
care of LGBTQIA+ patients. These findings were
synthesized to reveal three general themes: an
existence of healthcare system discrimination,
a disregard for patient’s sexual orientation and
gender identity, and a lack of adequate education on
LGBTQIA+ healthcare issues in prelicensure nursing
programs.
Experiences of Discrimination
in the Healthcare System
In some situations, past experiences of
interpersonal healthcare discrimination can result in
LGBTQIA+ patients being reluctant to seek medical
attention despite their health conditions. According
to Irwin (2007), 31-89% of LGBTQIA+ patients
reported negative attitudes directly related to their
sexual orientation from healthcare workers. A
study of the utilization of healthcare service by the
LGBTQIA+ community in Turkey revealed that only
31% of participants seek aid from Family Health
Centers (FHC) due to the fear of homophobia and
subpar care. This also correlates with the finding
that merely 2% agreed that they would reveal
their sexual orientation to medical professionals,
as this information was perceived to be possibly
disadvantageous to the quality of care received
(Uysal Toraman & Agaritoglu, 2018).
Additionally, in their administration of the United
States Transgender Survey (USTS) Kachen and
Parr (2020) discovered that 31% of transgender
females and 29.3% of transgender males have
experienced stigma in healthcare. A disturbing
21.6% of participants in the study also indicated
that due to possible discrimination, they opted to
postpone the seeking of care (Kachen & Pharr, 2020).
Interestingly, nonbinary respondents, who may be
perceived as possibly cisgender, had significantly
lower rates of prejudice in their care. Kachen
and Pharr (2020) correlate this phenomenon with
the pertinence of the “passing privilege,” which
they describe as one’s ability to “remain within
the framework of intelligibility due to phenotypic
similarities to dominant groups” (p. 147). Being
deemed a cisgender patient by providers seems
to be advantageous, as those who present in such
a manner encounter substantially fewer health
disparities.
We must also consider the prevalence of
intersectional discrimination in our society
and therefore our healthcare system, and
the mechanisms in which it affects patients.
Intersectionality is defined as “a theoretical
framework that proposes individuals have multiple,
overlapping identities, and the understanding of the
interconnectedness of those identities can help us to
recognize how systemic injustice and social inequality
occurs” (Damaskos et al., 2018, p. 31). An individual’s
identity is comprised of multiple factors like age,
ethnicity, race, sexual orientation, gender identity,
socioeconomic status, education level, disabilities.
Intersectional discrimination recognizes that each of
these identities intersects to create a system where
certain individuals face heightened health disparities
and marginalization due to multiple aspects of their
identity. When caring for patients, it is crucial that
nurses understand how a person’s multifactorial
identity impacts their encounters with the medical
sector, and the need to utilize the most appropriate
interventions to ensure person-centered care
(Margolies & Brown, 2018).
Disregard for Patients’ Sexual Orientation and
Gender Identity
A patient’s sexual orientation and gender identity
(SOGI) are vital data needed by nurses and clinicians
to adequately provide person-centered care.
Healthcare systems being unaware of a patient’s
SOGI can also intensify the intersectional oppression
they encounter, and result in incompetent care. The
lack of SOGI specification on most medical intake
forms causes LGBTQIA+ patients to be overlooked.
Moreover, reluctance from doctors and nurses to
verbally inquire for this information may lead the
patient to ponder whether disclosing their SOGI
is safe (Margolies & Brown, 2018). At times, the
hesitancy hindering data collection may originate in
the provider’s belief that LGBTQIA+ patients may
not feel comfortable disclosing their SOGI. However,
a 2017 study performed in emergency departments
(ED) of Maryland and Washington D.C. revealed that
even though 77.8% of clinicians believed patients
would refuse to provide SOGI information, only
10.3% of LGBT patients shared the same notion
(Haider et al., 2017).
Even with SOGI documentation, negligence in the
use of proper pronouns may interfere with creating
a pleasant patient encounter. In 2015, Carabez et
al. determined that while 70% of baccalaureate
nursing (BSN) students at a university in the US
felt comfortable using the pronouns of choice of
transgender patients, just 28% acknowledged that
addressing patients with correct pronouns “matters a
lot” (p. 52). This demonstrates that a large portion
of the nursing student population underestimates
the significance of pronouns. Such insensitivity
may be perceived as condemnation, especially for
transgender patients who do not physically present
like those who biologically identify with their gender
and cause them to feel like unwanted visitors at a
healthcare facility.
Lack of LGBTQIA+ Education in Pre-Licensure
Nursing Programs
A gap in nursing education curriculum may be
associated with BSN students placing diminished
importance on preferred pronouns in that the
literature revealed limited coverage of LGBTQIA+
health needs in the formal education of nurses.
Results from a survey of over 1000 nursing faculty
nationwide found 2.12 hours to be the median
time spent on LGBTQIA+ topics in the entirety of
a Bachelor of Science in Nursing (BSN) program
(Lim, et al., 2015). This lack of adequate attention
to LBTQIA+ health topics is something this author
has also experienced anecdotally. As a thirdsemester
BSN nursing student, I have yet to obtain
knowledge regarding the LGBTQIA+ community and
their health-related issues through my curriculum.
Interestingly, nursing bodies, like the Accreditation
Commission for Education in Nursing (ACEN) and the
Commission on Collegiate Nursing Education (CCNE)
do not specifically require such subject matters to
be included for nursing program accreditation (Lim
et al., 2015). Standard 4.5 in the ACEN accreditation
manual states that the baccalaureate curriculum