The Primary Care Approach to Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning Populations

Daniel R. Mead, MSN, APRN, NP-C; Rachel C. Dana, MSN, RN; and Catherine A. Carson, MSN, APRN, NP-C

ABSTRACT: The heteronormative biases of health care providers coupled with a lack of knowledge about the health care needs of the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) population create barriers to health care services for many in this community. These barriers can make persons who identify as LGBTQ susceptible to high-risk behaviors such as the abuse of alcohol, tobacco, and illicit drugs; unprotected sex leading to sexually transmitted diseases; and mental health disorders or violent behaviors. This systematic literature review aims to identify the inequalities of access to health care by persons in the LGBTQ populations, their risk factors, and their primary care needs, and to identify how primary care providers can bridge this specific health care gap.

KEYWORDS: Lesbian, gay, bisexual, transgender, queer/questioning, gender identity, primary care, health disparities, cultural competence
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While society has embraced advancements in technology and health care delivery, society also has shown resistance to accepting individuals who do not adhere to what historically has been thought of as a “conventional lifestyle,” such as persons in the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. When health care providers are unable to identify their own heteronormative biases, coupled with lack of knowledge about the health care needs of the LGBTQ population, an environment of vulnerability and isolation is created.¹ This situation creates barriers to health care services for many persons who identify as LGBTQ, making them susceptible to high-risk behaviors such as the abuse of alcohol, tobacco, and illicit drugs; unprotected sex, leading to sexually transmitted diseases (STDs); and mental health disorders or violent behaviors.²

As the LGBTQ community, which comprises 4% to 10% of the US population,³ strives to find its identity, health care providers must be cognizant of how these patients identify themselves, while creating an environment free of marginalization in order to decrease vulnerability. This review aims to identify, summarize, and incorporate research on the health risk factors and disparities specific to LGBTQ patients, as well as the practice implications for the primary care providers.

Background

Individuals in the LGBTQ population have complex factors that affect their access to health care; among these factors is social stigma, which contributes greatly to disparities in health care delivery. Whitehead and colleagues⁴ have outlined 3 types of stigma that negatively impact LGBTQ health and overall well-being: anticipated, internalized,⁵ and enacted. Anticipated stigma is defined as the “concern for possible future instances of discrimination,” internalized stigma is the “devaluation of self, based on sexual orientation or gender identity,” and enacted stigma is the “actual instance of experienced discrimination.”⁴

A large body of literature has shown a variation in health outcomes between heterosexual individuals and individuals identifying as a member of the LGBTQ community. Compared with heterosexual men and women, gay men, lesbian women, and bisexual persons are more likely to engage in high-risk behaviors, including excessive alcohol intake and drug and tobacco use, further increasing their chances of acquiring preventable health problems.^4,6 Due to the amount of anticipated and enacted stigma, including a fear of judgment and opposed views, LGBTQ individuals often avoid seeking a primary health care provider.^4,5 Internalized stigma within a community or an individual also can have a powerful effect on health status.⁵ This combination, coupled with a lack of health education, poses major barriers to primary prevention practices among LGBTQ persons.

Decreased access to health care is a leading problem, particularly in rural communities,^4,5 where lower incomes and access to transportation present barriers, especially for persons with chronic conditions whose management requires frequent close follow-up.⁴ Thus the cumulative effects of the various types of stigma are multifactorial. Social structures, including family dynamics, educational background, exposure to and acceptance of religious practices, and societal influences all affect how members of the LGBTQ community and health care providers view health care.² The combination of perceived and actual threats stems from longstanding conflicts that individuals face at various life milestones. Conflicts arise during childhood as a sense of self is being established, during periods of illness or disability, and as one becomes older.² These milestones are especially difficult for those in the LGBTQ community who already experience a sense of isolation, which in turn prohibits disclosure of thoughts, feelings, and behaviors to health care providers, or even the willingness to seek care.

Literature Search

We conducted a literature search of PubMed, Web of Science, and the Cumulative Index to Nursing and Allied Health Literature electronic databases using literature-identified search terms and medical subject headings (MeSH) terminology.

Combinations of the following terms were used: gay, lesbian, bisexual, transgender, advanced practice nurse, health disparities, primary care, and cultural competence. The inclusion criteria were quantitative, mixed-method, and qualitative research studies; systematic and narrative reviews; cohort studies; practice reviews; and expert opinions. English-only articles published from 2011 to 2016 were included in order to maintain current relevance of practice recommendations and ease of translation of findings. Unpublished manuscripts and abstracts were excluded, as were periodicals pertaining exclusively to the treatment of children or to specific disease states.

NEXT: Data Collection and Synthesis

Data Collection and Synthesis

The initial search identified 153 articles that potentially met the inclusion criteria. After review, 56 of these articles were found to overlap or to be duplicates and thus were excluded. Titles and abstracts of the remaining 97 articles then were evaluated for relevancy and measured against the inclusion and exclusion criteria; of these, 60 articles were excluded due to their lack of availability by electronic means. Twenty-five more studies were excluded because they offered no new data for consideration or because they did not discuss LGBTQ patients separately from specific disease states (eg, HIV/AIDS). The final sample comprised 12 articles, which are summarized in the accompanying Table.^1-12

Results

Among the 12 articles meeting the inclusion criteria was a study of a rural LGBTQ sample⁴ compared with heterosexual persons, which found that transgender persons had poorer health scores related to enacted or anticipated stigma, as well as mismanagement of chronic health problems, possibly related to inconsistent provider visits.⁴ The same sample of LGBTQ persons reported feeling depressed due to the inconsistency in primary care and/or decreased primary care visits; bearing this in mind, the increased rate of attempted suicide in LGBTQ persons^6,7 might coincide not only with depression related to varying factors, including stigma, but also with struggles in finding the best provider to suit individual patient needs.

That being said, it is imperative to note that Whitehead and colleagues⁴ found that most transgender and nonbinary patients were 3 times more likely than nontransgender patients were to chose a primary care provider simply on the basis that the provider will see LGBT patients with their specific needs. This can present an access barrier for these patients, given that most transgender patients also reported having to travel more than 1 hour to an urban location in order to be seen by such providers.⁴

Health and Mortality Disparities

Not revealing sexual orientation can place more psychological stress on an individual.

Stressors can stem from negative past experiences with the health care system and a lack of statistical data or valid sources of information. Researchers have found that homosexual women are 10 times more likely to not receive preventive services such as gynecologic or breast examinations than are heterosexual women, because the risk of acquiring an STD is perceived to affect only the heterosexual female population or to result from promiscuity.² Women who identify as lesbian have also reported negative encounters, untoward reactions, and even rejection from health care providers. Conversely, gay and bisexual men have reported that disclosing personal information about sexual orientation has led to feelings of shame and exclusion and to increased anxiety, depression, sexual compulsion, and abuse of substances.²

Increased occurrences of childhood abuse, intimate and domestic partner violence, and adult victimization result from the social struggle that LGBTQ individuals face.⁷ Previous studies have concluded that these factors are markedly increased in LGBTQ populations compared with heterosexual populations. Trauma due to sexual discrimination and social stigma create a domino effect of negative associations, in turn negatively impacting health outcomes, and thus decreasing quality of life.⁶

Aside from social stigma impacting LGBTQ communities, social stressors push certain individuals to a level of desperation for acceptance that makes them more susceptible to emotional distress and ambiguity. For example, transgender persons have been found to have the highest rate of lifetime suicide attempts.⁷ Gay men and lesbian women were 4 times more likely to attempt suicide,⁶ and lesbian, gay, and bisexual adolescents were 3 times more likely to attempt suicide.^6,7

NEXT: Prevention and Screening

Prevention and Screening

The American Academy of Family Physicians has approached the care of the LGBT population with recommended curriculum guidelines for family medicine residents.⁸ The guidelines’ preamble states that a growing body of research identifies health disparities that negatively affect LGBT individuals, who are at increased risk for mental health problems, substance abuse, and discrimination, violence, and victimization. Moreover, the guidelines note, “LGBT individuals generally receive less preventive care and fewer cancer screenings, which is likely related to access barriers such as lack of adequate health insurance coverage and discrimination in medical settings. It is particularly important for medical educators to recognize that LGBT communities encounter unique barriers to accessing and using appropriate health services.”⁸

Women who identify as lesbian have a higher risk of heart disease (risk factors such as reduced physical activity, obesity, and smoking are more prevalent among lesbian women than among heterosexual women), breast cancer (risk factors among lesbian women include fewer full-term pregnancies, fewer mammograms and/or breast examinations, and being overweight), cervical cancer (lesbian women are less likely to seek medical assistance for regular screening tests), obesity (studies have shown a multifactorial reasoning for the higher rate of obesity among lesbian women), and suicidal ideation (2 to 2.5 times higher than heterosexual women). Women who are lesbian also have a higher incidence of smoking (2 times higher than that of heterosexual women) and alcohol consumption.⁹

General concerns of the LGBTQ community include higher incidences of injury, violence, and harassment, which can adversely affect their mental health. As a report from the Substance Abuse and Mental Health Services Administration⁹ notes, adverse, punitive, and traumatic reactions from parents and caregivers in response to their children’s sexual orientation have been found to be closely correlated with poor mental health and an increase in substance use. Moreover, the report notes that the results from an anonymous survey administered in 33 US health care sites showed that sexual orientation is associated with higher levels of emotional stress and other types of mental health disorders.⁹

Much of the mental anguish of LGBTQ individuals stems from coming out; thus, it is critical for providers to discuss with patients their coming out experience or their plans to come out to friends and family. Often, these patients will require resources and support for this critical milestone.⁹ It is vital that providers support these patients, regardless of age, in whatever health care needs arise to assist them through this difficult time. It is possible that providers who do not help with this milestone owing to their personal beliefs could be considered professionally unethical.

Primary care providers should identify individual patients who may identify with one or more groups in the LGBTQ community and use the corresponding screening methods established by the US Preventive Services Task Force. Given the findings about LGBTQ and health care, it would be prudent to further screen these individuals for alcohol and substance abuse and depression and other mental health issues brought on by social stigma. Theoretically, this would have a positive health benefit in this population, although insufficient data have appeared in the literature about higher-sensitivity screening techniques for the LGBTQ population with corresponding health outcome analysis.

Implications for Primary Care

Among the implications of these observations for primary care practice is the implementation of screening for prevention. Given the higher incidence of mental health problems and substance abuse, proper identification and building rapport with LGBTQ patients can help improve mental health and physical health outcomes. Differences in beliefs about homosexuality, which in many religions is considered abnormal and unacceptable, is a major sociologic barrier to health care of LGBTQ persons. Primary care providers, regardless of their personal belief, have a duty to provide care to these individuals and require adequate education to recognize the unique needs and health risks of the LGBTQ population.

For example, Matza and colleagues¹¹ recommend the following in primary care practices: having brochures and educational materials for patients; using assessment forms with neutral terms; adding transgender to the gender box on intake forms; asking about relationship status rather than marital status; displaying visible safe-space signs and nondiscrimination policies; acknowledging relevant days of observance; and making community resources available to patients.

Matza and colleagues¹¹ further outline several diagnostic challenges in the care of patients in the LGBTQ community. They note that although homosexuality was removed as a disorder from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1973, same-sex attraction was not yet considered a normal variation in human sexuality. They continue that, in fact, new diagnoses were created to replace homosexuality, including “sexual orientation disturbance” in the DSM-II and “ego-dystonic homosexuality” in the DSM-III. It was not until 1987 that diagnoses of sexual orientation were removed from the DSM, after much debate and opposition. Similarly, gender variance also has been pathologized in the DSM as gender identity disorder (DSM-IV) or gender dysphoria (DSM-5). The authors write, “Given the absence of adequate training on LGBT issues, it is reasonable to assume that psychologists will have gaps in their knowledge on this topic and limited referral sources for LGBT persons, potentially further contributing to disparities in health/mental health care for the LGBT population.”¹¹

Historically, LGBTQ-focused health has been neglected in medical education due to lack of awareness, discomfort with the topic, and time demands, coupled with a lack of faculty or curriculum development. Several studies, however, support the position that medical education efforts about the health needs of LGBTQ individuals improve learner attitudes and their willingness to clinically engage with LGBTQ patients.⁷

Several studies have shown how damaging simply not knowing the language with which to effectively communicate and engage members of the LGBTQ population can be—for example, addressing only gender schema or sexual orientation can increase feelings of isolation.¹²

The Take-Home Message

The goal of every health care provider is to establish a trusting relationship with each patient, in order to promote openness, security, and confidence in both physical and emotional health care delivery, resulting in quality care. The articles reviewed identify the population-specific barriers that LGBTQ communities encounter and offer sufficient evidence to support the exploration of additional education for health care providers to improve interactions with these patients.

Health care providers should address numerous social issues, have a sensitivity to pronoun use, and have intimate relationship discussions with patients who identify as LGBTQ. Specific education in these and other approaches could increase patient satisfaction, build a trusting and therapeutic relationship, and facilitate enhanced communication between patient and provider. In addition, specialized telephone consultations and outreach clinics⁴ are examples of methods to aid in health care promotion for LGBTQ persons who have reservations about seeking primary care, as well as those who have transportation barriers.

Inclusion of lesbian, gay, bisexual, transgender, and queer selections for gender on patient identification forms is one way to help negate fear of judgment when a person seeks to establish care at a clinic.

Daniel R. Mead, MSN, APRN, NP-C, is a nurse practitioner in internal medicine, a doctor of nursing practice student, and an adjunct professor of nursing at DePaul University in Chicago, Illinois.

Rachel C. Dana, MSN, RN, is a recent graduate of the Adult-Gero Primary Care Nurse Practitioner program at the University of Cincinnati, Ohio, and works on the inpatient epilepsy unit at NYU Langone Medical Center in New York, New York.

Catherine A. Carson, MSN, APRN, NP-C, is a surgical oncology nurse at the James Cancer Hospital and Solove Research Institute in Columbus, Ohio.

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