Patient Safety Concerns and the LGBTQ+ Population
Challenges to Obtaining Needed Patient-Centered and Safe Healthcare for LGBTQ+ People
The lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) community encompasses a diverse community of people who face unique challenges when receiving care for their health. This broad and diverse population comprises individuals who vary in demographic characteristics, including race, ethnicity, generation, religion, and socioeconomic status. Estimates of how much of the United States population identifies as LGBTQ+ vary greatly, although recent surveys show that estimates of this proportion of the population continues to grow, perhaps due to increased efforts to collect accurate survey data from and about LGBTQ+ persons.1
LGBTQ+ community members experience healthcare disparities and inequities associated with various social, cultural, and political factors that manifest throughout the entire lifespan of LGBTQ+ individuals. Members of the LGBTQ+ community are at higher risk for certain mental and physical health conditions.2,3 Meyer’s minority stress theory emphasizes the impact that stressors, such as discrimination, internalized homophobia, and stigmatization have on mental health.4 LGBTQ+ youth are more likely to consider, attempt, and die by suicide than their heterosexual and cisgender peers.5 Studies have also found that LGBTQ+ people experience trauma, including violence and victimization, at higher rates than the general population, and may exhibit a higher prevalence of post-traumatic stress disorder.6 In terms of physical health, disparities in diseases such as human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) are well documented. Studies have also shown that certain cancers disproportionately affect LGBTQ+ populations based on tobacco use, nulliparity, and HIV.7
Challenges to Access to Care
Access to care continues to be a challenge for LGBTQ+ people, who may have decreased access to the healthcare they need for a variety of reasons, including lack of health insurance coverage for needed services and tendencies to delay care because of concerns about stigma and bias in the healthcare system. Some of these challenges to access, for example, stigma, stem from heteronormative attitudes imposed by health professionals.8,9 Transgender patients report avoidance or delays in seeking care based on experienced or perceived bias. A survey of LGBTQ+ people about their experiences of discrimination showed that 37% of respondents who identify as gay, lesbian, queer, or bisexual experienced some form of negative and/or discriminatory treatment from a doctor or healthcare provider in the last year; 59% of transgender respondents experienced some form of negative and/or discriminatory treatment from a doctor or healthcare provider in the last year.10
Patient Safety and Communication Concerns
Health-Related Risks for LGBTQ+ Patients
Although there are known healthcare disparities and access challenges, it is less clear to what extent LGBTQ+ patients are also at risk for harm when being treated within the healthcare system. Known patient safety risks are primarily based on issues communicating with providers and a lack of psychological safety.11 LGBTQ+ patients must feel comfortable enough with their care teams to disclose their private health information to ensure care is being provided appropriately.12 Based on existing literature, it is likely that LGBTQ+ patients who feel unsafe or disavowed in healthcare settings are less likely to disclose private health information to their healthcare teams in multiple healthcare settings. As a result, LGBTQ+ patients may not receive appropriate healthcare, with concomitant consequences for their health and well-being.
Communication to Promote Patient Safety
Good communication is key to patient safety. Sharing sexual and gender history and personal health information is important in identifying, treating, and diagnosing conditions and preventing adverse events. Patient discomfort in communicating with healthcare providers increases safety risks; the potential for missed screenings, misdiagnoses and a lack of appropriate prevention interventions increases substantially. This challenge can be ameliorated with effective communication and culturally and linguistically appropriate dialogue between LGBTQ+ patients and healthcare workers. Knowing a patient’s gender history is important in laboratory testing and in understanding why lab results may not match standard levels. For example, to avoid an adverse event during diagnostic exams, transgender men may need to be screened for pregnancy prior to receiving an X ray. Lack of awareness of patient health histories and information by provider teams can result in these missed opportunities to discuss testing.13
Role of Psychological Safety
Psychological safety is also essential in ensuring safe patient outcomes. Patients must feel that they will not be punished, humiliated or discounted for speaking up with ideas, questions, concerns, or mistakes.14 Compared with non-LGBTQ+ people, LGBTQ+ people are more likely to report that their provider did not believe they were telling the truth (16% vs. 8%), suggested they were personally to blame for a health problem (13% vs. 8%), assumed something about them without asking (21% vs. 11%), and dismissed their concerns (29% vs. 16%).10 Ensuring a psychologically safe environment is essential for improving communication between patients and providers.15
Recommendations to Mitigate Risks, Minimize Adverse Events and Promote Safe Environments
Sexual Orientation and Gender Identity (SOGI) Information Collection
Collecting SOGI information in electronic health records (EHRs) is one recommendation that may improve the quality of care provided and shed light on the prevalence of safety problems among LGBTQ+ people. 16, The Department of Health and Human Services continues to make the collection of SOGI data a priority and the Centers for Disease Control and Prevention (CDC) has noted that collecting SOGI data leads to high-quality care. The White House issued Executive Order 14075 to advance equality for LGBTQ+ individuals, which includes a directive “to advance the responsible and effective collection and use of data on sexual orientation, gender identity, and sex characteristics.” The Office of Management and Budgeting (OMB) issued Recommendations on the Best Practices for the Collection of Sexual Orientation and Gender Identity Data on Federal Statistical Surveys in support of the goals of Executive Order 14075.
By asking questions about sexual orientation, gender identity, sex originally listed on birth certificate, names, and pronouns, healthcare workers can be better informed about their patients and provide more patient-centered, compassionate care to LGBTQ+ patients. Accrediting organizations, like The Joint Commission, also emphasize the importance of collecting these data to support aspects of the healthcare system outside of direct patient care, including evaluating the effectiveness of programs, quality improvement efforts, and community outreach initiatives. By collecting patient SOGI information at the initial point of contact, such as registration or admission, health systems can leverage these data to deliver the appropriate types of care needed.18 Studies show that SOGI data are still missing from EHRs most of the time. Continued education and training on collecting SOGI data and emphasizing the importance of the data will improve data collection efforts.18,19
LGBTQ+ Patient-Centered Training
Training healthcare workers in providing culturally and linguistically competent care is also paramount to reducing potential harm toward LGBTQ+ patients. The LGBTQ+ population has unique healthcare needs for which many medical professionals have not received training. Medical schools are beginning to include transgender medicine in their curricula, but there is a shortage of providers with the training and experience that transgender patients need. Federal agencies like the Substance Abuse and Mental Health Services Administration (SAMHSA) created trainings with the goal of teaching providers how to deliver patient-centered care in a psychologically safe environment. Trainings for health professionals about providing a safe and inclusive environment for patients could facilitate the implementation of more effective communication approaches among providers that would promote increased patient disclosures, ultimately leading to better care.
Quality Improvement Initiatives
Researchers at the CDC led a quality improvement initiative using elements from the Practice Improvement Collaboratives and Project ECHO (Extension for Community Health Outcomes) that aimed to transform primary care for LGBTQ+ people. Participating Federally Qualified Health Centers (FQHCs) implemented quality improvement initiatives to create more safe care spaces, improve SOGI data collection in the EHR, improve the collection of risk-based sexual histories of LGBTQ+ people for sexually transmitted disease (STD) and HIV screenings, and increase the percentage of LGBTQ+ patients receiving appropriate STD and HIV screenings. By creating new workflows for data collection and providing scripts for answering patient questions, the participating FQHCs were able to increase documentation of SOGI data.20 This initiative provides a prospective model of care that addresses issues of communication and safety that could be applied by healthcare teams in healthcare settings to provide a context for better healthcare for LGBTQ+ patients.
Although research to understand the healthcare needs of LGBTQ+ patients and associated disparities in care has increased substantially over the last 15 years, there continues to be a need to understand the specific harms and adverse events that members of the LGBTQ+ population may encounter when accessing healthcare services.21 An appropriate and comprehensive approach to promoting safer healthcare environments and better healthcare outcomes for LGBTQ+ patients would include the mitigation of risk, prevention of adverse events and promotion of a safe climate through (1) accurate SOGI data collection; (2) provision of culturally and linguistically competent training of healthcare providers; and (3) the implementation of effective quality improvement initiatives. There continues to be progress in provider education and increasing awareness of healthcare gaps facing the LGBTQ+ community. Improving data collection and fostering environments of psychological safety and patient-centered communication, where patients feel comfortable and safe sharing information, will help us to create more inclusive healthcare settings and promote safe care for all.13
Editor’s note: This essay uses LGBTQ+ to describe the lesbian, gay, bisexual, transgender, and queer or questioning community. The “+” represents those who are part of the community, but not reflected by LGBTQ. There are many variations of this acronym used in other resources. Transgender refers to people whose gender identity differs from the sex they were assigned at birth (sometimes abbreviated as trans). Cisgender describes people who are not transgender and whose gender is aligned with the sex assigned at birth (sometimes abbreviated as cis).22
Connor Wesley, RN, BSN
MultiCare Allenmore Hospital
Cindy Manaoat Van, MHSA
American Institutes for Research (AIR)
Sarah E. Mossburg, RN, PhD
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