Editor’s note: Connor Wesley, RN, BSN, is a registered nurse in Tacoma, WA. In addition to his role as the Assistant Nurse Manager of the Emergency Department at MultiCare Allenmore Hospital, Connor lectures locally and nationally on providing healthcare to members of the lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) community. We interviewed Connor to discuss patient safety and the LGBTQ+ community.

Sarah Mossburg: Welcome, Connor. Can you please tell us a little bit about yourself and describe your current role?

Connor Wesley: I am a nurse and have been a nurse for almost 10 years. I am the Assistant Nurse Manager of the Emergency Department at MultiCare Allenmore Hospital. I started in oncology before moving to the emergency room. I am also a graduate student at the University of Washington in the doctorate of nursing practice program studying to become a family nurse practitioner. In addition to my own life experience, my passion for this topic began when I was a nursing student where we received very little education on the LGBTQ+ community, particularly the transgender community, which is more my area of focus. I decided to create a lecture to fill the gap and started giving the lecture to the nursing students while I was still a nursing student. I have been lecturing locally and nationally since then.

Sarah Mossburg: Today we are talking about the LGBTQ+ community and patient safety. What do you think are some of the key patient safety issues that the LGBTQ+ community faces?

Connor Wesley: It can depend on location. There are places in the country that may be less safe for LGBTQ+ folks to live their normal lives and access healthcare. In the United States, we have the Emergency Medical Treatment & Labor Act, which legally requires that anyone who needs emergency care, receive it until they are stabilized.¹ There are additional laws in place in select states that affect access to other types of care. For instance, Arkansas recently passed a law to make it a felony for young trans people under the age of 18 to access gender-affirming care because they view gender-affirming care as not evidence-based, but experimentation.²

Nationally, there are some legal protections for people who are LGBTQ+. For example, in June of 2020, the United States Supreme Court ruled that members of the LGBTQ+ community cannot be fired from a job for being LGBTQ+.³ But that only relates to employment, there are different laws for housing—there are 27 states where housing discrimination can exist for being LGBTQ+ because there are no explicit protections for the LGBTQ+ community^.4 When living in a state where being LGBTQ+ can result in loss of housing, it can become even more unsafe to access healthcare. When we talk to our healthcare providers, we talk to them about our biggest stressors because we know that they impact health. When you live in one of those 27 states, you may avoid talking about sexual orientation and gender because of the fear of potentially losing housing because it is not protected.

The LGBTQ+ community faces a great deal of health disparities, and a lot of that is rooted in stigma and general views of society about the LGBTQ+ community. That stigma eats away at you. Lack of representation can also eat away at you. Young people need representation to feel like they can be successful in life as adults. For the LGBTQ+ community, not being able to see yourself as a successful adult reflected in somebody else means you don't believe that you can be a successful adult. It can cause maladaptive behaviors. We see higher levels of smoking, drinking, and obesity. As many as 40% of homeless youth are LGBTQ+^.5 We see a lot more homelessness, which leads to things like participating in survival sex, or using sex in exchange for safety, housing, food, and basic needs.⁶

All of these things lead to our massive health disparities. Healthcare may not necessarily be a safe space because providers are human and some providers either don’t recognize or struggle to avoid bringing their bias into their practice. There are invalidations that providers may not realize they are saying based on the power of their words. For example, misgendering people, or choosing not to use names that patients have asked you to use. Another example is when gay mothers take their kids to the doctor and are asked, who is the mom? These things have so much power that I do not think people always realize. Ultimately, as providers, our job is to recognize our biases and overcome them, but many people struggle to avoid bringing their bias into their practice. When that happens, accessing healthcare and expecting to actually get the healthcare LGBTQ+ patients need becomes difficult.

When I give my lectures, I hear comments from people talking about colleagues that don’t want to use a patient's name or pronouns because they do not want to enable something that goes against their beliefs of normal. When it comes to healthcare though, their beliefs of normal shouldn’t interfere with someone’s ability to get care. And ultimately, all of this leads to people not wanting to access healthcare. In these cases, easily managed health needs like high blood pressure or diabetes can progress to acute and potentially life-threatening medical conditions.

There are other challenges in accessing healthcare and identifying providers. The documentary “Southern Comfort” shares the story of Robert Eads, a trans man who lived in Georgia, was diagnosed with ovarian cancer, but he could not find an oncologist to treat him.⁷ Providers were afraid that their other patients would not want to receive care from a provider that would care for a trans man. By the time he was able to find a provider to care for him, his cancer was too far progressed and he died from ovarian cancer three years later.

Healthcare can be a really scary place for a lot of people. Even I get scared about accessing healthcare, and I am a nurse. I have a great provider and I work in the emergency room. If I need emergency care, I go to the emergency room where I work. I can't imagine going anywhere else, because I am trans and am unsure about the care I would receive elsewhere. I had a health issue at work the other day that required me to check into the emergency room, and even in those moments I have anxiety because my coworkers and the providers I work with are accessing my electronic medical record (EMR). When I tell somebody that I am trans—when I get to come out to them—I get to see their reaction. I get to make sure I know that I’m still safe, and that relationship is still okay. But when someone is reading my chart and I do not see that reaction, I do not know what their feelings are. Further, our EMRs follow us everywhere and can include hurtful words. I know my EMR includes the word “transgenderism,” which many people consider to be offensive because it suggests that you prescribe to a set of ideals or beliefs, rather than this is just who you are.⁸ In these cases, healthcare is still very fallible.

Sarah Mossburg: Some of the key things that I hear you talking about in relation to the patient safety and the LGBTQ+ community, are that it's contextual in terms of region and location in the United States, that care is politicized, and that there is an extreme amount of discrimination across sexual and gender orientations. There is also a significant amount of disparities related to stigma among them, and that there are significant challenges related to emotional, psychological, and physical safety when pursuing and receiving care in healthcare settings. Finally, that there are a lot of downstream effects that lead to poor outcomes among members of this community. You described some challenges in accessing care and issues when in the hospital or different care settings. What about post-care patient safety issues? Do you see any potential patient safety issues in that part of the healthcare continuum?

Connor Wesley: I think challenges with post-care is a result of what happens in care or when appropriate care is not received despite a healthcare visit. A lot of the fear that LGBTQ+ have when going to providers is—am I going to be seen as a human? Am I going to get the care I need? People may go to a provider because they have an injury or concern, and providers can only focus on their gender presentation and neglect to talk about a presenting condition like a broken arm. In these cases, members of the LGBTQ+ community are not receiving appropriate care, which results in still having a care need.

There is also that trauma of accessing care and feeling that bias and stigma, which can prevent patients from accessing care the next time. It is like a snowball effect—not getting the care needed, or not being treated in a respectful way—leads LGBTQ+ patients to avoid accessing healthcare and getting potentially sicker and sicker. Many trans and nonbinary patients will seek safe emergency rooms and if there are none, then will avoid care and their health issues are not being dealt with.

Some LGBTQ+ people, trans people in particular, cannot access the healthcare that they want or need, or aren’t able to afford it. Federal changes in legislation affect what insurance companies do and do not pay for. Not all insurance companies cover gender-affirming care, such as sex reassignment surgery.⁹ Some employers pay for extra components their insurance plans offer to cover gender-affirming care, but the majority do not. Hormones are expensive and most people will need to pay for them out of pocket.

Sarah Mossburg: The LGBTQ+ community describes a broad group of people that have differing challenges and needs when it comes to their health—what are some of the specific challenges or needs that are sometimes overlooked that could result in patient safety issues and adverse events?

Connor Wesley: Yes, being part of the LGBTQ+ community is like a tiny window. It's this tiny window of who we are as people, but can color how the majority of the world sees us. I am trans, but I also have high blood pressure and high cholesterol. I was seen in the emergency room that I work in, because I went into atrial fibrillation, and had to be cardioverted to get my heart to beat regularly again. Because I’m trans, if I were somewhere else in the world, or in this country, I may not have felt safe to go to the hospital to get that taken care of.

One thing commonly done in healthcare is trans-care hormone replacement therapy. It is done for cisgender women and men who have low testosterone. It is not specialty care, but because patients are in the LGBTQ+ community, people think that our healthcare is specialized. Another example is cancer screenings. When screening for the human papillomavirus (HPV), it is often based on sexual interaction, but providers are often too uncomfortable to ask questions about what types of sex someone is having. While these are simple, although awkward questions, answers will inform if a provider has to worry about if a patient could have HPV.

There may not be true specialized care for the LGBTQ+ community because the things that we do are generally no different than the things people do outside the LGBTQ+ community. Members of the LGBTQ+ community tend to be more open about sexual orientation and gender identity because they may be under so much scrutiny. It's the ability to open your mind and see the human in front of you as the components that make up that human—whether they're cisgender or transgender, heterosexual or queer—there is no special care for our community.

Sarah Mossburg: We talked about the issues and challenges facing this community. How can healthcare systems address patient safety issues?

Connor Wesley: One way to address patient safety is by allowing a person to be seen as who they are and who they love. Many EMRs have sexual orientation and gender identity (SOGI) screens that asks about sexual orientation, which can be important in healthcare. SOGI screens also ask for the name the patient uses versus the name they have, and the pronouns they use. These screens can also include an organ inventory, which every patient would benefit from. Sadly, it is not often used. I once went to urgent care and needed a chest x ray completed. Part of a typical x ray screening is asking if there's any chance you could be pregnant. That would have been a great time to do an organ inventory and find out if people even need to ask this question in the future. I do still have a uterus. So yes, people need to ask me that question.

The trans and queer community are ever evolving. We are learning more and more about ourselves, and growing, and changing, and new terms are coming out, and so our language continues to change. We are working on not saying preferred pronouns and preferred name, because preferred implies a preference, not just asking who you are. When I first came out in the 1990s, we used bio-man and bio-woman, instead of cisgender, because the term cisgender didn't exist yet in our vocabulary. Now we would never use bio-man or bio-woman because it implies that someone who isn’t biologically male will never be truly male, for example.

Other ways of being supportive include showing overt signs of support to represent that healthcare is a safe space. If all of the imaging in your organization is of straight, white people, only straight, white people are truly going to feel safe in your organization. If your pamphlets don't show people of color, if your pamphlets don't show varying sexual orientations or implied potential sexual orientations, people don't see themselves safe there. Members of the LGBTQ+ community need to see signs that they matter so they can feel safe. For example, I have on my hospital identification badge a heart shaped pride flag. We also have pronoun stickers so that everyone can put their pronouns on their badge, so that people feel safe. Many people have a hard time asking patients what their pronouns are because they feel uncomfortable and awkward about it. Having pronouns available or introducing yourself with pronouns shows that you understand that pronouns matter, and it's safe to share them with me.

Clinicians can still have a hard time asking trans men about being pregnant whether it comes to surgery or imaging, but I think education needs to happen on both sides of that fence. The trans community is a traumatized community that is used to people asking from a place of curiosity, and not from a place of care. That trauma hinders the ability to sometimes see when people, like clinicians, are asking for the right reasons, and not for the wrong reasons. In the 1990s and early 2000s, people asked about my genitalia on a regular basis. I had so much internalized shame that I answered those questions and did not set boundaries with those people. I did not feel empowered to say that is a really inappropriate question.

I think, as trans men we need to be more comfortable with parts of our bodies that we wish we didn't have and recognize that providers asking if there's any chance you could be pregnant is not a reflection of your gender identity. It's not a reflection of the man that you are. It is a reflection of the body you have and wanting to be open to how you choose to use that body.

Another thing is to always understand the why, when asking your patients questions. The number one thing I can tell providers is to make your intentions of support clear. Tell your patients that you are here to support them. I know that people have a huge problem with using they/them pronouns. That is universal. Nobody is good at it right out of the gate. If your patient uses they/them pronouns, tell them that you absolutely support who they are as a human being and be direct that you are not good at using they/them pronouns, but are working on it. Say that if I make a mistake, please correct me, if I do not correct myself.

People often hold a lot of tension in our bodies when we are uncomfortable, whether it is because of our own failures or because we are uncomfortable with the situation we are in. When we read the body language of someone else we do not know, we will never be able to read their intentions. We can only read the body language. I can see tension in somebody's body very easily, but I will never understand the reason without them telling me. As a provider, your body language may be tense because you are afraid of making a mistake or hurting my feelings in some way, not because you are uncomfortable with me being trans. I need to hear that. Always making those intentions of support clear with your patients is important.

Sarah Mossburg: You've done a great job talking about how care needs to be patient-centered, how communication is so critical in terms of helping people understand what your intentions are, and why you are asking the questions that you are asking. I know that psychological safety is also a really critical condition to ensure safe patient outcomes. How can providers foster psychological safety when caring for patients who are LGBTQ+?

Connor Wesley: Understand your why when asking questions. Avoid making assumptions about people and their families, or what cancer screenings they need to have.¹⁰ Ask the awkward questions. Figure out how to ask the awkward questions, because you could potentially miss something important in your patient's health. Asking trans men if there is any chance you could be pregnant, and stating that this is absolutely no reflection of your gender, but a reflection of the organs in your body. In those moments of discomfort, always making those intentions of support clear and those intentions of understanding is helpful.

The bottom line is understanding that supporting the LGBTQ+ community in healthcare is no different than the way you support the heterosexual, cisgender human. Patient-centered care should always be how we provide care, and representation matters to everybody. Not specific to the LGBTQ+ community, but to everybody in a community, representation matters. We are humans and this tiny thing that is different about us does not need to take up so much space in the world. It doesn't need to be our whole care. This community needs to be seen as people—every November 20th is the Transgender Day of Remembrance to honor the people in the trans community that were murdered because of their gender identity.

There is so much stigma. Meyers devised the Minority Stress Model specifically for the LGBTQ+ community.¹¹ This model describes how stigma, internalized homophobia versus external homophobia, and family rejection impacts your mental and physical health.

We all have hearts, we all have people we love, we all are beings trying to get through this world with the least amount of trauma that we can, and ideally creating the most amount of good we can. We just want to be seen as humans, so that we can get our blood pressure managed on a regular basis. I am trans, but I am also a grad student. A manager of an emergency department. I am a twin. A dog parent of three. I am a million different things. But the thing I talk about most is being trans because it is the thing that people do not understand the most.

Sarah Mossburg: Do you have any thoughts about next steps in this work or other areas of research that should be pursued in this space?

Connor Wesley: There is not a lot of research done on the LGBTQ+ community because we're so small. We can do more research on gender-affirming care and youth. Because so many states are starting to make it a felony, we need research to show that gender-affirming care is life-affirming care. Any research that will help the world see us as humans.

Sarah Mossburg: That's great. Thank you for taking this time to talk with us.

Editor’s note: In this interview we use 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). The term transgender woman (or trans woman) refers to a woman assigned male at birth; transgender man (or trans man) refers to a man assigned female at birth. Cisgender describes people who are not transgender and whose gender is aligned with the sex assigned at birth (sometimes abbreviated as cis). Pronouns are words that are used to refer to a person other than their name; pronouns are viewed as essential, not preferred. Gender-affirming care ­refers to care and surgical procedures that can help people adjust their bodies to match their gender identity.¹²

1. Emergency Medical Treatment & Labor Act (EMTALA). Center for Medicare and Medicaid Services. Updated December 5, 2022. Accessed December 7, 2022. https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA

2. HB1570 – To Create the Arkansas Save Adolescents from Experimentation (SAFE) Act. Arkansas State Legislature 93^rd General Assembly – Regular Session 2021. Accessed December 7, 2022. https://www.arkleg.state.ar.us/Bills/Detail?id=HB1570&ddBienniumSession=2021%2F2021R

3. Bostock V. Clayton County, Georgia, 590 US 1 (2020).

4. Freedom for All Americans. LGBTQ Americans Aren’t Fully Protected From Discrimination in 29 States. Accessed December 7, 2022. https://freedomforallamericans.org/states/

5. True Colors United. Our issue. Accessed November 14, 2022. https://truecolorsunited.org/our-issue/

6. Walls NE, Bell S. Correlates of engaging in survival sex among homeless youth and young adults. J Sex Res. 2011;48(5):423-436. doi:10.1080/00224499.2010.501916

7. Southern Comfort. Next Wave Films. Accessed December 7, 2022. https://nextwavefilms.com/southern/index.html

8. Bouman WP. Sumamus exordio: International Journal of Transgender Health. Int J Transgend Health. 2020;21(1):1-2. Published 2020 Jan 8. doi:10.1080/15532739.2020.1709316

9. Transgender health care. Department of Health and Human Services. Accessed December 7, 2022. https://www.healthcare.gov/transgender-health-care/

10. The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. The Joint Commission; 2011. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/health-equity/lgbtfieldguide_web_linked_verpdf.pdf

11. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674-697. doi:10.1037/0033-2909.129.5.674

12. Sexual & gender minority: Terms and definitions. National Institutes of Health. Accessed December 7, 2022. https://www.edi.nih.gov/people/sep/lgbti/safezone/terminology