INTRODUCTION TO LGBTQ
HEALTH CARE ISSUES
An educational resource from
Michele J. Eliason, PhD,
Assistant Professor, San Francisco State University
Suzanne L. Dibble, DNSc, RN,
Professor, University of California, San Francisco
Jeanne DeJoseph, CNM, PhD,
Emeritus Professor, University of California, San Francisco
Peggy Chinn, RN, PhD,
Emeritus Professor, University of Connecticut
Carla Randall, RN, PhD
Assistant Professor, University of Southern Maine
JANICE LANGBEHN AND LISA POND, TOGETHER 18 YEARS, WERE
ABOUT TO DEPART ON A CRUISE WITH THEIR 3 CHILDREN,
WHEN LISA COLLAPSED. THE HOSPITAL REFUSED TO ACCEPT
INFORMATION FROM JANICE REGARDING LISA'S MEDICAL
HISTORY, INFORMING HER THAT SHE WAS IN AN ANTIGAY CITY
& STATE AND THAT SHE WOULD RECEIVE NO INFORMATION OR
ACKNOWLEDGMENT AS FAMILY.
A DOCTOR FINALLY TOLD JANICE THAT THERE WAS NO CHANCE
OF RECOVERY. DESPITE THE ACKNOWLEDGMENT THAT NO
MEDICAL REASON EXISTED TO PREVENT VISITATION -- AND
THE FACT THAT JANICE HELD A DURABLE HEALTHCARE POWER
OF ATTORNEY FOR LISA -- NO HOSPITAL EMPLOYEE WOULD
ALLOW JANICE OR THE COUPLE’S CHILDREN TO SEE LISA
UNTIL NEARLY EIGHT HOURS AFTER THEIR ARRIVAL, ONLY IN
TIME TO WITNESS THE LAST RITES.
A Lawsuit was filed April, 2009
The need for LGBTQ content in
health care education
As the opening case example indicates, LGBTQ
people and communities have too often
experienced discrimination and poor care.
This section addresses basic terminology used in
L,G,B,T, and Q?
The initials LGBTQ are used in this presentation
to stand for:
Queer and questioning
These are not the only terms used for sexual identity:
there are many terms that vary by geographical
region, age group, racial/ethnic group, and so on.
Why include the “Q”
Many people, especially youth, do not use
LGBT, but define themselves as “queer” a
Some use it to reclaim a word flung at them
in hatred, because to use it oneself takes the
power out of it.
Q can also stand for questioning, a necessary
step in developing identities, and a
potentially stressful time for many who later
adopt an LGBTQ identity.
Why the need for LGBTQ
There is little accurate information in our
culture about LGBTQ people. Families,
schools, religious organizations, the media,
etc., still contain many myths and
Health care professional education currently
contains little or no information to counteract
Why the need for education?
LGBTQ people and families make up a
significant portion of the health care
Everyone has LGBTQ friends, relatives,
coworkers, and everyone has a sexual and
gender identity, so understanding these
issues helps everyone.
Case Example Discussion:
• Could what happened to Janice and Lisa
occur in the health care setting where you
• Why or why not?
Concepts related to sex, gender, and
What’s in a Word?
What a confusing term! Sex has two
meaning, neither one very clear cut.
Sex = biological characteristics that distinguish
men from women, such as chromosomes,
genitals, internal organs of reproduction,
Sex = a set of behaviors associated with sexual
arousal, pleasure, reproduction, and other human
The social and cultural characteristics that are
associated with being a man or a woman in a
Includes dress, hairstyles, adornments,
communication styles, postures, etc.
Assumes that there are two and only two sexes
(male and female), thus only two gender types
(masculine and feminine).
The term that refers to whether we are attracted
to men, women, or both, and in western
Many other terms are used by specific subsets of the
population, and some people do not use labels at all.
Other terms related to
Sexual orientation implies a fixed and
permanent sexuality. Alternatives include:
Sexual preference refers to a sexual choice or style
that is modifiable
Sexual identity refers to the part of the self-
concept that is related to sexuality, like other
personal identities based on race, gender, age, etc
We recommend using sexual identity—it is
the most neutral term.
Other terms related to
Identity Terms (what people call themselves):
Queer, gender queer
Homosexual, same gender loving, two spirit
Behavior Terms (what people do):
MSM (men who have sex with men)
MSMW (men who have sex with men and women)
WSW (women who have sex with women)
WSWM (women who have sex with women and
How people act out their sexual desires
Differs widely among people, regardless of
their sexual and gender identities
Heavily influenced by culture, especially
Sexual expression is not directly tied to sexual
identity (i.e., there is no such thing as “gay
Self-concept related to gender:
how well do I fit into male/female, and
feminine/masculine expectations for my culture?
Gender identity is established early in life, as
children identify their own gender around age
3, and the gender of others around 6.
An umbrella term that describes people
whose gender identity is not congruent with
their physical bodies or sex assigned at birth.
Includes transsexuals, cross-dressers,
androgynous people, drag queens and kings,
and gender queer identifications, among
Male-to-female (MTF, MtF, M2F)
Female-to-male (FTM, FtM, F2M)
Transition: the process of altering the body
and behavior to pass as one’s psychological
Can include hormone treatments, surgeries,
speech therapy, psychological therapy,
electrolysis, and other things.
Not all transgender people do all or any of these
Intersex is an umbrella term for a number of
biological conditions or variations that affect
reproductive organs or genitals, so that the
person does not clearly fit into the categories
of male or female.
Some of these are apparent at birth (as
ambiguous genitalia); others manifest later
Examples: congenital adrenal hyperplasia,
androgen insufficiency syndrome, hypospadias
Intersex Advocacy and
The Intersex Society of North America
recently closed, but continues to have
information posted on a web site.
A new organization, Accord Alliance, will
continue the work ISNA started to improve
health care for people with intersex bodies.
How people choose to present themselves on
a continuum of feminine and/or masculine:
How did you express your gender today?
How much variation is there day to day in
your gender expression?
Sources of Diversity in
Most of the definitions used here are the
western, middle-class academic terms; there
are variations by:
Sociocultural group: ethnicity, geographic region,
religion, non-western cultures, socioeconomic
class differences, age group, sex/gender.
Is LGBTQ a “Culture?”
LGBTQ people organize around a common
identity and express a sense of community
with shared beliefs
There is a long and extensive LGBTQ history
with a unique language (coming out,
transition, passing, stealth, gender queer,
There are LGBTQ social and political
organizations, many concerned with health
Is LGBTQ a Culture?
There are rituals and rites of passage in
LGBTQ communities and personal
There are cultural productions from an
LGBTQ sensibility: music, art, theater,
literature, etc, that reflects the communities
experiences in the world.
Having a culture does not mean agreement
on all issues.
Coming Out and Disclosure
Sexual and gender identities are not always
visible differences, so LGBTQ people have to
first identify their own sexuality or gender
and then make decisions about who/where to
reveal them to others.
Coming out: the process of understanding one’s
own sexuality and gender
Disclosure: the process of telling others
Can occur at any age or stage in life
Can be a very stressful time, with concern
about how family, children, peers, coworkers
religious leaders, neighbors, and others will
Is a process that continues throughout the
Disclosure to health care
Health care settings are often a “Don’t ask,
don’t tell” situation. Health care providers
typically do not ask, and written forms have
no option for patients to identify themselves.
Disclosure is potentially dangerous if health
care professionals have negative attitudes
about LGBTQ people.
Some Disclosure Stories
Miguel, who was usually very careful about
sexual behavior, had an unsafe sexual
encounter with a man while on vacation, and
decided to ask his primary care provider at
the HMO for an HIV test. The PCP seemed ok
about his disclosure, but every time after
that, every symptom he had was interpreted
in the framework of HIV/AIDS.
How would you feel if every symptom you
had was evaluated this way?
When Gloria divorced her husband and
started a new relationship with a woman, she
told her nurse practitioner that she was
bisexual. The NP’s response was that she had
not received much information in school
about bisexual health issues, and hoped that
Gloria would feel comfortable telling her
what she needed.
What do you think of this NP’s response?
Mae came out as a lesbian to her
gynecologist at a yearly exam, and thought it
went well, but her doctor started to ask her
very personal questions about her sex life
that did not seem relevant to her routine
care. She started to feel very uncomfortable
with this health care provider.
What assumptions do you think this physician
had about Mae?
Rachel told the nursing staff where she had
just started working that she was a
transgender woman and had been born male.
The charge nurse insisted that Rachel reveal
her birth name and that other staff members
call her by her “legal” name, since Rachel had
not yet officially changed her name.
What effect might this insistence on the
“legal” name have on Rachel and the staff of
this nursing unit?
Disclosure to health care
Patients may disclose to:
Get better care, be able to include a partner in
health care decision-making, to be honest
Patients may not disclose to:
Prevent discrimination or poor quality care, avoid
loss of job, custody of children, insurance benefits,
avoid losing family or community support, avoid
gossip, protect their privacy
In your health care work
How are LGBTQ patients/clients currently
Do written forms include sexual and gender
Do health care providers ask patients about
sexuality and gender?
Are there openly LGBTQ workers? Are they
Is there talk about LGBTQ patients at the nurses’
station? What kind of talk?
THE DEADLY EFFECTS OF STIGMA
Being perceived as belonging to a group
about which society has negative attitudes,
or considers “deviant.”
Stigmatization: the process of creating
stigma, also called “othering.”
Sets up “us versus them” mentality.
TERMS RELATED TO THE STIGMA
OF LGBTQ IDENTITIES
Can you remember the first time you learned
about the existence of LGBTQ people?
What did you learn?
What was the context (who told you, where,
how old were you)?
Did you learn something positive, negative,
or neutral about LGBTQ people?
• Negative attitudes about lesbian and gay people
• More common in:
– Men than women
– Youth and older adults than young or midlife adults
– Evangelical/fundamentalist religions than other
religions or no religious affiliation
– Less educated people than more educated
– People with unacknowledged/unaccepted same-sex
– People who are also racist and sexist
Negative attitudes about people who are
Comes from stereotypes about bisexual
Same correlates as homophobia, but can also
be found among lesbian and gay people
Negative attitudes about people who are
transgender or challenge gender stereotypes
Gender is one of the most deep-seated set of
stereotypes in western culture—strong
beliefs that there are only two sexes and they
are fixed at birth or even before birth.
Stereotypes at the Root
Stereotyping lies at the root of homo-, bi-,
and trans-phobia. As a youth, what
stereotypes did you learn about:
Negative attitudes about people with
Related to a combination of racism,
homophobia/biphobia, fears of contagion,
and stigma of potentially terminal illnesses.
Some people still think of HIV/AIDS as only a
The institutional level of stigma
Biases found in the dominant institutions of
society, such as medicine/science, education,
the media, law, government, and religion.
Another concept, “heteronormativity,” refers
to the fact that the majority of society is
based on a heterosexual model that makes
LGBTQ people invisible.
An institutionalized belief system that:
There are only two sexes
You stay the sex you are born all your life
Gender comes from sex: femininity comes from
being in a female body and masculinity comes
with a male body
Gender variation is harshly punished in our
Think of the taunts on the
playground when you were
Which of those insults were
Which ones were based on
The stigma that stems from homophobia,
biphobia, and transphobia can be internalized
by people who adopt LGBTQ identities and
Shame and guilt (can lead to depression)
Self-hatred (can lead to suicide attempts)
Self-destructive behaviors (substance abuse,
unsafe sexual behaviors)
Example of Internalized
Casey grew up in a fundamentalist Christian
religion that permeated the family and
community. Casey was taught that all LGBTQ
people are sinners who will go to hell, and
when Casey felt different from others,
became severely depressed and ran away
from home, consumed with shame and guilt
that the family would find out.
Intersections of Oppression
• Many LGBTQ people also belong to other
stigmatized groups, adding to their daily
levels of stress. These can include:
– Anti-semitism and other forms of religious
Experiences with Discrimination
Social Effects of Stigma
• Lack of recognition of relationships and family
– Same-sex couples cannot marry in most states in the
– Definitions of family are narrow and exclude many
– Same-sex couples cannot adopt in most jurisdictions
• Hate crimes and violence
– 20-30% of LGBTQ people have experienced violence
due to sexuality or gender
Social Effects of Stigma
Most damaging when families of origin are
Discrimination in employment and education
Discrimination in housing
COMMON MYTHS AND
STEREOTYPES ABOUT LGBTQ
MYTH: People could change their
sexual orientation if they wanted.
There is no evidence that sexual orientation
can be altered by psychological therapy or
Every professional organization in healthcare
and human services denounces the use of
“reparative” therapies to attempt to change
sexual orientation. These therapies do more
harm than good.
MYTH: Gay men are like
heterosexual women; lesbians are
like heterosexual men.
• Sexual orientation is different than gender.
Most lesbians are similar to heterosexual women
in most ways and gay men are more like
heterosexual men than they are like women.
• LGB people may show more variations in their
gender expression than heterosexual people
because they feel freer of societal expectations.
MYTH: Children are at risk if
exposed to LGBTQ people.
Exposure to LGBTQ people is not what “causes”
a sexual orientation. Most LGBTQ people were
raised and/or socialized by heterosexual parents,
siblings, teachers, and peers.
A child is 100 times more likely to be molested
by a heterosexual than an LGB person (J of
Pediatrics, Jenny et al, 1994)
MYTH: LGBTQ People Do Not Have
Relationships are hard—nearly half of
heterosexual marriages end in divorce.
LGBTQ people are no more or less successful
in relationships than anyone else.
Many LGBTQ people have long-term,
monogamous relationships and families.
MYTH: Religion says LGBTQ
People are Sinful
• There is huge variation in the position of the
world’s religions on sexual orientation and
gender identity, with some accepting and
• References to same-sex sexuality in the Bible
are vague or taken out of context and may
not be relevant in today’s world.
• Many LGBTQ people practice a formal
religion, and many others follow spiritual
MYTH: There is no such thing as
Sexuality is on a continuum, not just two
points, gay or straight. The majority of
people fall between these extremes.
People who identify as bisexual typically have
stable identities over time and are no more
confused about sexuality than anyone else.
MYTH: There are two and only
• Physical bodies are enormously diverse and
many people have bodies that are
intermediate between male and female
• As many as 4% of the population has a
disorder of sexual development (intersex)
that causes genitals, reproductive organs, or
chromosome patterns that are not neatly
male or female.
MYTH: Men and women are different
mostly because of their biology.
Men and women are more than 99% alike in
their human genomes, so most of the
differences are due to socialization, not
Gender socialization starts before we are
even born, and continues through-out life.
MYTH: Transgender identity is
• Reference books like the DSM state that 1 in
10,000 people are male-to-female
transsexuals and 1 in 30,000 are female-to-
male. But a recent study suggested that 1 in
3100 people in the U.S had a gender
• Transsexuals are only one subset of the
transgender population, which may be much
larger than we think.
How does stigma operate where you work or
go to school
Who constitutes the “us” and the “them”?
FAMILY AND OTHER FORMS OF DIVERSITY
What is family?
Family has been defined by:
blood ties, and
affinity ties (people who are important to us)
Which definitions should be used in health
The Joint Commission’s
“person(s) who plays a significant role in an
individual’s life. This may include a person(s)
not legally related to the individual. This
person(s) is often referred to as a surrogate
decision maker if authorized to make care
decisions for the individual should he or she
lose decision-making capacity”
• Same-sex couples are not allowed to marry in
most of the United States
• Children in LGBTQ families can come from
– Previous or current heterosexual relationships
– Alternative insemination procedures
Intimate Partner Relationships
How do LGBTQ relationships differ from
heterosexual and typically-gendered
May be slightly more likely to be in open
relationships, but most are in couple,
More free from gender-role expectations about
division of household labor
Have the same levels of relationship satisfaction
Children of LGBTQ Parents
Most of the research has been on children of
lesbian couples. Compared to children of
No differences in gender identity or sexual
No differences on most measures of adjustment
or behavioral problems
Some studies find them more mature and
understanding of diversity
LGBTQ Communities include
people who are
From all racial/ethnic groups
From all religions and spiritual traditions
From all geographic regions
Across the entire lifespan
Disabled and nondisabled
Across the entire political spectrum
From all levels of health and illness
Age/Life Course Differences
Childhood: fitting in, importance of family
support, bullying, feeling “different”
Adolescence: identity formation, importance of
peer acceptance, experimentation phase,
vulnerability to victimization from peers and
Life Course Development
Young Adults: intimate relationships,
independence from family of origin, starting
families, career development
Midlife Adults: maintaining relationships,
generativity, worry about the future, deepening
Older Adults: generational differences in
attitudes about being out, fear of dependence
and poor treatment, dealing with youth culture
EFFECTS OF STIGMA ON HEALTH
Stigma affects health through:
External sources: e.g., negative attitudes of
health care professionals and others in
society may affect accessing health services
Internal sources: e.g., internalized
oppression, may increase use of unhealthy
coping strategies and accumulated stress.
Stigma has been associated with elevated
risk for many mental health problems,
Alcohol, drug, and tobacco dependence
Suicide ideation and attempts
Example: Major Depression, Past
(data from Cochran, Sullivan, & Mays, 2003)
Most studies find the rates of intimate
partner or domestic violence to be similar
among other-sex and same-sex couples.
Reasons for violence are also similar.
The differences lie in access to services.
Where do LGBTQ people go for help?
There is less research on the impact of stigma on
chronic physical health conditions, but some
Higher levels of elevated BMI/obesity among lesbians
(Case et al, 2004)
Greater reports of functional impairments and
disability among lesbian and bisexual women than
other groups (Cochran & Mays, 2007)
Greater rates of HIV/AIDS among gay and bisexual
men than other groups (CDC, 2007)
% on Disability Income:
(data from Cochran & Mays, 2007)
MAKING HEALTH CARE SETTINGS
INCLUSIVE AND WELCOMING
Welcoming and Inclusive
Start with the reception or waiting area
Is there a patient rights or nondiscrimination
statement in prominent view that includes sexual
and gender identity?
Does the artwork, magazines, newsletters,
pamphlets reflect the community?
Do all staff members use inclusive language?
The language of written forms can be exclusive
of LGBTQ people and families.
Does your intake form
Have a place for patients/clients to indicate sexual
orientation and/or gender identity if they choose?
Have a place to indicate relationship and family
Make assumptions that all patients/clients are
heterosexual and typically male or female?
Does your facility ask patients for permission to
record information about sexuality and gender?
Do visiting policies include non-traditional
Sharing of Information (health care proxy)
Is there a place to record when patients have durable
power of attorney for health care papers? Are they
Health care benefits for same sex partners? If
so, are they the same as married couples get?
Nondiscrimination statement for hiring,
tenure, and promotion decisions?
Sexual orientation and gender identity are
included in sexual harassment policies?
Did your health care education program include
content about LGBTQ issues?
Have you had continuing or inservice education
about LGBTQ health care issues?
Have you done personal reading about LGBTQ
health care issues?
Do you know openly LGBTQ people?
Do you feel comfortable saying the words
lesbian, gay, bisexual, and transgender?
Are you comfortable working with LGBTQ
patients or clients?
If not, why not? What did you learn about LGBTQ
people in the past that has created a level of
discomfort? What can you do to ease that
Clinical or Educational
Do you ask patients or clients about sexuality
and gender? If so, what do you do with the
Is the language you use to take a health
history inclusive of all patients or clients?
Have you paid attention to your body
language when you do histories with
patients? What do you typically do when you
are not comfortable?
What steps can you take?
Education, awareness, reach out to LGBTQ
coworkers, family, and friends
Review and change policies as needed to be
welcoming and inclusive. Enforce the policies.
Vote for inclusion rather than exclusion. Challenge
social injustice when you see it.
Final Case Study
George, a bisexual man in a committed
relationship with Joseph, has a heart attack and
comes to the ED with Joseph. They are accepted
as a couple and Joseph stays with George
through the stressful procedures. When George
is admitted to the ICU and stabilizes, the staff
comfort Joseph and make sure he has contact
information for the unit before he goes home.
Joseph is included in all discussions about
George’s discharge plan.
LGBTQ patients want the same things from a
health care experience that all people want:
high quality care, safety, comfort, recovery,
acceptance, and being treated with dignity.
A welcoming and inclusive health care
environment will benefit all patients and