Students and practitioners are learning about the impact of health disparities and implicit biases for LGBTQ patients.
Nurse practitioner Catherine Trossello, DNP, FNP-BC, AAHIVS, and her colleagues at Callen-Lorde Community Health Center in New York City were exploring the possibility of starting a nurse practitioner fellowship focused on caring for LGBTQ patients when they discovered a surprising fact.
They learned in 2019 that theirs would be the first fellowship in the country to offer this type of postgraduate specialty training for NPs.
In a country where 7.2% of people identify as lesbian, gay, bisexual, or transgender health education related to this patient population was surprisingly low when Trossello was planning the fellowship in 2019. Her team evaluated the amount of time nurses, physician assistants, and physicians spend learning about LGBTQ patients and their care in training programs, and the numbers ranged from one hour up to 40 hours.
"Many healthcare providers are entering the clinical setting without understanding critical aspects of care related to hormone therapy, HIV prevention, increased risks for certain diseases and other health issues," Trossello said.
Callen-Lorde specializes in addressing the needs of LGBTQ patients, and the demand for services is such that there is an ongoing waiting list of patients -- including from other states -- who are interested in services.
Fellowship offers culturally responsive training
The Keith Haring Nurse Practitioner Postgraduate Fellowship in LGBTQ+ Health focuses on training NPs to provide compassionate care to members of the LGBTQ+ communities, through a lens of diversity, equity, and inclusion, and with an anti-racist approach.
The Keith Haring Foundation selects three fellows a year. In its first year, 2020, two NPs received fellowships. The fellows participate in six sessions to learn about specialized LGBTQ care, including HIV management and transgender health. They also will see patients alongside preceptors and care for patients independently.
New York University's College of Nursing has been a pioneer in LGBTQ education, and students learn about health disparities for this population, including increased risk of tobacco, alcohol and drug use, cardiac disease, suicide and mental health conditions.
Educators also discuss the complex reasons behind the health disparities, said Caroline Dorsen, PhD, FNP-BC, an assistant professor at NYU.
"A common thread in this population is stigma and marginalization, which is linked to issues like lower rates of health insurance coverage and decreased access and utilization of care," Dorsen said. "Nurses need to know about these health disparities to care for these patients."
To close this knowledge gap, educators at NYU have started incorporating LGBTQ patient cases into the curriculum, and gender nonbinary mannequins and LGBTQ actors are included in simulation exercises, she said.
Danger of implicit bias with LGBTQ patients
While knowledge about topics such as health disparities is invaluable, nurses' personal attitudes also can influence their ability to adequately care for these patients, said Dorsen, who conducted a study on this topic. She found that some nurses feel conflict between the cultural and religious messages they receive in their personal lives and the messages in the professional setting.
"We gently need to accept the fact that we all have biases," she said. "Until we are able to do that, we will be making mistakes and providing substandard care, often unintentionally."
While some nurses claim they do not need to ask patients about gender identity and sexual orientation because they provide equal care to everyone, Dorsen said it is critical to gather this information.
For example, Dorsen is aware lesbian women might have a slightly increased risk of breast cancer because many have not had children or nursed babies, which are protective factors against breast cancer. Thus, she might initiate conversations about mammogram screening earlier with a lesbian woman.
Dorsen also provides primary and gynecologic care to homeless LGBTQ patients. She is cognizant that suicide risk is particularly high among these youth. Rather than asking adolescents if they tried to commit suicide, she asks how many times they have tried.
"By phrasing the question this way, they see that I know something about their situation," she said. "This normalizes their experiences and builds trust."
Increasing transgender services
Although there are common health disparities among LGBTQ patients, the needs of each group within this population vary. Paula Neira, MSN, JD, RN, CEN, a nurse, lawyer and Navy veteran, was the nurse educator in emergency medicine at Johns Hopkins Hospital in 2015 when she met surgeons who shared her interest in providing more services specifically for transgender patients.
These clinicians were interested in performing gender-affirming surgery at Johns Hopkins, and Neira co-led a task force that worked to open comprehensive transgender services at the facility.
The group conducted focus groups and online surveys with the transgender community to better understand their healthcare needs. In 2017, the health system opened the Johns Hopkins Center for Transgender and Gender Expansive Health, which now serves more than 2,000 patients and provides care for children, adolescents, adults, and older adults.
"The demand has outstripped the available resources," said Neira, who is the clinical program director of the center. While most patients are interested in gender-affirming surgery, others are looking for help with hormone medication management, primary care or other gender-affirming treatments.
Through the center, parents also can seek supportive care for their children as they explore their gender identity. Neira has worked with leaders at Johns Hopkins Medicine to incorporate sexual orientation and gender identity (SOGI) information in each patient's electronic health record.
Most patients prefer to enter this data into their record personally, she said, so the health system now provides an opportunity for patients to log in to their accounts to share demographic information about their sexual orientation, gender identity, sex assigned at birth, chosen name if different from their legal name and the pronouns they use.
She hopes that by providing this information to clinicians, LGBTQ patients will receive culturally competent and relevant care. "There is an increased level of anxiety in the LGBTQ community in our current political climate, and our goal is to help people access medically necessary, supportive and affirming care," Neira said. "And we are definitely making progress."
Editor's Note: This article was originally posted in December 2019 and has been updated.
Take these courses to learn more about caring for the LGBTQ+ community:
Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+): An Introduction (1.5 contact hours) Sexuality and gender identity have received significant attention in the last few decades across the spectrum of health and human services. This module presents a brief overview of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community and its history within society and healthcare systems. It offers definitions of key concepts related to sexuality and gender identity, as well as general implications for clinical education, practice, and research.
Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+): Health Disparities (2 contact hours) The Health and Medicine Division's (HMD) Healthy People 2030 and the Agency for Healthcare Research and Quality have highlighted the health disparities affecting LGBTQ+ populations. As evidence of health-illness patterns continues to be reported in the literature, this module presents the complex social determinants of health unique among the LGBTQ+ community.
HIV/AIDS for Healthcare Professionals (2 contact hours) Newer drugs with fewer adverse effects and more convenient dosing schedules have enabled even more patients to participate in and adhere to these more effective regimens. New combinations of effective therapies, however, contribute to the clinician's arduous task of prescribing antiretroviral medications and educating patients about these therapies. This module provides information about HIV infection and treatment.
