Sexual Minority Populations (LGBTQ)

Background and Importance

Sexual minority individuals cross every demographic, and multiple cultural and societal influences can affect their visibility and disclosure of sexual and gender identity. They represent a diverse continuum of individuals without a strict heterosexual identity (lesbian, gay, bisexual. queer, or questioning [LGBTQ]) and include those whose gender identity is different or fluid from their sex-based gender assigned at birth. Although sexual minorities share many similarities, there are also key differences. There is a wide range of perceptions on the prevalence of sexual minorities in the United States (US). This reflects societal bias, lack of research, and barriers to disclosing or collecting data regarding an individual’s sexual and gender identities. One recent estimate is that 4.5% or 11 million Americans identify as a sexual minority, and at least 0.6% or 1.4 million identify as transgender. ^, Importantly, sexual and gender identities should be considered separate from sexual behavior. It is estimated that 8.7% of women and 8.2% of men have had same-sex sexual behavior.

Terminology and Concepts

To create a welcome and inclusive environment for sexual minorities, health care providers should be familiar with culturally competent terminology to better communicate and avoid unintentional offense ( Table 188.1 ). Providers should avoid terms associated with bias or prejudice. Terms like “homosexual” or “sexual preference” may be common in language, but have stigma when used in the sexual minority community. The use of the word “homosexual” is associated with past bias and discrimination; therefore preferred terms include lesbian, gay, or bisexual. Similarly, because there is no legitimate evidence that sexual orientation is a choice, the term “sexual preference” should not be used. Patients should be asked about their partner(s) in gender neutral terms without assuming that they are in a heterosexual relationship. Asking open-ended questions will signal being receptive to patients not in traditional heterosexual relationships or gender identities. When in doubt, ask the patient for their preferred terms, or allow them to define their relationships.

Historical Context

Same-sex relationships and transgender identity have existed throughout recorded history, although societal acceptance and tolerance has varied over time. Laws and attitudes against same-sex sexual behavior were common in the United States, which adversely influenced attitudes of health care providers and isolated sexual minorities from medical care. Despite recent increased acceptance of sexual minorities, past actions and discrimination can still be a powerful barrier to equitable care. Although the majority of Americans support sexual minority rights, it is far from universal, and continued implicit and explicit bias along with outright discrimination and refusal of care still exist. Basic health care rights and choices assumed by the majority are often not afforded to sexual minorities, or are incomplete. Some forms of discrimination, including employment discrimination, are still legal in many states, making patient-provider trust and confidentiality of substantial importance to the sexual minority patient. Emergency care providers should be prepared to assure LGBTQ patients of laws protecting their medical records from disclosure.

Identity

Sexual minorities undergo a deeply personal process of accepting their sexual orientation or gender identity and then disclosing it to the outside world, known as “coming out.” This process should occur on the patient’s own terms and timeline. Since many individuals who engage in same-sex behaviors may never identify themselves as a sexual minority for a variety of reasons, clinicians should inquire about specific sexual activity and not just sexual orientation or identity when it is pertinent to their clinical presentation.

Legal identity and the patient’s gender identity may be discordant for transgender patients, leading to confusion and discomfort. If the patient’s insurance uses their gender assigned at birth, their preferred name and gender may not appear in many electronic health records (EHRs), and services and prescriptions using their preferred name and gender may not be covered. Few transgender people have all of their identification materials with their preferred name and gender, and for 68% none of their identification reflects their preferred name and gender, financial costs being one of the largest barriers to acquiring updated identification. Creating an inclusive environment without assumptions or judgment about identity will best promote an honest and trusting dialogue that will enhance health decisions and care.

Factors Affecting Equitable Care