Module #13 │
LGBT+ Patients

Module #13 addresses the care and treatment of LGBTQ+ patients in the home health setting. ‘LGBT+’ stands for lesbian, gay, bisexual, transgender, or trans, and others. The LGBT+ community is diverse, and the plus aims to include all identities. We have used the term LGBT+ in this information. But we realize that people identify themselves in many ways and that some people may prefer a different term.

Read each question carefully, then determine the best answer. There are 10 questions and 5 minutes to complete. Passing grade is 70%; you must get 7 or more answers correct to  pass this module. You have 8 chances to successfully pass this module. Your results will be forwarded to admin.


In-Service Exams provided by Essential In-Services for Home Health, 2021

Upon completion of the LGBT+ module. You should be able to:

Define the acronym LGBT+.

State three health disorders often found in LGBT+ persons.

List five examples of discrimination against LGBT+ persons.


Lesbian, gay, bisexual and transgender (LGBT+) individuals often face challenges and barriers to accessing needed health services and, as a result, can experience worse health outcomes.

These challenges can include stigma, discrimination, violence and rejection by families and communities, as well as other barriers, such as inequality in the workplace and health insurance sectors, the provision of substandard care and outright denial of care because of an individual’s sexual orientation or gender identity.

Specific to home health, some elder LGBT+ individuals, even those who are out of the closet, often end up returning to the isolation of the closet when they are cared for by health care personnel. Those who remain out may face social discrimination from their peers, as well as hostility and illegal discrimination from staff.

Family members provide about 80% of the elder care in the United States. Some LGBT+ elders have been disowned or are estranged from their biological families. Those who are single, childless, separated or widowed often find themselves with nowhere to go for elder care. You probably already have one or more LGBT+ patients at your agency.

Withdrawal and social isolation are common effects of trying to maintain an existence of staying in the closet. People who are socially isolated tend to be at greater risk of health issues, from mood disorders like depression to stress-related conditions like heart disease. New research suggests that being socially isolated may have a greater risk of early death, especially among the elderly.

It is important for staff to understand the unspoken issues that your patients are facing. Home health aides are in the best position to provide culturally appropriate care. Your patients’ sexual orientation should never negatively affect the care they are provided.


Bisexual: An individual who is sexually and romantically attracted to men and women.
Gay: An individual who identifies as a man and who is predominantly sexually and romantically attracted to other men.
Gender: An individual’s socially-constructed identity as man or woman.
Lesbian: An individual who identifies as a woman and who is predominantly sexually and romantically attracted to other women.
QueerAn individual who does not identify as lesbian, gay, bisexual or transgender but feels more comfortable identifying as queer, which is commonly thought of as a term that is fluid and inclusive of diverse sexual orientations and/or gender identities. This is sometimes represented by a Q on the end of the LGBT acronym (although this Q can also represent questioning). “t is important to note that the word queer is an in-group term, and a word that can be considered offensive to some people, depending on their generation, geographic location and relationship with the word.

QuestioningAn individual who is unsure about his or her sexual orientation and/or gender identity and prefers to identify as questioning rather than adhering to a label that does not designate how he or she feels. This is sometimes represented by a Q on the end of the LGBT acronym (although this Q can also represent queer).

Sex: Designation of male or female based on biological characteristics. sexual orientation: A label used to designate an individual’s desire for intimate, emotional and/or sexual relationships with people of the same gender/sex, another gender/sex or multiple genders/ sexes.

Transgender: An individual who identifies as the opposite sex from the sexual genitalia that he or she was born with.

Source: The Welcoming Project, www.thewelcomingproject.org

A Different World

Today’s older LGBT+ patients grew up or reached adulthood in a world in which people were thrown in jail or involuntarily committed to mental hospitals due to their gender identity or sexual orientation. In the past, some considered homosexuals to be sexual deviants. LGBT+ patients may have encountered a lifetime of discrimination, persecution, violence, hostility, cruel treatment and antagonism. As a result, many distrust health care workers and fear they will face discrimination in health care today. The Stonewall Inn was a Greenwich Village, N.Y., bar that was owned by the Mafia in the 1960s. It catered to people with alternative lifestyles and was popular with members of the LGBT+ community.

At that time, people with alternative lifestyles faced numerous gender, race, class and generational obstacles. Police raids on gay bars were common in the 1960s. One such raid incited a violent riot.

The police quickly lost control of the situation, and over the next few weeks, tensions continued to build. Village residents organized activist groups to establish places for members of the LGBT+ community to patronize without fear of arrest. This marked the beginning of the equal rights movement for the LGBT+ community. Although we have come a long way, discrimination is still widespread more than five decades later. Same-sex marriage has now been legalized in every U.S. state. However, elderly members of the LGBT+ community remain scarred by their experiences in the fight for equality. Many still face discrimination (legal or illegal).

Legal Protection
Home health staff cannot discuss a person’s sexuality or personal issues with other patients or staff members unless they have a need to know through the HIPAA laws.

All staff must remember that members of the LGBT+ community are not demanding special rights. They ask only for equal rights. Members of the LGBT+ community do have legal protections, including state-by-state nondiscrimination ordinances. There are many LGBT+ groups advocating for equality in care and treatment. The National Center for Lesbian Rights (NCLR) Elder Law Project fights discrimination against LGBT elders through a comprehensive approach that includes litigation, legislative advocacy at the state and federal levels, and public outreach.

According to a Lambda Legal study of 4,916 respondents conducted in 2009, almost 56%% of lesbian, gay or bisexual respondents had an experience of being refused care, health care professionals refusing to touch them, health care professionals using harsh or abusive language, being blamed for their health status or physical abuse from a health care professional at least once. Seventy percent of transgender respondents have had one or more of these experiences.

(Access the study here: www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_ when-health-care-isnt-caring.-pdf.)

Abuse Issues for LGBT+ Members
Many elderly members of the LGBT+ community become depressed. Some withdraw and refuse to participate in community activities. Some refuse to leave their homes. Some will not attend religious services for fear of bullying. Some will refer to their same-sex partners as sisters, cousins or friends. Some will not participate in social groups and other popular therapeutic activities, as this would involve sharing information about their gay partners, which they believe would subject them to more bullying. It is critical that the home health aide give the person unbiased emotional support.

A groundbreaking report — LGBT+ Older Adults in Long-Term Care Facilities: Stories From the Field — highlights the mistreatment that some LGBT+ elders may encounter. A broad coalition of LGBT+ groups led by the National Senior Citizens Law Center released the report. The groups included the NCLR, Lambda Legal, the National Center for Transgender Equality (NCTE), the National Gay and Lesbian Task Force (NGLTF), and Services & Advocacy for GLBT Elders (SAGE).

Please read the following findings from the report. The responses refer to treatment in a long-term care facility; however, much can be learned.

The report collected information and stories from 769 individuals who responded to an online survey. Of the total respondents, 50% reported abuse, which added up to 853 instances of abuse, including:

  • Harassment by residents and staff
  • Refusal by staff to accept a medical power of attorney
  • Refusal by staff to use preferred name and/or pronoun
  • Refusal to provide care
  • Wrongful transfer or discharge

Nearly nine in 10 respondents said that they thought long-term care staff would discriminate against someone who came out in a facility; eight in 10 responded that they would expect mistreatment or bullying from nursing home residents; one in 10 reported that nursing home staff had disregarded a medical power of attorney when it was assigned to a resident’s partner.  Transgender elders, in particular, reported that they experienced isolation and staff refusal to recognize their gender identities.

The report outlined several recommendations to change the climate in nursing homes and protect the LGBT+ community:

  • Staff training is vitally important. By mandating it, management and other leaders in institutional facilities make clear that anti-LGBT+ discrimination will not be tolerated. To find an organization to conduct a training at a facility near you, contact your LGBT+ community center, local or statewide Equality Federation organization, SAGE or look for resources on the National Resource Center on LGBT+ Aging.
  • In addition, advocates can push for laws mandating training for nursing home personnel and its residents. In 2008, California passed a law that does just that, requiring the Department of Public Health to design and implement regular cultural competency training on LGBT+ issues. In California and elsewhere, other laws are in development.
  • Ombudsman programs must take a stronger advocacy role in protecting LGBT+ residents by asking specifically about practices and strategies for dealing with anti-LGBT bullying by residents or staff.


Additional research and data collection is needed to uncover additional problems LGBT+ residents face in nursing homes, and-just as important- what strategies, model policies and programs successfully create welcoming institutional environments.

It is also very important for LGBT+ elders, their families, and their friends to proactively seek out inclusive agencies. There is no comprehensive list of LGBT+-friendly agencies, so it falls on us to investigate. You can do this by asking questions such as:

  • Does the agency have an explicit LGBT+ non-discrimination policy?
  • Have staff members been trained by a local LGBT elder advocacy organization?
  • Does the facility display LGBT+ symbols or literature, or include LGBT+-welcoming materials among their brochures?
  • Are intake forms and marketing materials LGBT+-inclusive? (For instance, do forms for new patients include a place to note a same-sex partner?
  • Do these agencies support “families of choice” in their policies and programs (i.e., friends and others who are the main sources of support for many LGBT+ elders)?

Specific Health Concerns

While sexual and gender minorities have many of the same health concerns as the general population, they experience certain health challenges at higher rates, and also face several unique heath challenges.

In particular, research suggests that some subgroups of the LGBT+ community have more chronic conditions as well as higher prevalence and earlier onset of disabilities than heterosexuals. Other major health concerns include:

  • Mental illness
  • Substance use
  • Sexual violence
  • Physical violence

In addition to the higher rates of illness and health challenges, some LGBT+ individuals are more likely to experience challenges obtaining care. Barriers include gaps in coverage, cost-related hurdles and poor treatment from health care providers.

You should always screen patients for mental health issues, excessive use of alcohol, and substance abuse. When viewed individually, you will see that each group within the LGBT+ population has its own unique health care needs and concerns.

Transgender Patients

Transgender patients are people who identify as the opposite sex from the sexual genitalia with which they were born. You should always ask how the transgender patient wishes to be addressed.

Additionally, a transgender person may identify as straight, gay, lesbian or bisexual. Transgender patients may be taking large doses of hormones, depending on how much they’ve decided to transition to their choice of gender.

It’s important to understand that often, transgender people feel they were born the wrong sex; often, they’ve identified with their current gender since childhood, but weren’t allowed to express themselves in that way.

Transgendered people can be born as males and identify as females; they can be born as females and now identify as male; they can be born with ambiguous genitalia and now identify as either gender. They are to be treated as the gender with which they identify.

Transgendered people can be on a spectrum of transitioning, so some simply dress like the opposite gender, others take hormones to be like the intended gender, and some have surgery to change their bodies to the intended gender.

A transgender person can be at any one of these steps of transitioning. Please note that a transgender person is not simply a crossdresser, a term generally referring to heterosexual males who wear feminine clothing. They are also not to be referred to as drag queens, a term generally used to describe gay men who dress up as women for entertainment.

A transgender person will likely be offended if he or she is described using these colloquial terms. For transgender patients taking hormones, it’s important to note that it takes several months before hormones begin to work. If treatment is interrupted or stopped, the person loses the changes in their sexual characteristics for which the hormones were intended. Changes related to hormone therapy follow.

Transgender Women
In transgender women, estrogen may cause changes in the body, including:

  • Fat increases on the hips
  • Smaller penis and testicles
  • More difficulty achieving erections and orgasm Reduced muscle strength and bulk
  • Increased breast size, along with lumps and tenderness
  • Less growth of facial and body hair
  • Male-pattern baldness may slow or stop but is not reversed

Transgender Men
In transgender men, testosterone may cause these changes in the body:

  • Increased facial hair and body hair growth Male-pattern baldness
  • Slightly larger clitoris
  • Increased libido
  • Increased muscle bulk
  • Deepening voice, but is not usually as deep as the pitch of other men
  • If the person has not been through menarche, menses will stop, but there may be some breakthrough bleeding
  • Acne

Transgender people who have not undergone reassignment surgery or hormone therapy may require additional medical care. For example, some women may require prostate exams, while some men may need breast exams. Persons who have undergone reassignment surgery may need hormone therapy, tests and examinations specific to their physical anatomy. An accurate surgical history is essential to providing quality person-centered care.

Women who identify as lesbians as elders may not have always identified themselves this way. Some lesbians may have had regular male sexual partners in the past. Some may have been pregnant and have children in their lives. Some may have had high-risk behavior for STDs. It is estimated that a larger percentage of lesbians do not have health insurance than others in the general population. Because of this, they may have not had a preventive mammogram or pap smear in years.

In addition to the conditions already mentioned for the LGBT+ community, other high-risk conditions specific to lesbians include:

  • Higher incidence of obesity than heterosexual women
  • More smoking than heterosexual women
  • Diabetes
  • Hypertension
  • Heart disease
  • Domestic violence

Gay and bisexual males
Gay and bisexual men are at high risk for anal cancer, which is associated with human papilloma virus (HPV) infection. Examples of other high-risk conditions include:

  • Heart disease
  • Prostate, testicular and colon cancer
  • Hepatitis A, B, and C
  • HIV

Affordable Care Act

  • The Affordable Care Act (ACA) is mandated by the Department of Health and Human Services. It is colloquially known as Obamacare. ACA requirements include:
  • Promoting cultural competency training for health care providers; nurses must apply this knowledge and information when providing resident-centered care
  • Allocating resources for improving the primary care workforce
  • Increasing funding for community health centers to address health care inequity among the LGBTQ+ population
  • Requiring equal visitation rights for same-sex partners
  • Extending Medicaid spousal impoverishment protections that apply to facility care to cover persons receiving Medicaid home- and community-based services; it is unclear how or if this protection covers same-sex seniors and their partners/caregivers
  • Plans purchased through the marketplace may not discriminate based on sexual orientation or gender identity
  • The plans may not charge increased premiums based on sex or gender
  • There is no denial of coverage due to preexisting conditions including HIV-AIDS, cancer, or mental illness
  • All legally married persons are treated equally
  • No lifetime limit on benefits

LGBT+ Health Care Equality
Many of today’s laws, programs and services either do not acknowledge or do not protect a same-sex, unmarried life partner. LGBT+ elderly are not as likely as heterosexuals to use available services such as senior centers, housing assistance, meal programs, food stamps and other entitlements.

The U.S. General Accounting Office has identified more than a thousand federal statutory provisions in which benefits and rights are conferred or dependent upon marital status. Gradually, this is changing.



  • Develop or adopt a nondiscrimination policy that guards residents from discrimination based on personal characteristics, including sexual orientation and gender identity or expression.
  • Develop or adopt a policy ensuring equal visitation
  • Develop or adopt a policy identifying the resident’s right to identify a support person of their choice
  • Integrate and incorporate a broad definition of family into new and existing policies
  • Monitor organizational efforts to provide more culturally competent, present and family-centered care to LGBT+ residents, families and communities
  • Develop clear mechanisms for reporting discrimination or disrespectful treatment
  • Develop disciplinary processes that address intimidating, disrespectful or discriminatory behavior toward LGBT+ residents or staff
  • Identify an individual directly accountable to leadership for overseeing organizational efforts to provide more culturally competent and resident-centered care to LGBT+ residents and families
  • Appoint a high-level advisory group to assess the climate for LGBT residents and make recommendations for improvement
  • Identify and support staff or physician champions who have special expertise or experience with LGBT+ issues


Resident Care

  • Create a welcoming environment that includes LGBT residents
  • Prominently post the hospital’s nondiscrimination policy or resident bill of rights
  • Ensure that waiting rooms and other common areas reflect and include LGBT residents and families (for instance, by showing a rainbow flag or LGBT-friendly periodicals)
  • Create or designate unisex or single-stall restrooms
  • Ensure that visitation polices are implemented in a fair, nondiscriminatory manner
  • Foster an environment that supports and nurtures all residents and families
  • Don’t make assumptions about a person’s sexual orientation or gender identity based on appearance
  • Be aware of misconceptions, biases, stereotypes and other communication barriers
  • Promote disclosure of sexual orientation and gender identity while remaining aware that disclosure or “coming out” is an individual process
  • Make sure all forms contain inclusive, gender-neutral language that allows for self-identification
  • Use neutral and inclusive language in interviews and when talking with all residents
  • Ask the resident what pronoun is preferred
  • Listen to and reflect residents’ choice of language when describing their own sexual orientation and how the resident refers to his or her relationship or partner
  • Provide information and guidance for the specific health concerns of LGBT residents
  • Become familiar with online and local resources available for LGBT people
  • Seek information and stay up to date on LGBT health topics
  • Be prepared with appropriate information and referrals

Source: The Joint Commission. (2011). Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay. Bisexual, and Transgender (LGBT) Community: A Field Guide. Retrieved from www.jointcommission.org/lgbt/.

Case Study

Ellen, a 77-year-old woman, was just admitted to home health for follow-up nursing, therapy and the assistance of a home health aide as she recuperates from a hip replacement.

Wanda is the home health aide given the privilege of providing assistance with personal care to Ellen. The RN on the case has already visited the home and admitted the patient. The RN has a conference with Wanda to share information and review the care plan.

While in the home, Wanda meets Thea, who is introduced as Ellen’s sister who lives with her and has lived there for most of their adult lives. The home is filled with pictures of the two together holding hands, embracing and sharing good times. The home is small, with one bedroom. Personal items from both women are present in this one room.

Wanda suspects that the women have a long-standing lesbian relationship, but she does not inquire. When Wanda assists Ellen with bathing, Thea is usually present — but at a distance.

Ellen invites Thea to come closer, to wash her back. Wanda senses the women do want closer contact and for Thea to be involved in the care of Ellen. Wanda asks Ellen if she would like for Thea to wash her back and apply some lotion for comfort.

It is like a curtain has been lifted, and the women are given an unspoken permission to provide this care. In subsequent days, Wanda observes Ellen and Thea holding hands and expressing deep caring for one another — just as a heterosexual couple might do.

Wanda continues to provide care as ordered, always showing respect and compassion. When Ellen is discharged, both women express sincere gratitude to Wanda for her care. Then they share with her that they are not actually sisters, but rather a couple who has been together for many years in a loving relationship. They have never married due to social stigma. Wanda smiles sweetly and wishes them well.

Nursing Actions

The core competencies for nurses include cultural sensitivity and patient-centered care. Although the health needs of LGBT+ individuals are not uniform, The Joint Commission has published a comprehensive field guide that encourages us to create a welcoming, sate and inclusive environment that contributes to improved health care quality for LGBT+ residents and their families.

For information and a free download of the 99-page handbook, refer to www.jointcommission.org/lgbt/. Again, information provided in this guide is largely applicable to home health as well.

Nursing professionals and paraprofessionals are the largest group of health care providers in the United States. Because of our scope of practice and access to patients and families, we have both the privilege and the responsibility of providing compassionate, evidence-based care to IGBT elders. Some agencies believe that all older adults require the same services, regardless of sexual orientation. This is not true. Almost half of all LGBT elders report having physical limitations, mental health issues, disabilities or the need for adaptive devices.

Home health aides are in the best position to identify patient needs and provide culturally and physically appropriate care to members of this community. You can accomplish this by:

  • Being sensitive to your patients’ paths, choices and backgrounds
  • Developing trust and rapport
  • Remembering that aging is difficult for everyone.
  • Showing respect and avoiding passing judgment on patients’ ethnic and cultural preferences and choices
  • Listening, reflecting and clarifying information.

Home health aides are privileged to have a presence in very personal times of significant stress, turmoil and fear in patients’ lives. Caring for patients during very private moments is a privilege. Try to avoid becoming so distracted that you become insensitive to their needs and concerns. Providing privacy, support and culturally competent care while patients work through challenges to their health and well-being is a privilege and an opportunity to expand your knowledge. Providing welcoming, safe and inclusive care is a means of supporting your patients and their families, making a difficult experience bearable. In the process, you are fulfilling the highest calling: You are that family’s caregiver.