Hello!

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:

• HIV/AIDS
• 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 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.

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/.

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.

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.