The period during which gender identity is clarified and solidified is unclear. There is no single trajectory of gender identity development for gender minority children. Some gender non-conforming children experience significant distress, currently termed gender dysphoria. Signs of gender dysphoria may emerge as early as the preschool years. One study found that nearly all transgender men and women experienced gender dysphoria by age 7. Furthermore, most participants continued to experience gender dysphoria without treatment until their adult years. 60 However, gender incongruence in early childhood is variable whereas adolescents experience a more constant identity. 61 Health concerns of LGBTQ youth Given the caveat that this group is under- studied, especially through prospective longitudinal studies, it appears that gender diverse children who come to clinical attention, on average, have poorer relationships with parents and peers, experience high rates of mistreatment from peers, and are at increased risk of physical and sexual abuse in childhood, as compared to their gender conforming peers. 31,62,63 Compared with the general population, LGBTQ youth are at a higher risk for a wide variety of health concerns: substance use, STIs, cancers, CVD, obesity, bullying, isolation, rejection, anxiety, depression, and suicide. 1 It is difficult to tease out cause and effect in these associations. They also often receive lower quality of care because of stigma, lack of awareness among healthcare providers, and insensitivity to their unique needs. Twenty-nine percent of LGBTQ youth reported they had attempted suicide at least once in the previous year vs. 6% of heterosexual youth. In 2014, young gay and bisexual men accounted for 8 out of 10 HIV diagnoses among youth. 1 Changing Mindsets Healthcare providers must be caring and open in a non-biased way to provide an equal level of care for all patients. Sensing negativity may cause patients to withhold important information about sexual identity or avoid returning for follow-up care. It is important that personal belief systems are mutually exclusive of the healthcare relationships with all patients, including LGBTQ patients, to avoid influencing the interaction and quality of the healthcare provided. Although research and public advocacy groups cluster LGBTQ patients into categories, variances exist among each group, as do potential ethnic and familial risk factors. These factors compound the serious nature of LGBTQ health risks. Healthcare professionals traditionally receive minimal education about the LGBTQ population’s needs. The National LGBTQIA+ Health Education Center 33 has published resources and maintains a website with webinars and learning modules. Knowledge of basic terms and definitions will assist in establishing a mutual understanding and increasing communication with LGBTQ people. 64-66
Previous studies have demonstrated that healthcare providers felt their medical education was inadequate in regards to issues specific to patients who identify as LGBTQ. 67,68 Calls have gone out to reform undergraduate and graduate medical education to better prepare clinicians to address the health of this population and decrease the documented health disparities. 69,70 In addition, new curricula are available for medical residency and training programs to provide formal education about appropriate care for LGBTQ patients. 71
Cultural Differences The concept of understanding and demonstrating respect in interactions with individuals from different cultures has long been labeled “cultural competency”. But, more recently, the term “cultural humility” is being favored over cultural competency. Can one every really be competent in a culture other than their own? And, if you are not culturally competent, are you then, in fact, culturally incompetent? Still, many bureaucratic agencies continue to promote “cultural competency” in their educational considerations for members of healthcare fields. In contrast, cultural humility emphasizes a continuum of education, self-evaluation, self-critique and improvement in our interactions with communities that are different from our own, rather than the “either or” implication of cultural competency. 73 The following section will explore both cultural competency and humility. Cultural competence in healthcare is understood as the ability to provide care to people from diverse backgrounds and adapting or designing that care to meet their social, cultural, and linguistic needs. 74 To achieve cultural competence in healthcare systems, there must be policies in place along with training and education to change behaviors at the systems and personal levels. For systems, there may be the provision of language assistance or a cultural specialist that is part of the care team and interacts in the community. Benefits to these changes are social, such as promoting inclusion, increasing community participation in their health, and increased trust. Health benefits include improved preventive care, fewer missed appointments, and reduced disparity. There are several stages in cultural competency: blindness (ignorance), awareness (you know you do not know), knowledge (you see differences and accept the person and their beliefs), and skills (gain ability to interact with different cultures). 75 Cultural competence develops in stages with individuals moving through stages at various rates with the assistance of education, training, commitment, and practice. 75 While cultural competency training can be beneficial, there is a concern of forming assumptions and stereotypes, 75 and no one person manifests all expectations of their culture. Cultural humility involves a personal commitment to self-evaluation and critique to focus on improving relationships. 76 The benefit to cultural humility is a focus on individuals, getting to know a person’s health goals, fears, and expectations, allowing for person-centered care. Cultural humility also calls for self-reflection of one’s thoughts and biases, allowing for an equal provider-patient relationship and not requiring specific courses. Regardless of the method, identification of one’s feeling as they encounter someone with a different lifestyle or experiences is important in both cultural competence and humility. Culturally affirming care seeks to support, validate, and honor the culture of the individual while recognizing current and historical oppression experienced by members of that culture. 77
Clinician Consideration
In addition to self-education and national guidelines, healthcare providers and their patients benefit from identifying specialty providers familiar with LGBTQ concerns and risks and knowledge of local LGBTQ-friendly resources. Displaying sensitivity to the healthcare needs of all patients is an important step in decreasing healthcare disparity in the United States. Healthcare Preferences Martos and colleagues 72 examined qualitative data from Lifestyle Interviews of LGB persons in three age cohorts from the Generations Study, looking for influences on healthcare preferences in the population. Findings centered on themes of stigma, expertise, identity, service type, and access. Stigma was the factor that most influenced participants’ preferences and communication with providers. Martos and colleagues 72 defined stigma as “real or perceived negative social attitudes directed toward participants about one or more of their identities”. Findings showed that stigma influenced participants’ communication with their providers and varied from concern over one’s own comfort to comfort of both provider and participant. Although avoiding stigma was a high priority, there were many different ideas on how to achieve this goal in the healthcare experience. They included a desire for an LGB-provider/venue, or a provider of a particular gender, to no concern at all if the provider was comfortable with the patient’s sexuality. Expertise was also a priority, and providers were frequently selected based on their specific skills. Barriers in access to healthcare were varied by age groups and insurance coverage. A frustration for many was the additional cost for utilization of a provider outside the network or the compromise between preferences such as skill set or “queer friendly.” 72 Clinicians should ensure that they keep up to date with the concerns and needs of the LGBTQ population through continuing education opportunities. Continuing education with a focus on human sexuality, sexual minorities, and specific aspects of LGBTQ healthcare can increase knowledge and provider/staff comfort, as well as decrease bias.
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