Cultural Competence: An Overview _____________________________________________________________
Sexual orientation : An enduring emotional, romantic, sexual, and/or affectionate attraction to another person. Individuals may experience this attraction to someone of the same gender, the opposite gender, both genders, or gender nonconforming. Transgender : An umbrella term describing a number of dis- tinct gender positions and identities including: crossdressing, transsexual, nonbinary, and intersex. One’s intrapersonal acceptance or rejection of societal ste- reotypes and prejudices, the acceptance of one’s self-identity as a sexual minority, and how much one affiliates with other members of the GSM community varies greatly among individuals [77]. Some authors stress the diversity within the GSM community by discussing “GSM populations” [78]. For example, it is understandable that a GSM population living in rural areas of the United States would have little in common with a GSM population living in urban areas or “gay-friendly” neighborhoods. Additionally, mental health experts have sug- gested that “GSM community” symbolizes a single group of individuals who express their sexuality differently than the majority of heterosexual individuals. However, many distinct communities have been identified, including lesbian, gay, bisexual, and transgender [79]. Each community is different from the other as well as different from the heterosexual com- munity. A culturally competent healthcare provider should keep this diversity in mind so that vital differences among these smaller groups are not lost when thinking of the GSM population in general. Commonalities exist among the GSM communities as well. For example, many adolescents, whether gay, lesbian, bisexual, transgender, or questioning their sexual identity, lack sexual minority role models to assist with successful psychosocial development [79]. The subtle and pervasive ways that discomfort with GSM individuals may be manifested have been examined and, in some instances, categorized as “cultural heterosexism,” which is characterized by the stigmatization in thinking and actions found in our nation’s cultural institutions, such as the educa- tional and legal systems [80]. “Cultural heterosexism fosters individual antigay attitudes by providing a ready-made system of values and stereotypical beliefs that justify such prejudice as natural” [81]. Perhaps the paucity of information about the GSM community in basic professional education has been a reflection of cultural heterosexism. Writers, funding sources, and publishers have been exposed to the same cultural institu- tions for many years. Individuals generally begin to absorb these institutional atti- tudes as children and may consequently develop “psychologic heterosexism,” which may also manifest as antigay prejudice. Many individuals, as children, have little contact with someone who is openly gay and, as a result, may not be able to associ- ate homosexuality with an actual person. Instead, they may associate it with concepts such as “sin,” “sickness,” “predator,” “outsider,” or some other negative characteristic from which
the individual wants to maintain distance [81]. Psychologic heterosexism involves (among other factors) considering sexual identity and determining that one does not want to think further about it. The direction of this thinking is undeniably negative, resulting in an environment that allows antigay hostil- ity [81]. The impact of antigay prejudice on the physical and mental health of members of the LGBTQIA community and their families should not be underestimated [82; 83]. Sexual minority individuals also are not immune to societal attitudes and may internalize negative aspects of the antigay prejudice experience. Anxiety, depression, social withdrawal, and other reactions may result [2; 84]. While the study of psychologic heterosexism, both blatant and subtle, is in the early stages of research, it has had a measurable impact on the mental health of the GSM community [85; 86; 87; 88]. Examples of the range of manifestations of heterosexism and/ or homophobia in our society are readily available. Without difficulty, each example presented here may be conceptual- ized as related to the emotional or physical health of a GSM individual or family member: • A kindergarten student calls another child an LGBTQ+ slur but does not really know what he is saying. • A teenage girl allows herself to become pregnant, “prov- ing” her heterosexuality to herself, her family, and her friends. • A parent worries that her 12-year-old daughter is still a “tomboy.” • An office employee decides to place a photo of an old boyfriend in her office rather than a photo of her gender-nonconforming partner of five years. • A college student buries himself in his studies in an effort to ignore his same-sex feelings and replace feel- ings of isolation. • Two teenage girls, thought by peers to be transgender individuals, are assaulted and killed while sitting together in an automobile. • A female patient is told by a healthcare provider that her haircut makes her look like a lesbian and is exam- ined roughly. • A gay man chooses not to reveal his sexual identity to his healthcare provider out of fear of a reduction or withdrawal of healthcare services. The manifestations of heterosexism have inhibited our learn- ing about the LGBTQIA population and its needs [78]. Gay patients have feared open discussion about their health needs because of potential negative reactions to their self-disclosure. Prejudice has impacted research efforts by limiting available funding [77]. All of these factors emphasize that the healthcare education system has failed to educate providers and research- ers about the unique aspects of LGBTQIA health [83; 89].
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