Essentials of Cultural Competence in Pharmacy Practice: Chapter 17 Notes Chapter Authors: Dr. Kristina A. Peterson and Dr. Duane A. Halbur Lesbian, Gay, Bisexual, and Transgender Patients

Learning Objectives 1. Describe health risks faced by LGBT individuals. 2. Articulate identity development for LGBT individuals. 3. Understand unique family issues relevant to health care for LGBT individuals. 4. Understand how heterosexual privilege can be used to effect change

What Does LGBT Mean? LGBT collectively refers to those who are lesbian, gay, bisexual or transgender. LGBTQ and LGBTQQ are often utilized as well to include such personally defined members as queer (although its inclusion comes with great controversy due to continue derogatory affiliations) and questioning. As with many cultures, terminology, membership and even concerns change as understanding and acceptance of this minority population changes.

Important Definitions According to Adler, Hirsch, and Mordaunt (2006), the following terms accurately represent each designation. Lesbian: A woman who is sexually attracted to other women. Gay: Individuals who are sexually attracted to others of the same sex. This term is currently usually reserved to describe men who are attracted to other men. Bisexual: Someone who is attracted to people of both genders. Transgender: Umbrella definition used for individual who is living in a gender other than his or her own biological gender.

Key Historic Points Kinsey Study of Sexual Behavior in This seminal project found that 4% of males who participated identified as exclusively gay and 37% of males had at least some overt homosexual experience to orgasm. This study helped to show how homosexuality was a part of normal adults. Additionally, studies in the early 1950’s by Evelyn Hooker found that homosexuals were no worse in social adjustment than the general population. These findings were influential in the removal of homosexuality as a mental disorder from the Diagnostic and Statistical Manual of Mental Illness (DSM) in Two years later, the American Psychological Association affirmed that action and continued to support the notion that homosexuality was indeed not a mental illness.

Where are LGBT people? The simple answer is—everywhere! In the U.S. those who identify as LGBT are present in every region, state and nearly every town. However, LGBT patients have congregated, likely for political and sociological issues, in some key cities and in metropolitan areas, a process common to many minorities. Some populous areas even have areas known as the “gay district,” often contemporary, chic and, of greatest importance, gay friendly.

Cass’ Model of Gay Identity Development StageWhat Occurs Stage I: Identity Confusion Awareness of being different or unique from others. Personal conflicts; reflection; trying to make sense of unexpected feelings and attitudes. Stage II: Identity Comparison Acknowledge the possibility of being attracted to the same sex. Challenges their ability to identify with others and makes it difficult to feel close to people such as their family and previous peer group. Often lonely time filled with a sense of social isolation and even alienation.

Cass’ Model of Gay Identity Development (continued) Stage III: Identity Tolerance Individual is not ready to accept and embrace their sexual orientation but begins to tolerate it. This stage is often characterized by the development of relationships with others who identity as LGBT, which often helps to reduce the isolation that is typically in this developmental stage. Stage IV: Identity Acceptance Increased contact with other LGBT members. Individuals typically begin to see being LGBT as an acceptable, potential identity. Although, there is still likely a sense of uneasiness with identifying as gay or lesbian, minority orientations are considered possible identities.

Stage V: Identity Pride Greater overt behavioral change in many individuals. LGBT individuals may spend an increased amount of their time with others from this community. Heterosexuality is no longer thought to be the only correct or appropriate orientation. Individuals not only increase their disclosure of their own sexuality orientation but gain a sense of pride in their revelations. Stage VI: Identity Synthesis This stage is characterized by the ability to integrate sexual orientation into their entire identity. Most are able to easily have meaningful, compatible relationships with those from both heterosexual and LGBT communities.

Communication Styles/Terms Not of Endearment There continues to be harsh discrimination of the LGBT culture. This continues to be reflected in the use of such words as “gay” as a derogatory term. “Gay” as an insult remains the number one utilized word in high-school hallways as a belittling comment often replaced for such words as “stupid” or “bad.” Other common insults include faggot, queer and calling boys by feminine names.

Family Roles/Organization Family roles are difficult to define for those who are LGBT. The most important assumption a pharmacist needs to eliminate is that family roles are defined in a specific way. Gender specific roles are not necessarily defined by such traditional concepts as “head of household.” However, that does not mean there is not a member of the family who acts in that capacity. Additionally, gay families come in many forms from single parent to lesbian couples without children. Consequently, assumptions of a nuclear family would be best placed by the wayside in dealing with families consisting of gay and lesbian individuals. Like other families, LGBT families may include stepfamilies, in- laws and multigenerational figures.

How Open? Those of the lesbian, gay, bisexual and transgender populations vary in how open they are in sharing their sexual orientation. Unlike some minorities, it is possible for some to keep their membership in this minority population secret. Many who are LGBT are not known as such by those around them. Many, for obvious reasons, have kept their sexual orientation quiet to avoid prejudice, discrimination and unfair treatment. This is important for healthcare professionals to remember.

Legal Issues and Family A specific concern that deserves attention is the continued lack of legal acceptance of gay marriage. This may put patients and pharmacists in a difficult role when dealing with confidential information and while dispensing medications. It is very possible for a child to have two moms, while only one has legal custody. However, some have obtained legal parental rights for both parents. Pharmacists should be intentional and proactive in working with these families. It may behoove the practitioner when aware of working with a gay or lesbian family to include HIPAA release forms in patient files so that medical issues can be shared by those who should be included in pharmacy care plans.

Transsexual/Transgender Issues Transgender is a term used to describe people whose gender identity (sense of themselves as male or female) or gender expression differs from that usually associated with their birth sex. Transsexuals are transgender people who wish to live full time as members of the gender opposite their birth sex. Such individuals usually seek medical interventions such as hormones and surgery to make their bodies more congruent with their preferred gender. Cross-dressers or transvestites are the most numerous transgender group. They wear the clothing of the other sex.

Transsexual/Transgender (cont’d) Transgender persons may or may not decide to go through the medical transition to live full time as their preferred gender. To have reassignment surgery, a transgender person must first see a psychologist for two years and live full time in the new gender role for a year. Health professionals may encounter a transgender person at any time during this process. It is important to be aware of any personal biases and refrain from making any assumptions about individuals.

Workforce Issues LGBT individuals work in all areas of employment. There is, however, a continuing history of discrimination that impacts the workforce. In roughly 30 states, it remains legal to fire or not offer employment to someone for being gay, lesbian or bisexual and in 38 states transgender individuals may be denied employment for being transgender. The military’s “don’t ask, don’t tell” policy, although a historical attempt to reach greater equality, gave a strong statement regarding the appropriateness of those who are gay being authentic in the military. Nearly 200 major American businesses do offer full protection and benefits for LGBT employees.

Health Issues A difficulty faced by any health care professional is that the majority of gay and lesbian people do not disclose their sexual orientation to health care providers. Many LGBT people do not seek out health care because of homophobia and discrimination. HIV and AIDS was once thought to be a “gay man’s disease.” HIV and AIDS continue to be a health issues faced by gay men. Gay men also have higher rates of substance abuse and tobacco use. They also face a significantly higher risk for other sexually transmitted diseases, which may be associated with the higher prevalence of substance abuse.

Health Issues (continued) Many women generally access preventive health care within the context of routine gynecological visits related to obtaining birth control. Consequently, as this is not a need for many lesbian women, they make fewer gynecological visits. This puts them at risk. Although lesbian women generally have a lower rate of STDs, HIV and AIDS-related problems, they, like gay men, tend to have a higher rate of substance abuse than the general population. Both gay men and lesbian women also have higher rates of tobacco use, which puts them at risk for lung cancer and other problems related to smoking.

Spirituality Institutionalized religion is often rooted with homophobic notions. It does, however, provide some of the same comforts for lesbians and gays that it does for heterosexual men and women. Being a member of a religious institution provides members with a sense of something greater than themselves, a sense of community, answers to some universal questions, and moral guidance.

Spirituality (continued) Many LGBT men and women choose not to let anyone in the church know they are gay. Other responses range from overtly confronting the homophobia to choosing to leave the organization altogether in search of a more accepting place to practice spirituality. Buddhism is one religious entity that contains no trace of homophobia. The AIDS crisis has produced relevant issues involving religion and spirituality in the gay community.

Reflection Questions 1. What challenges do you anticipate when working with those you know are lesbian, gay, bisexual or transgender? 2. What are your own biases regarding LGBT individuals? How will this impact your professional practice? 3. What do you see as a pharmacist’s role in working with the families of LGBT individuals?