This post is a nod to the upcoming, opening plenary address at the 2016 CFHA Conference in Charlotte, NC.
health of children and adults who identify as lesbian, gay, bisexual, or
transgender (LGBT) has the potential to be greatly
impacted by their family, health care system relationships, and the broader
context of where they live. The research tells us this can be done in both
tremendously helpful and hurtful ways. Let’s take a deeper look…
Growing up, it was common to
have my mom accompany me and help me fill out forms detailing my personal
information when I went to see my primary care provider. The forms provided my healthcare
team basic background information like my demographics (i.e., gender, age, or
ethnicity) and personal/family medical histories (i.e., history of smoking,
heart attacks, or cancer). But, what if this basic information isn’t actually
so basic? What if my mom didn’t really know everything about me? What if it’s
because I couldn’t tell her everything about me?
Through all these background
forms we completed in my childhood, I didn’t tell my mom that I’m transgender.
I didn’t tell my mom I didn’t feel like a girl. I didn’t tell my mom that I
wanted the world to know and see me as a boy. No one knew the emotional turmoil
I kept inside me. No one knew about the anxiety and depression I felt every
time I was called a girl. The sigh I breathed and how I hung my head every time
I had to check the female box on my background forms.
doesn’t reflect all family dynamics and reactions to children who identify as
LGBT. There are many warm, accepting families that would adjust and support
Jenna sharing her identification as transgender. They might listen and validate
her struggles of being called, categorized, and labeled as female when she
actually felt and considered herself male.
A supportive family might even walk
with Jenna as she explores changing her name, preferring to be acknowledged by
the pronoun "he” rather than "she”, wearing different clothes, or beginning
hormone replacement therapy. They might, again, return with Jenna to the
primary care healthcare team to help start the conversation about what options
are available to address not only the physical symptoms, but also address the
anxiety, depression, and lifestyle changes.
what if our patients do feel similar to Jenna? What if our patients’ families
are dismissive or rejecting? What if they don’t understand and/or wouldn’t
accept their LGBT family members? Maybe there are some themes from Jenna’s
story that do apply to our patients.
If so, are there ways we can communicate
acceptance and safety in our offices to the LGBT community when they may be too
afraid to start that conversation? Are there resources/handouts available to
patients who might be secretly struggling? Are we, as the healthcare team, able
to offer patients safe spaces to begin talking about the issues that so far
they can only communicate about through their physical ailments?
primary care health care center, I spoke with a healthcare team that included 2
primary care providers (PCPs), a nurse, and case worker. Through this
conversation I realized there are many small acts that healthcare teams are
already doing that communicate care and support. This can be done in a more
indirect approach, such as asking teens about dating both boyfriends and
girlfriends at child-well checks, or it can be more direct, such as asking
specifically about a patient’s sexual orientation in relation to their physical
or mental health symptoms.
Within the family context there are also some ways
that a healthcare team can intervene to help restructure the family’s
communication about the patient identifying as LGBT. The specific intervention
or treatment approach will differ based on the personality and preference of
the PCP, nurse, or case worker but there are some general tips to keep in mind
when attending to patients who identify as LGBT:
Barriers to Consider and Possible Interventions
LGBT youth can lack power within the family system to
have control over their lives or access to their prescribed treatments.
ask LGBT youth about family reactions to their identity to assess for level of
family rejection, if any, and related health risks
- Ask questions such as: "Who are you out to”?
- If out to family, "How has your family reacted
to you coming out to them, or sharing this part of your identity with them”?
- If not out to family, "What do you think is
getting in the way of coming out to, or sharing this part of your identity with
psychoeducation to families of LGBT youth about the health risks associated
with lack of support for the youth based on sexual orientation and gender
identity, and ways to be supportive and engaged4.5,6,7,8
a safe, non-reactive space for LGBT patients to share through active listening
and empathic statements
- Become familiar with medical and behavioral health
providers in your are that have experience working with LGBT populations
- Provide information about LGBT community and
support groups in your area that can offer peer support and mentorship
on age, safety, and level of independence of patient, it may be appropriate to
help connect LGBT patients to public transportation, local community resources
that provide transportation, or mail-delivered prescriptions, if appropriate
and legal (Consult with PCP, pharmacist, and other health care providers as
- Refer patient and/or families to trained family therapy
providers, strength-based support groups or peer counseling, and on-line
credible resources for families of LGBT youth; follow-up with youth and
youth and adults may remain in silence
or denial about LGBT identity due to assumptions or fear of experiencing dismissive or rejecting reactions from the healthcare team, which may prolong
physical and mental health symptoms
posters or flyers in your clinics that include LGBTQ youth, same-sex couples,
all staff on LGBT health and competencies1
single stall, gender- neutral bathrooms1
gender identity and sexual orientation in non-discrimination policies1
patients to identify their sexual orientation and gender identity, as well as
preferred name and pronouns on appropriate forms1
office policy in compliance with local laws regarding confidentiality for
health history as a conversation, not a check list1
sensitive topics, such as sex and substance use, as routine questions for all
patients, using non-judgmental tone and body language1
youth, use the mnemonic H.E.A.D.S.2 for taking social and behavioral
questions about gender and sexuality, and don't make assumptions
- Use questions and statements
am going to ask you some questions about yourself and I want you to tell me how
you feel, not how you think others see you or how others think you should feel.
These are questions I ask all my patients.1
you attracted to boys/men, girls/women, or both? 1
do you feel about your attractions?1
words do you use to describe your sexual identity?1
gender do you consider yourself to be regardless of what body parts you may
- How do you feel about your gender? 1
patients may lack a social support
system due to family and/or community cultural values or religious beliefs that do not accept, tolerate, or embrace
LGBT patients quit taking medications for symptoms
(such as depression or anxiety) because they do not believe the medications
will help treat the root of their problems (i.e., stress of identifying as a sexual or gender orientation minority,
family rejection, community isolation, etc.)
for support needs in a respectful way by inquiring about the presence and types
of social supports of patients
opportunities for disclosure of relationships and supports, including respectfully
inquiring about patients’ relationships with others accompanying them at
appointments, keeping in mind it may or may not be family members or local
patients with LGBT community resources and trained behavioral health
specialists in LGBT care, as needed
patients with supportive online/social media LGBT resources
validation and normalization statements to increase LGBT patients’ communion
with others from the broader LGBT community and local healthcare center
Motivational Interviewing3 techniques to assess and promote
different ways patients’ may exercise their agency within their context.
Examples may include:
open-ended questions to help patients verbalize how they are making meaning
about the possible discrepancies between their personal identification and
cultural or family or religious values
- Provide affirmations to patients’ strengths
throughout the encounter, such as his/her courage to self-disclose in
respectfully curious about the reason they have stopped taking their medication
validation for patients’ experiences without expressing agreement
for possible additional personal or cultural biases related to medications that
may inhibit their willingness to adhere to treatment (i.e., medication =
patients on the health risks associated with stopping medication, stress, and
lack of social support
- Discuss alternatives to medication, including
journaling, meditation, increasing activity levels, individual and family
counseling, and offer LGBT community resources and supports
about a patient you’ve seen in the past that you may or may not have asked
about their sexuality or gender identity. How did knowing or not knowing this
information impact the care you provided? Were you curious about their sources
of support? Did you make assumptions about the sources of support they had, or
did you ask about it? How did it help to know the answer, or why do you wish
you would have known?
didn’t ask about these things, what do you think got in the way? What do you
think it will take for you to be able to ask these questions?
of our beliefs, we need to be prepared to have conversations that foster
openness and understanding with all patients. The healthcare team is uniquely
positioned to assess for social support needs and work with patients and their
families or families of choice to access the care and services they need for
whole health. Take a moment to think about your office and the ways you can
better create a safe space for your LGBT patients and their families, help
patients utilize social support for better health and healing, reduce the
health disparities and discrimination, and promote every aspect of our LGBT
Additional resources for
providers support LGBT adults and their social support networks:
- Fredriksen-Goldsen, K. I., Hoy-Ellis, C. P., Goldsen, J., Emlet, C. A.,
& Hooyman, N. R. (2014). Creating a vision for the future: Key competencies
and strategies for culturally competent practice with lesbian, gay, bisexual,
and transgender (LGBT) older adults in the health and human services. Journal
of Gerontological Social Work,57(2-4), 80-107.
- Lim, F. A., Brown Jr, D. V., & Kim, S. M. J. (2014). CE: Addressing
health care disparities in the lesbian, gay, bisexual, and transgender
population: A review of best practices.AJN The American Journal of
resources for providers supporting LGBT youth and their families:
- Ryan, C. (2009). Supportive families, healthy children:
Helping families with lesbian, gay, bisexual & transgender children.
San Francisco, CA: Family Acceptance Project, Marian Wright Edelman Institute,
San Francisco State University.
- Ryan, C., & Monasterio, E.
(2011). Providers’ guide for using the
FAPrisk screener for family rejection & related health risks in LGBT youth.
San Francisco, CA: Marian Wright Edelman Institute, San Francisco State
- Substance Abuse and Mental
Health Services Administration (SAMHSA). (2014). A practitioner’s resource guide: Helping families to support their LGBT
children. HHS Publication No. PEP14-LGBTKIDS. Rockville, MD: Substance
Abuse and Mental Health Services Administration, 2014.
1The National LGBT Health Education Center. Caring for LGBTQ
youth in clinical settings. Retrieved August 8, 2016 from http://www.lgbthealtheducation.org/training/learning-modules/
2Goldenring, J. M., & Rosen, D. S. (2004). Getting into
adolescent heads: an essential update.CONTEMPORARY
3Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people
York: Guilford Press.
4The National LGBT Health Education Center.
Resources and suggested readings. Retrieved
September 19, 2016 from http://www.lgbthealtheducation.org/lgbt-education/lgbt-health-resources/
5Bouris, A., Guilamo-Ramos, V.,
Pickard, A., Shiu, C., Loosier, P.S., Dittus, P., Gloppen, K., & Waldmiller, J.M. (2010). A systematic review
of parental influences on the health and well-being
of lesbian, gay, and bisexual youth: Time for a new public health research and practice agenda. Journal of Primary Prevention, 31, 273-309. doi:10.1007/s10935-010- 0229-1
6Ryan, C., &
Chen-Hayes, S. (2013). 13 Educating and Empowering Families.Creating Safe
and Supportive Learning Environments: A
Guide for Working With Lesbian, Gay, Bisexual, Transgender,
and Questioning Youth and Families, 209.
7Ryan, C., Huebner,
D., Diaz, R.M., & Sanchez, J. (2009). Family rejection as a predictor of negative health outcomes in white and
Latino lesbian, gay, and bisexual young adults. Pediatrics, 123,
346-352. doi: 10.1542/peds.2007-3524
8Ryan, C., Russell, S.
T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT
young adults.Journal of Child and Adolescent Psychiatric Nursing,23(4), 205-213.
|Jessica Goodman received her M.S. in Family Therapy from the
University of Massachusetts in Boston. She is currently a Ph.D. Student in the
Medical Family Therapy program at East Carolina University. Her present
research goal is to develop an evidence-based integrated care protocol for the
ED to reduce health disparities among minority and underserved populations
experiencing diverse concerns in an emergency setting. |
|Erin Sesemann is a current Ph.D. Student in Medical Family Therapy at East Carolina University. She has experience working in community mental health agencies, private practice, and integrated behavioral health care in primary care. She graduated with her M.S. in Marriage and Family Therapy from Oklahoma State University in Stillwater, OK.|