Download Chapter 17 - American Pharmacists Association

Lesbian, Gay, Bisexual, and
Transgender Patients
Essentials of Cultural Competence in Pharmacy
Practice: Chapter 17 Notes
Chapter Authors: Dr. Kristina A. Peterson
and Dr. Duane A. Halbur
Learning Objectives
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
1.
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 1948. 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 1973.
 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
Stage
What 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, inlaws 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
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?
1.