Throughout human history, individuals with diverse sexual orientations and gender identities have existed. Discrimination, lack of access to healthcare, and stigma can all contribute to poor health outcomes for LGBTQ+ individuals.
Occupational therapists should understand health equity and how it impacts LGBTQ+ people so they can help improve the quality of life and health outcomes for their clients.
All people have a sexual orientation and gender identity.
- Sexual orientation is how a person identifies their physical, emotional, and romantic attachments to others.
- Gender identity is one’s self-awareness of their gender, such as a man, woman, both, neither, or beyond. Gender expression is how we express gender to people around us through pronouns, clothing, names, etc.
Sexual Orientation Terminology
- Asexual: Someone who has little or no sexual attraction to others
- Bisexual: Attracted to people of more than one gender
- Gay: Predominantly attracted to the same gender as one’s own; often used to refer to men specifically but sometimes used as an umbrella term to refer to people of all genders
- Lesbian: Predominantly attracted to the same gender as one’s own; primarily used to refer to women
- Pansexual: Attracted to people of all genders or experiencing attraction without regard to sex or gender
- Straight: Predominantly attracted to a gender different from their own
- Queer: Refers to someone who may not identify as straight, bisexual, gay, lesbian, etc., but identifies by the fact they are not heterosexual; used as a slur in the past but reclaimed by some members of the community and used with pride; inclusive term for different orientations and identities; not a term liked/accepted by all community members
- Questioning: Refers to someone who is exploring their sexual orientation or gender identity and has not yet settled on their identity
A plus sign ( + ) is often used in acronyms such as LGBTQ+ or LGBTQIA+ to refer to those with other identities who are also part of the community (Keuroghlian & Dunn, 2021).
Gender Identity Terminology
- Binary: Refers to two choices (either/or); people who identify binary genders are people (whether cisgender or transgender) who identify as male or female
- Cisgender: A person whose gender identity or expression aligns with society’s expectations based on the sex they were assigned at birth
- Intersex: An umbrella term for differences in sex traits or reproductive anatomy
- Non-binary: Gender identities that aren’t binary such as a genderqueer or gender fluid person
- Transgender: A person whose gender identity or expression does not align with society’s expectations based on the sex they were assigned at birth
- Transfeminine: Someone with a feminine gender expression; can apply to binary or nonbinary identities
- Transmasculine: Someone with a masculine gender expression; can apply to binary or nonbinary identities
The terms individuals use to describe themselves may change over time as they develop or age. These terms are clinically relevant and dynamic and an important way of understanding clients’ evolving health variables (Keuroghlian & Dunn, 2021).
Understanding Health Equity
Health equity is the idea that equal opportunity leads to a healthy life. Some people require additional resources or assistance to reach the same level of health as others.
While equality seeks to offer the same level of assistance to all, equity acknowledges that different people may need various levels of support to attain a similar result.
Healthy People 2030, an initiative to improve health equity, states “Lesbian, gay, bisexual, and transgender (LGBT) people experience many specific health-related challenges and disparities. … LGBT adolescents are especially at risk for being bullied, thinking about and dying from suicide, and using illegal drugs.”
Social determinants of health include access to education, employment, housing, healthcare, and experiences of discrimination and violence. These determinants can create health disparities and contribute to poor health outcomes, which can be worsened by factors such as poverty, lack of social support, and trauma.
To achieve health equity, we must address social determinants of health, such as discrimination that impacts the LGBTQ+ community.
The Impacts of Stigma on Health
Three types of stigma are recognized that impact the LGBTQ+ community:
- Structural or institutional discrimination can intentionally or unintentionally restrict freedoms and opportunities for certain groups of people.
- Interpersonal stigma is stigma perpetrated between individuals such as between colleagues, between clients and practitioners, or between patients and physicians.
- Intrapersonal stigma refers to negative thoughts or feelings a person has toward themselves, which may include internalized homophobia or transphobia or fear of rejection. It is often accompanied by shame and distress.
Studies show that intrapersonal stigma is associated with HIV risk behavior (Hatzenbuehler et al., 2008). Experiencing stigma—or anticipating an experience of stigmatization—resulted in an approximately 40% increase in delaying both urgent and preventative healthcare in a sample of 2578 transmasculine people (Reisner et al., 2015).
Occupational therapists can focus on cultivating and promoting resilience in LGBTQ+ individuals, which can help mitigate the negative impacts of minority stress and discrimination on health outcomes.
Barriers to Healthcare Access
Stigma and fear of discrimination can cause many LGBTQ+ individuals to avoid seeking care altogether. This can lead to delayed treatment, worsening health outcomes, and an overall decrease in quality of life.
LGBTQ+ communities have higher rates of being uninsured or underinsured, thereby increasing the risk of not receiving the right medical care at the right time (Lambda Legal, 2010). LGBTQ+ individuals may also face barriers related to insurance coverage and financial resources. Insurance policies may not cover certain healthcare needs that are specific to transgender individuals, such as hormone therapy or gender-affirming surgery.
Creating Inclusive Environments
Creating inclusive healthcare environments for LGBTQ+ individuals is crucial to ensure that they feel safe, respected, and supported in healthcare settings.
Here are some tips for creating inclusive healthcare environments:
- Ask people what their pronouns are. A great way to do this is to introduce your own first. Another way to address someone respectfully is to use their first name.
- Use gender-neutral language to avoid assuming gender identity or sexual orientation. Instead of using ma’am or sir, simply ask how you can help them. Instead of asking,“Who are your mother and father” try asking, “Who are your parents or guardians? Who is here with you today?”
- Understand health equity and how it impacts LGBTQ+ people to improve quality of life and health outcomes for occupational therapy clients.
- Address social determinants of health and ensure equal access to resources and support.
- Use client-centered care to partner with clients on their goals and outcomes.
- Avoid saying things such as “You look like a real woman” or “I would have never known.” Such statements can be unintentionally hurtful and inappropriate
- We all make mistakes. If you accidentally use the wrong name or pronouns, understand and address intentions and impact and apologize without centering yourself.
Inclusive occupational therapists can educate themselves on LGBTQ+ issues, create safe spaces for LGBTQ+ rights, use respectful communication and active listening, and use their privilege and expertise on health equity to amplify LGBTQ+ voices.
Occupational therapists and other healthcare professionals can work together to create a more fair healthcare ecosystem by advocating for everyone to have access to the care they need.
Resources
An Introduction to Health Equity for Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual (LGBTQIA+) People, available on OccupationalTherapy.com, discusses inclusive and effective communication with LGBTQIA+ patients.
The Fenway Institute exists to optimize the health and well-being of sexual and gender minorities (SGM) and those affected by HIV. They also offer the LGBTQIA+ education center.
Healthy People 2030 Initiatives for LGBTQIA+ Community
GLMA is a national organization committed to ensuring health equity for lesbian, gay, bisexual, transgender, queer (LGBTQ), and all sexual and gender minority (SGM) individuals, and equality for LGBTQ/SGM health professionals in their work and learning environments. To achieve this mission, GLMA utilizes the scientific expertise of its diverse multidisciplinary membership to inform and drive advocacy, education, and research.
References
Hatzenbuehler, M. L., Nolen-Hoeksema, S., & Erickson, S. J. (2008). Minority stress predictors of HIV risk behavior, substance use, and depressive symptoms: results from a prospective study of bereaved gay men. Health Psychology, 27(4), 455-462.
Keuroghlian, A., & Dunn, M. (2021). An Introduction to Health Equity for Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual (LGBTQIA+) People. Available at www.OccupationalTherapy.com
Lambda Legal. (2010). When health care isn’t caring: Lambda Legal’s survey of discrimination against LGBT people and people living with HIV. New York: Lambda Legal.
Reisner, S. L., Pardo, S. T., Gamarel, K. E., White Hughto, J. M., Pardee, D. J., & Keo-Meier, C. L. (2015). Substance use to cope with stigma in healthcare among U.S. female-to-male trans masculine adults. LGBT health, 2(4), 324-332.
