By Michael B. Garrett, MS, CCM, CVE
Key Terms and Concepts
The Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) community is a mix of various gender identities and sexual orientations with different perspectives, preferences, healthcare needs, and opportunities. Professional case managers must understand critical terms and concepts to serve LGBTQ+ individuals and communities better. This includes understanding the challenges and opportunities faced by LGBTQ+ individuals and communities in society and with healthcare providers while using respectful and inclusive language.
Biological Sex
A healthcare provider assigns the biological sex of a newborn based on observation of external genitalia (Human Rights Campaign). This typically results in a binary manner so that the infant is either male or female. However, some individuals are intersex, and the medical term is disorders of sexual development (DSD), although many intersex people reject that term since it implies that there is something wrong with intersex bodies. Intersex is an umbrella term to describe differences in sex traits or reproductive anatomy that do not fit into the gender binary. There are many types of ways that intersex is experienced, including differences in external genitalia, internal organs, hormones, and chromosomes.
Gender Identity
Gender is a social construct that fluctuates depending on the time period, geographic location, and cultural environment. Some cultures only recognize the gender binary of male or female. However, other cultures acknowledge multiple genders and view gender on a spectrum. One's gender identity is not dependent on external genitalia but rather on how one thinks of one's gender identity. Some people identify as gender non-binary, meaning the person does not identify as exclusively as a man or woman. A transgender person is one whose gender identity and expression are different from the cultural expectations imposed on them based on the sex they were assigned at birth. In contrast, a cisgender person is one whose gender identity matches the sex they were assigned at birth (Human Rights Campaign).
Sexual Orientation
Sexual orientation is an inherent and immutable enduring characteristic regarding one's sexual attraction to other people (Human Rights Campaign). A person's sexual orientation is independent of their gender identity. There has also been evidence for decades that sexual orientation is not binary; in other words, there is a range of sexual attractions beyond being gay or straight. A person can be bisexual, for example, and yet a person's sexual orientation could be fluid so that it evolves and changes over time.
Gender Expression
Gender expression is the external appearance of one's gender, typically expressed through behavior, clothing, voice, hair, and body characteristics (Human Rights Campaign). One of the many reasons why there has been a focus on revealing pronouns is so that we do not make assumptions about one's gender identity or sexual orientation based on gender expression. Gender expression can also be fluid, such as one day, a person wears a skirt, and then another day wears pants. Gender expression is also heavily influenced by the geographic region, time period, and the community where a person lives.
Health Disparities and Health Equity
Health Disparities
There are many definitions of health disparities, and here is one example: Differences in health that are unnecessary and avoidable and considered unfair and unjust.
The policy implication of this definition is not to eliminate all health differences but to reduce or eliminate those resulting from avoidable and unfair factors. Disparity implies an inequity or an injustice rather than a simple inequality. (Whitehead, M., 1991). These disparities can be exhibited in the lack of necessary preventive services, lack of access to chronic care services, and different experiences of healthcare based on one's identity, such as sexual orientation, gender identity, race, etc.
Challenges Faced by LGBTQ+ Individuals and Communities with Healthcare Providers and Systems
There are several challenges faced by the LGBTQ+ community, including but not limited to the following (Bass & Nagy, 2023):
- Difficulty in openly discussing sexual health-related issues
- Providers fail to be sensitive in addressing sexual acts or complications unique to the LGBTQ community.
- Higher rates of anxiety, depression, eating disorders, and stress
- Higher rates of homelessness
- Higher rates of alcohol, tobacco, and substance abuse
- Individuals may be reluctant to share sexual practices and hormone use.
- Individuals may have prior traumatic experiences with clinicians.
- Insensitivity towards individuals who may engage in relationships with multiple partners or individuals of the same sex
- The lack of understanding by providers of LGBTQ terms and treatment needs
Each of the components of the LGBTQ+ community has particular challenges, such as providers not familiar with medical procedures and services for transgender patients or unnecessary medical procedures conducted on intersex patients without their consent. There are many reasons why LGBTQ+ individuals do not trust the healthcare system and providers, so the professional case manager should be aware of these and continually improve communication and care coordination techniques to serve this community of clients better.
Health Equity
There are also many definitions of health equity, and here is one example: Health equity means the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes. (Centers for Medicare & Medicaid Services). Since professional case managers are committed to providing equitable access to care for all clients who receive services, there should be a focus on improving the health equity for LGBTQ+ individuals as well as individuals from any other under-served or historically marginalized communities.
Effective Case Management Strategies
Several strategies and tactics can be implemented to serve the LGBTQ community and individuals better while delivering case management services. Professional case managers have always focused on providing patient-centered care, including all individuals who receive services, regardless of their demographics such as sexual orientation, gender identity, race, ethnicity, etc. Our practice standards require professional case managers to honor all our client's values, beliefs, and preferences. Below are some strategies and tactics to enhance the effectiveness and responsiveness of professional case management services for LGBTQ+ clients and communities.
Communication
A key to building trust with LGBTQ+ clients is to use respectful language. This can be accomplished by listening to how the client describes themselves and those who they identify as their family, regardless of blood relations or marital status. If a client describes themselves as queer, then that is the term the professional case manager uses. The client may also use terms to describe their significant other, spouse, or partner; that is the term the professional case manager can use. The client may also identify people with whom they do not want any information shared for various reasons, including the family of origin. The professional case manager can enhance communication skills by following the terminology and references that the client uses. One of the challenges for the professional case manager is when a client uses a name, gender, and pronouns that are not included in the eligibility, patient, or member files contained in the used system. At times, these systems have fields for nicknames; however, if that does not exist, the professional case manager will need to determine how to honor the client's request to use the name, gender, and pronouns that they have identified and revealed to the professional case manager. Additionally, the professional case manager should become aware of terminology, such as using terms that are common in the LGBTQ+ community, such as gender-affirming care and treatment, transgender, gender non-binary, etc. Words matter, and the professional case manager needs to pay attention to the language used in working with all clients, including but not limited to LGBTQ+ individuals.
Culturally Competent Care
Cultural competency has many definitions, and the American Hospital Association describes that "cultural competency in health care describes the ability of systems to provide care to patients with diverse values, beliefs, and behaviors; including the tailoring of health care delivery to meet patients' social, cultural, and linguistic needs. A culturally competent health care system acknowledges the importance of culture, incorporates cross-cultural relations assessment, recognizes the potential impact of cultural differences, expands cultural knowledge, and adapts services to meet culturally unique needs." The idea of cultural competency applies to healthcare systems and individual healthcare professionals, including but not limited to professional case managers.'
When referring health care providers to LGBTQ+ individuals, the professional case manager should consider finding not just "gay-friendly" providers since providers should be friendly to all patients! Rather, it recommends providers who have demonstrated a commitment to LGBTQ+ inclusive care. There are accessible provider networks that require providers to provide self-attestation to LGBTQ+ inclusive care, such as GLMA (health professionals advancing LGBTQ+ equality) and OutCare (focused on empowering LGBTQ+ individuals with comprehensive resources, support, and education, including an affirming healthcare directory). There are also paid subscription services for LGBTQ+ inclusive healthcare providers, such as Included Health Communities (connecting LGBTQ+ and Black members with vetted doctors in a dynamic directory) and FOLX Health (a nationwide healthcare provider network for the LGBT+ community).
When the professional case manager refers LGBTQ+ clients to healthcare systems, those should also be to facilities that offer LGBTQ+ inclusive care. The Healthcare Equality Index (HEI), supported by the Human Rights Campaign, is a national LGBTQ+ benchmarking tool that evaluates healthcare facilities' policies and practices related to the equity and inclusion of LGBTQ+ patients, visitors, and employees. The Long-Term Care Equality Index (LEI), supported by the Human Rights Campaign and SAGE) is a validated survey on LGBTQ+ inclusion in long-term care and senior housing communities, including skilled nursing facilities, assisted living facilities, independent living communities, continuing care retirement/life plan communities, memory care units, free-standing hospice communities, and affordable senior housing communities. These offer professional case managers resources in finding LGBTQ+ inclusive healthcare facilities, including acute care and long-term care settings.
Professional case managers should always check whether the individual providers or healthcare facilities are in-network for the client's benefit plan. Clients can optimize their benefit coverage by visiting in-network healthcare facilities and providers.
Assessments and Interventions
In light of the significant health disparities faced by the LGBTQ+ community and individuals, the professional case manager needs to be incredibly diligent in assessing and addressing the following:
- Social determinants of health
- Mental health and substance use disorders
- Literacy, including:
- Health literacy
- Digital health literacy
- Health insurance literacy
Of course, it is essential to not only conduct assessments of these domains (which should be done with all clients receiving professional case management services), but there should also be practical and focused interventions when needs are identified. It is also important to refer LGBTQ+ clients to services and programs that are LGBTQ+ inclusive. This may require the collection of data on local and regional LGBTQ+ resources. There are also some national resources that are focused on the LGBTQ+ community, such as The Trevor Project (the leading suicide prevention and crisis intervention non-profit organization for LGBTQ+ youth) and Center Link (LGBTQ+ community center directory in the U.S. and internationally). The professional case manager needs to be mindful that the services and programs are inclusive and welcoming to LGBTQ+ clients.
Clinical Reports and Guidelines
Some professional case managers conduct utilization review as part of their job functions; although some do not. In any case, it is advisable for the professional case manager to be aware of clinical reports and guidelines that impact the LGBTQ+ community. This includes clinical reports and guidelines on LGBTQ+ relative topics, such as gender affirming care and the care of intersex individuals. The World Professional Association of Transgender Health (WPATH) has publication entitled "Standards of Care for the Health of Transgender and Gender Diverse People" that is a great reference document to understand when medical, surgical, behavioral, and pharmaceutical treatments are indicated for transgender and gender diverse individuals. The United National Human Rights, Office of the High Commissioner (OHCHR) has published a document entitled "OHCHR Technical Note on the Human Rights of Intersex People: Human Rights Standards and Good Practices" which is another helpful document in understanding when medical, surgical, and other healthcare treatments are indicated, and when they are not indicated. A final example is from the American Academy of Pediatrics (AAP) that has published a document entitled "Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents" which would be helpful for professional case managers who work with children and adolescents who may be experiencing being transgender and/or gender-diverse.
Depending on the practice setting, it may also be important for the professional case manager to understand the coverage for other healthcare conditions impacting the LGBTQ+ community, such as family building (e.g., fertility, adoption, and surrogacy), mental health, substance use disorders, and sexually transmitted infections.
Becoming a Better LGBTQ Ally
There are many ways that professional case managers can become better allies. This includes at home, work, and social situations. This includes continuing to be a life long learner, since this area continues to evolve with terminology and respectful language, concepts of gender identity and sexual orientation, and medical advancements.
The Human Rights Campaign provides suggestions on how to be a better ally in various sectors in our lives:
When socializing with straight, cisgender family members and friends:
- Create social settings that bring your straight, cisgender and LGBTQ+ friends and family together
- Find opportunities to talk openly with your straight and cisgender friends about your LGBTQ+ friends and family and the issues they face
- Casually mention a news item about an LGBTQ+ issue in a positive way
- Mention other LGBTQ+ friends or family you might have in open conversations
When socializing with LGBTQ+ family members and friends:
- Talk openly and honestly with your LGBTQ+ loved ones about their lives
- Make sure that you include the partners/spouses of your LGBTQ+ loved ones in events and activities, just as you would any other friend's spouse or significant other
- Attend pride celebrations and other LGBTQ+ community events.
- Suggest a get-together to watch a movie or show with LGBTQ+ topics or characters
At work:
- Add your pronouns to your email signature or share your pronouns when introducing yourself to new friends or colleagues
- If you hear an anti-LGBTQ+ comment or joke, speak up and explain why such comments or jokes are harmful and offensive
- Integrate inclusive language into your regular conversations, professional interactions and/or spiritual life
- Put a supportive symbol or sign in your office or home, or on your vehicle, e.g., wear an LGBTQ+ ally button, add a rainbow sticker on your name badge at work, or put a LGBTQ+ sticker on your car or bag
At home and on your own:
- Read an LGBTQ+ publication
- Post a message in support of LGBTQ+ issues on social media
- Get involved with pro-LGBTQ+ groups; e.g., PFLAG
- Contact your elected officials about LGBTQ+ rights
- Join pro-LGBTQ+ causes or groups on social media and through other social networking opportunities
Becoming a better ally and enhancing professional case management services to the LGBTQ+ community and individuals is a journey, not a destination. It takes a commitment to life-long learning with the ability to adapt communications, behaviors, and attitudes for clients served by professional case managers.
Don’t miss Michael’s recent webinar "Enhancing Health Equity in Professional Case Management Practice for LGBTQ+ Individuals and Communities."
Dive deep into essential LGBTQ+ terms and concepts, learn ethical principles that promote inclusivity, and address health disparities. Plus, explore effective communication and care strategies tailored for LGBTQ+ individuals.
Presenter: Michael Garrett, MS, CCM, CVE
Earn 1.5 hrs RN, SW, CCM Ethics
FREE to Members | Non-Members: $40
Access the recording at https://www.pathlms.com/cmsa/courses/69311
Bio: Michael Garrett possesses more than 30 years of progressively responsible experience in managed care, care/case management, utilization management and review, chronic condition management, health information technology, healthcare quality, and population health management services. He has served in operational management, business development, product development, and strategic planning roles. His experience includes developing and implementing new care delivery models, such as patient centered medical homes and accountable care organizations (ACOs). Michael has experience working in a range of benefit programs, including fully insured medical plans, self-funded health plans, workers compensation, Medicaid, government employee plans, and long term disability. He served as the leader in the successful development, implementation, and on-going maintenance of quality management programs for care management programs He has also worked with health plans and healthcare providers in evaluating, improving, and optimizing health information technology and healthcare quality programs. His commitment to the healthcare industry is demonstrated by leadership roles in key organizations, including serving as a member and chair on the Commission for Case Manager Certification, a committee member and chair of URACs clinical accreditation committee, and a member of the Case Management Society of Americas Task Force for the Revision of the Standards of Practice for Case Management. He has served as an author, editor, and contributor on six case/care management books as well as the author of numerous journal articles in the field of care/case management. Michaels professional credentials include a Master of Science degree from the University of Idaho in clinical psychology and a Bachelor of Arts degree in psychology and religious studies from Gonzaga University. He is also a Certified Case Manager, Certified Vocational Evaluator, Nationally Certified Psychologist, and a Board Certified Patient Advocate.
References
American Academy of Pediatrics (AAP); Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents; https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for?autologincheck=redirected; Accessed 6/15/2024
The American Hospital Association; Becoming a Culturally Competent Health Care Organization; https://www.aha.org/ahahret-guides/2013-06-18-becoming-culturally-competent-health-care-organization#:~:text=Cultural%20competency%20in%20health%20care,social%2C%20cultural%20and%20linguistic%20needs; Accessed 6/15/2024
Bass B, Nagy H. (2023). Cultural Competence in the Care of LGBTQ Patients. 2023 Nov 13. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 33085323. https://pubmed.ncbi.nlm.nih.gov/33085323/; Accessed 6/15/2024
Center Link; https://www.lgbtqcenters.org/LgbtCenters; Accessed 6/15/2024
Centers for Medicare & Medicaid Services (CMS) Framework for Health Equity; https://www.cms.gov/priorities/health-equity/minority-health/equity-programs/framework; Accessed 6/15/2024
FOLX Health; https://www.folxhealth.com/; Accessed 6/15/2024
GLMA (Health Professionals Advancing LGBTQ+ Equality); https://glma.org/; Accessed 6/15/2024
Healthcare Equality Index (HEI); https://www.hrc.org/resources/healthcare-equality-index; Accessed 6/15/2024
Human Rights Campaign (HRC); Being an LGBTQ+ Ally. https://reports.hrc.org/being-an-lgbtq-ally; Accessed 6/15/2024.
Included Health Communities; https://includedhealth.com/employers/communities/; Accessed 6/15/2024
The Joint Commission; Meeting the needs of the LGBTQ+ community- then and now; LGBTQ Field Guide; https://www.jointcommission.org/resources/news-and-multimedia/blogs/advancing-health-care-equity/2022/06/meeting-the-needs-of-the-lgbtq-community/; Accessed 6/15/2024
Long-Term Care Equality Index (LEI); https://www.hrc.org/resources/long-term-care-equality-index; Accessed 6/15/2024
OutCare; https://www.outcarehealth.org/outlist/; Accessed 6/15/2024
The Trevor Project; https://www.thetrevorproject.org/; Accessed 6/15/2024
United Nations Human Rights, Office of the High Commissioner (OHCHR); OHCHR Technical Note on the Human Rights of Intersex People: Human Rights Standards and Good Practices; https://www.ohchr.org/en/documents/tools-and-resources/ohchr-technical-note-human-rights-intersex-people-human-rights; Accessed 6/15/2024
Whitehead, M. (1992). The concepts and principles of equity and health. International Journal of Health Services; Vol. 22, No. 3(1992); pp. 429-445. https://www.jstor.org/stable/45131055; Accessed 6/15/2024.
World Professional Association for Transgender Health (WPATH); Standards of Care for the Health of Transgender and Gender Diverse People; https://www.wpath.org/; Accessed 6/15/2024