Introduction to Affirming Care for Gender and Sexual Minorities

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Introduction

In the health care environments, LGBTQ+ adolescents and adults experience marginalisation, stigma and normative pressure resulting in their poor health and social outcomes. This may be due to health care providers' lack of training and sensitivity to the health needs of LGBTQ+ people. Healthcare workers report being uncomfortable communicating with sexual and gender minority (SGMs) patients. Additionally chronic stress related to marginalisation and discrimination contributes to the health care disparities among the SGMs group. They not only suffer poorer health but also worse healthcare experiences.Yet, their health care needs are well documented, as various reports indicate high rates of substance abuse, depression, suicide, and cardiovascular disease.

Gender and sexual minorities live in every part of the world and comprise all races and/or ethnicities, religions, and social classes. They require access to healthcare to meet their medical needs. At the same time, healthcare organisations must ensure that their environment is inclusive for LGBTQ+ patients by educating staff on cultural awareness and nondiscrimination policies.

Gender-Neutral Language

To ensure that the cultural responsiveness in understanding the needs of LGBTQ+ is well present, there is a worldwide movement towards the development of a more inclusive language. LGBTQ+ activists and linguists are working on creating entirely new non-binary terms and on changing already existing words and grammar constructions.The following are examples of gender-neutral language changes that were introduced to English and other world languages:

• English: there was no distinction between genders except for singular pronoun, which can be masculine or feminine. In 2019 “they” was added as the pronoun to use for a “single person whose gender identity is non-binary.”
• Spanish: all nouns have feminine and masculine cases. In daily conversations, the masculine “o” or the feminine “a” is now replaced with the gender-neutral “e” in certain words.
• Arabic: each verb, noun and adjective has always assigned either a male or female case. Public awareness of gender-neutral language remains extremely low in Arabic-speaking countries, and there is low social tolerance of this language.
• Hebrew: gender is assigned to verbs, nouns, and adjectives based on the noun. In gender-neutral language, there is a default to a feminine plural or a “mixed” gender, sometimes male and sometimes female for the same person.
• German: includes male, female and neutral grammatical genders, signified by the suffixes “r” or “rn” for men, and “in” or “innen” for women. In gender-neutral language, the uppercase "I" in compound nouns is used to address both males and females at once. A "gender star" in form of an asterisk has also been added to include persons who do not consider themselves either."
• French uses male or female gender in all nouns referring to an individual. The first step in gender-neutral language was to use asterisks to combine case endings to create gender-neutral plural, for example, “ami•e•s” for friends.
• Sweden: the word “hen” was added to the official dictionary, which indicates a gender-neutral pronoun as an alternative to the male pronoun “han” and female “hon".

Learn more about gender-neutral language here.

Gender and Sexual Minorities

Gender identity and sexual orientation are not the same things. Gender is a spectrum. Sexual orientation defines attraction and biological sex. Binary sex refers to maleness or femaleness. Intersex can define individuals who move from one sex to the other across their lifetime or who are born with a different degree of maleness or femaleness.

LGBTQQIIP2SAA+ stands for lesbian, gay, bisexual, transgender, questioning, queer, intersex, intersectional, pansexual, two-spirit (2S), androgynous and asexual. This is the most completed to date acronym for gender and sexual minorities.

• Lesbian: women who are romantically and/or sexually attracted to women.
• Gay: usually identifies men with romantic and/or sexual attraction to men.
• Bisexual: an individual who is sexually, romantically, physically, and/or spiritually attracted to more than one gender.Someone who is attracted to the same gender as their own and another gender.
• Transgender: people whose gender identity does not correspond to the sex they were assigned at birth.
• Questioning: person searching for their gender identity and/or sexual orientation
• Queer: a person who does not conform to cultural norms regarding gender or sexuality and who is attracted to people of many genders.Term that include anybody who's not cisgender and heterosexual, and is also used as a sexual orientation for those who don't really have a label. It sometimes may be an easy way to shorten LGBTQ+ acronym.
• Intersex: individuals who are born with components of traditionally male and female anatomy

• Intersectionality: “the network of connections between social categories such as race, class and gender, especially when this may result in additional disadvantage or discrimination”

• Pansexual: an individual who is sexually, romantically, physically, and/or spiritually attracted to members of all gender identities
• Two-spirit: a person whose gender identity has two spirits: masculine and feminine.
• Androgynous: a person whose gender expression does not fit into gender norms.
• Asexual: someone who does not experiences a sexual attraction and/or has no interest in pursuing a sexual relationship with others. An individual with persistent lack of sexual attraction towards any gender

You can read more about asexuality here.

Other acronyms and descriptions related to gender identity and sexual orientation :

• TGNC stands for Transgender and Gender Nonconforming
• Gender Nonconforming describes someone who does not conform to gender expectations (example: assigned female at birth, identifies as a woman, but has masculine presentation: short hair, wears men's clothes, etc).
• Cisgender: an individual who identifies with the gender assigned at birth
• Agender: persons who feel that they have no gender
• Genderfluid or genderqueer:people who feel like their gender fluctuates
• Monosexual: attracted to one type of gender identity
• Polysexual: attracted to several types of gender identities
• Homoromantic: a person interested in having relationships romantically with one person
• Heteroromantic: a person interested in having a relationship with two different genders
• Biromantic: person romantically attracted to people of two specific and distinct gender identities
• AMAB: assigned male at birth
• AFAB: assigned female at birth

Cultural Competence

According to Cross and colleagues cultural competence is “a set of congruent behaviours, attitudes and policies that come together in a system, agency or amongst professionals and enables that system, agency or those professionals to work effectively in cross-cultural situations.” Cultural competence aims to enhance healthcare delivery by providing quality care that is unbiased and culturally sensitive, and where diversity is respected and the healthcare outcome is not affected by providers' language, communication styles, attitudes, and behaviours.

Cultural competence is simply making an effort to reduce any cultural, linguistic, or other barriers that exist between, in this case, patients and medical professionals, such as yourself". Dr Durand

A systematic review of literature on the LGBTQ+ communities demonstrated that their inability to access equitable health care may have a profound impact on their overall well-being. They report having to teach providers about their healthcare-related needs, experiencing provider discrimination, receiving inappropriate care recommendations, and even the care they need is denied.

Cultural competence in healthcare can be achieved through appropriate staff training. Staff should be taught reflective awareness, empathy, and active listening techniques when facing racial and ethnic differences, or attending to marginalised population groups who may be different in other identities.

LGBTQIA+ Demographic

In 2021 the global survey on gender identity worldwide was conducted and the responders from 27 countries were asked about their gender identities and sexual orientations. The results were as follow:

• 3% per cent of respondents declared to be homosexual, gay, or lesbian
• The largest group of bisexual respondents were from India (9%)
• 1% of the interviewees declared to be pansexual or omnisexual (attracted to people of all gender identities and sexual orientations)
• 2% identified themselves as transgender, non-binary/non-conforming/gender-fluid, or in another way.
• 3% of responders from Germany and Sweden identified themselves with one of the genders.

The 2017 results of a 15+ LGBTQ+ Population Statistics in the United States were as follow:

• 1.7% of individuals self-identified as being either gay or lesbian
• 1.8% of people declared to be bisexual
• 4.5% of adults (about 11 million people) identified as LGBT (an increase from 8.3 million in 2012)
• 0.6% of individuals 15+ self-identified as transgender
• 12% of Millennials identified themselves as transgender or gender nonconforming
• 58% of LGBTQ+ individuals were white, 21% Latino(a), 12% black, 5% were of more than one race, 2% were Asian, 1% American Indian, and 1% were pacific islander
• 20% of LGBT was between 18-34, 12% between 35-51, 7% between 52-71, 5% was 72+ .

According to 2019 U.S. Census Bureau 5.6% of the U.S. population is LGBTQIA+ (18.5 million people).

Please watch this short video highlighting the life of elderly LGBTQIA+ in the US.

Physiotherapy Role in LGBTQIA+ Community

Medical issues commonly present in LGBTQIA+ individuals:

• Urinary Tract Infections are often related to holding the urine too long due to a lack of gender-neutral restrooms
• Gender dysphoria leading to postural changes: rounded shoulders, forward head, thoracic kyphosis
• Respiratory issues and pelvic floor issues related to inadequate engagement of the diaphragm as a consequence of poor posture
• Urinary tract complications including incontinence, urgency, or frequency

All clinical settings: outpatient orthopaedics, Long Term Care (LTC) facilities, Skilled Nursing Facilities (SNFs), home health, acute care, pediatric clinics

All specialities:

• Orthopedics: complications related to removal or augmentation of chest tissue, including thoracic spine mobility, upper extremity mobility, scar tissue, pain
• Women's/Men's Health: medical transition and gender-affirming surgery, physiotherapy for the pelvic floor, dilator training after vaginoplasty

Resources

• National Standards for Culturally and Linguistically Appropriate Services in Health Care. Final report. Available from https://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf