Providing Culturally Sensitive LGBTQ+ Diabetes Health Care
Editor’s Note: This piece refers to several studies on care conducted within the LGBTQ+ community. Wording around gender and sexuality is taken directly from each study.
2021 broke the record as the year for having an astronomical number of anti-LGBTQ laws, some of which impact medical care for LGBTQ individuals.
For example, in April, Arkansas passed the Save Adolescents From Experimentation (SAFE) Act, a law that bans gender-confirming surgery for individuals under 18 years of age and prohibits doctors from providing transgender youth puberty blockers or hormone therapy. Arkansas is just one of the many states that passed or introduced anti-trans legislation, adding to the myriad of barriers that already prevent LGBTQ folks from accessing health care, especially culturally sensitive LGBTQ+ diabetes health care.
Kyle Banks, founder and CEO of Kyler Cares—a nonprofit foundation that provides funding towards technology for kids and adults with type 1 diabetes—tells Beyond Type 1 that although he has had mainly positive experiences with the healthcare system, his friends have not. “So many friends that identify as LGBTQ+ are not feeling they’re being heard, feeling their healthcare providers are not seeing them as full human beings,” Banks says.
According to one study, 39 percent of transgender people face harassment when seeking health care. Examples of such harassment include demeaning comments, withholding information and making inappropriate jokes.
Experiencing stigma, discrimination, violence and rejection by family and community members (one study found that two years after a child came out as lesbian, gay, or bisexual, many parents still say that it was moderately or very hard for them to adjust to the news) can also lead to a lack of safe access to resources, such as insurance and income, for LGBTQ folks.
One research study found that 7.5 percent of almost ten thousand sexual minority (non-heterosexual) participants were not working and 4.9 percent were uninsured. According to the study, these rates were about double the unemployed and uninsured rates among heterosexual people. The reason for unemployment was due to illness or having a disability, while the lack of insurance was unknown.
Based on results from a 2017 nationally representative survey, LGBQ respondents (transgender respondents’ data listed separately, below) who had visited a doctor in the prior year reported a doctor or other healthcare provider refusing to see them because of their actual or perceived sexual orientation (eight percent), doctor or other healthcare provider refusing to provide health care (six percent), and a doctor or other healthcare provider using harsh or abusive language when treating them (nine percent).
For transgender respondents, 29 percent said a doctor or other healthcare professional refused to see them because of their actual or perceived gender identity, 12 percent refused to give them gender transition-related care, and 23 percent intentionally misgendered them. As a result, 6.7 percent of LGBTQ respondents reported avoiding doctor’s offices out of fear for discrimination.
In addition, many providers are not even aware that their patients identify as LGBTQ. Research shows that the most significant barrier to disclosure of LGBTQ identity was the provider not asking the patient. While some patients have experienced stigma, discrimination, or disbelief after disclosing their LGBTQ identity, those who expressed greater satisfaction with healthcare providers because they were able to openly disclose their gender identity or sexual orientation experienced higher rates of routine preventive screening, vital for optimum health and catching possible larger health issues.
One example of the importance of healthcare provider knowledge of LGBTQ identity is preventive cancer screenings. For example, lesbian women have multiple risk factors for breast cancer including higher smoking rates, higher levels of obesity and greater alcohol use. Provider knowledge can lead to early detection, proper diagnosis and treatment.
Young adults frequently reported not having a reaction to their LGBTQ identity disclosure, highlighting the missed opportunity for providers to build connections and offer support to their patients and a gap in current efforts to create positive and inclusive environments for LGBTQ folks. Gender-affirming health care has been shown to reduce suicide ideation and attempts among transgender individuals, as LGB youth are five times more likely to have attempted suicide compared to heterosexual individuals, according to the Trevor Project.
Coupled with the aforementioned barriers, LGBT people have difficulty finding providers who can provide culturally sensitive care and are knowledgeable about their needs, according to a report titled You Don’t Want Second Best Anti-LGBT Discrimination in U.S. Health Care. This is because transgender treatment is not taught in medical school curricula, with few physicians having knowledge or training. As a result, it can cause LGBT individuals to delay or forgo care.
LGBT Risk Factors For Diabetes
LGBT individuals have unique health challenges that increase their diabetes risks. For example, smoking directly increases the risk of insulin resistance, which can make insulin dosing more difficult for those already living with diabetes, or can lead to type 2 diabetes. Among LGBT youth, smoking rates have ranged from 38 to 59 percent. For adults, the rate has ranged from 11 to 50 percent. One study found higher menthol use among LGBT adults (36.3 percent compared to 29.3 percent for heterosexual adults). While there is no one cause of high smoking prevalence, potential causes include stress and discrimination in the coming out process.
Obesity is also a risk factor in diabetes, contributing to insulin resistance across all types of diabetes and increasing the risk of type 2 diabetes for those not yet living with the disease. Compared to heterosexual women, lesbians have higher overweight and obesity rates due to eating disorders, fewer concerns of body image when dating women compared to men, and lower levels of exercise.
Other risk factors for diabetes among LGBT individuals include psychological distress, substance use, depression and delay in prescription medicine fills. The barriers and risk factors underscore the importance of providing culturally tailored diabetes care.
Providing Culturally Sensitive LGBTQ+ Diabetes Health Care
In 2010, Theresa L. Garnero, APRN, BC-ADM, MSN, CDE, an assistant clinical professor and director of the diabetes management certification program at the University of the Pacific’s Benerd College, outlined provider tips for providing culturally sensitive care to LGBTQ folks with diabetes in an article titled Providing Culturally Sensitive Diabetes Care and Education for the Lesbian, Gay, Bisexual and Transgender (LGBT) Community.
Although published nearly a decade ago, the provider recommendations still apply today. Garnero tells Beyond Type 1 that culturally sensitive care first starts with examining perceptions and personal biases.
Because LGBTQ individuals experience stigma, discrimination, and lack of access to health insurance, their care can be delayed. However, type 1 and type 2 diabetes care requires routine care in order to properly manage diabetes, underscoring the importance of culturally competent care.
Culturally sensitive LGBTQ+ diabetes health care can increase and rebuild trust between the patient and provider, increase participation and involvement in health issues, reduce health disparities and reduce the number of missed medical visits. Research also suggests that cultural competence contributes to a patient’s overall satisfaction and experience.
Other ways that providers and clinicians can provide culturally sensitive diabetes care to the LGBTQ community is by making their offices and spaces more inclusive for LGBTQ folks. “The other thing a provider can do is put magazines that are tailored to the LGBT community in the waiting room or something that’s easily recognizable like the rainbow flag,” Garnero explains.
Garnero says that people can provide culturally competent diabetes care by including sexual orientation and gender identification on intake forms. Inclusion of LGBTQ identity in electronic medical records can also decrease the burden on patients to disclose multiple times to providers and in multiple healthcare settings. “It’s our role as healthcare providers to demonstrate that our practices are inclusive of everyone,” says Garnero.
When it comes to diabetes support materials, many of the materials assume heterosexuality. “Intake forms will say marital status. What about people who don’t want to go and get married because they’re worried about backlash,” Garnero questions. She adds that having options such as prefer not to answer can be more inclusive toward LGBTQ individuals and open up a dialogue between the patient and provider.
“So allowing people to say things like, prefer not to answer, or just to open up the dialogue so the provider can say, oh, I see here that you checked you prefer not to answer. I just want to know that whatever your situation is, I’m here to help you.”
As a Black gay man with type 1 diabetes, Banks says that culturally sensitive care allows him to better manage his diabetes. “Cultural differences should be considered. Developing a plan of action to care for people with various cultural backgrounds makes a huge difference,” Banks says. “And acknowledgment of these differences make a difference in health outcomes.”