FigureJodie* was a patient in an Atlanta-area ED when the nurse entered her room to collect information for the intake form. Among the questions, the nurse asked Jodie if she was single or married. “Well, I'm in a relationship, but it isn't recognized in Georgia. I don't fit in either the single or married categories,” thought Jodie. The nurse wanted Jodie to list an emergency contact and identify her relationship with the person. Jodie panicked, “How do I admit that my life partner is in the waiting room. Do I say I'm single to escape judgment? My head was swimming trying to think of a lie about who my partner was. Should I be safe and say she's a friend? If so, she would be denied visitation if something went wrong. Should I lie and say sister? How humiliating! I was afraid that if I admitted to being gay with a partner that I might get subpar care or even have my care and life sabotaged. After delaying my response, I felt I would take the risk and say that my relationship didn't fit into any of the boxes on the intake form.” When the nurse looked confused at Jodie's response, Jodie confessed that she was gay and her life partner was in the waiting room. The nurse continued to look confused and, after a pause, awkwardly said, “Uh...oh...huh, how do I handle that?” Jodie's fear about disclosing her sexual orientation to a healthcare provider isn't uncommon for LGBT individuals and is often based on past negative experiences. According to a 2009 Lambda Legal survey, more than half of the LGBT participants reported experiencing at least one of the following types of healthcare discrimination: being refused needed care, healthcare professionals refusing to touch them or using excessive precautions, healthcare professionals using harsh or abusive language, LGBT individuals being blamed for their health status, or healthcare professionals being physically rough or abusive.1 In addition to healthcare discrimination, LGBT individuals also experience a number of health disparities related to higher rates of mental health issues, cancer, physical and emotional violence, obesity, substance use (tobacco, alcohol, and drugs), and HIV and other sexually transmitted diseases as acknowledged in Healthy People 2020.2 Healthcare discrimination and health disparities are compounded by the lack of legal protections for LGBT individuals. Although the United Nations declared in 1948 that “the family is the natural and fundamental group unit of society and is entitled to protection by society and the State,” these protections haven't held for LGBT families.3 The definition of a family has been changing to become more inclusive of various family structures, yet policy has been slow to keep pace with the modern family.4 One practice-oriented approach to defining family is “any group of people related either biologically, emotionally, or legally. That is, the group of people that the patient defines as significant for his or her wellbeing.”5 Definitions and discussions in articles, books, and policies are a step toward inclusivity, but the true test is seen in how these definitions and discussions are translated into patient care, including recent policy advances and strategies for enhancing nursing care for LGBT patients and families. (See Table 1 for a description of the Department of Health and Human Services' [HHS] National Prevention Strategy.)Table 1: National Prevention StrategyState of the science Recognizing the need for better understanding of LGBT health, the National Institutes of Health (NIH) tasked the Institute of Medicine (IOM) with assessing the state of the science. In its March 2011 report, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding, the IOM outlined current knowledge of the health status of LGBT populations, research gaps and opportunities, and a research agenda for the NIH. The IOM framed its report using a life course perspective, which allowed for assessment of the health status of LGBT populations at childhood and adolescence, early/middle adulthood, and later adulthood.6 Among its findings from the available research, the IOM determined that: LGBT adolescents may have an elevated risk of attempted suicide and depression. LGBT adults fear discrimination in healthcare settings and are concerned about the lack of providers who are knowledgeable about LGBT health and barriers to LGBT adults accessing quality healthcare. Older LGBT individuals are more likely to depend on friends as caregivers rather than biological family members. The IOM called on the research community to increase data collection of sexual orientation and gender identity in federally funded health surveys. (See Table 2 for more information on the HHS's recent announcement on data collection efforts.) The IOM also recommended that sexual orientation and gender identity data be collected through electronic medical records (EMRs).Table 2: Data collectionHospital visitation and nondiscrimination In 2008, while on vacation in Florida with her partner and children, Lisa Pond suddenly collapsed and was taken to a nearby hospital. Although her partner, Janice Langbehn, held Lisa's durable healthcare power of attorney, the hospital refused to accept information from Janice regarding Lisa's medical history and treated her and their children with prejudice and apathy. Although a physician acknowledged there was no medical reason to prevent visitors, Janice and their children weren't allowed to see Lisa until almost 8 hours after they arrived at the hospital. The physician also finally told Janice that Lisa had no chance of recovery. After Lisa's death, Janice continued to fight to be recognized as Lisa's family by attempting to obtain Lisa's death certificate to receive life insurance and social security benefits for their children, both of which she was denied. In 2010, moved by Janice's story, President Obama issued a presidential memo directing the secretary of HHS to take steps to address hospital visitation and other healthcare issues affecting LGBT families. In response to President Obama's memo, HHS announced new regulations that require federally funded hospitals to inform and protect patients' right to designate visitors, including a same-sex partner. The regulations also require hospitals not to limit visitation on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. As part of its enforcement of this new regulation, HHS has instructed hospitals to protect patients' right to designate a person of their choice, including a same-sex spouse or partner, to make medical decisions on their behalf should they become incapacitated. Also in 2010, after seeking input from LGBT health advocates, The Joint Commission issued new standards to ensure access to a support person of the patient's choice and prohibit discrimination based on sexual orientation and gender identity or expression. The Joint Commission is now evaluating organizations accredited under its hospital and critical access hospital programs on these new criteria.7 In November 2011, The Joint Commission released a resource to help hospitals implement these standards to create a more welcoming, safe, and inclusive environment for LGBT patients. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide offers strategies, practice examples, resources, and testimonials, and provides information to help hospitals identify gaps, safety risks, and areas of improvement.8 Cultural competency training The IOM report and HHS memos have recognized that the lack of cultural competency training is a significant barrier to LGBT individuals receiving adequate healthcare. An example of a local effort aimed at addressing this barrier is a mandatory cultural competency training program for New York City Health and Hospitals Corporation (HHC) employees. Launched in May 2011 and produced in collaboration with the National LGBT Cancer Network, the training is estimated to reach 38,000 nurses, physicians, technicians, administrators, and support services staff through multiple approaches.9 HHC recognized the need for cultural competency training for all hospital employees because patients interact with multiple hospital employees throughout the course of a hospital visit. Barriers surface at all levels of care, and this program recognizes and addresses that reality. Another local effort, with funding from the Health Resources and Services Administration, is a cultural competency training program designed specifically for nurses to help improve LGBT geriatric care. Health Education About LGBT Elders, or HEALE, was developed by the Howard Brown Health Center in collaboration with other LGBT health providers and has reached over 200 nurses and other healthcare providers throughout Illinois. Taken together, these government and health system initiatives are laying the foundation for individual practitioners to improve healthcare for LGBT patients and reduce the health disparities these communities experience. However, policy changes won't be enough. Healthcare providers must seek continuing-education opportunities to learn more about LGBT health disparities and how to provide care for these populations. Cultural competency training that includes LGBT content is essential for all healthcare professionals to create a health workforce that can meet the needs of LGBT patients. Because nurses are the health professionals who spend the most time with patients, these policy changes and local models for cultural competency training have significant implications and opportunities for nurses. Welcoming environments Nurse leaders can play a key role in helping to create welcoming and safe environments for LGBT patients. Strategies for creating a welcoming environment include addressing the physical environment, practice documentation (such as intake forms, EMRs, and discharge forms), communication used (verbal and nonverbal expressions), health histories conducted, resources offered, and policies displayed and enforced. The Gay & Lesbian Medical Association's Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients outlines concrete examples for practice changes.10 (See Table 3.)Table 3: Strategies for creating a welcoming environment10At the hospital in Atlanta, Jodie felt humiliated and afraid. At the hospital in Florida, Janice was treated as if she and her children weren't her partner's family and had no right to be with her as she lay dying. Both women experienced challenges in receiving quality and respectful healthcare. It's up to all of us—federal and local government agencies, hospitals and health systems, advocates and healthcare providers—to ensure that all patients receive the best healthcare possible. Jodie, Janice, and the millions of other LGBT patients and families like them are counting on us. Is your nursing care sensitive to the needs of LGBT patients? What will you do to make a difference? * This story was submitted to Lambda Legal as part of a “Share Your Story” project for its Health Care Fairness Campaign. Individuals provided permission for the use of their stories and names for educational purposes. Some information was removed to protect the privacy of those individuals.