BY MICHAEL B. GARRETT, MS, CCM, CVE, BCPA
Background: Key Terms and Concepts
The lesbian, gay, bisexual, transgender and queer (LGBTQ) community is very diverse, with a wide range of health needs from healthcare providers and systems that have not always treated this community with respect and dignity. Case managers can provide services for members of the LGBTQ community that result in better outcomes, improved patient/client experience and reduced overall health expenses – realizing The Triple Aim.
Gender identity is how a person thinks of themselves in the context of gender. Regardless of the physical anatomy, a person may consider themselves female, even though they have the physical attributes of being male. This means the individual is transgender. A cisgender person has alignment between their anatomy and how they think of their gender. A person may also consider themselves to be gender non-binary, meaning they do not see themselves fitting into our binary concept of male or female. Gender expression is how an individual presents to the world based on how the culture defines masculine and feminine expression, although gender expression does not indicate one’s sexual orientation necessarily. Sexual orientation describes who someone is attracted to. These terms are social constructs and are influenced by the culture, region of the world and the time period. All these terms are also all on continuums, so that they are not just binary in nature but fluid. The Human Rights Campaign website includes an excellent glossary of key LGBTQ terms and concepts at www.hrc.org/resources/glossary-of-terms.
Of course, LGBTQ individuals face a range of healthcare issues that are not necessarily related to their sexual orientation or gender identity.
The Challenges
LGBTQ individuals face many health challenges, such as:
- Low rates of preventive services
- Lack of adherence to chronic care guidelines
- Higher rates of behavioral health issues, including suicidality, substance use disorders, depression, anxiety, etc.
- Higher rates of sexually transmitted infections
- Lack of comprehensive coverage of applicable services, such as limited to no coverage for gender affirmation treatment
LGBTQ individuals also encounter challenges with healthcare providers and systems, such as:
- Outright hostile encounters, including physical and psychological assaults
- Lack of understanding of the healthcare issues faced by LGBTQ individuals
- Lack of understanding of the meaning of key terms, such as sexual orientation and gender identity
- Disrespectful behavior, such as refusing to use the preferred name as well as the correct gender pronouns
- Inability or administratively burdensome processes to change gender
- Discounting a same sex partner or spouse
These are enormous barriers for the LGBTQ client/patient, and these kinds of negative experiences may result in an initial distrust of the case manager. As a result, the case manager can incorporate communication and intervention strategies that are LGBTQ-inclusive.
The Opportunities
Communication strategies
There are several communication methods the case manager can use to demonstrate LGBTQ-inclusiveness to the patient/client:
- Preferred Name: Regardless of what the case management system indicates, confirm how the individual wants to be called.
- Pronouns: It is crucial that the case manager does not rely solely on the perception of the individual’s gender based on gender expression or what is contained in a system. The case manager can reveal their own pronouns first, indicating that using the correct pronoun is important.
- Family: Some LGBTQ individuals may not want to involve or communicate with their family of origin due to rejection or banishment. The case manager can demonstrate patient-centeredness by asking who they consider to be family. The case manager can also confirm who the individual does not want to have any communication with.
- Gender Neutral Language: The case manager can use gender neutral language, such as asking about a spouse or partner, rather than using terms like husband, wife, etc.
- Use the Terms Used by the Individual: An LGBTQ individual may describe themselves as queer. They may describe their significant other as a partner or spouse. The case manager should use whatever terms the individual uses to show patient-centeredness.
Intervention Strategies
There are a few interventions the case manager can do with LGBTQ individuals, providers and colleagues to support LGBTQ-inclusive healthcare:
- LGBTQ-Inclusive Providers: There are several resources where providers commit on a self-attestation basis of their LGBTQ-inclusiveness. There are also emerging verticalized navigation solutions that focus on providing LGBTQ-inclusive care, such as Folx Health and Included Health.
- Assessing and addressing social determinants of health (SDOH): LGBTQ individuals are disproportionately impacted by SDOH needs. It is important for the case manager to assess and address social needs for all patients/clients, and the LGBTQ community is no exception.
- Assessing and addressing behavioral health: As mentioned above, LGBTQ individuals have higher rates of behavioral health issues, so it is important to incorporate behavioral health assessments, and, if there are positive screening results, make appropriate referrals for services, preferably from LGBTQ-inclusive providers.
- Linkages to LGBTQ resources: There are many resources for LGBTQ individuals, as well as family members and friends, for services and supports.
- Advocating for increased coverage of applicable services: The LGBTQ individual may face limitations and exclusions for certain healthcare services, such as gender affirmation treatment. The case manager can advocate for these services by becoming familiar with applicable clinical guidelines, such as the World Professional Association for Transgender Health (WPATH) Standards of Care.
- Collaborating with colleagues on LGBTQ issues: The case manager can demonstrate advocacy by educating colleagues on issues impacting the LGBTQ community and by sharing resources.
The case manager can demonstrate competency with the LGBTQ community by becoming educated on key terms and concepts, incorporating effective communication methods and intervention strategies. Becoming an LGBTQ ally is a way for the case manager to become a better advocate for the LGBTQ community.
Resources
LGBTQ+ Individuals, Family, and Friends
Children of Lesbians and Gays Everywhere (COLAGE)
https://www.colage.org/
National organization expressly dedicated to supporting people with one or more LGBTQ+ caregivers, uniting them with a network of peers and supporting them as they nurture and empower each other to be skilled, self-confident and just leaders in their communities.
Gay and Lesbian Medical Association (GLMA) – Including a provider directory to LGBTQ+ inclusive providers
https://www.glma.org/
Nationwide provider directory of LGBTQ+ inclusive providers.
Gender Odyssey
https://genderodyssey.org/
Annual event offering multiple informative and empowering workshops, films, receptions, performances and the chance to make lifelong friends.
Gender Spectrum
https://genderspectrum.org/
National organization committed to the health and well-being of gender-diverse children and teens through education and support for families, and training and guidance for educators, medical and mental health providers and other professionals.
InterACT: Advocates for Intersex Youth
https://interactadvocates.org/
Advocacy organization for the human rights of children born with differences in sex traits or reproductive anatomy.
OutCare Health – including a provider director to LGBTQ+ inclusive providers
https://www.outcarehealth.org/
Comprehensive resource for LGBTQ+ healthcare, offering provider and healthcare resource directories, mentorship, medical education reform and cultural competency training; offers the OutList, an online, nationwide directory of healthcare providers who identify as culturally competent in the care of the LGBTQ+ community.
PFLAG
https://pflag.org/
Nationwide organization dedicated to supporting, educating, and advocating for LGBTQ+ people and their families.
SAGE: Advocacy & Services for LGBTQ Elders
https://www.sageusa.org/
National advocacy and services organization providing multiple programs to build welcoming communities for LGBTQ+ elders.
Trans Lifeline
https://translifeline.org/
Providing peer support for the Trans community, run entirely by and for Trans people.
Healthcare Providers and Systems
HRC and Sage (Advocacy & Services for LGBT Elders) Long-Term Equality Index (LEI)
https://thelei.org/
Promoting equitable and inclusive care for LGBTQ older adults in residential long-term care and senior housing.
Human Rights Campaign (HRC) Healthcare Equality Index (HEI)
https://www.hrc.org/resources/healthcare-equality-index
National LGBTQ+ benchmarking tool that evaluates healthcare facilities’ policies and practices related to the equity and inclusion of their LGBTQ+ patients, visitors and employees.
The National LGBT Health Education Center (Fenway Institute)
https://fenwayhealth.org/the-fenway-institute/education/
Educational programs, resources and consultation to healthcare organizations with the goal of optimizing quality and cost-effective healthcare for lesbian, gay, bisexual, transgender, queer, intersex, asexual and all sexual and gender minority (LGBTQIA+) people.
Employers
Are you supporting the health of your LGBTQ employees?
https://www.bizjournals.com/seattle/news/
2021/06/23/are-you-supporting-the-health-of-your-lgbtq-employ.html
Article published in the Puget Sound Business Journal.
HRC Municipality Equality Index (MEI)
https://www.hrc.org/resources/municipal-equality-index
Data index examining how inclusive municipal laws, policies and services are of LGBTQ+ people who live and work there; cities are rated based on non-discrimination laws, the municipality as an employer, municipal services, law enforcement and leadership on LGBTQ+ equality.
Human Rights Campaign (HRC) Corporate Equality Index (CEI)
https://www.hrc.org/resources/corporate-equality-index
National benchmarking tool on corporate policies, practices and benefits pertinent to LGBTQ employees.
Out & Equal Workplace Advocates
https://outandequal.org/
Organization working exclusively on LGBTQ workplace equality; helping LGBTQ people thrive in the workplace and supporting organizations creating a culture of belonging for all.
Michael B. Garrett, MS, CCM, CVE, BCPA, is an independent consultant focusing on optimizing health equity and clinical management programs. He has over 30 years of case management experience. His undergraduate and graduate degrees are in psychology. He is board certified in case management, vocational evaluation and patient advocacy.
