The Journey Toward LGBT Cultural Proficiency

Tim Rodden, MDiv, MA, BCC, FACHE, is the Director of Pastoral Services at Christiana Care Health Systems and is Co-chair of the United Way of Delaware PRIDE Council LGBTQ Health Equity Task Force.

There is growing attention to providing culturally competent health care to our patients/families who are lesbian, gay, bisexual or transgender (LGBT). This raises a few questions: Why is this needed? What does LGBT culturally competent health care mean? How do we go about achieving this? I hope to offer some insight into these basic questions in this blog and to whet your appetite to learn more in a Train-the-Trainer webinar that will occur in June 2016.

Let’s begin with a working definition of cultural competence. There are several definitions that have been offered over the years. One of the seminal works in the field of “cultural competence” dates to 1989 when Terry L. Cross, et al wrote Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed [Cross, Bazron, Dennis, and Isaacs (1989)].  In it they describe cultural competence as a “set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals to work effectively in cross-cultural situations.” In practice, “a culturally competent system of care acknowledges and incorporates, at all levels, the importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that result  from cultural differences, the expansion of cultural knowledge, and the adaptation of services to meet culturally unique needs”.

Why should we address LGBT cultural competence in health care? It has been difficult to get a completely accurate picture of the health disparities facing the LGBT communities because we don’t regularly collect sexual orientation and gender identity data like we do for other demographic groupings e.g., race, ethnicity and language. There have been a few relevant studies conducted that help us understand the need for addressing this today in the health care arena. In the 2007 California Health Interview Survey we see the disparities between LGB populations and the heterosexual population in seeking preventive care and in divergent use of emergency services:

% adults delaying/not seeking health care

           - Heterosexual – 17%

           - LGB – 29%

% adults receiving emergency health care

           - Heterosexual – 18%

           - LGB – 24%

In the study When Healthcare Isn’t Caring (2010, Lambda Legal’s Survey on Discrimination Against LGBT People and People Living with HIV) we get a picture of the “perception of care” from the perspective of these groups. 7.7% of LGB and 26.7% of Transgender respondents report they were refused medical care because of sexual orientation or gender identity. Given this it is not unsurprising to see that some LGBT people have the perception that they will be refused future health care for the same reason: nearly 10% of LGB and 52% of Transgender respondents believe they will be refused health care.

Our work is to reduce health disparities and to encourage people to get the health care needed in spite of cultural differences whether sexual orientation, gender identity, or any other cultural factor.

What does LGBT culturally competent health care mean? One of the leaders in advocacy for LGBT people in receiving equality in health care is the Human Rights Campaign Foundation which publishes the Healthcare Equality Index (HEI) each year. The HEI provides a road map for healthcare systems in measuring best practices for LGBT patient – and- family centered care and for LGBT workforce inclusion. 

The Core Four Requirements of the HEI address the following four broad policy and procedure areas for health care facilities:

In addition the self-reported survey assesses best practices and gives concrete examples for practices in the following areas:

• LGBT Patient Services & Support
• Transgender Patient Services & Support
• Patient Self Identification
• Medical Decision Making
• Employee Benefits and Policies
• Community Engagement

LGBT patients and families are looking to this published index more and more to seek out health care facilities and by extension their providers who can provide LGBT culturally competent care. Facilities that rank the highest receive the designation of Leader in LGBT Healthcare Equality which sets them apart from other facilities/providers.

How do we go about achieving LGBT cultural competence? Better yet the question might be asked, how do we go about striving for LGBT Cultural Proficiency? Cross, et al describes cultural proficiency: when cultural differences are highly regarded and the need for research on cultural differences and the development of new approaches to enhance culturally competent practices are recognized. This level of achievement goes beyond cultural competence:  when cultural differences are accepted and respected; continuous expansion of cultural knowledge and resources and continuous adaptation of services occur; continuous self-assessment about culture and vigilance toward the dynamics of cultural differences exist.

Achieving cultural competence and perhaps cultural proficiency is a developmental process. First you have to recognize the need for doing things differently, that you may not have all the answers. Secondly, you need to determine who the key stakeholders are in making needed changes to policies and procedures. Thirdly, you need the buy-in and active engagement of leadership so that there is impetus behind the transformation. Lastly I would say you need to actively involve the LGBT community in assessing current state, what needs to change, what can change and to provide the motivation for making the changes. 

Delaware’s largest private employer, Christiana Care Health System, has been participating in the Healthcare Equality Index since 2011 and since 2012 the system’s two hospitals: Christiana Care Wilmington Hospital and Christiana Care Christiana Hospital have received the designation of Leader in LGBT Healthcare Equality. All new nurses hired by the system receive comprehensive orientation. During the orientation day titled “Exceptional Experience” they participate in an education module called Your LGBTQ Patient: Providing Culturally Competent Care. 

The strategies employed in this education module with additional resources will be presented in the Train-the-Trainer Webinar that Tim Rodden, MDiv, MA, BCC, FACHE and Bret Herb, LCSW will conduct on June 16, 2016 for the Association for Nursing Professional Development. (Tim coordinates LGBT health for Christiana Care and Brett is a gender therapist and mental health consultant for Christiana Care.)