Inhospitable Healthcare Spaces: Why Diversity Training on LGBTQIA Issues Is Not Enough
- 2.4k Downloads
In an effort to address healthcare disparities in lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations, many hospitals and clinics institute diversity training meant to increase providers’ awareness of and sensitivity to this patient population. Despite these efforts, many healthcare spaces remain inhospitable to LGBTQ patients and their loved ones. Even in the absence of overt forms of discrimination, LGBTQ patients report feeling anxious, unwelcome, ashamed, and distrustful in healthcare encounters. We argue that these negative experiences are produced by a variety of subtle, ostensibly insignificant features of healthcare spaces and interpersonal interactions called microaggressions. Healthcare spaces and providers often convey heteronormative microaggressions, which communicate to LGBTQ—and, we suggest, intersex and asexual (IA)—people that their identities, experiences, and relationships are abnormal, pathological, unexpected, unwelcome, or shameful. We identify heteronormative microaggressions common to healthcare settings and specify how they negatively impact LGBTQIA patients. We argue that standard diversity training cannot sufficiently address heteronormative microaggressions. Despite these challenges, healthcare institutions and providers must take responsibility for heteronormative microaggressions and take steps to reduce their frequency and mitigate their effects on LGBTQIA care. We conclude by offering strategies for problem-solving at the level of medical education, institutional culture and policy, and individual awareness.
KeywordsMicroaggressions Heteronormativity LGBTQIA health Diversity training Queer bioethics
The authors would like to thank Nabina Liebow, participants at the 2014 meeting of the American Society for Bioethics and Humanities and the 2015 meeting of Canadian Bioethical Society, and two anonymous reviewers for their helpful comments on this paper. Megan Dean would like to thank the Social Sciences and Humanities Research Council of Canada for its support.
- Balsam, K.F., Y. Molina, B. Beadnell, J. Simoni, and K. Walters. 2011. Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Cultural Diversity and Ethnic Minority Psychology 17(2): 163–74.Google Scholar
- Banks, C., N. Muhajarine, K. Waygood, L. Duczek, and G. Hellquist. 2003. The cost of homophobia: Literature review on the human impact of homophobia in Canada. Community-University Institute for Social Research. http://www.usask.ca/cuisr/sites/default/files/BanksHumanCostFINAL.pdf.
- Barbara, A.M., S.A. Quandt, and R.T. Anderson. 2001. Experiences of lesbians in the health care environment. Women & Health 34(1): 45–62.Google Scholar
- Barker, M. 2014. Heteronormativity. In Encyclopedia of Critical Psychology, edited by Thomas Teo, 858–860. Springer New York. http://link.springer.com/referenceworkentry/10.1007/978-1-4614-5583-7_134.
- Bauer, G.R., R. Hammond, R. Travers, M. Kaay, K.M. Hohenadel, and M. Boyce. 2009. “I don’t think this is theoretical; this is our lives”: How erasure impacts health care for transgender people. Journal of the Association of Nurses in AIDS Care, Transgender Health and HIV Care, 20(5): 348–361.Google Scholar
- Beals, K.P., and L.A. Peplau. 2005. Identity support, identity devaluation, and well-being among lesbians. Psychology of Women Quarterly 29(2): 140–148.Google Scholar
- Ben-Asher, N. 2006. The necessity of sex change: A struggle for intersex and transsex liberties. Harvard Journal of Law and Gender 29: 51–98.Google Scholar
- Bogaert, A.F. 2006. Toward a conceptual understanding of asexuality. Review of General Psychology 10(3): 241–250.Google Scholar
- Boysen, G.A., and D.L. Vogel. 2008. The relationship between level of training, implicit bias, and multicultural competency among counselor trainees. Training and Education in Professional Psychology 2(2): 103–110.Google Scholar
- Buchholz, S.E. 2000. Experiences of lesbian couples during childbirth. Nursing Outlook 48(6): 307–311.Google Scholar
- Cant, B. 2002. An exploration of the views of gay and bisexual men in one London borough of both their primary care needs and the practice of primary care practitioners. Primary Health Care Research & Development 3(02): 124–130.Google Scholar
- Chambers, T. 2006. Closet cases: Queering bioethics through narrative. Literature and Medicine 25(2): 402–411.Google Scholar
- Davis, V. 2000. Lesbian health guidelines. Society of Obstetricians and Gynaecologists of Canada 22(3): 202–205.Google Scholar
- Dogra, N., S. Reitmanova, and O. Carter-Pokras. 2009. Twelve tips for teaching diversity and embedding it in the medical curriculum. Medical Teacher 31(11): 990–993.Google Scholar
- Dysart-Gale, D. 2010. Social justice and social determinants of health: Lesbian, gay, bisexual, transgendered, intersexed, and queer youth in Canada. Journal of Child and Adolescent Psychiatric Nursing 23(1): 23–28.Google Scholar
- Eliason, M.J., and S.L. Dibble. 2015. Provider-patient issues for the LGBT cancer patient. In Cancer and the LGBT community, edited by Ulrike Boehmer and Ronit Elk, 187–202. Springer International Publishing. http://link.springer.com/chapter/10.1007/978-3-319-15057-4_12.
- Fredriksen-Goldsen, K.I., H. Kim, C.A. Emlet, et al. 2011. The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults. Seattle: Institute for Multigenerational Health.Google Scholar
- Frye, M. 1983. The politics of reality: Essays in feminist theory. Crossing Press.Google Scholar
- Goldberg, L., A. Harbin, and S. Campbell. 2011. Queering the birthing space: Phenomenological interpretations of the relationships between lesbian couples and perinatal nurses in the context of birthing care. Sexualities 14(2): 173–192.Google Scholar
- Goldberg, L., A. Ryan, and J. Sawchyn. 2009. Feminist and queer phenomenology: A framework for perinatal nursing practice, research, and education for advancing lesbian health. Health Care for Women International 30(6): 536–549.Google Scholar
- Greenberg, J. A. 2012. Health care issues affecting people with an intersex condition or DSD: Sex or disability discrimination? Loyola of Los Angeles Law Review 45: 849–908.Google Scholar
- Guasp, A., and J. Taylor. 2012a. Bisexuality. Stonewall Health Briefing. https://www.stonewall.org.uk/sites/default/files/Bisexuality_Stonewall_Health_Briefing__2012_.pdf.
- ———. 2012b. Experiences of Healthcare. Stonewall Health Briefing. https://www.stonewall.org.uk/sites/default/files/Experiences_of_Healthcare_Stonewall_Health_Briefing__2012__.pdf.
- Haslanger, S. 2008. Changing the ideology and culture of philosophy: Not by reason (alone). Hypatia 23(2): 210–223.Google Scholar
- ———. 2012. Resisting reality: Social construction and social critique. New York: Oxford University Press.Google Scholar
- ———. 2015. What is a (social) structural explanation? Philosophical Studies, January, 1–18.Google Scholar
- Hunt, R., and A. Minksy. 2012. Reducing health inequalities for lesbian, gay, and bisexual people: Evidence of health care needs. Stonewall Health Briefing. http://www.ilga-europe.org/sites/default/files/reducing_health_inequalities_for_lesbian_gay_and_bisexual_people_evidence_of_health_care_needs.pdf.
- Hutchinson, M.K., A.C. Thompson, and J.A. Cederbaum. 2006. Multisystem factors contributing to disparities in preventive health care among lesbian women. Journal of Obstetric, Gynecologic, & Neonatal Nursing 35(3): 393–402.Google Scholar
- Institute of Medicine. 2011. The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. National Academies Press Washington, DC.Google Scholar
- Jones, L. 2009. The third sex: Gender identity development of intersex persons. Graduate Journal of Counseling Psychology 1(2): 9–17.Google Scholar
- JSI Research and Training Institute. 2000. Access to health care for transgendered persons in greater Boston. Boston: JSI Research and Training Institute.Google Scholar
- Kaplan, D. M. 2006. Can diversity training discriminate? Backlash to lesbian, gay, and bisexual diversity initiatives. Employee Responsibilities and Rights Journal 18(1): 61–72.Google Scholar
- Kumaş-Tan, Z., B. Beagan, C. Loppie, A. MacLeod, and B. Frank. 2007. Measures of cultural competence: Examining hidden assumptions. Academic Medicine: Journal of the Association of American Medical Colleges 82(6): 548–557.Google Scholar
- MacInnis, C.C., and G. Hodson. 2012. Intergroup bias toward “Group X”: Evidence of prejudice, dehumanization, avoidance, and discrimination against asexuals. Group Processes & Intergroup Relations 15(6): 725–743.Google Scholar
- Makadon, H.J., K.H. Mayer, J. Potter, and H. Goldhammer. 2015. The Fenway guide to lesbian, gay, bisexual, and transgender health. 2nd ed. Philadelphia: American College of Physicians. https://www.acponline.org/acp_press/fenway/.
- Mathieson, C.M., N. Bailey, and M. Gurevich. 2002. Health care services for lesbian and bisexual women: Some Canadian data. Health Care for Women International 23(2): 185–196.Google Scholar
- McDonald, C., M. McIntyre, and B. Anderson. 2003. The view from somewhere: Locating lesbian experience in women’s health. Health Care for Women International 24(8): 697–711.Google Scholar
- McManus, A.J., L.P. Hunter, and H. Renn. 2006. Lesbian experiences and needs during childbirth: Guidance for health care providers. Journal of Obstetric, Gynecologic, & Neonatal Nursing 35(1): 13–23.Google Scholar
- McNair, R.P. 2003. Lesbian health inequalities: A cultural minority issue for health professionals. The Medical Journal of Australia 178(12): 643–645.Google Scholar
- MetLife Mature Market Institute, and the Lesbian and Gay Aging Issues Network of the American Society on Aging. 2010. Out and aging: The MetLife study of lesbian and gay baby boomers. Journal of GLBT Family Studies 6: 40–57.Google Scholar
- Meyer, I. H. 2003. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin 129(5): 674–697.Google Scholar
- Mobley, M., and T. Payne. 1993. Backlash! The challenge to diversity training. Security Management 37(9): 35–42.Google Scholar
- Nadal, K. L. 2013. That’s so gay!: Microaggressions and the lesbian, gay, bisexual and transgender community. Washington, D.C.: American Psychological Association.Google Scholar
- Nadal, K.L., K.C. Davidoff, L.S. Davis, and Y. Wong. 2014. Emotional, behavioral, and cognitive reactions to microaggressions: Transgender perspectives. Psychology of Sexual Orientation and Gender Diversity 1(1): 72–81.Google Scholar
- Nadal, K.L., M. Issa, J. Leon, V. Meterko, M. Wideman, and Y. Wong. 2011. Sexual orientation microaggressions: “Death by a thousand cuts” for lesbian, gay, and bisexual youth. Journal of LGBT Youth 8(3): 234–259.Google Scholar
- Nadal, K.L, D.P. Rivera, and M.J.H. Corpus. 2010. Sexual orientation and transgender microaggressions: Implications for mental health and counseling. In Microaggressions and marginality: Manifestation, dynamics, and impact, edited by D.W. Sue. John Wiley & Sons.Google Scholar
- National Center for Transgender Equality. 2012. Factsheet: Transgender sexual and reproductive health: Unmet needs and barriers to care. http://www.transequality.org/sites/default/files/docs/resources/Factsheet_TransSexualandReproHealth_April2012.pdf.
- Neville, S., and M. Henrickson. 2006. Perceptions of lesbian, gay and bisexual people of primary healthcare services. Journal of Advanced Nursing 55(4): 407–15.Google Scholar
- Penner, L.A., J.F. Dovidio, T.V. West, et al. 2010. Aversive racism and medical interactions with black patients: A field study. Journal of Experimental Social Psychology 46(2): 436–440.Google Scholar
- Pettinato, M. 2012. Providing care for GLBTQ patients: Nursing 42(12): 22–27.Google Scholar
- Röndahl, G. 2009. Lesbians’ and gay men’s narratives about attitudes in nursing. Scandinavian Journal of Caring Sciences 23(1): 146–152.Google Scholar
- Röndahl, G., E. Bruhner, and J. Lindhe. 2009. Heteronormative communication with lesbian families in antenatal care, childbirth and postnatal care. Journal of Advanced Nursing 65(11): 2337–2344.Google Scholar
- Röndahl, G., S. Innala, and M. Carlsson. 2006. Heterosexual assumptions in verbal and non-verbal communication in nursing. Journal of Advanced Nursing 56(4): 373–381.Google Scholar
- Schatz, B., and K. O’Hanlan. 1994. Anti-gay discrimination in medicine: Results of a national survey of lesbian, gay and bisexual physicians. American Association of Physicians for Human Rights (AAPHR).Google Scholar
- Sinding, C., L. Barnoff, and P. Grassau. 2004. Homophobia and heterosexism in cancer care: The experiences of lesbians. CJNR (Canadian Journal of Nursing Research) 36(4): 170–188.Google Scholar
- Spinks, V.S., J. Andrews, and J.S. Boyle. 2000. Providing health care for lesbian clients. Journal of Transcultural Nursing 11(2): 137–143.Google Scholar
- Staats, C. 2014. State of the Science: Implicit Bias Review 2014. Kirwan Institute for the Study of Race and Ethnicity. http://kirwaninstitute.osu.edu/wp-content/uploads/2014/03/2014-implicit-bias.pdf.
- Stevens, P.E. 1995. Structural and interpersonal impact of heterosexual assumptions on lesbian health care clients. Nursing Research 44(1): 25–30.Google Scholar
- ———. 1998. The experiences of lesbians of color in health care encounters. Journal of Lesbian Studies 2(1): 77–94.Google Scholar
- Sue, D.W. 2010. Microaggressions in everyday life: Race, gender, and sexual orientation. John Wiley & Sons.Google Scholar
- Teal, C.R., R.E. Shada, A.C. Gill, et al. 2010. When best intentions aren’t enough: Helping medical students develop strategies for managing bias about patients. Journal of General Internal Medicine 25(2): 115–118.Google Scholar
- The Fenway Institute. 2015. Publications. The National LGBT Health Education Center. http://www.lgbthealtheducation.org/lgbt-education/publications. Accessed September 1, 2015.
- The Sex Information and Education Council of Canada. 2012. Understanding asexuality. http://sexualityandu.ca/uploads/files/CTRasexualityFeb2012En.pdf.
- Valanis, B.G., D.J. Bowen, T. Bassford, E. Whitlock, P. Charney, and R.A. Carter. 2000. Sexual orientation and health: Comparisons in the women’s health initiative sample. Archives of Family Medicine 9(9): 843.Google Scholar
- Valian, V. 1999. The cognitive bases of gender bias. Brooklyn Law Review 65: 1037.Google Scholar
- Wahlert, L., and A. Fiester. 2014. Repaving the road of good intentions: LGBT health care and the queer bioethical lens. The Hastings Center Report 44 (Suppl 4): S56–S65.Google Scholar
- Wilton, T., and T. Kaufmann. 2001. Lesbian mothers’ experiences of maternity care in the UK. Midwifery 17(3): 203–211.Google Scholar
- Wong, G., A.O. Derthick, E.J.R. David, A. Saw, and S. Okazaki. 2013. The what, the why, and the how: A review of racial microaggressions research in psychology. Race and Social Problems 6(2): 181–200.Google Scholar
- Young, I. M. 1990. Justice and the politics of difference. Princeton: Princeton University Press.Google Scholar