Inhospitable Healthcare Spaces: Why Diversity Training on LGBTQIA Issues Is Not Enough

Abstract

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.

This is a preview of subscription content, log in to check access.

Notes

  1. 1.

    These examples might also fit into the category “use of heterosexist and transphobic terminology.” However, in That’s So Gay, Nadal reserves this category for slurs. In an earlier article (Nadal et al. 2010), the terminology category is broader and would include the above examples. In any case, it is clear that the use of these terms and phrases are microaggressions according to Nadal’s taxonomy.

  2. 2.

    This is despite prolonged activist efforts and work by the Hastings Center to argue that these “normalizing” surgeries should not be performed without the individual’s consent, unless there are other medically relevant considerations. Greenberg reports: “Most doctors, however, oppose a moratorium on infant genital cosmetic surgeries and believe that surgical alteration is in the best interests of a child born with an intersex condition … According to one comprehensive study published in 2007, most parents still choose to consent to genitoplasty on behalf of their infants” (2012, 866).

  3. 3.

    This trend of “feminizing” intersex patients has been critiqued heavily, and these cases are not as common as they used to be (Greenberg 2012, 860).

  4. 4.

    It should be noted that individuals who do not explicitly share their LGBTQIA status with a provider may not be withholding anything; they may simply feel that the information is irrelevant to their care at that time.

  5. 5.

    This point holds for providers who belong to the LGBTQIA population as well as those who are cisgender and heterosexual.

References

  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. Bogaert, A.F. 2006. Toward a conceptual understanding of asexuality. Review of General Psychology 10(3): 241–250.

  9. 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.

  10. Buchholz, S.E. 2000. Experiences of lesbian couples during childbirth. Nursing Outlook 48(6): 307–311.

  11. 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.

  12. Chambers, T. 2006. Closet cases: Queering bioethics through narrative. Literature and Medicine 25(2): 402–411.

  13. Davis, V. 2000. Lesbian health guidelines. Society of Obstetricians and Gynaecologists of Canada 22(3): 202–205.

  14. 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.

  15. 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.

  16. 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.

  17. 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.

  18. Frye, M. 1983. The politics of reality: Essays in feminist theory. Crossing Press.

  19. 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.

  20. 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.

  21. 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.

  22. Guasp, A., and J. Taylor. 2012a. Bisexuality. Stonewall Health Briefing. https://www.stonewall.org.uk/sites/default/files/Bisexuality_Stonewall_Health_Briefing__2012_.pdf.

  23. ———. 2012b. Experiences of Healthcare. Stonewall Health Briefing. https://www.stonewall.org.uk/sites/default/files/Experiences_of_Healthcare_Stonewall_Health_Briefing__2012__.pdf.

  24. Haslanger, S. 2008. Changing the ideology and culture of philosophy: Not by reason (alone). Hypatia 23(2): 210–223.

  25. ———. 2012. Resisting reality: Social construction and social critique. New York: Oxford University Press.

  26. ———. 2015. What is a (social) structural explanation? Philosophical Studies, January, 1–18.

  27. 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.

  28. 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.

  29. Institute of Medicine. 2011. The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. National Academies Press Washington, DC.

  30. Jones, L. 2009. The third sex: Gender identity development of intersex persons. Graduate Journal of Counseling Psychology 1(2): 9–17.

  31. JSI Research and Training Institute. 2000. Access to health care for transgendered persons in greater Boston. Boston: JSI Research and Training Institute.

  32. 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.

  33. 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.

  34. 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.

  35. 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/.

  36. 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.

  37. 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.

  38. 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.

  39. McNair, R.P. 2003. Lesbian health inequalities: A cultural minority issue for health professionals. The Medical Journal of Australia 178(12): 643–645.

  40. 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.

  41. 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.

  42. Mobley, M., and T. Payne. 1993. Backlash! The challenge to diversity training. Security Management 37(9): 35–42.

  43. Nadal, K. L. 2013. That’s so gay!: Microaggressions and the lesbian, gay, bisexual and transgender community. Washington, D.C.: American Psychological Association.

  44. 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.

  45. 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.

  46. 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.

  47. 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.

  48. 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.

  49. 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.

  50. Pettinato, M. 2012. Providing care for GLBTQ patients: Nursing 42(12): 22–27.

  51. Röndahl, G. 2009. Lesbians’ and gay men’s narratives about attitudes in nursing. Scandinavian Journal of Caring Sciences 23(1): 146–152.

  52. 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.

  53. 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.

  54. 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).

  55. 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.

  56. Spinks, V.S., J. Andrews, and J.S. Boyle. 2000. Providing health care for lesbian clients. Journal of Transcultural Nursing 11(2): 137–143.

  57. 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.

  58. Stevens, P.E. 1995. Structural and interpersonal impact of heterosexual assumptions on lesbian health care clients. Nursing Research 44(1): 25–30.

  59. ———. 1998. The experiences of lesbians of color in health care encounters. Journal of Lesbian Studies 2(1): 77–94.

  60. Sue, D.W. 2010. Microaggressions in everyday life: Race, gender, and sexual orientation. John Wiley & Sons.

  61. 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.

  62. The Fenway Institute. 2015. Publications. The National LGBT Health Education Center. http://www.lgbthealtheducation.org/lgbt-education/publications. Accessed September 1, 2015.

  63. The Sex Information and Education Council of Canada. 2012. Understanding asexuality. http://sexualityandu.ca/uploads/files/CTRasexualityFeb2012En.pdf.

  64. 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.

  65. Valian, V. 1999. The cognitive bases of gender bias. Brooklyn Law Review 65: 1037.

  66. 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.

  67. Wilton, T., and T. Kaufmann. 2001. Lesbian mothers’ experiences of maternity care in the UK. Midwifery 17(3): 203–211.

  68. 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.

  69. Young, I. M. 1990. Justice and the politics of difference. Princeton: Princeton University Press.

Download references

Acknowledgments

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.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Megan A. Dean.

Additional information

An erratum to this article is available at http://dx.doi.org/10.1007/s11673-016-9745-x.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Dean, M.A., Victor, E. & Guidry-Grimes, L. Inhospitable Healthcare Spaces: Why Diversity Training on LGBTQIA Issues Is Not Enough. Bioethical Inquiry 13, 557–570 (2016). https://doi.org/10.1007/s11673-016-9738-9

Download citation

Keywords

  • Microaggressions
  • Heteronormativity
  • LGBTQIA health
  • Diversity training
  • Queer bioethics