It is more than sex and clothes: Culturally safe services for older lesbian, gay, bisexual, transgender and intersex people

When Stigma, Disclosure, and Access to Care Collide: An Ethical Reflection of mpox Vaccination Outreach

Experiences of stigma in health care encounters among LGBTQ+ populations (lesbian, gay, bisexual, transgender, and queer and questioning) have long been a barrier to care. Marginalization and historically grounded fears of stigmatization have contributed to a reluctance to disclose sexual behavior and/or gender identity to health care providers. We reflect on how student nurses grappled with the ethics of patient disclosure while providing mobile outreach in Chicago for mpox (formerly monkeypox) from fall 2022 to spring 2023. Student nurses addressed how requiring disclosure of sexual behavior or sexual orientation may serve as a barrier to accessing preventive care, such as mpox vaccination. Accounts of stigma and criminalization experienced by LGBTQ+ people provide insight on challenges historically associated with disclosure in health care.

Review of current 2SLGBTQIA+ inequities in the Canadian health care system

Gender identity and sexual orientation are determinants of health that can contribute to health inequities. In the 2SLGBTQIA+ community, belonging to a sexual and/or gender minority group leads to a higher risk of negative health outcomes such as depression, anxiety, and cancer, as well as maladaptive behaviors leading to poorer health outcomes such as substance abuse and risky sexual behavior. Empirical evidence suggests that inequities in terms of accessibility to health care, quality of care, inclusivity, and satisfaction of care, are pervasive and entrenched in the health care system. A better understanding of the current Canadian health care context for individuals of the 2SLGBTQIA+ community is imperative to inform public policy and develop sensitive public health interventions to make meaningful headway in reducing inequity. Our search strategy was Canadian-centric and aimed at highlighting the current state of 2SLGBTQIA+ health inequities in Canada. Discrimination, patient care and access to care, education and training of health care professionals, and crucial changes at the systemic and infrastructure levels have been identified as main themes in the literature. Furthermore, we describe health care-related disparities in the 2SLGBTQIA+ community, and present available resources and guidelines that can guide healthcare providers in narrowing the gap in inequities. Herein, the lack of training for both clinical and non-clinical staff has been identified as the most critical issue influencing health care systems. Researchers, educators, and practitioners should invest in health care professional training and future research should evaluate the effectiveness of interventions on staff attitudinal changes toward the 2SLGBTQIA+ community and the impact on patient outcomes.

Cultural Safety for LGBTQIA+ People: A Narrative Review and Implications for Health Care in Malaysia

LGBTQIA+ people in Malaysia constitute a marginalised population as they are subjected to cisheterosexism that permeates every layer of society. Cisheterosexist ideologies in Malaysia find their eligibility on secular and religious laws that criminalise LGBTQIA+ identities, which have detrimental consequences on LGBTQIA+ people’s mental health and their ability to access equitable health care. Existing literature has revealed limitations for healthcare providers to employ a blinded approach (i.e., treat everyone the same) and practise culturally competency when seeing LGBTQIA+ patients. In this narrative review, we compiled international evidence of culturally safe care for LGBTQIA+ people and outlined its relevance to interrogating power relationships within healthcare practices and structures. Our reviewed findings brought together five components of culturally safe care for LGBTQIA+ people: power-enhancing care; inclusive healthcare institutions; continuous education and research; promotion of visibility; and individualised care. These components set crucial milestones for healthcare providers to reflect on ways to equalise power dynamics in a provider–patient relationship. The applicability and implication of culturally safe healthcare in Malaysia are succinctly discussed.

Reflexive Practice as an Approach to Improve Healthcare Delivery for Indigenous Peoples: A Systematic Critical Synthesis and Exploration of the Cultural Safety Education Literature

Cultural safety is increasingly being taught in tertiary programmes of study for health professionals. Reflexivity is a key skill required to engage in culturally safe practice, however, there is currently limited literature examining how reflexivity is taught or assessed within cultural safety curricula. A systematic review of the literature up until November 2021 was conducted, examining educational interventions which aimed to produce culturally safe learners. Studies were limited to those with a focus on Indigenous health and delivered in Australia, Aotearoa New Zealand, Canada, and the United States. A total of 46 documents describing 43 different educational interventions were identified. We found that definitions and conceptualisations of reflexivity varied considerably, resulting in a lack of conceptual clarity. Reflexive catalysts were the primary pedagogical approaches used, where objects, people, or Indigenous pedagogies provided a counterpoint to learners’ knowledges and experiences. Information regarding assessment methods was limited but indicates that the focus of existing programmes has been on changes in learner knowledge and attitudes rather than the ability to engage in reflexivity. The results demonstrate a need for greater conceptual clarity regarding reflexivity as it relates to cultural safety, and to develop methods of assessment that focus on process rather than outcomes.

Experiences of informal caregiving among older lesbian and gay adults in Australia

Objective

This study examined older lesbian and gay adults' experiences regarding informal caregiving, including challenges and positive aspects of caregiving.

Methods

Interviews were conducted with 16 lesbian women and gay men in Australia, aged 60+, who were engaged in informal caregiving. Analyses involved a qualitative thematic approach.

Results

Most participants were caring for a friend or partner and regarded caregiving as a form of love and did not seek external support despite noting several impacts. Some participants found that they too were beginning to require care. For some, formal care was being considered, but with a degree of reluctance.

Conclusions

Older lesbian and gay adult caregivers experience a range of challenges and support needs in relation to their experiences with the caregiving role. This research highlights a need for ensuring that caregiving policies and practices be responsive to the experiences and challenges faced by older lesbian and gay people.

Aboriginal and Queer Identity/ies in Western Australia: When There is a Need to Know in Therapeutic Settings

A central question for the exploratory Aboriginal and LGBTQ+ researcher led project 'Breaking the Silence: Being Indigenous and identifying LGBTQ+' (Breaking the Silence) is how provision of genuinely inclusive service responses for Aboriginal and Torres Strait Islander people identifying as LGBTQ+ can be developed. This article presents the qualitative findings of this mixed-methods research project to show how organizational staff working in health, education and social support services in Western Australia consider the Aboriginal LGBTQ+ identity/experience. Analysis of the written, interview and focus group responses to a question about the relevance of LGBTQ+ identity show that these questions need to be considered and evaluated within diverse service cultures and philosophies of services. Staff views are diverse and organizational consensus on the relevance (or not) of LGBTQ+ identity needs to be the precursor before the development or consideration of changes to service delivery and models.

Culturally safe, high-quality breast cancer screening for transgender people: A scoping review protocol

AIM

To develop evidence-based recommendations for provision of culturally safe, high-quality services for breast cancer screening for transgender people.

DESIGN

The scoping review will follow the JBI methodological guidance for scoping reviews.

METHODS

A search using MEDLINE (PubMed), Embase (Ovid), Scopus, the Cochrane Library, including the Cochrane Methodology Register, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and the World Health Organization, Australia Government Department of Health and Google Scholar will be undertaken. The review will include people of any age and ethnicity defined in the source of evidence as transgender. The review will include individuals who have used gender-affirming interventions or not and sources of evidence that report information relevant to the provision of culturally safe, high-quality breast cancer screening services for transgender people. English language sources of evidence published from database inception with information from any country will be eligible for inclusion. Sources will be screened for inclusion by three independent reviewers. Results will be extracted using a purpose-built tool and presented in relation to the review questions and objective in the final report using tables, figures and corresponding narrative. Project funding was approved by the Australian Government Department of Health in June 2020.

DISCUSSION

There are a range of factors that impact on the equity of health access and outcomes for people who are not cisgender. Transgender people are at risk of breast cancer but there is relatively little evidence about how their risks may or may not differ substantially from cis-gendered individuals and little guidance for health providers to ensure inclusive, culturally safe, high-quality breast cancer screening services for both transgender males, transgender females and gender diverse people who may not identify as male or as female.

IMPACT

It is important to provide culturally safe, high-quality services for breast cancer screening for transgender people.

"Feeling Safe, Feeling Seen, Feeling Free": Combating stigma and creating culturally safe care for sex workers in Chicago

BACKGROUND

Previous studies have established that sex workers experience discrimination and stigma within healthcare settings, limiting their access and receipt of culturally safe care. These barriers impact sex workers' ability and desire to routinely engage with the healthcare system. Community empowerment interventions that are culturally safe offer an effective strategy to improve access to services and health outcomes for sex workers.

OBJECTIVES

This project was designed to inform the development of community empowerment interventions for sex workers by understanding their self-management, health promotion, and harm reduction needs.

METHODS

In-depth interviews (N = 21) were conducted with sex workers in Chicago. Transcripts of individual interviews were analyzed in Dedoose using rapid content analysis.

RESULTS

Participants had a mean age of 32.7 years; 45% identified as White, 20% as Black, 15% as Latinx, and 20% as multiple races; 80% identified as Queer. A total of 52% of participants identified as cisgender women, 33% as transgender or gender fluid, 10% as cisgender men, and 5% declined to answer. Themes of self-management practices, stigmatizing and culturally unsafe experiences with healthcare providers, and the prohibitive cost of healthcare emerged as consistent barriers to routinely accessing healthcare. Despite identifying patient-centered care as a desired healthcare model, many participants did not report receiving care that was respectful or culturally responsive. Themes also included developing strategies to identify sex worker-safe care providers, creating false self-narratives and health histories in order to safely access care, and creating self-care routines that serve as alternatives to primary care.

CONCLUSION

Our findings demonstrate how patient-centered care for sex-workers in Chicago might include holistic wellness exercises, accessible pay scales for services, and destigmatizing healthcare praxis. Focus on culturally safe healthcare provision presents needs beyond individualized, or even community-level, interventions. Ongoing provider training and inbuilt, systemic responsivity to patient needs and contexts is crucial to patient-centered care.

Towards health equity for people experiencing chronic pain and social marginalization

Objective

For people who experience social inequities and structural violence, pain and related care are inexorably linked to experiences of injustice and stigma. The purpose of this study was to examine in greater depth the experiences of pain and discrimination and stigma across diverse marginalized communities in order to recommend equity-oriented healthcare approaches.

Methods

This community-based qualitative study reports on four focus groups that included 36 people living with pain. All participants identified with one of three groups known to experience high levels of inequities and structural violence including an Indigenous group, a LGBTQ2S group, and two newcomer and refugee groups.

Results

Pain was entangled with and shaped by: social locations and identities, experiences of violence, trauma and related mental health issues, experiences of discrimination, stigma and dismissal, experiences of inadequate and ineffective health care, and the impacts of these intersecting experiences.

Conclusions

Equity-oriented responses to chronic pain would recognize pain not only as a biomedical issue but as a social justice issue. The EQUIP Framework is an approach to integrating trauma- and violence-informed care; culturally-safe care; and harm reduction in health care that may hold promise for being tailored to people experiencing pain and social marginalization.

Older lesbian and gay men's perceptions on lesbian and gay youth in Australia

Older lesbian and gay people are increasingly open about their sexuality but have also experienced a lifetime of discrimination. These groups have experienced a long history of changes to lesbian and gay rights, and many were also at the forefront of activist movements during the latter half of the 20th century. A deeper knowledge is needed of the life experiences of these groups, including how they view their lives in relation to younger lesbian and gay people. This would assist agencies working with older lesbian and gay people, such as health and support services, to provide more informed engagement, support, understanding, and culturally safe services. Drawing on 33 qualitative interviews with older (60+ years) lesbian and gay people, we explored their experiences during their younger years and their perspectives on how these experiences compare with those of younger lesbian and gay people today. Our findings note that older lesbian and gay people feel life is, in some ways, easier, and in others, still challenging for young lesbian and gay people, and they articulate a need for mutual respect across age groups.

Experiences of LGBTIQA+ People with Disability in Healthcare and Community Services: Towards Embracing Multiple Identities

Healthcare and disability support services are increasing their efforts towards inclusion and recognising the needs of different groups. This research project was conducted by academic and peer researchers (LGBTIQA+ people with disability) in Victoria, Australia using four focus groups with LGBTIQA+ people with disability. We report on two overarching themes relating to participants’ experiences of accessing health services as LGBTIQA+ people with disability: difficulties in managing multiple identities and the impacts of community services and supports. Participants described having to repeatedly ‘come out’ in a range of ways and contexts as complex and layered processes in which it was difficult to present their full range of needs and experiences to services. We also found that the role of community in promoting a sense of belonging and resilience increased capacity to manage health service use and advocacy. Services and communities aiming to be inclusive to all have the opportunity to recognise and respond to the issues faced by LGBTIQA+ people with disability as a way to pay attention to how overt and subtle practices of discrimination continue to operate despite repeated attempts at or claims of being ‘inclusive.’ Our research suggests actual inclusive, accessible services can be achieved in part through policy and practice that actively responds to the specific needs of LGBTIQA+ people with disability, in addition to LGBTIQA+ education for disability services and disability and accessibility education for LGBTIQA+ focused services. As we do in this article, we argue that this work must be done by prioritising authentic participation of LGBTIQA+ people with disability in the services and research that is about them.

Older Lesbians' experiences of ageing in place in rural Tasmania, Australia: An exploratory qualitative investigation

While there is increasing awareness of the specific health and aged care needs of older lesbian and gay people, little is known about their needs and experiences of ageing in rural communities. In Australia, older people are over-represented in regional and rural areas, however, rural communities face particular challenges to age friendliness, including infrastructure and transport limitations, reduced health and social services. In this context, few studies explore older lesbians' gendered experiences of ageing in place. To address this gap in the literature, this article draws on qualitative interviews with 13 rural Tasmanian lesbians over the age of 55, exploring their perceived barriers and enablers for 'healthy ageing' in their communities. Findings reveal that geographical isolation was a literal barrier to accessing specialist healthcare and lesbian-inclusive services, which may be absent in rural areas. The women perceived community health initiatives and social activities aimed at 'healthy ageing' in rural towns as heteronormative and unappealing for lesbians. In some cases women reported experiencing homophobic discrimination in these social groups. In contrast, rural communities were positively associated with a good quality of life derived from closeness to nature and feelings of reciprocity with rural neighbours and communities. These findings suggest that specific approaches to lesbian-inclusive rural health and social care are required. Rural communities are well-placed to build on community strengths to ensure higher quality of place-based health and social care for isolated older people, including those of diverse genders and sexualities.

[Recommendations to Nursing Practice with Sexual and Gender Diversity Older Adults : A Scoping Review]

Context : The elder population is growing up and sexual and gender diversity older adults (SGDOA) live discrimination from healthcare professionals. In this context, this scoping review sought to describe the extent of knowledge about nursing practice among SGDOA and to synthesize the implications for clinical nursing practice. Method : The scoping review method according to the framework of Peters et al. of the Joanna Briggs Institute has been adopted. Results : The recommendations were grouped into five axes : raising awareness of the existence of SGDOA, their historical context and their health problems ; refrain from heterocissexist and heterocisnormative assumptions by adopting an inclusive language and an open attitude ; support SGDOA and their caregivers or their family of choice ; create a safe and confidential environment ; and promote the inclusion of SGDOA in the health care system. Conclusion : The results could be used by nurses and other health professionals to optimize the quality of care for SGDOA and to promote their inclusion.

Gender, mental health and ageing

This article presents a broad narrative review of the epidemiological evidence on how and why the mental health of older adults varies by gender. We draw upon international research literatures spanning gerontology and population mental health, as well as major reports from global health agencies. Compared with older men, older women are more likely to experience common mental disorders such as depression and anxiety, although the gender gap is smaller than it is at younger ages. In contrast, the mortality-related impacts of poor mental health, including suicide, are more severe for older men. These gendered patterns vary by country and other social contexts. Factors proposed to account for these findings include cultural and social norms, differentiation of gender roles, disadvantage and (dis)empowerment across the life course, and the coping styles of older men. However, little research has explicitly tested these explanations. Research to date has overwhelmingly focused on identifying differences in the mental health of older men and women. Notably, most studies have been restricted to binary comparisons, lacking the data to disentangle sex and gender dynamics, and few studies have examined the mental health of minority gendered adults in later life. Finally, there remains a need for high-quality population-based research into the mental health of those aged over 80 that includes coverage of people living in residential aged care settings.

Experiences and perceptions of residential and home care services among older lesbian women and gay men in Australia

The needs of older lesbian and gay people regarding access and use of aged-care services remain underresearched. This paper reports the findings of 33 qualitative interviews with older lesbian women and gay men about their perceptions and experiences of residential aged-care and home-based aged-care services in Australia. The focus of this paper is their preparedness for using aged-care services. The results highlight that participants had a number of concerns related to accessing residential-care services in particular, including perceptions of a lack of inclusivity and concerns of potential for discrimination and hostility, loss of access to community and partners, decreased autonomy and concerns relating to quality of care and the potential for elder abuse. Participants noted a number of strategies they employed in avoiding residential-care services, including the use of home-care services, renovating the home for increased mobility, moving to locations with greater access to outside home-care services, a preference for lesbian/gay-specific housing and residential-care options if available, and the option of voluntary euthanasia to ensure dignity and autonomy. Participants, on the whole, were hopeful that they would never require the use of residential-care services, with some believing that having current good health or the support of friends could prevent this from happening. The findings suggest that older lesbian and gay people have a variety of concerns with aged-care and may need additional support and education to improve their perceptions and experiences of services, whether these are needed presently or in the future.

Organisational enablers and barriers to the recognition of sexuality in aged care: A systematic review

AIM

To identify organisational characteristics and practices that promote or inhibit the recognition of sexuality in the care of older people in health and aged care settings.

BACKGROUND

Sexuality in old age is poorly understood by health professionals and rarely addressed in care planning and delivery. Nurse managers are ideally placed to lead organisations in promoting a culture of acceptance that enables the expression of sexuality.

EVALUATION

A search for research/expert opinion papers published from January 2004 to February 2017 was undertaken. Two reviewers performed data extraction and appraisal of 34 included studies using Joanna Briggs Institute tools. The primarily qualitative research was analysed to identify 152 findings that were organised into 22 categories and combined into four syntheses.

KEY ISSUE(S)

An organisation's philosophies frame the way older people's sexuality is perceived. Cultivating a culture and environment of acceptance, engagement and knowledge and delivering care in a way that promotes opportunity for safe and private expression of sexuality are key enabling factors.

CONCLUSION(S)

Organisations and nurse leaders can support and facilitate older adults' expression of their sexuality through the review and development of philosophies, policies, procedures, staff attitudes and knowledge and the creation of a conducive environment.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers play a pivotal role in developing a sexuality-positive organisational ethos by ensuring policies, care practices, the environment and amenities are supportive of the expression of sexuality and by role modelling attitudes of respect and inclusivity.