Pride month is a celebration of LGBT+ (lesbian, gay, bisexual and trans) life and has many different aspects to it. Yet, the stereotype of LGBT+ people as being mostly a young demographic still persists. There is estimated to be 1.2 million older lesbian and gay people in the UK and between 300 000—500 000 older trans people (National Care Forum (NCF), 2017).
It is the responsibility of nurses and all members of the healthcare community to meet the needs of LGBT+ patients. The Equality Act 2010 (Legislation UK, 2010) makes it illegal to discriminate or deny access to a public service to anyone on the grounds of a protected characteristic, which includes sexuality and assigned gender. The Nursing and Midwifery Council (NMC) code of conduct states that all nurses must treat their patients with dignity, uphold the patient's rights and challenge any discrimination towards them (NMC, 2020). Equality for LGBT+ patients is a requirement on the part of all nurses and cannot be considered as ‘politically correct’ or to be done when time allows. This article will discuss how nurses should treat LGBT+ patients with dignity and respectand what their equality requirements are. It will also discuss ways a district nurse (DN) team can be more welcoming to the LGBT+ community.
LGBT+ people and healthcare
Unfortunately, many LGBT+ people are distrustful of healthcare, often having a reluctance to fully engage with it. This is due to the prevalence of homophobia.
- Up to 23% of LGBT+ people have, at one time, witnessed anti-LGBT remarks by healthcare staff
- 40% of trans people have endured at least one negative experience based on their gender when accessing healthcare (LGBT Foundation, 2020)
- 13% of LGBT people have experienced unequal treatment from healthcare staff because they are LGBT+
- 19% of LGBT+ people aren't out to any healthcare professionals about their sexuality when accessing medical care, which rises to 40% of bisexual men and 29% of bisexual women
- 14% of LGBT+ people have avoided treatment for fear of discrimination (Bachmann and Gooch, 2018).
These statistics are reflective of healthcare in general, although the LGBT+ patients in the DN caseloads are yet to be surveyed. However, if such discrimination occurs in the healthcare sector, then it is not far-fetched to consider its prevalence in district nursing services.
The author has witnessed, and has received, anti-LGBT+ treatment during their nursing career. But these statistics can be turned around; good healthcare can be delivered that meets the needs of LGBT+ patients. The author has seen this in their own workplace. This article will discuss ways to achieve this.
Experiences of older LGBT+ people
Many older LGBT+ people have lived through very homophobic times—a time when it was not safe to be LGBT+.
- Gay men feared prosecution for consenting sexual relationships with other men, even after the partial decriminalisation in 1969
- LGBT+ people were labelled as mentally ill and some had ‘corrective’ treatments such as aversion and conversation therapies
- Many LGBT+ people had to lead double lives, hiding their sexuality, because they could lose their jobs and/or face ostracisation
- Some LGBT+ people were rejected by their families because of their sexuality or gender identity (The National Council for Palliative Care (NCPC), 2016).
Such societal homophobia, which was prevalent during the author's own lifetime, can foster feelings of distrust or wariness towards institutions.
Many older members of the LGBT+ community may not have children or be close to their blood relatives. Partners and friends—their ‘chosen family’, might be far more important to them, forming their support network (NCPC, 2016). Many older LGBT+ people may have previously been in heterosexual marriages, and due to coming out about their sexuality or gender identity, may be estranged from their previous spouse and children. Other older LGBT+ people may not have ‘traditional’ family networks and the expected next of kin.
Coming out as LGBT+ is not a one-off, single event in a person's life. It must be done several times, or at least considered with each new person they meet, and should be encouraged in every new situation (NCPC, 2016). Previous negative experiences from healthcare professionals may cause a person to be reluctant to come out to the next professional they meet for fear of receiving the same persecutive experience (Almack, 2020). It is unfortunate that there are a lot of anecdotes of LGBT+ members receiving homophobic discrimination from healthcare professionals.
It is not unusual that older LGBT+ people may fear having to go back into the closet and hide their sexuality/gender in order to be able to receive healthcare or avoid homophobia (NCPC, 2016). In the same way, healthcare professional visits at home can elicit fear in older LGBT+ people as they feel that items in their home can expose their sexuality. To avoid this, before any visit, the older person might try and hide pictures, books or items that may identify them as LGBT+ (NCPC, 2016).
A nursing service may also have ‘invisible’ LGBT+ patients—patients who do not feel safe to open up about their sexuality to staff. These patients' needs may be missed. Just because a service does not have any openly LGBT+ patients on their caseload, it does not mean that it should not be openly welcoming of LGBT+ patients. Two examples from the author's own experience are as follows:
- An elderly male patient had no contact with his family and his only contact was another elderly male friend, who lived a short distance away. The two men had only ever been friends. This patient became palliative and there was a sudden rush from healthcare professionals to identify his ‘next of kin’—a living relative. The man's closet relationship, his friendship which spanned nearly half his adult life, was ignored. The author pointed this out to a senior nurse, which turned in to a heated argument
- An elderly single woman was suffering from incontinence. During the continence assessment, she became very upset when asked several times about any children she might have had. She ended up snapping, ‘I've never had sexual intercourse with a man!’. The nurse carrying out the assessment wrote down that the patient was a virgin. When the author suggested to the nurse that the patient could have had relations with women, the nurse became upset and saw this as a ‘slur’ towards the patient.
Both of the above examples were not due to active homophobia. They demonstrate that healthcare professionals can fail to consider that their patients could be members of the LGBT+ community. It can be equally pressurising to try and make someone admit they are LGBT+ when they are not comfortable doing so. Instead, it is imperative that patients are given an indication that the service is welcoming to LGBT+ patients, such as wearing a Rainbow Badge and/or having an LGBT+-inclusive statement in a DN leaflet.
Next of kin
The usual assumption is that a person's next of kin is a heterosexual spouse of a blood relationship; anyone else is not ‘legally’ a next of kin (NCPC, 2016). This is a problematic assumption as ‘next of kin’ is not a legal term (Khatib, 2015). There are provisions by the law for children under 18, but for adults, there is no such legal requirement (Khatib, 2015). The Mental Capacity Act 2005 (Legislation UK, 2005) provides a framework within which a person can nominate another person or people who can make decisions on their behalf, if or when they are incapacitated. The Human Tissue Act of 1961 (Legislation UK, 1961) allows that a non-relative can receive a person's body and arrange their funeral; they do not need to be next of kin. Yet, there are healthcare services that will only discuss a person's care with their next of kin (Royal College of Nursing (RCN), 2016). Should healthcare professionals still be using this term? There is no legal basis for it and it has a problematic and out-dated image. Should they rather be using ‘significant other’ or ‘nominated person’? Should there be an active discussion with patients regarding who can be involved in their care and who professionals can and cannot discuss their care with? This would benefit many patients, not just those from the LGBT+ community-patients who are not married to their partner, patients who only want certain people involved in their care, patients who want their friends consulted and not their relatives. Having the district nursing team discuss what is meant by ‘next of kin’, remembering that it is not a legal term, can help staff reevaluate what is being said to patients.
‘We treat everyone the same’
This can be a problematic statement, as it can reenforce the assumption that everyone is the same. It can ignore the needs of those who do not conform to this view (Almack, 2020). Older LGBT+ people have concerns and needs that fall outside of this assumption. ‘We treat everyone the same’ can often imply that the service is geared to meet the needs of only the majority of patients.
‘We don't have any LGBT+ patients’ can be equally as problematic because how does one know this for certain? (NCPC, 2016). A service could have ‘invisible’ LGBT+ patients, who do not identify themselves as LGBT+. This statement has been used as an excuse for not making a service LGBT+ welcoming, but is it true? Many older LGBT+ patients can still be in the closet about their sexuality and/or gender identity and therefore, be invisible. Rather than saying ‘we treat everyone the same’, a service should be working towards making itself welcoming to LGBT+ patients (the same way it should be making itself welcoming to all minority patients), even if there are apparently no LGBT+ patients in its caseload.
Should we not be talking about person–centred care and meeting patients' needs, rather than making statements like ‘we treat everyone the same’? Talking about what is meant by equality can help us look at our current practice and how we can make it accessible to all. This is why staff training on LGBT+ awareness is extremely important.
HIV and older patients
The stereotype of the person with human immunodeficiency virus (HIV) is that of the young man, but this is rapidly becoming out-dated. In 2019, 42.4% of people accessing HIV care were aged 50 years and over, that is, two out of every five patients (Public Health England (PHE), 2019)-a number that is only set to increase. Current antiretroviral therapy has virtually changed HIV into a chronic health condition. Unfortunately, possibly due to the chronic inflammatory nature of HIV infection, these individuals, and especially older patients, are more at risk of cardiovascular and metabolic diseases, infectious and non-infectious cancers, osteopenia (reduced bone mineral density) and osteoporosis, declining cognitive function, and renal and liver diseases (Ridgers, 2013). Like many other chronic health conditions, HIV can have long-term negative effects on a patient's whole body. An increasing number of older patients with HIV will require treatment in primary care. With this, there will be an increasing number of older people with HIV requiring healthcare, coming onto DN caseloads, and not only for treatments relating to HIV.
An example of this comes from the author's experiences, when their team was managing an elderly man's lymphoedema. It was chronic, very difficult to manage and distressing to the patient and their husband. It was also secondary to him being HIV positive, which he had been for over 20 years. Therefore, here, the DN team was managing a patient's chronic condition which was secondary, but related to, a long-term HIV diagnosis.
Though attitudes to HIV have changed in recent years, older patients may have lived through times when HIV infections were highly stigmatised (Ridgers, 2013). Doctors may have refused to treat patients with HIV, nurses may have dressed in full personal protective equipment (PPE) to carry out the simplest of tasks, patients may have been placed in full isolation and may have been told that it was their ‘fault’ they have HIV, and patients may also have been demonised in the popular press. This stigma is not easily forgotten and patients can still fear receiving discrimination and judgemental care from healthcare professionals. Nurses need to be aware of this, especially when caring for older patients with HIV and work to show patients non-judgemental care. Simple measures can make a lot of difference-not over-using PPE, especially not applying two pairs of gloves, and re-assuring the patient that infection control procedures are there to protect the patient.
Making services more welcoming
Staff training is the first step towards making a service more welcoming, as staff are considered one of the most important parts of the service. A survey of LGBT+ health and social care staff found that 33% stated that the NHS and social care services should be doing more to meet the needs of LGBT+ patients (Somerville, 2015). While research into older LGBT+ people's experiences in care homes found 78% of care home staff had no LGBT+ training, only 9% of staff said their care home made LGBT+ literature available (Trueland, 2021).
The need for training is obvious, but LGBT+ awareness training may not be obviously available. Most NHS Trusts have equality and diversity leads who may know of locally available resources. Organisations who provide this training include:
- LGBT Foundation, Pride in Practice (https://lgbt.foundation/prideinpractice)
- MindOut LGBTQ Mental Health Service (https://mindout.org.uk/training-2/)
- Switchboard (https://www.switchboard.org.uk/training/)
- LGBT health (https://www.england.nhs.uk/about/equality/lgbt-health/)
These four organisations offer generic LGBT+ awareness training for healthcare professionals, with the LGBT Foundation's Pride in Practice endorsed by the RCN. They aim to raise awareness of LGBT+ patients' needs in healthcare. District nursing is very different to most other clinical settings, but the awareness of LGBT+ patients are not. Though community nurses and DNs are skilled in providing care in patients' homes, this type of training would give them awareness, which they can transfer into their practice.
Due to the nature of district nursing, it may not be possible for the whole team to simultaneously have an LGBT+ awareness training session, especially considering that most of the above organisations usually provide training online. However, different members of the team can undertake this training at separate occasions, perhaps over the course of a week or a fortnight, and then reflect on what they have learnt together during a team meeting. Team members should discuss what attitudes were challenged, what issues were new to them, what was the takeaway message from these sessions and what can be put to practice. The paperwork a team uses should also be reviewed. Does the paperwork reinforce heterosexist attitudes? That is, does it only refer to husband/wife and next of kin, rather than more neutral terms like spouse and emergency contact? Does the paperwork ask for children's contacts, rather than a nominated person? Is the paperwork assuming all patients are heterosexual? Making the official team leaflets and welcome information more open and inclusive is also important-does it contain any heterosexist language? Do they contain any reference to LGBT+ people? Does the district nursing team have leaflets detailing what services the team provides? If so, what pictures illustrate it? Are they just of opposite sex couples? If so, why not include pictures of a same-sex couple or single people?
These do not need to be completely re-written, but they must, at the very least, consider including a statement for inclusivity, a reference to the needs of LGBT+ people, or perhaps a picture of a Rainbow Badge. Simple changes like these can be especially reassuring to an older LGBT+ patient, as it might be the first time a healthcare service has recognised them.
Another important project is the Rainbow Badge - a campaign for NHS staff to wear rainbow NHS badges to show they are open, non-judgemental and inclusive of people that identify as LGBT+ (https://www.evelinalondon.nhs.uk/about-us/who-we-are/NHS-Rainbow-Badges.aspx). When worn sincerely, the badge will indicate to an older LGBT+ patient that a member of staff is welcoming.
Patient information recording
Nurses should also be aware of the kind of information they document when they are with LGBT+ patients. Many older LGBT+ patients may not be comfortable having their sexuality and/or gender recorded in medical notes (RCN, 2016). Older LGBT+ patients may have had negative experiences in the past, with information about them being used against them in a homophobic manner. Nurses should always discuss what information they are recording with the patient, and work closely to create a safe environment for them.
Consider what language is used to describe LGBT+ people. Derogatory terms should never be used (as with any minority groups), but many LGBT+ people may not be comfortable using various terms to label or define themselves (RCN, 2016). Always work in partnership with the patient, and ask them how they want to be referred to.
Assessment
Assessment is an important part of the community nurse's role; how an assessment is carried out can speak volumes to a patient. However, as these are standardised, they can often be unintentionally heterosexist. An example of this is the continence assessment. To make it more hospitable to LGBT+ patients, consider the following:
- Incontinence is an intimate issue and can be embarrassing to any patient, including an LGBT+ patient
- It can affect their body image; now take in to consideration that many LGBT+ members have experienced a lot of body image pressures in their lives, judged primarily on their physical looks and expected to look a certain way
- The language of a continence assessment can be heterosexist, assuming that women have given birth and asking questions about the number and types of births. This is important for continence, but a woman may not have had children or may be a trans woman. Be aware of how this question is asked to the patient, or if there even is a need for it to be asked, as the LGBT+ patient may have already indicated that this question is not relevant
- A continence assessment may require an intimate examination. For many LGBT+ patients this can be very uncomfortable but they may only agree to it being done by a member of their own gender. What arrangements are in place, for example, for a male patient to have this examination performed by a male nurse?
- Person–centred care should be at the heart of any good assessment, especially for one that is as sensitive as a continence assessment. Before starting, take some time to talk to the patient-ask them about themselves and their needs. Listen to their replies. Do they have children? Do they have a spouse? Are they sensitive or embarrassed about anything? Not every patient having a continence assessment will be LGBT+, but do not assume that all patients are heterosexual.
Going beyond the stereotypes
Just as all people are different, so are members of the LGBT+ community. There are stereotypes around LGBT+ people-some maybe true but not all LGBT+ people conform to them. Not all gay men are well groomed, not all gay women want to be called a lesbian. Not every LGBT+ person is the same person (NCPC, 2016). Therefore, person–centred care is still important, as it is with every patient. Not every LGBT+ person refers to themselves with the same terms and names (RCN, 2016), and therefore it is important to get to know a patient on their terms. Older LGBT+ people do have specific (NCF, 2017), as well as general health needs, but their sexuality and/or gender identity should never be questioned or judged in the process of delivering healthcare.
Conclusion
There are so many negative statistics around LGBT+ people's experiences in healthcare, but many of them could be reversed by making services welcoming to LGBT+ patients, and achieving this does not require a global change in service. Small and simple changes, such as not assuming all patients are heterosexual, can make a lot of difference to LGBT+ patients. At the heart of these changes is staff training and opening staff 's attitudes to the needs of LGBT+ patients. The Equality Act 2010 (Legislation UK, 2010) requires that all LGBT+ patients are treated without discrimination, and this can only be achieved when a service becomes more open and welcoming to their to their LGBT+ patients.