CE Article: The ABCs of LGBT: Creating a Positive Space in the Ambulance

Objectives

• Understand and define the differences between sex, sexual orientation, gender, and gender identity.
• Describe the disparities and health threats unique to LGBT patients.
• Identify measures that can help create a positive environment in your ambulance or sphere of care.

Creating a positive space for patients is difficult at the best of times. Having called 9-1-1, few patients would describe their day as going well. Developing rapport and building trust are essential abilities of today’s healthcare practitioner.

This may be especially punctuated in prehospital care, where the stakes are high and time is short. For paramedics, EMTs, and first responders, this is a tall order to fill; we serve a diverse population of adults and children, Catholics and Muslims, Africans and Asians, young and old, gay and straight. 

Recent case law, legislation, and constitutional challenges in the United States have highlighted rights for lesbian, gay, bisexual, and transgendered (LGBT) people in the context of healthcare delivery and discrimination by providers.^1–3

With 4%–12% of the population self-identifying as LGBT,⁴ you’ve certainly already cared for an LGBT person in the back of your ambulance. While some healthcare workers turn a blind eye to this population, they have unique health needs to consider, and there remain challenges in ensuring LGBT patients feel comfortable, accepted, and safe.

Definitions

Words mean different things to different people. Here are some commonly accepted definitions relevant to LGBT populations:

Sex—The anatomic distinction between male and female. Sex can be chromosomal (XY for male, XX for female) or anatomical (testes for men, ovaries for women). Many developmental conditions result in being intersex, where external genitalia may not be congruent with internal sex organs, hormone function, or chromosomes.

Gender—The social construct associated with men (masculinity) and women (femininity). Social constructs, or “gender norms,” that define what it means to be a man or a woman differ historically and culturally.

Sexual orientation—How a person thinks of him- or herself in terms of whom they are either emotionally or physically attracted to. 

Gender identity—An individual’s own sense of their gender. It may or may not conform to the sex at birth and can be linked to a feeling of being male, female, both, or neither. Various nonbinary (male or female) descriptions are included in this category, including gender-fluid (moving between male and female), gender-queer (an intermediate between male and female), agender (having no gender), or poly- or bigendered (being both or many genders).

Heterosexism—The assumption made by institutions or individuals that everyone is heterosexual and/or that heterosexuality is inherently superior to homosexuality or bisexuality; any prejudiced attitude, action, or practice that subordinates people because of their nonheterosexual identity.

Lesbian—A woman who is attracted to women in an emotional or physical sense. Not all women who engage in same-sex sexual intimacy identify as lesbian.

Gay—A man who is attracted to men in an emotional or physical sense. Not all men who engage in same-sex sexual intimacy identify as gay.

Bisexual—A person who is attracted to more than one gender in an emotional or physical sense. They may have a preference for one gender over others.

Cisgender—A person whose gender identity is congruent with their biological sex.

Transgender—A person whose gender identity is not congruent with their biological sex. Sexual orientation is separate from gender identity. 

Cross-dressing—In and of itself, this refers to a behavior that’s independent of gender identity and not synonymous with a transgender identity.

Queer—An umbrella term that embraces a variety of sexual orientations and gender identities. The term “queer” may not be adopted by all people who self-identify as LGBT. 

Questioning—A person who is in the process of questioning their gender identity and/or sexual orientation.

Ally—A person who confronts homophobia, heterosexism, transphobia, and heterosexual privilege in themselves and others; respectfully shows concern for the well-being of people who identify as LGBTQ; and believes that heterosexism, homophobia, and transphobia are social justice issues.

Homophobia—The fear of, discrimination against, or hatred of people who do not conform to rigid sex roles and sexuality stereotypes.

Coming out—May refer to the process by which one recognizes, acknowledges, and/or embraces one’s own sexuality or gender identity (to “come out” to oneself). This term may also refer to the process by which one shares one’s sexuality or gender identity with others (to “come out” to friends, family, etc.).

Tolerance—The act of putting up with something. 

Acceptance—Regarding something as proper, normal, or inevitable. 

Why Discuss LGBT Health?

LGBT persons have several health disparities compared to non-LGBT people. LGBT persons are more likely to be smokers, drink alcohol, and have mental health problems, which is likely due to lower socioeconomic status and marginalization compared to straight people.⁵ They may also be less likely to access healthcare services for fear of stigmatization.⁶

The suicide rate among LGBT people is higher than for straight people. Suicide is the second-leading cause of death among 15–24-year-olds, with suicide rates four times higher in gay and lesbian teens.⁷

Gay men have higher risk for anal cancer, HIV/AIDS, suicidality, and eating disorders. Lesbians are at increased risk of breast cancer, obesity, substance abuse, and cardiovascular disease.⁶

Many of these pathologies may relate to disparities in disease screening. Transgender men and women experience more physical and sexual violence, increased rates of suicide and depression, lack of health insurance due to lack of stable employment, and complications from sex-reassignment therapy that may include hormones and/or surgery.⁶  

It is important to know these populations are more susceptible to certain health conditions but may seek healthcare less often due to fears of stigmatization.⁸ This means LGBT people often present to healthcare providers in the later stages of disease compared to their straight counterparts. It is important, then, that healthcare workers are aware of the disparities and work to make their organizations welcoming to all patients, especially those least likely to seek care.

LGBT Rights and Healthcare

The debate about access to healthcare in the United States is still unsettled. In many ways the furor over the Affordable Care Act and how healthcare should be structured in the country revolves around the right to healthcare.

There are laws in place that help prevent discrimination against the most severely sick who need medical attention, including the Emergency Medical Treatment and Active Labor Act and Americans With Disabilities Act. And of course there are Medicaid and Medicare to catch those who cannot afford private insurance. The 1990 CARE Act (later named the Ryan White Act) set aside federal funding to help treat marginalized victims of the HIV/AIDS crisis.⁹

In fact, the HIV/AIDS crisis in the United States was a catalyst for debate about access to medical care, and it resulted in both the American Medical Association and American Dental Association updating their ethical codes to make it unethical to refuse to treat someone on the basis of their HIV or AIDS status.

Today these ethical codes are often written into healthcare contracts, and with the addition of the ADA’s prohibition of discrimination on the basis of disability, most will receive care when they really need it, at least in emergencies. (Despite this, some suggest it’s murky at best whether U.S. physicians have a duty to care in all cases.¹⁰)

However, there is still no clear U.S. federal law that prohibits discrimination based on sexual orientation or gender identity in all situations. Title VI of the Civil Rights Act of 1964 prohibits discrimination by federally funded programs on the basis of “race, color, or national origin,” but there is no obvious protection based on sexual orientation or gender identity.¹¹

There are federal protections for employment and workplace harassment, and many states have antidiscrimination laws for housing and employment, but there are also states attempting to make it legal to discriminate against LGBT people in some situations. Most pointedly, some have attempted to pass “religious freedom” laws that might allow a hypothetical EMT to refuse to care for someone identified as LGBT.¹²

It is hard to argue there are clear legal prohibitions against discrimination against LGBT people. We can argue, however, that there are strong moral and ethical ones.

The NAEMT’s Code of Ethics pledges to “encourage the quality and equal availability of emergency medical care” and requires service with “compassion and respect for human dignity,” while not judging “the merits of the patient’s request for service.”¹³ It is unfortunate that the 2013 update to the original 1978 code did not update the list of grounds upon which discrimination takes place, but the spirit of the code is to help everyone, regardless of their background, circumstances, or culture.

This code is much less detailed than those of other U.S. healthcare professions. One has only to look at the code of ethics for the National Nursing Association to see what a comprehensive code looks like.¹⁴ In that code healthcare is taken as a fundamental right and the nurse is responsible for creating a “moral milieu that is sensitive to diverse cultural values and practices.”

From these documents one can argue that healthcare providers from all levels have a duty to reduce disparity and treat people equitably, regardless of differences in cultural, religious, or moral norms. Surely LGBT patients should be afforded these same rights while the law catches up. Prehospital healthcare providers should be sensitive to their responsibilities to provide equitable care for all.

However, despite this ethical imperative, many LGBT people are marginalized and stigmatized and do not seek healthcare for fear of being judged or harassed by their providers.¹⁵ Such patients often perceive they are not welcome.

A healthcare provider or institution may not literally refuse to care for an LGBT person, but the experience may not feel welcoming, leaving some patients feeling vulnerable and threatened. To reduce and one day eliminate this, most healthcare institutions have delivered “positive space” training to their staff to provide knowledge, suggest communication strategies, and establish performance expectations.¹⁶

In Closing

While LGBT discrimination is a moving target in the United States, most EMS services have policies that prohibit discrimination. But acceptance cannot be legislated—only a cultural shift can bring about equality.
Doing your part to foster an environment that’s respectful and accepting of all healthcare workers and the patients they serve could significantly affect a person’s experience on what may otherwise be a very crummy day. Creating a positive space in the back of an ambulance may be difficult. But difficult is what paramedics do best.  

References

1. Obergefell, et al. v. Hodges, 135 S. Ct. 2584, www.supremecourt.gov/opinions/14pdf/14-556_3204.pdf.

2. Thompson IS, Strangio C. Victory! Social Security Administration Drops Surgery Requirement for Gender Change. ACLU Washington Markup, 2013 Jun 19; www.aclu.org/blog/lgbt-rights/victory-social-security-administration-drops-surgery-requirement-gender-change.

3. U.S. Equal Employment Opportunity Commission. Facts About Discrimination in Federal Government Employment Based on Marital Status, Political Affiliation, Status as a Parent, Sexual Orientation, and Gender Identity, www.eeoc.gov/federal/otherprotections.cfm.

4. GLAAD. Accelerating Acceptance 2017, www.glaad.org/publications/accelerating-acceptance-2017; Gates GJ. In U.S., More Adults Identifying as LGBT. Gallup, https://news.gallup.com/poll/201731/lgbt-identification-rises.aspx. 

5. Institute of Medicine (U.S.) Committee on Lesbian, Gay, Bisexual and Transgender Health. “Context for LGBT Health Status in the United States.” In: The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press, 2011.

6. Kates J, Ranji U, Beamesderfer A, et al. Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender (LGBT) Individuals in the U.S. Kaiser Family Foundation, Disparities Policy, www.kff.org/report-section/health-and-access-to-care-and-coverage-for-lgbt-individuals-in-the-u-s-update-health-challenges/.

7. Kann L, Olsen EO, McManus T, et al. Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9–12—United States and selected sites, 2015. MMWR, 2016 Aug 12; 65(9); www.cdc.gov/mmwr/volumes/65/ss/pdfs/ss6509.pdf.

8. Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. Ann Emerg Med, 2014 Jun; 63(6): 713–20.

9. Teshome G, Closson FT. Emergency Medical Treatment and Labor Act: the basics and other medicolegal concerns. Pediatr Clin North Am, 2006 Feb; 53(1): 139–55.

10. Meier D. The Refusal of Care. Healthcare Risk Management Review, 2016; www.hrmronline.com/article/the-refusal-of-care.

11. U.S. Department of Justice. Title VI of the Civil Rights Act Of 1964, 42 U.S.C. §2000d Et Seq.

12. Maggiore WA. State laws & religious beliefs. J Emerg Med Serv, 2015 Sep 9; www.jems.com/ems-insider/articles/2015/07/state-laws-religious-beliefs.html.

13. National Association of Emergency Medical Technicians. Code of Ethics and EMT Oath, www.naemt.org/about-ems/emt-oath.

14. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. American Nurses Association, 2015.

15. National Women’s Law Center. Health Care Refusals Harm Patients: The Threat of LGBT People and Individuals Living With HIV/AIDS, https://nwlc.org/resources/health-care-refusals-harm-patients-threat-lgbt-people-and-individuals-living-hivaids/.

16. Schneider KT, Wesselmann ED, DeSouza ER. Confronting subtle workplace mistreatment: The importance of leaders as allies. Front Psychol, 2017, 8: 1,051.

Sidebar: Transgender Communication Tips

• The idea of “passing” for one gender or another is a controversial subject in the trans community. It can imply that a person is not genuinely what they appear to be. It’s not appropriate to comment on the extent to which a trans person appears to be cisgendered.
• It is not a requirement that a trans person “out” themselves to you or other healthcare providers. It is also untrue that you will be able to immediately tell who is transgender and who is not. Rather, try to get used to the fact that gender does not imply a binary of man or woman but instead exists on a spectrum. 
• It’s important to honor the pronoun each person uses. An unfamiliar or seemingly counterintuitive pronoun can cause anxiety. Some may even balk at using a person’s chosen pronoun due to a conflict of values or perceptions. It is OK to make a mistake and correct yourself. It will take time to lose this anxiety. Try normalizing pronoun choice by indicating your own pronoun in your interaction or on your nametag. When you don’t know someone’s pronoun, use a gender-neutral one such as “they.” This will show your support for people across the gender spectrum.

Sidebar: LGBT Q&A

How can I create a positive space in my ambulance?

When interviewing patients use phrases that do not assume heterosexuality. For example, if you see a wedding ring on a female, don’t ask, “When did he propose?” but rather, “When did your partner propose?” Small cues signal to LGBT people that you are open to their existence. Treat spouses and partners of LGBT patients the same as you would any other spouse, including them as appropriate in information-gathering and decision-making. They will have the same pertinent information about a patient as any spouse. Other steps include asking your employer to post a positive-space symbol on your ambulance window or inside the patient compartment or incorporate it into the uniform. The upside-down rainbow triangle and rainbow flag are recognizable symbols. Advocating for positive-space training from your employer or acknowledgement of days of observance like World AIDS Day or the National Transgender Day of Remembrance are actionable steps.

What if I hear a colleague use words like “gay” in a pejorative or derogatory way or make homophobic comments?

It’s easy for us to sit here in our offices and say, “Speak up and tell them that’s not OK!” But doing so in practice is difficult. Use the situation as an opportunity for connection, education, and discussion. Keep in mind that change starts from a few people who stand up to the status quo. Remember that silence can be construed as agreement, by both the person making the comments and those subjected to them. LGBT employees spend a lot of emotional energy modulating their behavior to fit into homophobic workplace cultures; having a straight ally confront this behavior can go a long way to reducing the stress of LGBT coworkers.19 It is important to be aware of workplace policies and codes of conduct (and, in some places outside the U.S., hate-speech legislation). 

If I am treating a transgendered person, how should I address them?

The easiest thing to do is ask! Don’t be embarrassed to ask a transgendered person their preferred pronoun. Use their preference in all conversation, being attentive to the use of words like “mister” or “she” or “his.” If they have organs that do not correspond to their gender identity, it may sound odd, but in this case “her testicles” or “his ovaries” is correct. 

What if their chromosomal sex matters in my medical management or differential diagnosis?

Explain to the patient that to best assess them, you would like to know what reproductive organs they were born with and what organs they have now. For example, “I’m trying to rule out some serious causes of abdominal pain. Do you have ovaries or a uterus?”

How should I chart or report transgender people?

A transgendered man refers to a person who was born female and identifies as male. This can be reported as a female-to-male (FTM) transgender person. A transgender female refers to a person who was born male and identifies as female. This can be reported as a male-to-female (MTF) transgender person. These individuals may or may not have undergone gender confirmation surgery. If your charting system has an “other” or “override” option, you can use it to describe the gender of your patient. Many new healthcare charts include a transgender option. If you cannot choose something other than male or female, the current gender identity is preferred. UC San Francisco’s Center of Excellence for Transgender Health sets the standard as recording both the gender and sex on their birth certificates.

For more information see https://transhealth.ucsf.edu/protocols. 

—Michael Kruse and Blair Bigham

Michael Kruse, BSc, EMT-P, is an advanced care paramedic for York Region Paramedic Services and a medical student at McMaster University, Hamilton, Ontario.

Blair Bigham, MD, MSc, EMT-P, is a former helicopter paramedic and resident emergency department physician. He has authored over 30 scientific articles, led major national projects to advance prehospital research, and participated in multiple collaboratives, including the Resuscitation Outcomes Consortium. E-mail him at blair.bigham@medportal.ca. He is a member of the EMS World Editorial Advisory Board.