Stakeholders' Recommendations to Improve Patient-centered “LGBTQ” Primary Care in Rural and Multicultural Practices

Results

Three to 15 individuals, ages 18 to 75 years, volunteered for each local/rural dialog (n = 32). Participants reported anti-LGBTQ sentiment that led some LGBTQ people to “pocket” or closet themselves, a persistent lack of culturally sensitive health care, deficits in provider knowledge and/or lack of provider inquiry into LGBTQ-specific health issues, fragmentation of health care services (particularly for persons with HIV), insufficient health care options for rural LGBTQ patients, and isolation of youth, elders, and transgender persons. A comprehensive description of town hall findings was presented in the opening address for the New Mexico Sexual and Gender Diversity Summit. The 175 summit attendees (see Table 1 for demographic information) identified additional health care gaps for 7 populations: LGBTQ youth, elders, American Indians, Latinos/Latinas (native and immigrant), transgender persons, bisexual people, and all LGBTQ rural residents. Quotations derived from the town hall dialogues reflecting dominant perceptions/experiences, as well as a summary of summit participant suggestions to address gaps in the health care system, are presented here.

One urban dialogue participant's comment captured the tone of these conversations: “It is not good here. But I have access to care if I need it. Imagine being a trans woman of color in Portales!” For this participant, Portales, a rural community of 12,233 people, 43% of whom are Hispanic, exemplified New Mexico communities shaped by specific cultural contexts and the lack of resources for LGBTQ-centered health care. Many rural participants reported struggles with “fear” and “anxiety” due to perceived discrimination and bias during health care encounters, and claimed to omit relevant information about themselves as a strategy to ensure access to care and avoid staff/provider discomfort. One gay participant told us, “Here, it is better not to disclose your sexuality. My partner went to the emergency department for gastrointestinal problems. He could not get a hold of me and was totally on his own. When the nurses found out he was gay, they left him for hours… . Homophobia is real here. How do you think they reacted when they found out he was HIV positive?”

To meet such needs, summit attendees identified primary care as a key setting for first-level interventions because of its person-centeredness and accessibility for rural and economically challenged New Mexicans. When asked whether extant primary care treatment guidelines would be helpful to share with clinicians statewide, the majority were unaware that such guidelines existed, whereas those in the know indicated that the guidelines did not focus sufficiently on the needs of rural gender/sexual minorities.

Summit attendees suggested that clinics may be unaware of and/or lack sufficient resources to integrate LGBTQ-specific care recommendations into practice. A lesbian who worked for a managed care organization explained, “It is not that providers are bad people, or want to be insensitive. There are always going to be those whose views are homophobic, or overtly religious and conservative. But others just haven't had training, and do not know what to say to a male-to-female transgender patient who was just beaten for walking down the street or having a drink in a local bar.”

Summit participants believed strongly that staff and clinicians would benefit from LGBTQ health care training and evaluation, indicating that guidelines calling for full cultural competency coaching for all staff/providers would increase sensitivity, confidentiality, and positive interactions for LGBTQ patients. A gay man who participated in a dialogue explained, “I want them to ask me. I want them to offer anal paps. But, the docs are uncomfortable talking about sex, much less talking about gay sex.”

Summit participants pointedly appealed for “realistic action steps” that could lead to “immediate improvements” for LGBTQ patient-centered care:

1. Create a safe, welcoming environment

   • Post LGBTQ-positive visual representations, for example, images of people/families of differing gender/sexual, cultural, ethnic/racial backgrounds, in lobbies/examination rooms

   • Use culturally appropriate, culturally specific terms on intake forms; that is, recognize that some patients may prefer local terminologies such as Native American use of “Two-Spirit,” patient preference for “queer” over “lesbian,” “gay” or “bisexual,” and/or use of “they” as a preferred gender pronoun by people across the sexual/gender minority spectrum

   • Include gender/sexual difference in displayed antidiscrimination policies

2. Develop culturally competent medical staff

   • Invite local LGBTQ community members/leaders to clinic meetings to discuss the experiences/treatment needs of LGBTQ patients

   • Encourage respectful, direct, open-ended questions using culturally relevant terminology in provider–patient interactions regarding identity, sexual history, and risk factors

   • Use local university/community-based safe zone training¹⁵ centered on how to be an LGBTQ ally while enhancing understanding of anti-LGBTQ stigma/phobias and microaggressions for all providers and staff to encourage patient feelings of security

3. Update medical training

   • Deploy technologies in rural settings, for example, video/Web conferencing for consulting LGBTQ specialists

   • Acquire information on LGBTQ-specific health, for example, hormone therapies and associated risks for transgender patients, gender-sensitive cancer screenings

   • Participate in research to improve LGBTQ health care