Lesbian, gay, bisexual, transgender, questioning or queer, intersex, and ally (LGBTQIA) refers to a diverse community from a gender, sexual, and cultural perspective (please see Table 1 for a summary of identity terminology). A 2013 Pew Research Center survey of LGBT adults found that while an overwhelming majority of participants reported perceiving society as more accepting (92%), 43% also reported having been the victim of stigma or discrimination as a result of their sexual orientation over the past year [1]. While these groups tend to be grouped under the broad heading of LGBTQIA, the diversity and differences among and between these groups couldn't be more obvious or evident.  Adding to this complexity are the other variant characteristics of culture with which these individuals may identify. Variant characteristics of culture may change or remain stable over a lifetime such as nationality, race, ethnicity, religious affiliation, socioeconomic status, educational status, political affiliation, immigration status [2].  In light of these various cultural influences, and in an effort to provide the most comprehensively competent care for all of their patients, including members of the LGBTQIA community, it is imperative that nurses have a sound understanding of cultural competence and the health related issues that may impact LGBTQIA.

Table 1: community from a gender, sexual, and cultural perspective.

Cultural competence has been previously defined as the explicit use of culturally based care and health knowledge that is used in meaningful ways to be congruent with the needs of individuals or groups the ongoing process in which the healthcare provider continuously strives to effectively work within the cultural context of the client self-cultural awareness, knowledge, and understanding of the client's culture and adaptation of care to be congruent with the client's culture Purnell and a dynamic, fluid, continuous process whereby an individual, system, or healthcare organization meaningful and useful care delivery strategies based on knowledge of the cultural heritage, beliefs, attitudes, behaviors, and worldview of those to whom they provide care [3-5]. While these models have been primarily focused on cultural competence with regards to racial and ethnic diversity, they can provide a loose framework for understanding the subcultures that underlie prevailing cultural influences such as those found among LGBTQIA individuals and communities.  Purnell's model consists of twelve cultural domains and their concepts. The twelve domains are overview/heritage, communication, family roles and organization, workforce issues, biocultural ecology, high-risk health behaviors, nutrition, pregnancy and the childbearing family, death rituals, spirituality, healthcare practices, and healthcare providers Purnell. Whereas there are 14 places where LGBTQIA have relevance these populations, some may be of particular concern when considering culturally competent care of individuals who identify, either openly or not, as members of the LGBTQIA community; such as family role and organization, high-risk health behaviors, and health-care practices.

The Institute of Medicine (IOM) (Institute of Medicine) reported on the health of lesbian, gay, bisexual, and transgender people and the issues related to health and wellness among the LGBTQIA community. The report is sub-divided into lifespan developmental stages [6].

The Institute of Medicine (IOM) (Institute of Medicine) reported on the health of lesbian, gay, bisexual, and transgender people and the issues related to health and wellness among the LGBTQIA community. The report is sub-divided into lifespan developmental stages [6].

Childhood and Adolescence

Nurses working with children and adolescents are increasingly challenged with working with individuals who may or may not be aware of their own sexual orientation or gender identity. Childhood and adolescence is often challenging for these young individuals who may be trying to understand how and why they may be different from their peers, particularly if they come from familial or community backgrounds that stigmatize being different from a sexual or gender perspective. This is precisely where the other domains of culture such as heritage/ethnicity, family roles and expectations, socioeconomic factors, education, and religion need to be considered as they may conflate the challenges of coming to terms with one's own sexuality or gender identity. Among all the challenges that may exist for young LGBTQIA persons, depression and suicide have been identified as major risk factors for lesbian, gay, and bisexual youth and youth who report same-sex romantic attraction in comparison with their heterosexual counterparts, even when controlling for other confounding risk factors such substance misuse and depression (IOM). While the IOM reports that interventional approaches to reducing the incidence of suicide in this population have been lacking, it is important for nurses and other healthcare providers to be aware that resources exist. One such resource is The Trevor Project [7]. Founded in 1998, The Trevor Project is a leading national organization providing crisis intervention and suicide prevention services to lesbian, gay, bisexual, transgender, and questioning (LGBTQ) young people ages 13-24 [7]. Other areas of concern that tend to have higher rates among youth and young LGBTQIA adults include eating disorders/body image disturbances (particularly among gay men), transgender specific mental health issues, substance misuse, and HIV and other sexually transmitted infections. Even as society is witnessing more acceptance of LGBTQIA individuals (especially in larger urban areas) and in light of more visible positive role-models for young LGBTQIA persons, it is important to keep in mind that risk factors for young LGBTQIA individuals still include harassment, victimization, bullying, and violence.

Early and middle adulthood, defined loosely as ages 20 through 60, is another lifespan phase that can present numerous challenges to individuals who identify as LGBTQIA.  Many of these individuals have witnessed the positive effects of the gay rights movement as well as the devastating effects of the AIDS/HIV epidemic. There is no doubt that both of these phenomena have had an influence on the LGBTQIA community at large. Early and middle adulthood is a time when many LGBTQIA individuals must weigh the need for being "out" or not. How honest should one be with one's family and friends about their sexual orientation?  All people want to live productive lives, something heterosexuals, with regards to their sexuality at least, may take for granted. Marriage equality, which has been legal since 2015 in the U.S., has done much to provide LGBTQIA persons with more legitimacy with regards to the loving, personal relationships in which they engage. Nevertheless, heteronomativity in society at large remains strong. The overwhelming nature of the dominant United States' culture promotes heterosexuality while often deeming non-heterosexuality as controversial.  Religion, to a great extent, is one of the reasons this may be the case. Nevertheless, nurses and other health-care providers must be aware that many people who identify as LGBTQIA have spiritual needs and may or may not be affiliated with an organized religion.  In terms of health and illness, nurses need to be aware that certain health-related conditions may be more prevalent in LGBTQIA populations.  For example, since the IOM report on lesbian health in 1999, breast cancer rates for lesbian women have remained higher than rates for heterosexual women.  Lesbian and bisexual women are also at increased risk for overweight, obesity, tobacco use, and drug and alcohol use disorders. Nurses must assess for these conditions regularly and provide appropriate referrals. Men who have sex with men (MSM), and particularly MSM infected with HIV, have the highest rate of anal cancer among all people diagnosed with anal cancer  and must be evaluated and referred for anal Pap smears accordingly [8]. Additionally, annual assessment and screening for HIV, syphilis, Chlamydia, and gonorrhea should be considered for all men who have sex with men.

Later and late adulthood is defined as those aged 60 and greater.  For many people in this stage of life, this is often a time of immense health-related challenges. Older lesbians, bisexual, and gay men have a higher prevalence of mental health problems, disability, and disease and physical limitations than their heterosexual counter parts.  Numerous studies have reported that gays and lesbians have higher rates of substance abuse, tobacco use, alcohol abuse, and domestic violence. However, sampling for these studies have come from gay and lesbian bars; thus the results may not be accurate for these populations as a whole [9]. Transgender older adults are also at higher risk for poor physical health, disability, and depressive symptoms compared to cisgender adults [10].  Many older LGBTQIA adults live alone, and depending on their life circumstances, may or may not have a support system to help them maneuver the challenges of older age and illness.  Nurses would be wise to familiarize themselves with the resources available in their communities that would benefit older adults. LGBT older adults may find support through chosen families and informal support networks such as LGBT community organizations and gay-affirmative religious networks. LGBTQIA older adults need to be recognized by the Older Americans Act (OAA) as a “greatest social need” group, opening up important funding avenues to prioritize services for this group. Anti-discrimination legislation and expanding the definition of family to include families of choice are among policies that could improve sensitivity to LGBTQIA elders and effective culturally sensitive training for service providers could help improve the experiences of LGBTQIA elders with health-care providers, alleviating expectations of discrimination that may cause a delay in seeking care [10].

An area of increasing concern for nurses is caring for transgendered populations following surgery and ensuing complications. Pelvic pain and persistent menses is common in transgender men and can be a clinical challenge for nurses. However, the workup of pelvic pain in transgender men is similar to that for non-transgender women. Etiologies to consider include atrophic or infectious vaginitis, cervicitis, cystitis, STIs, adhesions, and musculoskeletal and neurogenic disorders.  Behavioral etiologies include depression, history of emotional trauma (including sexual assault or abuse), and post-traumatic stress disorder. Transgender men who have pelvic pain after hysterectomy but have retained one or both ovaries/gonads should be screened for a gonadal pathology. Administering testosterone often results in estrogen deficient, atrophic vaginal tissues akin to a post-menopausal state in cisgender women (University California San Francisco). Hysterectomy with and without salpingectomy/oophorectomy is considered to be a medically necessary component of gender affirming surgical therapy for transgender men who choose this procedure; It is unknown how many transgender men obtain hysterectomy for gender affirmation or gender dysphoria. In the National Transgender Discrimination Survey, 21% of Tran’s men had undergone hysterectomy; 58% desired a hysterectomy at some time in the future, and 21% had no desire for a hysterectomy. Hysterectomy has been successfully combined with other gender affirming surgeries performed on the same day, including vaginectomy, mastectomy, and genital reconstruction (University California San Francisco). Female to male sex reassignment surgery has had less success, because of the difficulty of building a functioning penis from the much smaller clitoral tissue. For some, removing the breasts with top surgery is enough. Some FTMs use a prosthetic penis called a packer that is either glued or strapped on. Females to male to male can undergo a phalloplasty to surgically create a penis. Penis construction can be done a year after the preliminary surgery in which the uterus and ovaries can be removed. The procedure combines several surgeries during which a penis shaped structure is constructed by peeling and rolling skin from the abdomen or upper thigh and attaching it over the clitoris to preserve as much sexual stimulation as possible. This procedure often creates unsatisfactory urination ability. Although the penis can be used for intercourse, it is less than perfect (World Professional Association for Transgender Health: Standards of Care 2017.

Best practices for providing culturally congruent care for the LGBTQIA community begins with being aware that the term LGBTQIA represents a variety of groups, each having unique health-related concerns specific to their group. Know that sexual identification does not necessarily align with sexual activity and that health-related risks are more related to activity vs. identification [11]. Someone may identify as a heterosexual man and routinely engage in sex with other men, putting him at greater risk for HIV and other sexually transmitted illnesses (STIs) while a male identifying gay may be in a monogamous relationship and at very low risk for HIV and STIs. Know that people who identify as LGBTQIA experience significant disparities in access to health care compared with cisgender heterosexual people. For example, lesbian women are less likely to receive the human papillomavirus vaccine, cervical cancer screening, and mammograms, and men in same-sex relationships are twice as likely to have unmet medical needs [11,12].  McNamara and Ng point out that these disparities can be minimalized by creating environments that are more welcoming to all clients. Changes to the environment might include having gender neutral  restrooms, avoiding signage that appear only welcoming to one gender, and altering forms to allow for the collection of information pertaining to the client's preferred name and pronoun, gender and sexual identity, gender assigned at birth, and partner status and other family [13]. To achieve the goal of providing culturally competent care, nurses must continuously strive to provide informed, client-centered congruent care in a non-judgmental manner when interacting with all clients inclusive of those who identify as LGBTQIA.

1. Pew Research Center. A Survey of LGBT Americans Attitudes, Experiences and Values in Changing Times. Retrieved from. 2013.
2. Purnell LD. The Purnell model for cultural competence. In L. Purnell Ed, Transcultural health care: A culturally competent approach Philadelphia PA: Davis. 2013.
3. Leininger MM. The theory of culture care and the ethnonursing research method. In Leininger Transcultural nursing: Concepts, theories, research & practice. 2002; 71-116.
4. Bacote JC. The process of cultural competence in the delivery of healthcare services: A model of care. J Transcultural Nursing. 2002; 13: 181-184.
5. Giger JN, Davidhizar RE. The Giger and Davidhizar Transcultural Assessment Model. J Transcultural Nursing. 2002; 13: 185-192.
6. Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, D.C. National Academies Press. 2011.
7. The Trevor Project. 2017.
8. Fenkl EA, Jones SG, Schochet E, Johnson P. HPV and anal cancer knowledge among HIV-infected and non-infected men who have sex with men. LGBT Health. 2016; 3: 43-48.
9. Purnell L. Cultural Competence for the Physical Therapist: Working with Clients with Alternative Lifestyles. Monograph. American Physical Therapy Association. 2003.
10. Choi SK, Meyer IH. LGBT Aging: A Review of Research Findings, Needs, and Policy Implications. Los Angeles: The Williams Institute. 2016.
11. Namara MC, Ng H. Best practices in LGBT care: A guide for primary care physicians Cleveland Clinic J Medicine. 2016; 83: 531-541.
12. Buchmueller T, Carpenter CS. Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000-2007. American J Public Health. 2010; 100: 489-496.
13. Agenor M, Peitzmeier S, Gordon AR, Haneuse S, Potter JE, Austin SB. Sexual orientation identity disparities in awareness and initiation of the human papillomavirus vaccine among U.S. women and girls: A national survey. Annals of Internal Medicine, 2010; 163: 99-106.