January 2012 Issue

Providing Optimal Diabetes Care and Education to the LGBT Community
By Judith Riddle
Today’s Dietitian
Vol. 14 No. 1 P. 42

Diabetes patients who identify as lesbian, gay, bisexual, or transgender have unique health disparities and worse outcomes than their heterosexual counterparts. Today’s Dietitian provides an in-depth look at this vulnerable population and strategies dietitians and CDEs can use to positively impact the lives of these patients.

Linda, 52, a newly diagnosed type 2 diabetes patient, meets with Mary, her dietitian and certified diabetes educator (CDE), for the first time. While completing a medical history form, Linda doesn’t check any of the boxes regarding her marital status. She isn’t married, divorced, or widowed; she doesn’t consider herself single, so she leaves that section blank.

When Mary questions her about it, Linda hesitates. “I’m not married, divorced, or widowed,” she explains.

“Oh, then just check single,” Mary says, handing her back the form.

“I’m not single. I’m in a committed relationship with my partner.”

“Oh I see,” says Mary, whose smile turns to a frown as she inches away from Linda.
Linda’s heart sinks.

As Mary begins discussing diabetes and the dietary and lifestyle changes Linda must make, she avoids looking at Linda and rushes through her conversation. At the end of the visit, Linda leaves the diabetes education pamphlets on the table, walks out of Mary’s office, and vows never to return.

This experience isn’t uncommon among diabetes patients in the lesbian, gay, bisexual, and transgender (LGBT) community. Often healthcare practitioners, due to their own biases or lack of education about the special healthcare needs of this population, either can’t, or in some cases won’t, provide the same high level of care as they do to their heterosexual clients.

According to the article “How to Close the LGBT Health Disparities Gap,” published in 2009 by the Center for American Progress, blatant hostility from healthcare providers is a common occurrence among LGBT patients. Just as alarming is the fact that up to 39% of people who identify as transgender face harassment when seeking routine healthcare.

“We have a long way to go to accept individuals in the LGBT community as people who have their own healthcare needs,” says Michelle Barth, MS, RD, CDE, a clinical dietitian at Community Hospital of the Monterey Peninsula in California. “We need to look beyond their sexual orientation and look at them as people.”

This article will discuss the prevalence of diabetes in the LGBT community, the unique risk factors, and the importance of education concerning this subgroup and provide strategies to help dietitians and CDEs offer culturally sensitive diabetes care.

Prevalence of Diabetes
Limited data exist on the prevalence of diabetes among LGBT individuals, causing the healthcare community to make assumptions based on currently available information and statistics, according to a study published in the July 2010 issue of Diabetes Spectrum. Even less data exist for those who identify as transgender—people who express a gender identity different from the one with which they were born.

Recent data examining the percentage of LGB individuals in the population found that 4.1% of adults identify as such. Specific regions of the country show a higher rate of 15.4%.1 Based on this information, it’s estimated that 8.8 million LGB adults (a subgroup with significant diabetes risk factors) are living in the United States, of which 1.3 million have diabetes, or at least 5% of the 23.6 million people with the disease.2

One can surmise that the LGB diabetes community is a large minority group equal to, if not greater than, the populations with type 1 or gestational diabetes, according to the July 2010 study. In addition, more than 25% of same-sex couples include a racial or ethnic minority—blacks and Hispanics being the two largest groups3—which grapple with their own share of health disparities apart from those inherent in the gay community. These numbers indicate that dietitians and CDEs are probably counseling more diabetes patients who identify as LGBT than they realize, calling for a greater awareness of the healthcare needs of this special population.

Unique Risk Factors
The July 2010 study also reported that members of the LGBT community have unique risk factors for developing diabetes and worse health outcomes than heterosexuals, which is clinically relevant in the delivery of diabetes care and education. Quality healthcare begins with a thorough patient assessment. So if healthcare professionals miss critical information about their patients, the diabetes care plan will be incomplete and possibly discourage patients from seeking the long-term care and support they need.

What’s important to know is that factors unique to LGBT individuals raise their risk of developing diabetes and the associated complications. LGBT diabetes patients are more likely than heterosexuals to smoke cigarettes, abuse drugs and alcohol, and battle with overweight and obesity. Binge and heavy drinking is much more likely to occur in lesbians than in heterosexual women and in LGB Latino adults, according to the 2009 article published by the Center for American Progress and a 2009 study by Diamant and colleagues published in Archives of Family Medicine. Furthermore, the prevalence of polycystic ovary syndrome (PCOS), a common endocrine disorder in women of reproductive age, is highest among those who identify as lesbian (38% vs. 14% among heterosexual women). PCOS is a well-established precursor to type 2 diabetes, as it’s characterized by high levels of androgens (male hormones such as testosterone) from the ovary and is associated with insulin resistance.

The risk of type 2 diabetes is also high among overweight transgender women who are on hormone therapy. “Hormone therapy sends blood sugar through the roof,” says Theresa L. Garnero, APRN, BC-ADM, MSN, CDE, author of the study published in Diabetes Spectrum. “Diabetes is a lonely and scary disease. When you’re in the LGBT community, it becomes even more problematic.”

The reasons such risk factors disproportionately affect LGBT individuals are significantly complex. Garnero speculates that destructive behaviors such as excessive drinking, drug abuse, and overeating (precursors to diabetes) are used as coping mechanisms for dealing with the challenges of being gay in a society that often doesn’t accept them.

“There’s nowhere to turn sometimes,” Garnero says. “People use drugs and alcohol as a way to escape the oppression, and CDEs need to know this.”

Importance of Cultural Competency Education
To provide the best care and diabetes education to LGBT patients, RDs/CDEs must learn about their culture, lifestyle, health disparities, and the daily challenges they face. Garnero’s study indicates that cultural competency is a long process that begins with raising awareness about how to interact professionally with LGBT patients, “accepting responsibility for personal beliefs and biases, and becoming sensitive to the norms that shape patients’ lives. This includes showing respect for family structures and roles within the LGBT community.”

The trouble is nutrition and other healthcare professionals don’t receive cultural sensitivity training in school concerning the LGBT community, so most if not all are at a disadvantage when caring for this population. According to Garnero’s study, “Most multidisciplinary professionals have not received tools to care for LGBT individuals. More than half of medical school curricula include no information about LGBT people, and programs in public health schools are also unlikely to include information beyond HIV/AIDS. Furthermore, transgender treatment is rarely taught in medical schools.”

Garnero says, “The healthcare community just doesn’t know about the subtleties concerning this population.”

Barth adds, “We need to understand the culture of the LGBT community just like we need to understand the culture of every other population group so we can gear the diabetes information to their needs. Once we educate ourselves, we won’t be as fearful, and we can be more open to giving that community what it needs.”
Nutrition professionals can educate themselves about the LGBT community by attending workshops, speaking openly and candidly with LGBT individuals, and reading all they can about their healthcare needs and challenges, Barth says. (See “Education Resources” below.)

Knowing Who the Patient Is
In the 10-minute cultural competency training video To Treat Me, You Have to Know Who I Am, produced by The National LGBT Cancer Network in an effort to launch an employee training program geared to improve access to healthcare for LGBT individuals and help reduce health disparities related to sexual orientation and gender identification, physicians, healthcare practitioners, and members of the LGBT community discuss the importance of knowing who the patient is to deliver optimal care.

According to Ed Goldberg, MD, one of the physicians interviewed in the video, “It’s as important to know a patient’s sexual orientation … and even more what their sexual scenario is as it is to know if they’re getting a good night’s sleep or if they have a good appetite or if their bowel movements are normal. It’s all part of basic bodily functions that are required for a maximum quality of life.”

Lisa Reeves, MD, who also spoke in the video agreed, saying, “It’s important to have an open and honest relationship with your patient. So if you don’t know what their sexual orientation is or how they identify, that patient is not going to feel safe telling you everything they need to tell you for their proper medical care.”

Joan Bennett, a certified physician assistant, notes that if patients aren’t comfortable disclosing their sexual orientation, healthcare professionals may miss the opportunity to refer them for routine testing or screening.

Garnero says this is precisely why it’s imperative for RDs/CDEs to provide culturally sensitive, individualized care to LGBT diabetes patients. It can mean the difference between an LGBT patient embracing nutrition and lifestyle changes that will improve long-term health or not embracing them altogether, leading to disastrous health consequences down the road.

“It’s all about making the person feel comfortable enough that they’re willing to share anything with you,” Garnero says. “If patients don’t trust you, they won’t listen to you. They’ll question your authority. They need to feel supported and safe to share their life with you. And dietitians are in the perfect position to do this when practicing cultural sensitivity in the LGBT community.”

— Judith Riddle is editor of Today’s Dietitian.

 

Create an LGBT-Friendly Environment
As an RD/CDE you can provide culturally sensitive diabetes care to lesbian, gay, bisexual, or transgender (LGBT) individuals by implementing the following changes in your workplace that will help make them feel more accepted and welcome:

• Post a nondiscrimination policy that includes gender or provide medical brochures that address the health concerns of various groups.

• List other sexual orientations on patient history forms such as lesbian, gay, bisexual, and transgender.

• Use the words “spouse” or “domestic partner” in addition to the words “married,” “divorced,” “single,” and “widowed” on assessment forms and when speaking with patients.

• Place magazines that cater to the LGBT community in your waiting room.

• Hang a rainbow poster or flag that boasts six colors of the rainbow to symbolize diversity and pride in the LGBT community.

• Provide pamphlets, brochures, and online resources from local and national organizations and support groups that address the healthcare needs of LGBT patients.

— JR

 

Ask the Right Questions
Because lesbian, gay, bisexual, or transgender (LGBT) diabetes patients have special healthcare needs, you’ll need to get certain information from them that will help you improve their care. Asking the following questions can help:

“Are you withholding insulin to lose weight?” Withholding insulin may not be a sign of diabulimia but possibly a gesture of trying to commit suicide. Gay men are six times more likely and lesbians are twice as likely as their heterosexual counterparts to attempt suicide, and suicide attempts among LGBT youths are between 20% and 42%, according to the Gay and Lesbian Medical Association and National Coalition for LGBT Health.

“Are you being bullied at school?” Many LGBT adolescents with diabetes are harassed regularly in school because of their sexual orientation.

“You didn’t complete the section on marital status on the patient form. Are you in a relationship? Do you have a domestic partner?” This opens up dialogue between you and the patient who may have a same-sex partner but is afraid to tell you.

“Diabetes affects many systems in the body, such as sexual function. Is this an issue for you?” Phrasing a general question instead of one that includes the words “husband” or “wife” will help elicit the answers you need to help the patient.

“Is there anything you’d like to tell me that’s not on the patient form that will help me provide the care you need?” This question lets the patient know you’re there for them no matter what information he or she may bring to the table.

— JR

 

Education Resources
The following resources will help educate you about the culture, lifestyle, and healthcare needs of the lesbian, gay, bisexual, and transgender community (LGBT):

• The 10-minute cultural competency training video To Treat Me, You Have to Know Who I Am (available on YouTube.com)

Fenway Guide to Lesbian, Gay, Bisexual, Transgender Health (American College of Physicians, 2008)

The Handbook of Lesbian, Gay, Bisexual, and Transgender Public Health: A Practitioner’s Guide to Service (Routledge, 2006)

• The National Coalition for LGBT Health (www.lgbthealth.net)

 

References
1. Gates GJ. Same-sex couples and the gay, lesbian, bisexual population: New estimates from the American community survey. The Williams Institute. http://escholarship.org/uc/item/8h08t0zf - page-1. October 2006.

2. Jowett A, Peel E. Chronic illness in non-heterosexual contexts: An online survey of experiences. Feminism Psychol. 2009;19(4):454-474.

3. Gates GJ, Ost J. The Gay & Lesbian Atlas. Washington, D.C.: Urban Institute Press; 2004, p. 1-17.