KIM CARTER on why nurses may need to step out of their comfort zone to ensure good care for all clients across the spectrum of sexuality and gender identity.
We make huge assumptions all the time about our clients.
We generalise and label people for lots of reasons – from their ability to pay, their likely priorities, and how good their parenting skills are to how well they take care of themselves. We also usually assume everyone is heterosexual and is the gender they appear to be.
I am no expert in the field of sexuality and gender issues (other than my own!); however, I think rethinking such assumptions is becoming increasingly important as the visibility, voice and needs of lesbian, gay, bisexual, transgendered, queer and intersex (LGBTQI) people grows.
LGBTQI people are generally an under-screened and under-served community due in part to the constant need to 'come out' to every health provider they are in contact with. Some LGBTQI people find this coming out process so difficult that many will simply not present for care, or if they do, present late, and may withhold valuable information that might be relevant to their care. It also means that the special and significant people in the lives of LGBTQI people are often not involved in their care, which further isolates and separates LGBTQI people from the very support so needed by all of us at times of crisis and recovery.
I think what lies underneath the problems experienced by LGBTQI people is the lack of comfort clinicians have about sexuality and gender issues generally. To illustrate this point, ask yourself when you last raised the issue of sexuality with a client? Do you assume people are heterosexual or do you routinely ask how people identify their orientation? Do you assume because someone appears to be male or female that this is how they identify themselves? Are you mindful there is a difference between sexual identity and gender identity and the implications for this in clinical practice?
When did you last discuss what effects chemotherapy or menopause might have on libido? Have you discussed ways that people might cope with ostomy bags, urinary catheters or disabilities so they can continue healthy and fulfilling sexual lives? In your last ‘safe sex‘ discussion with a client, did you tailor your information because you already knew that person’s sexual orientation or did you assume they were heterosexual?
Do you routinely ask clients about any issues with incontinence? What do you advise parents who tell you their son wears nail polish and skirts or likes pink shoes? Have you considered that transgender men might still need to be offered breast and cervical screening and transgender women prostate screening? Do these questions make you squirm?
You may ask why considering these issues matters but I believe we improve care for all people when we make sexuality part of our everyday work. If we acknowledge that sexuality and gender expression is a fundamental part of human experience, identity and wellbeing, then we should incorporate and normalise sexuality as a regular part of our care interactions.
This in turn provides environments and opportunities for LGBTQI people to be honest and open with us as clinicians; however, it also requires that we are educated and informed about sexuality and gender issues, and prepared to provide holistic, unbiased and relevant care to everyone.
In addition, it requires a truly open and non-judgemental approach, which in my view and experience is significantly lacking.
A small first step is to change our language. A lesbian client recently asked me to explain her hospital discharge letter, which advised that she should refrain from intercourse for six weeks after her surgery. She was confused about the word ‘intercourse’ as it related to her life. She was even more bemused because the surgeon was aware she was lesbian, and had met her partner, so she didn’t understand why he couldn’t be specific and relevant in the post-op instructions. Not only were these form letter instructions confusing, and therefore meaningless, but they also conveyed a lack of respect and care for her individual situation.
This example demonstrates how language can be enabling and supportive but equally it can be a barrier and cause confusion. Language can facilitate trust and openness or close down communication. Language can be helpful or unhelpful, convey respect or discrimination and be insidious or explicit. Language is the wide open door through which we engage or the door we close tightly against anyone too challenging and different from ourselves.
I think we need to start talking about sexuality and gender openly and often. Not just to make life easier for LGBTQI people, but to make it easier for all people, because many of our clients experience challenges related to sexuality and gender within their lives and relationships. Most never raise this with us or seek advice and we miss the opportunity to provide help because we also don’t open a door to a conversation or provide an environment which makes it okay to raise these issues. Our own level of discomfort and lack of knowledge is a big challenge to overcome but what a difference we can make in helping people with both the significant and the small things.
Whatever your own personal sexual and gender identity, and whatever your own perspectives, we have a duty of care and ethical professional responsibility to provide for everyone in a holistic and appropriate way and this includes sexuality and gender.
Therefore, I encourage you to consider how approachable and welcoming your service, building and team are for people in all their wonderful diversity. This could be as simple as considering the appropriate use of pronouns (i.e. he or she), asking people how they want to be referred to, or making it a policy to ask and record sexual orientation and gender identity when any client enrols with your service.
I also encourage you to reflect on your own clinical practice and consider where you might be able to change your language to be a little more inclusive, a little more accepting of difference and a little less afraid to start difficult conversations. It is bad enough that LGBTQI people are marginalised in our society – let’s not keep them invisible within the health system as well.
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