Enhancing Dental and Dental Hygiene Student Awareness of the Lesbian, Gay, Bisexual and Transgender Population
==============================================================================================================

* Elizabeth Aguilar
* Jacquelyn Fried

## Abstract

**Purpose:** Although cultural competence education is being incorporated into most health care curricula, content addressing sexual minorities is lacking or, if present, inadequate. This void can result in compromised health care and can contribute to the social stigma surrounding the lesbian, gay, bisexual and transgender (LGBT) community. Increasing the knowledge and demystifying sexual minority issues can enhance the confidence and attitudes of health care workers when treating LGBT individuals. Suggestions for creating a more welcoming health care environment for LGBT individuals in different health care settings such as private clinics, public health settings and school based programs are offered.

The purpose of this literature review was to systematically review available literature on health care providers' delivery of culturally competent care to the LGBT community. The investigators searched electronic databases that included Medline (Ovid), Eric and PubMed with consultation from information specialists at the Health Sciences and Human Services Library at the University of Maryland. The information was categorized into content areas. Discussion of the findings and future directions regarding health care delivery for the LGBT community are provided.

*   cultural diversity
*   LGBT
*   sexual minorities
*   health care services
*   dental and dental hygiene education

## Introduction

If the U.S. hopes to achieve effective and equitable delivery of health care services, the attainment of cultural competence through increased cultural awareness must be included in health care providers' education.1,2 Cultural awareness in health care means having an understanding of the many lenses through which people assess health and interpret and understand health care concepts. Taylor defined cultural competence as “the use of evidence to guide practice featured prominently, including research from a range of disciplines concerning caring for, and working with, people from different cultures and religions.”1 Culturally competent delivery of care adapts to and is mindful of individuals' unique characteristics. The more health care workers and health professions' students achieve cultural competence and become aware of cultural sensitivities, the better they will transmit desired health information and render individualized care to their patients. In turn, patients may experience better health care outcomes. The delivery of culturally competent care has the potential to reduce health disparaties.2,3

The purpose of this literature review is to systematically review available literature on health care provider's delivery of culturally competent care to the lesbian, gay, bisexual and transgender (LGBT) community. The investigators searched electronic databases that included Medline (Ovid), Eric and PubMed with consultation from information specialists at the Health Science and Human Services Library at the University of Maryland. The literature search for peer reviewed articles and published documents began the fall of 2011 and continued through the year 2012. The following key words framed the search: cultural diversity/awareness, lesbian, gay, bisexual, transgender and sexual minorities, health care services, and dental and dental hygiene education.

### Professional Underpinnings

Recognizing diversity, understanding gender based issues and adopting ethical approaches to health care are essential inclusions in cultural competence education. The American Dental Hygienists' Association's Code of Ethics states that justice and beneficence are integral to a high standard of dental hygiene practice. Equitable service delivery, health promotion and “doing good” are essential attributes of care for all populations served. The Code of Ethics further states that dental hygienist must “serve all clients without discrimination and avoid actions toward any individual or group that may be interpreted as discriminatory.”4 Another charge is to “recognize that cultural beliefs influence clients' decisions.”4 The Commission on Dental Accreditation's (CODA) guidelines for dental hygiene education mandates the need for cultural awareness, the attainment of competence in effective communication with individuals, diverse population groups and other health care providers. The guidelines further state that dental hygienists should recognize “the cultural influences impacting the delivery of health services to the individual and the communities” and that patients with special needs such as medical, physical, psychological or social require adaptation and modification of oral health care delivery.5 The patient's experience at a health care visit encompasses the entire encounter where the whole health care/dental team plays an integral role in the patient's experience and the delivery of care.

To achieve optimal health care for all, cultural diversity training should be designed to address all demographic aspects of the population, including sexual identity and sexual orientation. The LGBT population is a group characterized by unique sexual identities and sexual orientations; its uniqueness must be addressed and incorporated into health care delivery. The literature indicates that health care professionals from various disciplines misunderstand and/or stigmatize the LGBT population.6,7 When seeking health care, many members of the LGBT population are hesitant to report their sexual identity or sexual orientation;8 similarly, many health care workers are reluctant to probe the sexual identities of patients. These constraints have led to a description of the LGBT population as “the nation's invisible population.”7-9

Data gathered through scientific inquiry create the foundation for public health. Research data are essential to addressing the needs of the U.S. population and to guide legislative action to improve the health of the public.8 Research can increase the understanding of sexual minorities, their similarities and differences form the heterosexual majority. The widespread neglect of LGBT individuals in public health research has devastating consequences for the health of this community.8 Limited research on sexual minorities may contribute to the failure of public health providers and programs to address the needs of the LGBT population.10 Recognizing that generalizing the conditions and illnesses of the heterosexual population to that of the LGBT community may be invalid,8 the National Center for Transgender Equality in conjunction with the National Gay and Lesbian Task Force conducted a national survey of the LGBT population to establish baseline population data.11 The survey instrument was developed and distributed electronically and hard copies were disseminated by community advocates, LGBT friendly centers, transgender leaders and researchers. An 80.6% response rate was obtained. The respondents (n=6,456) represented the 50 U.S. states, the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands.11 Respondents reported experiencing widespread discrimination in community clinical, private, and hospital health care settings.11 Other sources indicate that LGBT individuals have poorer experiences in health care as compared to the general population7,9,12 and sexual minority issues in cultural competency training appear to get little to no attention.6,13

### Culturally Competent Health Care

The U.S. is rich in diversity and cultural heritage. This increasing diversity affects all aspects of health care delivery.7,14-16 Health disparities among cultural minorities and vulnerable populations are well documented.3,15 The idea of culturally competent health care is not new; however, it has recently gained popularity in the health care professions as health disparities continue to grow.3,8 The U.S. Surgeon General's Report points to the need for a culturally competent dental workforce to increase access to care and enhance oral health.14 According to some researchers, the delivery of culturally competent health care services may increase the efficacy of health care workers and staff, thus reducing the incidence of medical/dental errors.3 By becoming more culturally competent, it is hoped that oral health professionals will recognize the importance of respecting differences among groups and not place diverse cultures into homogenous groups. The need to integrate the patients' definition of what health care means to them in service delivery is critical.17 Keenan states that, “We need to ensure the cultural safety of our patients by embracing their differences.”17

### LGBT Experiences in Health care Settings

Experiences in the health care system can affect how patients view their relationships with health care professionals and whether they decide to seek medical/dental advice.9 Patients' perceptions can influence their treatment and health status.9 Some LGBT individuals report negative health care experiences involving prejudice and denial of services.6,9,11 Compared with heterosexual and non-transgender socioeconomically matched peers, LGBT individuals are more likely to face barriers accessing appropriate medical care.12 These barriers can create or increase existing disparities.12 The extent of health care disparities among LGBT individuals has prompted the U.S. Department of Health and Human Services to elevate sexual orientation from a noted disparity in their Healthy People 2010 objectives, to a target group of concern and needed improvement in Healthy People 2020.8,18,19

A nationwide U.S. survey addressing LGBT experiences in health care revealed some important findings. Survey participants reported that when sick or injured, many postponed medical care due to discrimination.11 Nineteen percent of respondents stated that they were refused medical care altogether.11 LGBT patients report anxiety about disclosing sexual identity and avoidance of preventive services for fear of discriminatory treatment.6,13 Some LGBT patients allow the health care professional to assume they are heterosexual for fear that disclosing their sexual identity would decrease the quality of health care delivered.6,8

Regarding their personal privacy, LGBT patients need a clear understanding of why health care workers' questions are relevant to their health care, who would have access to their information, how persons viewing the information would handle the answers received and how the information would be stored.6 Wilkerson found that LGBT patients feel safe revealing sexual and gender identity information only after their concerns are addressed.6 LGBT individuals report difficulty in accessing culturally competent primary care services.20 Family physicians' lack of awareness regarding LGBT issues and respect for the LGBT community has been described as a “blind spot.”20 Among LGBT individuals, transgender patients report the highest levels of health care worker discrimination.6,11 Transgender patients struggle to find health care workers with enough cultural competence and knowledge to support their gender identity transitions.6 In the case of negative reactions from health care workers, transgender patients' greatest fears relate to safety and privacy concerns associated with disclosure.6

LGBT individuals suffer disproportionately from a range of conditions and are at disproportionate risk for others.7-9,12 According to Wilkerson, LGBT patients have a desire for their health care workers to understand why the LGBT community's risks exists, to talk to them about these risks within the social context, and to offer culturally relevant solutions for reducing harm.6 A U.S. nationwide survey revealed that LGBT individuals have a 41% rate of attempted suicide versus 1.6% in the general population.11 LGBT individuals have a high prevalence of tobacco and alcohol use.7 Suicide counseling, tobacco and alcohol cessation are services that could help prevent death and reduce harm. Oral health professionals are positioned to address substance abuse problems and to make referrals for their LGBT patients.

### Health Care Providers' Attitudes toward Treatment of LGBT Patients

Health care providers' negative attitudes towards patients with stigmatized conditions constitute a barrier to the LGBT population's optimal utilization of health care services.21 In several studies, health care workers reported facing barriers when attempting to provide culturally competent care to LGBT patients.6,13,15 Some health care workers, who provide care to a significant number of LGBT patients, fear discrimination by homophobic patients or coworkers.6 Health care workers also find it difficult to provide culturally competent care when coworkers lack education about LGBT health.6 Providers' attitudes may be influenced by public opinion. Data from a random sample of U.S. citizens found that 30% would change providers if they learned that their provider was LGBT; and 35% reported they would switch to a different clinic or practice if they learned that the practice employed LGBT health care providers.13

### LGBT Education in Professional Health Care Programs

The lack of health professions students' education in cultural competence particularly in the area of sexual identity may result in future providers who are uncomfortable working with LGBT patients.13 Health care workers' formal education needs to challenge the negative attitudes and stereotypes about LGBT people. Students and providers must learn how to ask their patients questions about sexuality and gender.13 The Association of American Medical Colleges has recommended that “medical school curricula ensure that students master the knowledge, skills, and attitudes necessary to provide care for LGBT patients.”12

A study conducted in the U.S. reported that the “result of the lack of education in most medical education is that many physicians feel uncomfortable working with LGBT patients.”13 The same study found that in one medical school, approximately half of the subjects responded that they had no education about gay male issues, 61% received no content on lesbian health, 78% reported no education on bisexual health and 76% received no information on transgender health.13 These trends were consistent in medical residencies and medical continuing education classes.13

Research related to the LGBT population in dental school environments is scarce.7 In a study of U.S. and Canadian dental schools, 76.6% of respondents reported receiving no education related to LGBT issues.7 Additional studies conducted in the U.S. and the United Kingdom regarding the LGBT community found similarities.9 Without designated cultural competence education on LGBT issues, physicians, medical students and oral health professions' students may reflect the same extent of homophobia and heterosexism present in the broader society.13 The lack of adequate education and experience has been a major reason for oral health professionals' reluctance to care for patients from sexually stigmatized populations; integrating the topic of homosexuality in the curriculum may help increase student sensitivity toward sexuality, gender questions and comfort levels treating LGBT patients.7,21

Clinicians' knowledge is limited by the dearth of available population-based data. Practice environments also may be affected by the contentious and stigmatized nature of homosexuality, with health care professionals holding a range of beliefs about minority sexual orientation that are occasionally pathological and commonly minimizing.18 To address these concerns, the 2011 Institute of Medicine report to the National Institutes of Health recommended focused intra and extramural research efforts to build a LGBT health evidence base, to amass demographic data on LGBT individuals, develop standardized sexual orientation/gender identity measures and to improve research methods for conducting LGBT health research.12

Dental and dental hygiene education must prepare future oral health care professionals to treat patients from non-heterosexual backgrounds in a professional manner.7 Standards of best practices for the LGBT community are lacking, policies vary and training on LGBT health issues are inadequate.6 Health care professional training programs that do not address the LGBT community add to its stigmatization. In addition to considering the extent to which LGBT-related issues are addressed in the formal dental school curriculum, the academic climate must be inclusive so students, staff, faculty members and patients from LGBT backgrounds are not subjected to discrimination.7 By providing oral health professions students with more inclusive curriculum, they can become more patient-friendly and accepting of individuals with diverse sexual orientations.21,22

### Improving LGBT Experiences in Health Care Settings

An analysis of the clinical environment relevant to the delivery of culturally competent health care includes 3 aspects: interpersonal, structural and systemic.6 A systematic review offered the following suggestions for improving LGBT experiences in health care settings. To improve interpersonal relationships between the health care professional and the patient, the following topics were identified:6,7,9 

1.  Avoiding homophobia and heterosexism and assuming that a patient is heterosexual

2.  Improving health care workers' knowledge

3.  Being perceptive to the terminology used by the patient to engender patient trust

4.  Understanding embarrassment and the importance of affirmation

5.  Reducing over-cautiousness

Ideas as simple as displaying an LGBT friendly sticker in a well viewed window can improve the structural environment. Not designating restrooms as male and female, but having both figures on the door or simply the word “restroom,” is another measure of inclusivity (Woodward, personal communication, 2012). LGBT individuals have mentioned the lack of LGBT-friendly resources in the waiting room as a concern in a number of studies.6,9 Having LGBT friendly pamphlets and reading material might make the LGBT community feel more welcome.

Improving protocols, appropriate referrals and patient confidentiality can deflect systemic barriers.6,9 Continuity of care also is desirable for anyone utilizing health care services but it may be particularly important for LGBT individuals; i.e., continuity of care limits the number of times a person is required to reveal their sexual orientation, and it promotes the formation of a trusting relationship between patient and health care worker.9

Both patients and health care workers would like an LGBT-friendly provider directory.6 Patients say they would use the directory to identify health care workers who have made providing care to LGBT patients a focus of their practice, and Health care workers believed the directory would assist them when referring LGBT patients to a specialist.6

Investing the whole health care team in relevant interpersonal, structural and systemic changes, can create an environment in which LGBT patients feel less stigmatized and receive more culturally competent health care.6,13 Staff meetings and in-service programs are vehicles for enabling positive change (Woodward, personal communication, 2012).

## Discussion

The LGBT community requires health care monitoring and prevention. This community faces discrimination by society and inadequate health care.11 Despite the work of the Human Rights Campaign and Gay and Lesbian Medical Association, gaps exist in defining and implementing culturally competent LGBT health care.9,11 As patient advocacy groups across the nation are calling for cultural competency training for physicians and other health care providers, these calls must include diversity related to sexual and gender identification.19

Research suggests that LGBT populations suffer from a range of conditions and are at disproportionate risk for others.7-9,12 Increased awareness of the LGBT population may help to decrease the stigma surrounding it.6,7 Raising awareness and increasing the knowledge base regarding the LGBT population could begin to break down the barriers to health care delivery and increase the health care worker's confidence in treating LGBT individuals.6-8,20,21 Pioneer psychologists from the mid-twentieth century established that through communication comes understanding.23

A limitation of the current study is the dearth of studies available about LGBT's oral health care providers and health care delivery.20 Another limitation is the sensitive nature of the topic. A recurrent theme found in this literature review is the hesitation and fear LGBTs have in revealing their sexual identities and providing health care workers with related information.6-11,13 This reticence interferes with the ability to collect data about this population.7 Further research is needed to better understand the health care needs of the LGBT community.11 Longitudinal studies would be useful to observe changes over time in attitude and or confidence of students and health care workers when treating LGBT patients. The government, accreditation agencies and regulatory bodies are calling for action to address the health care needs of the LGBT population. Studies that track curricular innovations in health professions' education, and that assess private and public sectors' implementation of governmental directives and adherence to ethical principles in health care delivery are essential.

Accredited continuing education courses, online learning and published works in journals provide options for health care workers to learn about the LGBT community. Dental/medical conventions are venues where information can be presented. Academic programs can provide many opportunities for student engagement. Students can be involved in cultural awareness projects, community events, participate in poster sessions, and engage in practicums at centers where LGBT populations are a segment of the target population. Ethics and cultural competency courses provide opportunities to incorporate content related to sexual minorities, gender bias, discrimination, justice and the importance of culturally competent care.

## Conclusion

The demographic changes in the U.S. cannot be ignored. Health care providers including dentists and dental hygienists need to adapt to meet the needs of the people.4,5 Cultural awareness education for effective health care delivery is required.1,2 Health disparities can potentially be reduced when cultural and sexual minorities receive culturally competent care.2,3

Dental and dental hygiene educators must include the LGBT community in their discussion of unique patient populations.7 Incorporating culturally competent didactic and clinical learning experiences into the educations of future oral health professionals may enhance the delivery of relevant and high quality health care to the LGBT population.3,2,12 More research is needed to better understand the LGBT community, their unique health care concerns and provider attitudes toward treating this population.

## Acknowledgments

To my family and close friends, for encouraging me every step of the way. To Sheryl Syme, for igniting the passion in me for cultural research in dental hygiene.

## Footnotes

*   *Elizabeth Aguilar, RDH, MS, is a Clinical Dental Hygienist, Dental department: Whitman-Walker Health. Jacquelyn Fried, RDH, MS, is an Associate Professor, Director of Inter-Professional Initiatives, Department of Periodontics, Division of Dental Hygiene, University of Maryland, Dental School, Baltimore.*

*   This study supports the NDHRA priority area, **Health Promotion/Disease Prevention:** Investigate how diversity among populations impacts the promotion of oral health and preventive behaviors.

*   Copyright © 2015 The American Dental Hygienists’ Association

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