CA: a cancer journal for clinicians. Case study analysis lesbian patient life-course perspective provides a useful framework for the above-noted varying health needs and experiences of an LGBT individual over the course of his or her life. Support providers of sexual minority women with breast cancer: who they are and how they impact the breast cancer experience. The socio-demographics of our sample are described in Table 1. The American Medical Association recently updated their policies Female masturbation games LGBT issues and noted that not obtaining sexual orientation and gender identity from patients was akin to a failure to screen or diagnose. In some cases, the committee used secondary sources such as reports. Each of these chapters addresses the following by age cohort: the development of sexual orientation and gender identity, mental and physical health status, risk and protective factors, health services, and contextual influences affecting LGBT health. Discrimination is an inevitable process on a person who wants to express herself.
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A year-old male with a mass in the right ischial rectal fossa AP This case study by the research team at RAND focuses on the successful quality improvement methods employed by a health plan to improve customer service for its members. Already a Patient? A 67 year old post transplant patient with cutaneous nodules and ulcers AP An year-old girl with Thuge insertions of hyperthyroidism CP A 36 year old male with HIV infection and multiple cranial neuritis. A 10 year old girl with a hepatic Epstein-Barr virus-associated smooth muscle tumor AP A year-old woman with intermittent joint pain in her wrists and ankles Case study analysis lesbian patient An 11 year old female who collapsed during out-patient clinic visit AP A 57 year old man with a systemic disease and an intracerebral hemorrhage CP Protozoan form G.
Sigmund Freud's views on homosexuality have been described as deterministic, whereas he would ascribe biological and psychological factors in explaining the principal causes of homosexuality.
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Metrics details. It has been demonstrated that health disparities between lesbian, gay, bisexual and queer LGBQ populations and the general population can be improved by disclosure of sexual identity to a health care provider HCP. One-on-one semi-structured telephone interviews were conducted, audio-recorded, and transcribed. A qualitative descriptive analysis was performed using iterative coding and comparing and grouping data into themes.
Findings revealed that disclosure of sexual identity to PCPs was related to three main themes: 1 disclosure of sexual identity by LGBQ patients to a PCP was seen to be as challenging as coming out to others; 2 a solid therapeutic relationship can mitigate the difficulty in disclosure of sexual identity; and, 3 purposeful recognition by PCPs of their personal heteronormative value system is key to establishing a strong therapeutic relationship.
This will allow LGBQ patients to feel better understood, willing to disclose, subsequently improving their care and health outcomes. Health and health care disparities between lesbian, gay, bisexual, and queer LGBQ populations and the general population are well-known [ 1 — 4 ].
LGBQ individuals are at higher risk than heterosexuals for mental health disorders [ 1 , 5 ]. Sexually transmitted infections are overrepresented, as well, [ 7 , 10 ], including gay, bisexual, and other men who have sex with men being disproportionately affected by human immunodeficiency virus HIV [ 11 ]. The LGBQ population has a similarly elevated prevalence of substance use. LGBQ individuals may also be less likely to engage in preventive health care than their counterparts [ 2 ], including screening e.
Disclosure of sexual identity to a health care provider HCP has been linked to health benefits among LGBQ populations [ 16 — 18 ] and their use of health services [ 19 , 20 ]. Meanwhile, the lack of disclosure to a HCP is associated with health and health care disparities [ 8 , 21 ] and significantly decreases the likelihood that appropriate health promotion, education and counseling opportunities will be provided [ 22 ]. The related sexual and social stigma are linked to the health care inequities that affect this population [ 2 , 25 ], stressing the importance of holistic strategies to prevention and care.
These findings are particularly important when considering the unique role of the primary care physician PCP , as compared to other HCPs. Nonjudgmental discussion and history-taking to elicit information about sexual orientation and gender identity is an essential part of eliminating health care disparities [ 29 ] and is part of holistic patient care.
The literature suggests that many HCPs assume patients are heterosexual [ 19 , 30 , 31 ]. Heteronormative assumptions and lack of disclosure may lead to suboptimal care [ 22 ]. We used qualitative descriptive methodology for this exploratory work to develop rich, straight descriptions of a phenomenon [ 32 , 33 ].
The data analysis yielded a description of the data, rather than in-depth conceptual description or development of theory [ 34 ]. The study was conducted in a single large urban Canadian city. Following approval by the University of Toronto Research Ethics Board, participants were recruited by advertisement posted at a local community centre. The recruitment poster invited LGBQ individuals to anonymously share their experiences with primary health care by participating in a 30—45 minute interview.
Snowball sampling was also used, whereby participants were asked to suggest potential participants who might supply rich information for the study. Interviews were scheduled at a mutually convenient time and private location. The interviewer AM explained the study to each participant and obtained written consent prior to conducting the interview.
One-on-one in-depth telephone interviews were conducted in using a semi-structured interview guide Fig. Twelve interviews were conducted to form a rich description of the group of participants at hand, representing a small group of LGBQ patients of a variety of identities. No transgendered or questioning persons came forward to be interviewed. Initial codes evolved as data analysis occurred in tandem with the data collection.
New data were constantly compared to codes developed from earlier analysis to refine and elaborate the codes and iteratively categorize them into broader themes. During the data collection, we purposively investigated both existing and new codes and identified limitations of the initial coding structure to ensure representativeness of emerging categories.
The resulting coding structure was applied to the data set. During final analysis, the research team read the transcripts and identified the thematic structure through iterative relating and grouping of codes. Our team identified three main themes related to disclosure of sexual identity to PCPs: 1 disclosure of sexual identity by LGBQ patients to a PCP was seen to be as challenging as coming out to others; 2 a solid therapeutic relationship can mitigate the difficulty in disclosure of sexual identity; and, 3 purposeful recognition by PCPs of the dominant heteronormative value system is key to establishing a strong therapeutic relationship.
First, participants articulated that disclosure of sexual identity to a PCP is a complex and challenging process equivalent to disclosure to family and friends. Disclosure to a PCP was part of a broader process of coming out.
Being in a clinical rather than social setting alone did not remove the barriers to disclosure. Patients described having longstanding relationships with their PCPs e. Disclosing to these PCPs was considered as challenging as coming out to a family member.
Participants suggested that the burden and challenge of disclosure could be lessened if physicians asked directly and early in a patient relationship about sexual identity. Second, PCPs can leverage a solid therapeutic relationship to mitigate the difficulty in disclosure of sexual identity.
The relationship is an interactive one, with both the LGBQ patient and the PCP having responsibility and variable influence within the relationship. From the perspectives of these participants, an effective PCP would build a strong therapeutic relationship and view the patient as a whole person with social context rather than an object with a certain disease.
This requires professionalism, compassion, and patient-centeredness on behalf of the PCP, thus facilitating a sense of trust for the patient. Confidentiality was identified by many as playing an important role in trusting patient-physician relationships. Compassion and patient-centredness also seemed to be important characteristics identified by participants. Participants suggested that having the physician convey a sense of understanding the patient in a holistic manner was an important part of a strong therapeutic relationship.
That was the experience I had in the past—feeling not as listened to or a little bit rushed with the doctor. So, yeah, I appreciate that. Third, the purposeful recognition by PCPs of the dominant heteronormative value system was key to establishing a strong therapeutic relationship. A therapeutic relationship established through trust, confidentiality and compassion was considered necessary but insufficient to allow some participants to feel comfortable about disclosing their sexual identity.
Many participants believed that PCPs additionally need to be deliberate in acknowledging heteronormativity as a social norm in medicine. Communication, as a necessary physician competence, ever present in the patient-PCP relationship, was said to impact the disclosure experience.
Language and tone, which conveyed their associated value system, were thought to affect empathy and subsequent comfort with disclosure to a PCP.
Regardless of whether they could remember experiencing heteronormative language in clinical encounters, participants agreed that gender-neutral language was key to opening discussion about sexual identity. This was perceived to indicate the absence of heteronormative assumptions. Other participants expressed that a lack of acknowledgement seemed to signal that their physician was uncomfortable.
When participants perceived the clinical encounter to be framed in a closed fashion, they suggested this led to erroneous heteronormative assumptions on the part of the PCP, thus limiting opportunities for LGBQ patients to disclose their sexual identity. Studies over the last decade have shown a significant proportion of the LGBQ population refrains from disclosing sexual identity to HCPs [ 22 — 24 ].
In our study, disclosure of sexual identity by LGBQ patients to a PCP was shown to be as challenging as coming out to families and friends, with participants identifying similar barriers. Participants identified that the power of a strong therapeutic relationship can help mitigate the difficulty in disclosure and included recognition by PCPs of their heteronormative value system.
Whitehead et al. This study suggested that the current dominant model of competency-based education trains future physicians to remove themselves as individuals from the clinical encounter. Use of roles to define physician competencies in outcomes-based educational models has become commonplace [ 35 ].
Congruent with Whitehead et al. To ensure the development of therapeutic relationships and reflexive, compassionate, person-centred practitioners, it may be useful to consider how the medical trainee as a person be made visible in the curriculum and in assessment tools [ 35 ].
Physicians who were considered by participants to be professional, compassionate and patient-centred embodied the message of the patient as whole, thus fostering a sense of trust in participants. Pierre [ 37 ] similarly highlighted the importance of the patient-provider relationship. Lastly, our data suggest that having PCPs acknowledge their own heteronormative values and how such assumptions may negatively impact the therapeutic relationship would be beneficial to LGBQ patients.
Being sensitive to the fact that the LGBQ community remains largely marginalized by a predominantly heteronormative environment is crucial. The challenge is to how best to promote this reflexivity. It is the responsibility of PCPs to ensure that they are cognizant of and explicit about their own social milieus. Our findings also suggest the need for a purposeful recognition by PCPs of their own heteronormative value system to help secure a solid therapeutic relationship.
In the role of communicator, ever-present in the PCP-patient relationship, PCPs enable patient-centred therapeutic communication through their language and tone, thus influencing a LGBQ patient to disclose or not. In our study, non-verbal communication impacted the disclosure experience as much as the language chosen. Participants noted heteronormative assumptions in PCPs when the encounter was limited by a restrictive visit e.
The literature suggests that many HCPs assume, or convey assumptions through questions and behaviour, that patients are heterosexual [ 19 , 30 , 31 , 40 ]. For example, lack of reaction on the part of a PCP may be erroneously perceived by a patient as a negative response, when in fact the PCP believes no reaction to be an indication of normalizing the disclosure.
Beyond individual PCP values and identity, attention is also needed to the health care system and clinical encounter to support both the PCP and the patient in these discussions. Employing social justice efforts, adopting relevant policy, and ensuring learning opportunities for current and future staff and physicians to actively engage in reflective and reflexive work are essential to help deflate ever present heterosexual hegemony.
This study has some limitations. Although participants were recruited in Toronto, representing an urban perspective, we do not know where they accessed care or where they were from. This limits ability to make recommendations linked to specific contexts.
Such perceptions can be deep-rooted and thus difficult to affect change on an individual level. Tjepkema M.
Health care use among gay, lesbian and bisexual Canadians. Heal Reports. Accessed 30 Sep Sexual orientation and sex differences in adult chronic conditions, health risk factors, and protective health practices, Oregon, — Prev Chronic Dis.
Gonzales G, Henning-Smith C. Disparities in health and disability among older adults in same-sex cohabiting relationships. J Aging Health. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry. Nonevent stress contributes to mental health disparities based on sexual orientation: Evidence from a personal projects analysis.
Am J Orthopsychiatry. San Francisco;
Severe acidosis in an adult female CP CHC , a private, non-profit, health system that provides comprehensive primary care services in Connecticut. An 80 year old man with a palpable groin mass AP Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan. A year-old woman with chronic fatigue and weakness AP A year-old woman with a long history of irritable bowel syndrome.
Case study analysis lesbian patient. Topics A - Z
Chest normal in appearance with no dyspnea noted. On auscultation lungs had CBBS, and equal chest rise with no retractions or accessory muscle usage noted. Heart tones were unremarkable. Abdomen has hyperactive bowel sounds in the lower quadrants, and upon palpation is soft, but patient seems to indicate tenderness in all quadrants through withdraw.
No deformities, masses, swelling, or pulsating noted on palpation. Anus and surrounding tissues appear aggravated from recent and frequent cleaning following diarrhea, and some runny, brown stool was noted in the patient's training pants. Extremities and posterior thorax are normal and patient can ambulate without assistance. Samples for both UA and stool cultures were obtained and sent to the lab. All UA findings were within normal limits, but stool culture showed Giardia lamblia trophozoites present in sufficient numbers to warrant a diagnosis of Giardiasis Giardia.
Pathophysiology of Diagnosis Giardia lamblia is a species of the genus protozoa. This protozoan is bi-nucleated and possesses four sets of flagella. Protozoan form G. Once infested in the intestine, studies have shown that G. Infestation can present with signs and symptoms of diarrhea, fever, cramps, anorexia, nausea, weakness, weight loss, abdominal distention, flatulence, greasy stools, belching and vomiting.
Symptom onset is usually around two weeks after exposure, and if untreated can last indefinitely, but usually only two to three months. The perpetuation and epidemiology of G. Except for ensuring clean water quality, there is no known chemoprophylaxis for Giardiasis.
Treatment, though, is usually uncomplicated and involves a standard course of metronidazole, furazolidone, or quinacrine. Treatment Performed XX was given a prescription for metronidazole Flagyl. Skip Navigation. I Want To I Want to Find Research Faculty Enter the last name, specialty or keyword for your search below.
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NCBI Bookshelf. At a time when lesbian, gay, bisexual, and transgender LGBT individuals are an increasingly open, acknowledged, and visible part of society, clinicians and researchers are faced with incomplete information about the health status of this community. Although a modest body of knowledge on LGBT health has been developed over the last two decades, much remains to be explored.
What is currently known about LGBT health? Where do gaps in the research in this area exist? What are the priorities for a research agenda to address these gaps? This report aims to answer these questions. The committee believes it is essential to emphasize these differences at the outset of this report because in some contemporary scientific discourse, and in the popular media, these groups are routinely treated as a single population under umbrella terms such as LGBT.
At the same time, as discussed further below, these groups have many experiences in common, key among them being the experience of stigmatization. Differences within each of these groups related to, for example, race, ethnicity, socioeconomic status, geographic location, and age also are addressed later in the chapter. Lesbians, gay men, and bisexual men and women are defined according to their sexual orientation, which, as discussed in Chapter 2 , is typically conceptualized in terms of sexual attraction, behavior, identity, or some combination of these dimensions.
They share the fact that their sexual orientation is not exclusively heterosexual. As explained throughout the report, these differences have important health implications for each group. In contrast to lesbians, gay men, and bisexual men and women, transgender people are defined according to their gender identity and presentation.
This group encompasses individuals whose gender identity differs from the sex originally assigned to them at birth or whose gender expression varies significantly from what is traditionally associated with or typical for that sex i.
The transgender population is diverse in gender identity, expression, and sexual orientation. Some transgender individuals have undergone medical interventions to alter their sexual anatomy and physiology, others wish to have such procedures in the future, and still others do not. Transgender people can be heterosexual, homosexual, or bisexual in their sexual orientation. Male-to-female transgender people are known as MtF, transgender females, or transwomen, while female-to-male transgender people are known as FtM, transgender males, or transmen.
Some transgender people do not fit into either of these binary categories. As one might expect, there are health differences between transgender and nontransgender people, as well as between transgender females and transgender males. Combining lesbians and gay men under a single rubric, for example, obscures gender differences in the experiences of homosexual people.
Likewise, collapsing together the experiences of bisexual women and men tends to obscure gender differences. And the transgender population, which itself encompasses multiple groups, has needs and concerns that are distinct from those of lesbians, bisexual women and men, and gay men. As noted above, despite these many differences among the populations that make up the LGBT community, there are important commonalities as well. The remainder of this section first describes these commonalities and then some key differences within these populations.
What do lesbians, gay men, bisexual women and men, and transgender people have in common that makes them, as a combined population, an appropriate focus for this report?
In the committee's view, the main commonality across these diverse groups is their members' historically marginalized social status relative to society's cultural norm of the exclusively heterosexual individual who conforms to traditional gender roles and expectations. To better understand how sexuality- and gender-linked stigma are related to health, imagine a world in which gender nonconformity, same-sex attraction, and same-sex sexual behavior are universally understood and accepted as part of the normal spectrum of the human condition.
In this world, membership in any of the groups encompassed by LGBT would carry no social stigma, engender no disgrace or personal shame, and result in no discrimination. Only a few factors would stand out for LGBT individuals specifically. We do not live in the idealized world described in this thought experiment, however. Historically, lesbians, gay men, bisexual individuals, and transgender people have not been understood and accepted as part of the normal spectrum of the human condition.
Instead, they have been stereotyped as deviants. Although LGBT people share with the rest of society the full range of health risks, they also face a profound and poorly understood set of additional health risks due largely to social stigma. While the experience of stigma can differ across sexual and gender minorities, stigmatization touches the lives of all these groups in important ways and thereby affects their health.
In contrast to members of many other marginalized groups, LGBT individuals frequently are invisible to health care researchers and providers. As explained in later chapters, this invisibility often exacerbates the deleterious effects of stigma. Overcoming this invisibility in health care services and research settings is a critical goal if we hope to eliminate the health disparities discussed throughout this report.
It is important to note that, despite the common experience of stigma among members of sexual- and gender-minority groups, LGBT people have not been passive victims of discrimination and prejudice.
The achievements of LGBT people over the past few decades in building a community infrastructure that addresses their health needs, as well as obtaining acknowledgment of their health concerns from scientific bodies and government entities, attest to their commitment to resisting stigma and working actively for equal treatment in all aspects of their lives, including having access to appropriate health care services and reducing health care disparities.
Indeed, some of the research cited in this report demonstrates the impressive psychological resiliency displayed by members of these populations, often in the face of considerable stress. As detailed throughout this report, the stigma directed at sexual and gender minorities in the contemporary United States creates a variety of challenges for researchers and health care providers. Fearing discrimination and prejudice, for example, many lesbian, gay, bisexual, and transgender people refrain from disclosing their sexual orientation or gender identity to researchers and health care providers.
In addition, research on LGBT health involves some specific methodological challenges, which are discussed in Chapter 3. Not only are lesbians, gay men, bisexual women and men, and transgender people distinct populations, but each of these groups is itself a diverse population whose members vary widely in age, race and ethnicity, geographic location, social background, religiosity, and other demographic characteristics. Since many of these variables are centrally related to health status, health concerns, and access to care, this report explicitly considers a few key subgroupings of the LGBT population in each chapter:.
Although these areas represent critical dimensions of the experiences of LGBT individuals, the relationships of these variables to health care disparities and health status have not been extensively studied. The member committee included experts from the fields of mental health, biostatistics, clinical medicine, adolescent health and development, aging, parenting, behavioral sciences, HIV research, demography, racial and ethnic disparities, and health services research.
The committee's statement of task is shown in Box The study was supported entirely by NIH. Statement of Task. In a similar vein, the committee decided not to address research and theory on the origins of sexual orientation. The committee's task was to review the state of science on the health status of LGBT populations, to identify gaps in knowledge, and to outline a research agenda in the area of LGBT health. The committee recognized that a thorough review of research and theory relevant to the factors that shape sexual orientation including sexual orientation identity, sexual behavior, and sexual desire or attraction would be a substantial task, one that would be largely distinct from the committee's main focus on LGBT health, and therefore beyond the scope of the committee's charge.
This study was informed by four public meetings that included 35 presentations see Appendix A. In addition, the committee conducted an extensive review of the literature using Medline, PsycInfo, and the Social Science Citation Index see Appendix B for a list of search terms , as well as other resources. The committee's approach to the literature is described below, followed by a discussion of the various frameworks applied in this study.
A brief note on the terminology used in this report is presented in Box A Note on Terminology. As discussed, the committee adopted the commonly used shorthand LGBT to stand for lesbian, gay, bisexual, and transgender. Given that chapters, academic books, and technical reports typically are not subjected to the same peer-review standards as journal articles, the committee gave the greatest credence to such sources that reported research employing rigorous methods, were authored by well-established researchers, and were generally consistent with scholarly consensus on the current state of knowledge.
With respect to articles describing current health issues in the LGBT community, the committee attempted to limit its review to these articles published since Likewise, in the case of history and theory, the committee reviewed and cites older literature. When evaluating quantitative and qualitative research, the committee considered factors affecting the generalizability of studies, including sample size, sample source, sample composition, recruitment methods, and response rate.
The committee also considered the study design, saturation the point at which new information ceases to emerge , and other relevant factors. In some cases, the committee decided that a study with sample limitations was important; in such cases, these limitations and limits on the extent to which the findings can be generalized are explicitly acknowledged. The inclusion of case studies was kept to a minimum given their limited generalizability.
Research on U. In cases in which no U. This was frequently the case for research involving transgender people. Only English-language articles were considered. The committee considered papers whose authors employed statistical methods for analyzing data, as well as qualitative research that did not include statistical analysis.
For papers that included statistical analysis, the committee evaluated whether the analysis was appropriate and conducted properly. For papers reporting qualitative research, the committee evaluated whether the data were appropriately analyzed and interpreted.
The committee does not present magnitudes of differences, which should be determined by consulting individual studies. In some cases, the committee used secondary sources such as reports. However, it always referred back to the original citations to evaluate the evidence.
In understanding the health of LGBT populations, multiple frameworks can be used to examine how multiple identities and structural arrangements intersect to influence health care access, health status, and health outcomes. This section provides an overview of each of the conceptual frameworks used for this study. First, recognizing that there are a number of ways to present the information contained in this report, the committee found it helpful to apply a life-course perspective.
A life-course perspective provides a useful framework for the above-noted varying health needs and experiences of an LGBT individual over the course of his or her life. This interrelationship among experiences starts before birth and in fact, before conception. A life-course framework has four key dimensions:. From the perspective of LGBT populations, these four dimensions have particular salience because together they provide a framework for considering a range of issues that shape these individuals' experiences and their health disparities.
The committee relied on this framework and on recognized differences in age cohorts, such as those discussed earlier, in presenting information about the health status of LGBT populations. Along with a life-course framework, the committee drew on the minority stress model Brooks, ; Meyer, , a. While this model was originally developed by Brooks for lesbians, Meyer expanded it to include gay men and subsequently applied it to lesbians, gay men, and bisexuals Meyer, b. This model originates in the premise that sexual minorities, like other minority groups, experience chronic stress arising from their stigmatization.
Within the context of an individual's environmental circumstances, Meyer conceptualizes distal and proximal stress processes. A distal process is an objective stressor that does not depend on an individual's perspective. In this model, actual experiences of discrimination and violence also referred to as enacted stigma are distal stress processes.
Proximal, or subjective, stress processes depend on an individual's perception. They include internalized homophobia a term referring to an individual's self-directed stigma, reflecting the adoption of society's negative attitudes about homosexuality and the application of them to oneself , perceived stigma which relates to the expectation that one will be rejected and discriminated against and leads to a state of continuous vigilance that can require considerable energy to maintain; it is also referred to as felt stigma , and concealment of one's sexual orientation or transgender identity.
Related to this taxonomy is the categorization of minority stress processes as both external enacted stigma and internal felt stigma, self-stigma Herek, ; Scambler and Hopkins, There is also supporting evidence for the validity of this model for transgender individuals. Some qualitative studies strongly suggest that stigma can negatively affect the mental health of transgender people Bockting et al.
The minority stress model attributes the higher prevalence of anxiety, depression, and substance use found among LGB as compared with heterosexual populations to the additive stress resulting from nonconformity with prevailing sexual orientation and gender norms.
The committee's use of this framework is reflected in the discussion of stigma as a common experience for LGBT populations and, in the context of this study, one that affects health.