https://orcid.org/0000-0003-3928-0487
The physical therapist profession is increasingly aware that lesbian, gay, bisexual, transgender, queer, intersex, and/or asexual (LGBTQIA+) persons have unique health care needs.1 Recognizing this need, the American Physical Therapy Association House Of Delegates adopted position statement P08-22-15-20 and motion RC 16-22 committing the profession to be inclusive for LGBTQIA+ persons.2 This commitment is reinforced by PT Proud, an American Physical Therapy Association Academy of Innovation and Leadership Special Interest Group concerned with improving health care for LGBTQIA+ persons.3
Practice guidelines help ensure that LGBTQIA+ persons receive affirmative care and are not discriminated against. Standards of care for LGBTQIA+ persons have been published in medicine,4,5 a systematic review evaluated several existing guidelines for primary care for patients who are LGBTQIA+ (though found that developmental rigor was poor),6 and professional practice guidelines have been published in the field of psychology.7 However, no practice guidelines to affirm LGBTQIA+ persons in physical therapy have been published. This paper provides recommended areas to address in the development of affirmative physical therapist practice guidelines for LGBTQIA+ persons (Figure). A glossary of terms to understand this issue is provided (Figure).
Foundations for Affirmative Physical Therapist Practice
Even before releasing the 2011 Institute of Medicine report on the Health of Lesbian, Gay, Bisexual, and Transgender People, physical therapists have been working to understand the unique needs of LGBTQIA+ persons.8 Although awareness and acceptance of LGBTQIA+ people have improved, this community is stigmatized as minorities and has been the subject of relatively little health research. Affirmative practice is an approach to health care that validates and supports the identities stated or expressed by those served.7 One salient factor in affirmative practice is the perception of care that LGBTQIA+ people receive from their health care provider. The perception of a therapist’s affirmative practices is associated with psychological well-being (β = .21, P < .01).6 This approach creates a stronger therapeutic alliance that mediates the association between affirmative practice and one’s sense of feeling safe within a clinical encounter.6 Practice guidelines support affirmative practice by addressing health care disparities, promoting cultural competency, providing evidence-based care, and encouraging inclusive practice.9 Recommendations 1.1 to 1.5 (Figure) address affirmative practice.
Addressing Health Care Disparities
Practice guidelines can help physical therapists address health disparities. Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by marginalized populations.10 LGBTQIA+ people face significant health care disparities and reduced access to care as compared to heterosexual and cisgender populations.11 Sources contributing to LGBTQIA+ health disparities include low health insurance coverage rates, high rates of trauma due to systematic harassment and discrimination, and a lack of cultural competency in the health care system.12 The prevalence of physical disability, noncommunicable diseases, and mental health conditions is higher among LGBTQIA+ people.11 Many of these inequalities are related to minority stress factors (eg, nonacceptance, social stigma, shame) that arise in the context of health care practice. LGBTQIA+ people describe discriminatory experiences by health professionals and often distrust or fear the health care setting.11 However, these experiences are not homogeneous for LGBTQIA+ people and may vary when multiple marginalized identities exist. The transgender, queer, and questioning groups face higher rates of discrimination regarding health equity.13 For example, being a woman and belonging to a racial minority were related to poorer physical and mental health outcomes.14 Transgender women, especially transgender women of color, often experience the most exposure to discrimination and violence and have worse health outcomes.9 This fact can partly be explained by transmisogyny (Suppl. Tab.). Considering minority stress is also useful in understanding some health behaviors that may occur in the LGBTQIA+ community, such as sedentary habits, isolation, substance abuse, or self-harm.15 These behaviors often constitute maladaptive coping mechanisms related to previous negative experiences, stress, trauma, stigma, and/or discrimination. Physical therapists can implement interventions such as inclusive education about sex, sexual and gender diversity, screen for bullying and suicide risk, and provide gender-affirming care.
Advocacy and Life-Long Learning
Practice guidelines can help physical therapists care for members of the LGBTQIA+ community by illuminating special considerations and encouraging physical therapists to educate themselves to avoid unconscious and perceived biases.14 Members of the LGBTQIA+ community have experienced a challenging history, but physical therapists can learn to provide compassionate, high-quality, and culturally competent care. Recommendations 3.1 to 3.3 address advocacy, while recommendations 3.4 to 3.5 have to do with life-long learning (Figure).
Advocacy in physical therapy takes place at many levels of care. We can advocate for direct patient needs, and policies within our institutions, for the betterment of our community, and at the state and national level. Advocacy begins with our patients and clients and recognizing the intersection of their needs with the needs of our profession. Physical therapists have a code of ethics to which we must all comply.16 Relevant to this discussion are “Principle 1: Physical therapists shall respect the inherent dignity and rights of all individuals” and “Principle 2: Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients and clients.”16 We spend more time in direct patient care than the average health care provider. This allows us an advantage in building rapport with our patients and clients while assessing their needs. A sense of belonging can lead to a valuable conversation regarding health care.17 These conversations can lead to discussions of well-being and a physical therapist may realize the need for a referral to other disciplines, such as mental health services. This is where we begin to advocate for our patients.
Next, our organizations have numerous policies and procedures. These guide the day-to-day operations, streamlining internal processes, and providing guidance in decision-making. They are regularly updated to address the needs of our patients and ensure that our facility is up to date with laws and regulations. We can directly influence the language of our policies and procedures to improve the quality-of-service delivery and create a safe work environment for our patients and colleagues in the LGBTQIA+ community.
Subsequently, laws are passed at the local, state, and federal levels. It is our responsibility to ensure that laws affecting our profession and the delivery of physical therapist services to our patients preserve the dignity of the human experience in line with Principles 1 and 2 mentioned above. We need to advocate for laws that increase access to quality care for marginalized communities including those addressing LGBTQIA+ individuals.
Additionally, this section warrants a discussion of life-long learning in which recommendations 3.4 to 3.5 play a larger role. Beginning with understanding the terms in the Supplementary Table can help physical therapists enhance cultural awareness and sensitivity and become better informed of the unique needs and experiences of LGBTQIA+ people. This can lead to better communication, more accurate diagnoses, and improved health outcomes.18 Terms and definitions vary depending on many factors, including the community, geographic area, and culture. As society evolves, relevant vocabulary and its glossary of terms continue to change. Although there is no universal agreement on definitions, the Supplementary Table provides foundational terminology to understand this issue.
It is recommended that physical therapists listen to and learn from patients in the LGBTQIA+ community. If a physical therapist is unsure of which terms are most affirming and appropriate, they may ask the patient how they or their partner or spouse should be described. Once the terms are established, a note should be made in the medical record to follow the pattern of description for future visits. Furthermore, physical therapists should consider that gender and sexuality exist in continuums with infinite possibilities. For many people, these are not static constructs. Everyone is unique and composed of multiple identities within and interacting with other sociocultural realms, such as socioeconomic status, geographic region, race and ethnicity, religious and spiritual affiliation, gender, and sexuality.
It is critical that we extend our role as learners to the role of educators for the future physical therapist. As we adopt inclusive practices that promote respect, acceptance, and affirmation for LGBTQIA+ people, our future generations take notice and inquire as to how they can do better. This begins with creating a welcoming and safe environment for learners to have conversations with mentors in the presence of patients from the LGBTQIA+ community. Regardless, many effective ways exist to create a genuinely safe, supportive, and inclusive practice with a learning environment that is welcome and open to conversation and change.
Evidence-Based Practice and Research
Effective practice guidelines are supported by research, clinical evidence, and consideration of lived experiences and perspectives.9 This section proposes guidelines that can be categorized into 2 avenues for the well-being of LGBTQIA+ persons: encouraging the utilization of sound evidence and the creation of new evidence.
We need to educate ourselves on the unique needs of the LGBTQIA+ population. Suicide is almost double in the LGBTQIA+ population when compared to heterosexual counterparts. This risk is even higher within the transgender community.19 Physical therapists are perfectly positioned as frontline providers to ensure that patients receive the services they need to survive and thrive. Additionally, of consideration are the unique needs of the patient seeking gender-affirming care. Gender-affirming care is any intervention that supports an individual in aligning their gender identity to their well-being. These may include speech therapy or vocal coaching, hair removal, puberty blockers, hormone therapy, gender affirmation surgery, counseling, binding, packing, tucking, and padding. The specific interventions chosen vary based on individual, goals, medical recommendations, and preferences.20
A preponderance of evidence indicates that eliminating barriers to care ensures access to necessary health care, enhances patient-provider relations, and encourages more successful outcomes. This applies to health care providers working with the LGBTQIA+ community.21 Physical therapists should strive to provide the best possible care for LGBTQIA+ to address barriers to care within their social determinants of health. The lived experience of each of our patients, clients, and colleagues is different and this is also true for members of the LGBTQIA+ community. By applying existing evidence from the health care community to our patients and clients who identify as LGBTQIA+, we can evaluate the role of intersectionality in their care.22 However, knowledge and supply of referral resources are critical to the success of any intersectionality analysis.
It is also integral that we produce strong and compelling evidence of the effect of our care with the LGBTQIA+ community. There is little health care research conducted specifically for this population. Our role as doctorly trained physical therapists is, in part, to contribute to the body of evidence. We should not delegate the designing of effective studies that capture the uniqueness of care for the LGBTQIA+ community to other professions. Let us be leaders on this evidential journey.
Many organizations are dedicated to the gathering and analysis of population data and statistics, and some look specifically at the needs of the LGBTQIA+ community. We are the physical therapist profession and need to do our part to gather and analyze data about the specific care we need to provide for LGBTQIA+ individuals. Members of the LGBTQIA+ community are not isolated members of society but live and work in all facets of the community and nation. Between 7.1% of the population of the USA, roughly 20 million citizens, identifies as LGBTQIA+. Our care should recognize their specific needs.23 Paramount to this effort is the adoption of inclusive practices that promote respect, acceptance, and affirmation for LGBTQIA+ people. This begins with creating a welcoming and safe environment through equitable physical therapist practice.24 These included establishing an inclusive organizational environment, trust between the patient and provider, and other items categorized as bigger picture.
We need to study our efforts in these areas and report our successes and failures to drive the narrative forward. What are our policies and practices that address and support the individual’s specific needs? These may include addressing privacy concerns,24,25 modifying the intake process,24,25 using a trauma-informed approach to care,24 discussing patient and client rights.24,25 It may also include simple gestures like displaying signage of support and with an array of diverse people, gender, and sexualities.26 How are we building trust between the patient and provider? Trust is established on a personal level but needs to be authentic.25 Vital to this end is comfort in conversation around LGBTQIA+ care.26 Providing personnel with training,24–26 resources,25,26 and organizational support24,25 encourages confidence in working with LGBTQIA+ persons. How are we committing to well-being which is crucial to accomplishing adequate care?24,25 As holistic primary care providers, it is our duty to address not only the specific ailment but the whole person. This may include advocating for safe places to engage in physical activity, cost-effective health care options, or preventative care programming.24 It may also include larger-scale community engagement. Regardless, we need to analyze our efforts in promoting safe, supportive, and inclusive practice through the publication of sound literature.
Conclusion
This is a call to action for American Physical Therapy Association to develop guidelines to affirm LGBTQIA+ persons. In the health care community, the term “practice guidelines” denotes a set of recommendations derived from the available evidence, aimed at assisting health care professionals in making informed decisions. We use the term not necessarily to imply the adoption of a standardized methodology for formal clinical practice guideline development, but rather to emphasize the practical applicability of the recommendations to real-world patient care scenarios. The American Physical Therapy Association, its component special interest groups, and its members have expressed a commitment to promoting equity and inclusivity while also addressing policies and practices perpetuating the exclusion of LGBTQIA+ persons in our association, the profession, and society.2 Other health care experts and associations have already published practice guidelines in this area. The recommendations in this Point of View can be adapted or adopted to affirm LGBTQIA+ persons. In addition, during the review of formal clinical practice guidelines, suggestions can be made to include LGBTQIA+ individuals.
Funding
There are no funders to report for this submission.
Disclosures
The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.
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