OT but interesting to read: Healthcare, Same Sex Intimate Partner Violence

[MaineWriter]

Brought to you as a public service from your resident RN...

This is actually very interesting (I thought). Highlights many of the problems that exist is society and our healthcare system. The article is also good because it has a comprehensive reference list, plus some useful statistics. I am not sure "enjoy" is the right word (which I so often use when I post a news item). Let's try, "I hope you learn something new."

Leslie

Health Care Barriers and Same-Sex Intimate Partner Violence: A Review of the Literature
Posted 04/27/2006
Pauline Freedberg

http://www.medscape.com/viewarticle/530360_1

(The article is long so I am not going to post the whole thing. Use the link!)

[rtprod]

Leslie, I think you have to register and login to read it -- can you paste directly?

thanks,

rt 

[MaineWriter]

Leslie, I think you have to register and login to read it -- can you paste directly?

thanks,

rt 

Really? Let me figger something out...

I think I have a solution.. it will be in three parts tho

[MaineWriter]

Health Care Barriers and Same-Sex Intimate Partner Violence: A Review of the Literature

Pauline Freedberg

J Foren Nurs.  2006;2(1):15-24,41. 
Posted 04/27/2006

Abstract and Introduction
Abstract

Minority groups experience barriers to accessing and receiving health care. Sexual minorities, which include gay men and lesbians, have no specific defining physical characteristics and are not as easy to identify as other minority groups. Consequently, their unique health care disparities are frequently overlooked. Myths and facts regarding the common barriers to health care, including those specific to same sex intimate partner violence, are explored.
Introduction

Members of minority groups are at increased risk for a variety of health problems (Baldwin, 2003; Brach & Fraserirector, 2000). However, these problems are easier to identify in some individuals than in others. Ethnic characteristics, skin color, and language differences may point to health issues commonly associated with a particular culture. Because health care providers are often familiar with such distinctive health conditions (e.g., African Americans and sickle cell anemia), they are more likely to be recognized and receive earlier intervention.

For at least 5 decades, gay men and lesbians have been identified as a minority group (Herek, 1991). These individuals lack the specific defining physical characteristics that classify many other minorities and they are therefore, not as easy to identify. They are instead, "invisible in plain sight" (Craft, 2004, p. 19). Consequently, their unique health needs and disparities in care are frequently overlooked (Harrison, 1996; Spinks, Andrews, & Boyle, 2000).

Being different from the accepted norm causes a group to be marginalized or set apart from society and may influence how its members access and receive health care (Diamant, Wold, Spitzer, & Gelberg, 2000; Meleis, 1999). Sexual minority groups are reluctant to seek conventional medical care and to reveal their sexual orientation to health providers because of the fear of stigma and discrimination (Dean et al., 2000; Gosner, 2000; Ungvarski & Grossman, 1999). In addition to disease, acts of domestic violence are a significant health problem that contributes to the mortality and physical health morbidity of sexual minorities (Federal Bureau of Investigation [FBI], 2004; Gay and Lesbian Medical Association [GLMA], 2001; Patton, 2004). The marginalization and fear that sexual minorities experience are obstacles to accessing health care and can increase their risk for the negative physical and psychological health consequences associated with domestic violence abuse.

Although members of sexual minority groups experience barriers to health care (GLMA, 2001), the purpose of this paper is to describe the barriers to identifying the health care needs specific to adult victims of same-sex intimate partner violence (SSIPV). The importance of SSIPV awareness among health professionals and the implications for victim recognition of SSIPV by health care providers are discussed. Related terms and definitions, homosexual prevalence in the United States, and changes in minority demographics that may contribute to existing health care disparities are presented. The myths and facts regarding common health care barriers that gays and lesbians encounter and those associated with SSIPV concerning its prevalence, assessment, and screening are discussed. In addition, the myths and facts regarding health professionals' cultural competence and knowledge, beliefs, and attitudes regarding homosexuality and SSIPV are highlighted. Finally, clinical implications and areas for further investigation are suggested.
Definitions of Terms Used
Intimate Partner Violence, Same-Sex Intimate Partner Violence, and Battering

A romantic relationship indicates the presence of physical attraction and sexual love between two partners (Burke & Fallingstad, 1999; Merriam-Webster, 2003). The term "intimate partner violence" (IPV) describes the actual or threatened abuse perpetrated by one person to gain control over another with whom they have, or have had, an intimate relationship (Family Violence Prevention Fund [FVPF], 2004). Therefore, the term "intimate partner" in this paper will imply the existence of a current or past romantic relationship. The term "same-sex intimate partner violence" describes the abuse that occurs between partners involved in same-sex romantic relationships; and the term "battering" describes the physical, sexual, or psychological abuse that occurs between opposite or same-sex intimate partners.
Sexual Orientation, Identity, and Behavior

The American Psychological Association (American Psychological Association [APA], n.d.) defines the terms that follow. Sexual orientation refers to an attraction toward an individual of the same (homosexual) or opposite (heterosexual) sex. Sexual identity refers to one's own identification as gay, lesbian, or heterosexual. Sexual behavior refers to the sexual activities an individual practices and plays an important role in health risk assessment (GLMA, 2001). Sexual orientation is not synonymous with sexual behavior and both can change over time. For example, one study reports that 77%-95% of women surveyed self-identified as lesbian, yet lifetime behaviors for approximately 80% of these lesbians included having sex with men (O'Hanlan, n.d.). Although individuals may sometimes practice same-sex behaviors, they may not always self-identify as exclusively homosexual for many reasons (as cited in Kinsey Institute, 1999), such as fear of rejection by their families and ethnic or racial groups (D. Smyth, personal communication, February 5, 2005).
Heterosexism, Homophobia, and Fear of Rejection

Heterosexism is the belief that heterosexuality is normal and thus more valued in society (Peterman & Dixon, 2003). Homophobia is the irrational hatred, fear, and intolerance of homosexuality (Merriam-Webster, 2003) that results in expressions of negative attitudes toward individuals because of their sexual orientation. It can range from social isolation (e.g., exclusion from the dominant group) to committing criminal acts of violence (Bonvicini & Perlin, 2003). For example, Federal Bureau of Investigation (FBI, 2004) statistics indicate 17% of the total number of hate crimes perpetrated against individuals or property reported in the United States was linked to victims' sexual orientation. However, the National Coalition of Anti-Violence Programs (NCAVP) reports the number to be about 40% higher (NCAVP, 2004).

Both heterosexism and homophobia are prevalent in the general population and within the health care environment as well (Institute of Medicine [IOM], 2002). Gay men and lesbians fear rejection, discriminatory and judgmental attitudes, and substandard care from health care providers if they reveal their sexual orientation (Harrison & Silenzo, 1996; Meyer, 2001; Rondahl, Innala, & Carlsson, 2004).
Coming Out and Outing

Coming out is the process in which gay men and lesbian women recognize and accept their own sexual orientation and disclose their homosexuality to others. Stepping out of a hiding place or closet describes this process (Gentry, 1992). Coming out is usually a voluntary act and is likely to be a continual, lifelong process influenced by many individual factors (APA, n.d.). Conversely, "outing" refers to the unwanted public disclosure of an individual's sexual orientation as gay or lesbian (Aulivola, 2004; Baum & Moore, 2003).
Significance of the Problem

Battered victims frequently use the health care system for treatment related to the consequences and sequelae of intimate partner violence (Campbell, 2004). However, they are reluctant to reveal their reason for seeking medical attention because of fear of retaliation or humiliation by their intimate partner or the law enforcement or legal systems. Some studies indicate a large percentage of domestic violence cases are not recognized by health providers (Davis, Parks, Kaups, Bennink, & Bilello, 2003; Hamberger et al., 2004). Approximately 25-50% of women who seek emergency medical care are IPV victims (Heinzer & Krimm, 2002). However, the emergency department staff recognize less than 50% of victims of abuse (Dearwater et al., 1998). Consequently, these victims receive no safety plan, referral, or follow-up.

The presence of heterosexism and homophobia and the lack of health professionals' awareness of IPV prevalence among same-sex intimate partners make the identification of victims of SSIPV even more difficult. It is critical for physicians and nurses in all health care settings to examine their own beliefs about homosexuality, develop the cultural sensitivity and educational expertise necessary to recognize victims of SSIPV, identify its physical and psychological consequences, and provide appropriate treatment and referrals (Freedberg, 2005). Intimate partner violence does not discriminate between opposite or same-sex intimate partners, nor should the health providers from whom victims seek support.
Homosexual Prevalence

There is controversy concerning the actual number of homosexuals in the United States. Data collection methods and variations in sexual self-identity, sexual orientation, and sexual behaviors limit accurate predictions of homosexual prevalence. Although the U.S. Census 2000 counts the number of same-sex partners in unmarried partner households, the statistics reflect living arrangement only. The census does not address the sexual orientation of respondents, nor does it count single gay or lesbian people or same-sex partners who do not cohabitate (Simmons & O'Connell, 2003). Even though the 2000 census reports a 314% increase in the total number of gay and lesbian families since the 1990 census, these figures underestimate the number of gays and lesbians in America (Smith & Gates, 2001; Tjaden & Thoennes, 2000).

The classic Kinsey Reports published more than 5 decades ago indicates 6%-10% of the total population in the United States is exclusively homosexual (as cited in Kinsey Institute, 1999) and more recent studies report estimates of between 4%-10% (Gosner, 2000; JAMA, 1996; Smith & Gates, 2001). However, because of the sensitive nature of homosexuality and the continued bias and discrimination against sexual minorities, underreporting is likely (Smith & Gates, 2001) and this percentage may be inaccurate (Black, Gates, Sanders, & Taylor, 2000; Spinks, Andrews, & Boyle, 2000).

Results from a recent Gallup Poll regarding homosexuality, although not scientific, indicate the American public estimates approximately 20% of the total population are gay or lesbian (Newport, 2002). Nevertheless, individuals in sexual minority groups represent a significant segment of the total population, yet remain uncounted as well as invisible.
Demographic Changes of Minority Groups

Members of minority groups in the United States experience a greater number of health problems as compared to members of the dominant group (U.S. Department of Health and Human Services [USDHHS], 2000a). A special report by the U.S. Bureau of the Census (2004) projects that ethnic and racial minority groups, now approximately one-third (31.6%) of the current population, will increase to over one-half (52.3%) by the year 2050. The report predicts the African-American population will increase (12.7% to 14.6%) and the Hispanic and Asian populations will double (12.6% to 24.4%; 3.8% to 8%).

Gays and lesbians have representation in all ethnic and racial minority groups (Harrison, 1996). For example, approximately 10% of all same-sex couples are African-American, 12.4% are Hispanic, and 2.3% are Asian (U.S. Bureau of the Census, 2001). Individuals who are members of both sexual and ethnic or racial minorities are even more vulnerable to health care disparities and encounter "dual" discrimination. Gay and lesbian people with double minority status experience discrimination related not only to ethnicity and race, but to sexual orientation as well.
Healthy People 2010

As minority groups become the majority, the health care system will face the major challenge of meeting the needs of a more diverse society. To help health care providers meet this challenge, the government created Healthy People 2010, a 10-year blueprint for public health. The goal of this national health promotion and disease prevention project is to improve the health of all Americans and eliminate health disparities between population groups (USDHHS, 2000b). To meet this goal, the government has budgeted $1.4 million in federal monies to provide for cultural competence training for clinicians and health professions students (Brach & Fraserirector, 2000; Health Resources and Services Administration [HRSA], 2000).

Because gays and lesbians experience unique health risks and barriers to care (Gosner, 2000; USDHHS, 2000b) and are not readily identifiable to health professionals, "Healthy People 2010: Companion Document for Lesbian, Gay, Bisexual, and Transgendered (LGBT) Health" (GLMA, 2001) was developed. The purpose of this document is to examine their special needs and make recommendations for improving access to care, preventive medicine, and health care provider cultural competency for multicultural sexual minorities (GLMA, 2001).

[MaineWriter]

Sexual Minority Barriers to Health Care: Myths and Facts

Gays and lesbians are culturally diverse. Consequently, they all do not have the same health care experiences and concerns. Yet similar barriers to health care do exist among this population, however many of these obstacles develop because of inadequate or incorrect information concerning gay and lesbian issues among health professionals.

A myth or misconception is a fictitious or mistaken idea or view widely believed as true (Merriam-Webster, 2003). Myths and misconceptions concerning gay men and lesbians exist among medical personnel. Homo phobia and heterosexism among health care providers are major obstacles to the access, delivery, and receipt of care for members of a sexual minority group (Dean et al., 2000; Diamant, Schuster, & Lever, 2000; Potter, 2002). However, myths and misconceptions about gays and lesbians can be barriers to care as well (Namenek, 2001), therefore, it is important for health care professionals to be informed about them in order to dispel them. Health professionals must examine their own beliefs concerning homosexuality and recognize those misconceptions that are not consistent with fact because they can affect the delivery of quality care.
Myth 1: Homosexuality is Pathologic

Fact: The American Psychiatric Association (APA) officially removed homosexuality from its categories of mental disorders in 1973. In 1986, the APA deleted the diagnosis, "ego-dystonic homosexuality" (e.g., experiencing unwanted homosexual rather than heterosexual arousal and relationships) from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Yet despite the APA's changes, many health professionals remain rooted in obsolete beliefs and diagnoses. They continue to look upon homosexuality as a disorder and label homosexual behavior as abnormal and dysfunctional (Greco & Glusman, 1998).

For example, in a survey of general practitioners, 11.4% thought homosexuality was an illness, only 32.7% felt comfortable with gay men, and 40.8% did not think schools should employ gay men (Journal of the American Medical Association [JAMA], 1996). Klamen, Grossman, and Kopacz (1999) surveyed second year medical students (N = 100) and used a 12-item questionnaire to measure attitudes toward homosexuals and homosexuality before subjects took a course on human sexuality. Although only 9% believed homosexuality was a mental disorder, 28% reported it was immoral and 29% reported it was dangerous to the family structure. Rondahl, Innala, and Carlsson (2004) surveyed nursing staff (n = 85) and nursing students (n = 155) to determine subjects' emotions toward homosexual patients and whether they would refuse to provide care for homosexual patients if they had the option. Student scores indicated higher levels of both negative (guilt and anger) and positive (delight) emotions when compared with nursing staff scores. A greater percentage of staff nurses (36%) as compared with student nurses (9%) indicated they would refrain from nursing homosexuals if given the choice. Some of the reasons cited by subjects for choosing to refrain from giving care were insecurity, fear, disgust, and condemnation of homosexuals.

The removal of this diagnosis from the DSM-III was a step in the right direction to help alleviate prejudice and discrimination against gays and lesbians. However, negative assumptions concerning the morality and sexuality of gays and lesbians continue within both the general population and the health care environment (Gosner, 2000; Spinks, Andrews, & Boyle, 2000).
Myth 2: Homosexuals and Heterosexuals Have Equal Access to Health Care

Fact: Although tangible barriers to accessing health care (such as limited income and lack of health insurance) are common among minority groups, personal barriers such as sexual orientation exist as well (Spinks, Andrews, & Boyle, 2000; USDHHS, 2000b). Diamant, Wold, Spritzer, and Gelberg (2000) investigated women's health behaviors, access, and use of health care. They reported that only 63% of lesbian women (n = 51) and 42% of bisexual women (n = 36) had health insurance as compared to 70% of heterosexual women (n = 4,610; p < .01). Their findings also indicate that financial barriers prevented lesbian and bisexual women from receiving needed prescription medications, mental health care, and medical care from a physician. In addition to the concrete barriers, gay men and lesbians also encounter intangible, personal barriers, the most common of which is avoidance of routine health care because of stigmatization by the medical community (Bonvicini & Perlin, 2003; Gosner 2000; Harrison & Silenzo, 1996). An example of stigmatization by a health professional follows.

A young woman visits a family physician for the first time...and the physician asks, "When was the last time you had sexual intercourse?" "I've never had sexual intercourse," she replies. "Never?" "No." "Do you have a boyfriend?" "No." "Well, don't worry. You will soon. Let's talk about birth control." The physician finishes the discussion about contraception and writes in the chart, "Not sexually active...[or in a] relationship. Contraception counseling [was] given" (Simkin, 1998, p. 370).

The physician's communication technique described is inappropriate for any patient. However, the sexually active lesbian in this situation was not given the opportunity nor did she feel comfortable revealing her sexual orientation to the physician. She does not return for routine follow-up visits and consequently, does not receive needed screening and or preventative care.
Myth 3: Health Professionals Provide Unbiased Care

Fact: There is information available indicating health care provider bias, prejudice and stereotyping may play a role in the differences in care received by minority groups (Baldwin, 2003; IOM, 2002). Harrison and Silenzo (1996) report results from several studies that indicate 31%-89% of health professionals have negative reactions (hostility, excessive curiosity, embarrassment, and disdain) after learning their patients are gay or lesbian.

Even though gays and lesbians believe that disclosure of sexual orientation and behavior may improve the quality of health care provided and received, many remain in the closet (Harrison & Silenzo, 1996). O'Hanlan (n.d.) reports the percentages of homophobic beliefs and behaviors among nurses, doctors, and medical students range from 8% to over 50%. Results from another investigation indicate that only 66% of lesbians (n = 1,084) and 63% of gays (n = 529) surveyed reported they disclosed sexual orientation to their health providers. Because of this disclosure, 26% and 16% respectively reported discrimination by their providers (Bradford, 2004). Consequently, due to fear of discrimination and substandard health care, many gays and lesbians do not disclose sexual orientation to their health providers.
Myth 4: Sexual Orientation and Behaviors do not Affect Health Care

Fact: Gays and lesbians are at increased risk for certain conditions related to sexual behavior rather than sexual orientation (Harrison & Silenzo, 1996). Health care is not the same for homosexuals as it is for heterosexuals. Health care providers often overlook the health risks and care needs exclusive to sexual minorities because these individuals do not reveal their sexual orientation (Gosner, 2000; USDHHS, 2000b). An example follows.

A young woman presents with lower abdominal pain and vaginal discharge; and in taking her history, the physician asks, "Are you sexually active?" "Yes," she replies..."I'm a lesbian." The physician...moves the differential diagnosis of pelvic inflammatory disease [PID] to the bottom of the list of possibilities. Her symptoms worsen and she eventually shows up in the emergency department. "Are you sexually active?"... "Sure am, I'm a lesbian." "Do you ever have sex with men?" "Sure do." This physician puts PID back at the top of the list (Simkin, 1998, p. 372).

Studies also indicate gay men and lesbians are at increased risk for particular types of cancer and sexually transmitted diseases, depression, and the adverse effects associated with substance abuse (GLMA, 2001); yet there is no research to support gays and lesbians have a genetic predisposition to these disorders (O'Hanlan, n.d.). Instead, epidemiological studies link these risks and conditions with lifestyle risks rather than with sexual orientation (Harrison & Silenzo, 1996). Therefore, it is especially important for health professionals not to confuse sexual identity with sexual behavior.
Myth 5: Health Professionals Recognize that Some Patients are Homosexual

Fact: Health providers assume heterosexuality if patients do not reveal their sexual orientation (Ungvarski & Grossman, 1999), even though prevalence statistics indicate 4%-10% of all patients are gay or lesbian. When heterosexuality is assumed, risk factors common to the homosexual population may go unrecognized, medical problems undiagnosed, and treatment may be inappropriate (Diamant, Wold, Spritzer, & Gelberg, 2000; Namenek, 2001). An example of a physician presuming a patient's sexual orientation follows.

After emergency surgery for a ruptured ovarian cyst, the surgeon patted his adult patient on the head and assured [her] that the scar would be so small, "it wouldn't bother her boyfriend"...she "would still be able to have babies" (Greco & Glusman, 1998, p. 162).

In this case, the clinician assumes the lesbian is heterosexual. Because of the fear of humiliation and discrimination, she avoids follow-up care. Consequently, the risk for postoperative complication is increased.
Intimate Partner Violence: Myths and Facts

Violence is universal, claims the lives of more than 1.6 million individuals each year, and affects people of every race, ethnic background, gender, and sexual orientation (Auliova, 2004; World Health Organization [WHO], 2002). Violence between intimate partners is a major problem in America (Cling, 2004) that has medical, public health, and financial consequences, and costs approximately $4.1 billion per year (National Center of Injury Prevention and Control [NCIPC], 2003). The myths and barriers previously described also negatively affect the screening and identification of gay and lesbian victims of IPV.
Myth 6: Intimate Partner Violence is a Heterosexual Women's Issue

Fact: The dynamics of domestic violence include the issue of exertion of power between intimate partners regardless of gender, because men or women can be the abusers or the victims (Island & Letellier, 1991; Lundy, 1993). It is estimated that 25-35% of heterosexual intimate partners experience battering. Domestic violence occurs at the same or greater frequency in gay and lesbian communities as in the heterosexual community (Baum & Moore, 2003; Coker, Smith, Bethea, King, & McKeown, 2000; Family Violence Prevention Fund [FVPF], 2004; Fortunata & Kohn, 2003; Island & Letellier, 1991). Although heterosexual men perpetrate most intimate partner crimes against women (85%), gay and lesbian intimate partners are victims of IPV as well (Bureau of Justice Statistics, 2003). Historically, the perception of domestic violence involves a male assault upon a female. Therefore, IPV between gay or lesbian partners is likely to be viewed as mutual battering or combat (Lundy, 1993).

It is estimated that 50,000-100,000 lesbians and as many as 500,000 gay men are victims of intimate partner battering each year (Murphy, 1995). It is more difficult to assess the extent of IPV in sexual minority groups. Rather than report abuse or seek help because of fear of discrimination related to their sexual orientation, victims of SSIPV prefer to remain in the closet (West, 2004). There are no official prevalence statistics regarding SSIPV due to lack of recognition of domestic violence issues in the gay and lesbian population and flawed data collection methods (Tjaden, Thoennes, & Allison, 1999). Consequently, available statistics are either inaccurate, underestimated, or both (Baum & Moore, 2004).
Myth 7: SSIPV Victims' Issues and Barriers to Seeking Care are not Unique

Fact: Although victims of SSIPV experience similar elements and forms of domestic violence abuse and face many of the same barriers to reporting as victims of opposite-sex IPV, differences exist that make them even more reluctant to disclose abuse than opposite-sex victims. Differences exclusive to same-sex relationships include homophobia, heterosexism, disclosure of sexual orientation, and outing. One of the biggest barriers for victims of SSIPV seeking assistance is the fear of outing to their families, employers, or law enforcement by their intimate partner. Outing can have devastating effects that include humiliation, isolation; loss of income, housing, support systems, or child custody (Island & Letellier, 1991; Potoczniak, Mouret, Crosbie-Burnett, & Poto czniak, 2003). These disparities are unique to same-sex intimate relationships, and are contributing factors to a victim's unwillingness to seek legal or medical assistance (Peterman & Dixon, 2003).
Myth 8: Screening for SSIPV Lacks Guidelines and is Too Time Consuming

Fact: Countless national and international health care professional organizations have published guidelines that suggest approaches for assessing and identifying abuse (Campana, 2005; FVPF, 2004). Consistent with the goals of Healthy People 2010, institutional and primary care facilities are required to have policies that address responding to same-sex as well as opposite-sex victims of domestic violence (FVPF, 2004). Most individuals access the health care system at some time in their lives, so health care providers are in an ideal position to screen for victims of IPV. However, despite guidelines, a large percentage of IPV cases that present to primary care facilities either go unrecognized or receive no referral (Rodriguez, Bauer, McLoughlin, & Grumbach, 1999).

One of the most effective means of identifying SSIPV victims is to ask brief, gender-neutral questions, and the process need not be time consuming. Asking a few straightforward questions is sufficient. For example, one study reports that posing just three questions detected 64.4% to 71.4% of individuals (N = 322) with a history of abuse who came to an emergency department for care. The following questions were effective in identifying victims of IPV:

   1. "Have you ever been hit, kicked, punched, or otherwise hurt by someone within the past year and if so, by whom?"

   2. "Do you feel safe in your current relationship?"

   3. "Is there a partner from a previous relationship who is making you feel unsafe now?" (Feldhaus et al., 1997, p. 1358).

Unbiased, routine screening of all patients for IPV regardless of gender or sexual orientation may provide an excellent opportunity for disclosure of abuse and for secondary prevention of related health consequences.
Myth 9: Conducting a Sexual Assessment is Offensive to Individuals

Fact: A sensitive approach and use of gender-neutral terms when conducting an assessment is not objectionable, whether a person is homosexual or heterosexual. Culturally-competent health professionals are aware of their own biases and attitudes concerning minority groups but are able to provide care that is sensitive to the needs of different populations (Meleis, 1999). However, cultural competence does not guarantee health professionals will provide culturally- sensitive interventions. Therefore, to avoid offending any individual, the use of gender-neutral terms when conducting an assessment is essential. For example, practitioners should ask about a "partner," rather than wife, husband, girlfriend, or boyfriend.

Clinicians should never make assumptions about an individual's sexuality. They should instead ask appropriate questions phrased in a direct and ordinary manner (Greco & Glusman, 1998). For example, "Do you have sex with men, women, or both men and women?" Listening attentively and remaining nonjudgmental to any response an individual may give increases the possibility of collecting relevant information (Campinha-Bacote, 2002). To gain trust when conducting assessments for individuals who may be members of a sexual minority, it is important for clinicians to create an open and nonjudgmental atmosphere so people will feel comfortable disclosing their sexual orientation (JAMA, 1996). If individuals feel safe discussing their sexual orientation, they may feel safe disclosing intimate partner abuse (Senseman, 2002).
Knowledge, Beliefs, and Attitudes Regarding Sexual Minorities: Myths and Facts

The myths associated with homosexual issues can affect the early recognition and prevention of SSIPV. Health professionals must have the opportunity to consider how their own attitudes and values regarding issues of sexuality and domestic violence might influence patient relationships and care. Therefore, training and continuing education programs regarding cultural competency, homosexuality, and domestic violence are necessary.
Myth 10: All Health Professionals Possess Cultural Competence

Fact: Cultural competence is a skill that develops over time and requires practice (Campinha-Bacote, 2003). Health provider insensitivity and bias can lead to mistrust, dissatisfaction with care, unsatisfactory provider-patient relationships, and poor health outcomes (Meyer, 2001). Therefore, cultural competence is of special import when caring for members of a sexual minority group. Because of changing demographics, health care professionals must be aware of the special needs of an increasingly diverse society and become more culturally competent to meet them (American Nurses Association [ANA], 1998; Andrews & Boyle, 2002; Campinha-Bacote, 2003; Jones, Cason, & Bond, 2004).

Repeated encounters with individuals from minority groups are necessary to develop cultural competency (Campinha-Bacote, 2003). For example, Wallick, Cambre, and Townsend (1993) surveyed medical students (N = 180) at three different time intervals during their first year in medical school to determine their affective responses to homosexuality. Results indicated that after attending panel and small group discussions with gay and lesbian physicians, homophobic responses significantly decreased (p = .06) by the end of the year. Students identified positive interaction with gays and lesbians as most useful in helping to decrease stereotypical attitudes towards homosexuals. More recently, Herek (2000) explored sexual prejudice and its correlates and the results of his work support that of Wallick, Cambre, and Townsend. He found that a strong relationship exists among heterosexuals, sexual prejudice, and knowing homosexuals personally; and "interpersonal contact and prejudice are reciprocally related" (p. 20). Exposure, contact, and positive interaction with members of sexual minorities can help health professionals develop cultural competency and an increased comfort level with gay men and lesbians (Eliason & Raheim, 2000).
Myth 11: Health Professionals are Educated About Domestic Violence and Homosexuality

Fact: Health care providers lack training concerning the dynamics of both heterosexual domestic violence and issues specific to homosexuality and SSIPV (Harrison & Silenzo, 1996; Island & Letellier, 1991; Saulnier, 2002). Many health professionals do not feel comfortable identifying, reporting, and providing referrals for domestic violence victims. Some physicians fear opening Pandora's Box because they lack knowledge and the time to provide for victims' needs (Sugg & Inui, 1992).

One might assume that health professionals acquire this training in basic and continuing education programs but research findings indicate otherwise. For example, Woodtli and Breslin (2002) surveyed baccalaureate nursing programs (n = 648) to determine the extent, placement, and faculty responsible for teaching violence- related content in their curriculum. The survey did not include violence specifically linked to sexual orientation. Results indicated that violence content associated with women, children, and self-destructive behaviors was taught in only 2-4 hours; and elder and sexual abuse in 1 hour.

In a similar design study, United States medical schools with departments of family medicine (n = 116), were surveyed to assess the content and number of hours devoted to the topic of homosexuality/bisexuality, care of gay, lesbian, and bisexual patients, and effect of geographic location. Although survey responses indicated a mean of 2.5 hours for this topic in a 4-year undergraduate medical education program, about half (50.6%) of respondents reported their departments spent zero hours teaching this content. There was no significant difference (p = .09) in time spent teaching the topic by geographic location (Tesar & Rovi, 1998). A similar study by Amato and Morton (2002) surveyed obstetrics and gynecology training programs (n = 118) to determine amount of time devoted to teaching lesbian health issues. Their results indicate that over the 4-year program, the mean time was only 1 hour and 52 minutes.

In another study, researchers surveyed physicians and nurses (N = 240) to determine awareness of domestic violence prevalence in a primary practice setting. Results indicated that 50% of physicians and 70% of the nurses surveyed believed the prevalence of domestic violence in their practice setting was only 1% or less. Of this group, 45% never or seldom asked about domestic violence when examining injured patients and 77% had not attended an educational program on domestic violence within the past year (Sugg, Thompson, Thompson, Maiuro, & Rivara, 1999).

Health professionals may miss opportunities for screening when not familiar with the prevalence of potential pathologic conditions among certain minority groups (Lavizzo-Mourey & Mackenzie, 1996). Therefore, they must seek and receive the education and training necessary to understand the unique health care needs and barriers gay men and lesbians face (GLMA, 2001; Harrison, 1996).
Myth 12: Health Professionals are Aware of Their own Biases

Fact: Studies indicate health professionals may not be aware they are giving biased care (IOM, 2002). Attending educational and training programs has the potential for developing cultural competence and for making attitudinal changes (Jones, Cason, & Bond, 2004; Hamberger et al. 2004; Schoening, Greenwood, McNichols, Heerman, & Agrawal, 2004).

For example, one study surveyed hospital employees (N = 752) before and after attending a domestic violence training program to determine if the program was effective in developing self-efficacy and in changing attitudes. There was a significant increase (p < .001) in ability to identify victims of violence following the program with a sustained increase over time. Results suggest increased self-efficacy may enhance health care providers' ability to identify, provide support, and make referrals to IPV victims (Hamberger et al., 2004). Therefore, it is vital for health providers to examine their values and beliefs concerning domestic violence, especially between same-sex intimate partners, and to acquire the education and skills necessary to provide equal care for all individuals (Campinha-Bacote, 2003; IOM, 2002; Spinks, Andrews, & Boyle, 2000).
Clinical Implications

IPV victims use the health care system more frequently than those who do not experience this type of violence, yet they often go unrecognized (Campbell, 2002). It is well documented that IPV victims experience both short- and long-term physical (broken bones, gastrointestinal disorders, headaches) and mental (post-traumatic stress disorder, depression) consequences of abuse, or death (Campbell, 2002; Crandall, Nathens, Kernic, Holt, & Rivara, 2004). Gay and lesbian victims of SSIPV are even more reluctant to reveal the abuse than opposite-sex victims because of the issues unique to this population, already discussed. Because this type of abuse is so prevalent, it is vital that health care providers recognize it and intervene appropriately.

However, the fact that health professionals' attitudes and values concerning homosexuality can negatively affect patient relationships and treatment outcomes (Bradford, 2004; Klamen, Grossman, & Kopacz, 1999; Meyer, 2001) is of concern. To provide effective preventative and therapeutic interventions for SSIPV, health professionals must be aware of and sensitive to the needs of this population. Therefore, it is critical to dispel the myths believed by many health care providers concerning homosexuality and SSIPV.
Recommendations for Further Investigation

Lack of education in health professionals' education programs and negative attitudes among health providers regarding homosexuality are factors that limit access and receipt of health care. Educational interventions (lectures, panel discussions, and role-playing) presented by teachers and mentors who demonstrate positive attitudes and behaviors towards gays and lesbians can be effective in reducing stereotypic thinking and negative attitudes toward homosexuals (Eliason & Raheim, 2000; Klamen, Grossman, & Kopacz, 1999) and in improving patient care. Research that examines the effect of integration of homosexuality content into nursing and medical school curricula on the attitudes of health professionals regarding gays and lesbians is recommended.

Societal discrimination based on sexual orientation is common. Release of confidential information from individuals' medical records to employers, insurance companies, or families has very real consequences. Although the Health Insurance Portability and Accountability Act (HIPAA) provides individuals with protection against the release of certain health information, it is not absolute. The privacy regulation does permit health providers to release information without consent in some circumstances such as to provide treatment or facilitate payment for treatment, or report a diagnosis (such as AIDS) or domestic violence to public health authorities, if mandatory (Lambda Legal and GLMA, 2003). Some states have laws in effect that afford additional protection against disclosing private information about health condition, sexual orientation, or gender identity. However, research that focuses on forming legislation and policies at the state and federal levels to create standards that would further limit disclosure of confidential information in medical records is recommended (Plumb, n.d.).

There is no research to support the premise that once screening identifies victims of IPV, specific interventions change the course of abuse (Nelson, Nygren, McInemey, & Klein, 2004). Therefore, research that identifies the efficacy of screening tools and interventions to decrease abuse and health-related consequences of IPV is recommended. Additional research on the obstacles facing sexual minorities, when accessing and receiving health care services, is recommended to better serve this population.
Conclusion

Gays and lesbians live in a heterosexist society. Nearly all of the health risks and barriers to accessing and receiving care that sexual minorities experience are associated with marginalization and homophobia, not homosexuality. The problems gays and lesbians experience in the health care system are not due to their sexual orientation, but rather to the health care provider's reaction to it (Namenek, 2001). Therefore, education and training for health professionals that dispels the myths and provides facts about caring for individuals in sexual minority cultures is necessary to reduce the barriers.

Given the changing cultural milieu in the United States, efforts must be expended to provide training for health professionals regarding gay and lesbian issues and to develop cultural competency.

Universal screening, no matter the reason for seeking care, may be potentially harmful to victims of IPV because of retaliation by their intimate partner (Senseman, 2002; Worster, 2004). However, routine, unbiased screening and sensitive gender-neutral assessment can be valuable tools to identify victims whose safety needs might not be addressed otherwise. Regardless of presenting symptoms or gender, these interventions have the potential for early detection and prevention of repeated, escalating violence by intimate partners. However, a cooperative effort among those individuals involved in the care of victims and survivors of domestic abuse is necessary to accomplish this goal.

Nurses are an integral part of the medical team, are highly respected and trusted by the public (Hughes, 2004; Moore, 2004), and are often the initial professional contact for victims seeking health care (Thomlinson, 2003). As a result, they are in a favorable position to work together with members of social and community agencies, and the health care, law enforcement, and judicial systems. Collaboration with other providers can help dispel the common myths described and affect positive outcomes regarding the recognition, prevention, and treatment of same-sex intimate partner violence.

[MaineWriter]

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Acknowledgements

The author extends her sincere appreciation to Peter Guarnero, PhD, MSc, RN, of the University of New Mexico, College of Nursing, Albuquerque, NM, and to Sandra McKinnon, MS, NP, RN, of Santa Clara, CA, who gave so generously of their time by reviewing a draft of this manuscript and for providing helpful comments and valuable insights. Also deserving of thanks are Patricia Crane, PhD, MSN, RNC, CRNP, and L. Kathleen Sekula, PhD, APRN, of Duquesne University, Graduate Program in Forensic Nursing, Pittsburgh, PA, for their expertise and continued encouragement and guidance for this manuscript.

Pauline Freedberg, MSN, RN, is a Professor of Nursing at Westmoreland Community College, Youngwood, PA.

[MaineWriter]

I realize this article, the way it is pasted here in 3 parts, is long and difficult to read. Also, it is not in the best format for saving. However, I can email it from the site. So...if anyone would like to receive a copy that way, please send me a pm with your email address and I will send it right off. Thanks,

Leslie, RN

[JennyC]

Leslie,

It's pretty interesting reading.  The myth vs. fact part is very informative.  It's a typical research paper to identify issues, it does offer some suggested solutions, but not a lot.