Running Head: ENHANCING HEALTHCARE ACCESSIBILITY AND QUALITY FOR LGBTQ

INDIVIDUALS IN RURAL AREAS

Enhancing Healthcare Accessibility and Quality for LGBTQ Individuals in Rural Areas

Colten M. Boyd

November 30, 2023

Research and Practice in Rural and Global Communities

NURS 8809

Weaver

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The research conducted in this paper was brought about through the use of database

searches done through EBSCO host and google scholar with use of keyword searches related

to the topic. Limitations to the searches included limiting timeframe to 2018 through 2023, Peer

reviewed articles, and subject keywords. Key phrases used included the following: LGBTQ,

LGBT, Queer, Gender Queer, Rural, Rural Areas, Rural Communities, Healthcare, Health,

Nursing, Nurse Practitioning, Primary Care, Access to Care, Healthcare Access, Access,

Cultural Competency, Qualitative, Quantitative, and Systematic Review. The main topics that

were found through these searches included barriers to healthcare including discrimination,

cultural competency issues, and insurance and financial barriers; Gender affirming care

including impact of gender-affirming care on mental health, Provider roles in gender affirming

care; Healthcare needs such as transgender specific care, healthcare provider education; and

health system and policy perspectives that included health system challenges and opportunities

and historical and ethical considerations.

The term Queer has held a number of meanings over the years, but it wasn't until

recently that it was used in a positive light. During the 1895 Oscar Wilde trials, it began being

used as a slur against LGBTQ identifying people. It wasn’t until the 1980’s HIV/AIDS epidemic

where the word was reclaimed to be used as a point of pride, and later an umbrella term to refer

to anyone that identifies as LGBTQIA+ (McKee, 2024). Though the world is ever changing and

there is much growth and debate into queer topics, LGBTQ healthcare has many improvements

that need to be made. The goal of this paper is to highlight common concerns and disparities

that are barriers for queer identifying patients to receive care, as well as some

recommendations for changes that can be done within the DNP-FNP scope of practice.

Barriers to healthcare are found in many communities across the country. Rural areas

add an extra layer of difficulty when it comes to LGBTQ healthcare. These disparities to

healthcare are only growing as new legislation is put into effect that restricts providers and

patients from healthcare services specific to sexual and gender minorities. In the year 2023,

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nineteen states have placed legislation that bans gender affirming care to minors (Choi, Mullery,

2023), greater than 417 bills were geared towards LGBTQ limitations, 142 of those bills were

geared towards healthcare, and 283 bills were set to limit discussion in schools of multiple

levels by april alone (Choi, 2023). A qualitative study found an increased occurrence of

discrimination towards LGBTQ individuals in rural areas and increase their visibility in the

community (making it harder to hide their queer identity from those that may discriminate them

directly, have fewer supports, and are generally less accepting of members of this community

as a whole (Henriquez, Ahmad, 2021).

Rural areas are already lacking when it comes to manpower in the healthcare workforce.

There are less providers in general, and the addition of specialized needs brings about a

problem for specialized provider availability as well. Research shows that discrimination

contributes to general stress, that which is experienced by all people everyday,

disproportionately increases psychological distress such as dysfunctional emotional regulation,

interpersonal problems, altered cognitive processes, increased mental illness, and poorer

economic, physical, and mental stability for queer identifying people (Skuban-Eiseler,

Orzechowski, Steger, 2023). When looking at cultural competence for older queer people, a

systematic review found that there was no current evidence or best practice on ways to improve

culturally competent clinical care due to a lack of research on the topic (MacCarthy, Darabidian,

Elliott, Schuster, Burton, Saliba, 2021). This systematic review does note that the combined

efforts of researchers and policymakers can bring about culturally competent clinical care.

As more research is put into effect, we see more ways that healthcare can improve for

LGBTQ identifying patients and their communities. Expanding telehealth services can broaden

the reach of many providers, including those that work in specialized clinics and can be geared

towards a patient's specific needs (Barenboim, Damitz, Brusky, Franco, 2023). It is seent that

services that offer telehealth are shown to have a higher likelihood of LGBTQ patient support,

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especially with services that are geared towards mental health and addiction recovery (Ware,

Austin, Srivastava, Dawes, Baruah, Hall, 2023).

In the most recent research, specific specialties are looking at what they can do to

improve LGBTQ healthcare. The use of inclusive language, presence of rainbow/pride flags,

implementation of gender neutral bathrooms, and advocacy for queer patients were all noted to

be improvements that any practice could implement in their workplaces to support queer

patients (Kirjava, Sladen, DeBacker, 2023). A recent qualitative study showed that there are

close to 1.6 million transgender people in the United States; 30% of them have experienced

healthcare discrimination or could not afford the cost of healthcare and another 20% avoided

addressing their healthcare needs by seeing a provider because of fear of discrimination. This

same study recognized a need for more legislative endeavors to protect queer people,

increased education for medical/healthcare providers, and increased healthcare programs that

are made to support trans and other queer populations (Kachen, Pharr, 2020). With any

improvements that can be done, qualitative studies and surveys are key to understanding the

voices of these minority groups and improve the understanding of sexual and gender minorities

struggles and unique healthcare needs (Henriquez, Ahmad).

With the integration of queer voices and the research that has been published, DNP can

begin to implement cultural competency for LGBTQ patients and improve care for sexual and

gender minorities. The increased understanding of what is not working for this group in the

healthcare system helps us to move forward to improve LGBTQ healthcare (Lamba, Obedin-

Maliver, Mayo, Flentje, Lubensky, Dastur, Lunn, 2023). The first step is to create a safe space

for queer patients. This can be as simple as displaying a rainbow flag, equality signs, and/or use

of inclusive language from all staff members. Use of comprehensive staff education and training

can help bring this about (Henriquez, Ahmad). Revising intake forms to better include diverse

gender identities and sexual orientations, as well as integrating these into the eMAR and

charting systems help create this environment as well as prevent mistakes from other providers

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and create consistency throughout the system. Use of telecommunications and telehealth can

expand the provider’s reach to help patients in more rural areas to receive culturally competent

care. Integration of peer support in rural areas can help combat stigmas that might be more

present to rural community members as well as allows patients to create a community for

themselves and support each other in regards to physical changes that might occur through

gender affirming care (Ware, Austin, Srivastava, Dawes, Baruah, Hall).

As more research is done and providers have a better understanding of queer needs,

practices can improve for sexual and gender minorities. Strides we take now can be the

cornerstone for future research for queer inclusion in healthcare advances. Healthcare workers

can combat discrimination through advocacy and support in their clinics and practices.

Implementation of education for providers, their staff members, and assisting with creating and

distributing educational materials for other providers and patients can reduce stigma in the

healthcare setting, but can also reduce limitations to access for many patients. Overall, the

efforts made by DNP and other healthcare workers will only benefit patients if done with sincere

desire to help with open minded flexibility to the recommendations from queer communities.

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References

Barenboim, H., Damitz, B., Brusky, L., & Franco, Z. (2023). How telehealth can work best for
our patients. The Journal of Family Practice, 72(5), 210–214. https://doi-
org.libpublic3.library.isu.edu/10.12788/jfp.0603

Choi, A. (2023, April 6) Record number of anti-LGBTQ bills have been introduced this year CNN
https://www.cnn.com/2023/04/06/politics/anti-lgbtq-plus-state-bill-rights-dg/index.html

Choi, A., Mullery, W. (2023, June 6) 19 states have laws restricting gender-affirming care, some
with the possibility of a felony charge. CNN https://www.cnn.com/2023/06/06/politics/states-
banned-medical-transitioning-for-transgender-youth-dg/index.html

Henriquez, N. R., & Ahmad, N. (2021). “The message is you don’t exist”: Exploring lived
experiences of rural lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ) people
utilizing health care services. SAGE Open Nursing, 7, 23779608211051174.

Kachen, A., & Pharr, J. R. (2020). Health care access and utilization by transgender
populations: a United States transgender survey study. Transgender Health, 5(3), 141-148.

Kirjava, S. A., Sladen, D. P., & DeBacker, J. R. (2023). Providing Mindful and Informed Health
Care for Patients Who Are LGBTQ+: Perspectives for Clinical Audiology. American Journal of
Audiology, 1-11.

Lamba, S., Obedin-Maliver, J., Mayo, J., Flentje, A., Lubensky, M. E., Dastur, Z., & Lunn, M. R.
(2023). Self-Reported Barriers to Care Among Sexual and Gender Minority People With
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MacCarthy, S., Darabidian, B., Elliott, M. N., Schuster, M. A., Burton, C., & Saliba, D. (2021).
Culturally Competent Clinical Care for Older Sexual Minority Adults: A Scoping Review of the
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https://doi-org.libpublic3.library.isu.edu/10.1177/01640275211004152

McKee, J. (2024, January 10) Queer or gay? Why LGBTQ+ people are fiercely debating former
slur being reclaimed Pink News https://www.thepinknews.com/2023/01/10/queer-or-gay-slur-
debate/

Skuban-Eiseler, T., Orzechowski, M., & Steger, F. (2023). Why do transgender individuals
experience discrimination in healthcare and thereby limited access to healthcare? An interview
study exploring the perspective of German transgender individuals. International Journal for
Equity in Health, 22(1), 211. https://doi.org/10.1186/s12939-023-02023-0

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Ware, O. D., Austin, A. E., Srivastava, A., Dawes, H. C., Baruah, D., & Hall, W. J. (2023).
Characteristics of Outpatient and Residential Substance Use Disorder Treatment Facilities with
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