How to tailor care for LGBTQ+ people living with diabetes
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Susan Weiner, MS, RDN, CDN, CDCES, FADCES, talks with Tessa Cushman, RDN, about addressing health inequities for people living with diabetes who identify as LGBTQ+.
Weiner: We’ve discussed in this column the importance of person-centered language and attitudes surrounding diabetes. How does language about gender identity fit into that framework?
Cushman: Language is our most powerful tool for connection, trust and rapport, which are essential for a strong and successful patient-provider relationship. Using inclusive language is the first step to achieving this. Providing your pronouns and using gender-neutral language is the baseline foundation for inclusive language for LGBTQ+ patients or clients. Examples of this include providing your pronouns on your name tag and when you introduce yourself (“Hello, I am __ and I use __ pronouns”). This process invites and creates a safe space for the other person to provide theirs, as they feel comfortable. Gender-neutral language includes using the pronouns “they/them/theirs” before obtaining someone’s pronouns to avoid assuming an individual’s gender, as well as using “folks,” “person,” “partner,” “spouse,” “parent/guardian,” etc, when addressing a group of people or someone related to the patient or client. Collecting gender identity, pronouns and sexual orientation on assessment or intake forms in an affirming way is another crucial part of language. Having access to inclusive language provides a safer space for the person receiving care and increases the likelihood of their return.
Weiner: Are people who identify as LGBTQ+ at increased risk for type 2 diabetes? If so, what might be drivers of that risk?
Cushman: Yes. Research shows that folks who identify as LGBTQ+ are at higher risk for type 2 diabetes and other chronic diseases compared with their cisgender and heterosexual counterparts. Drivers of this risk range from metabolic and medical to discrimination and unmet social determinants of health.
Higher rates of HIV and polycystic ovary syndrome among LGBTQ+ individuals are both risk factors for developing type 2 diabetes. Queer folks face increased rates of experiencing childhood or adult trauma and developing depression. Higher rates of disordered eating patterns or eating disorders with lower access to treatment exacerbate medical complications.
All of these health inequities and risks for diabetes can be traced and linked to discrimination, oppression and unmet social determinants of health. Family estrangement and legal discrimination in housing, employment, marriage or retirement benefits can lead to difficulty obtaining health care and economic stability. Unmet basic needs, such as food and housing, create barriers to a healthy and stable life, let alone preventing or managing diet-related diseases. All of these conditions create cumulative chronic stress and worsened health outcomes, exacerbated by systemic racism, ableism and weight discrimination for LGBTQ+ folks of color and who hold additional oppressed identities.
On top of these health disparities, diabetes care settings may be unsafe and inaccessible for LGBTQ+ people due to high fees, discriminatory practices or policies, or practitioners who hold unconscious biases. A 2021 report found that almost half of all transgender people and even more transgender people of color have experienced malpractice or mistreatment by health care providers. As stated in the March 2022 issue of ADCES in Practice, “non-LGBTQ specific groups may be perceived as potentially homophobic and/or transphobic, and therefore intrinsically non-safe spaces. This is all based on the limited research we have on LGBTQ+ health.
Weiner: How can diabetes care and education specialists tailor recommendations to reduce cardiometabolic risks for people with diabetes who identify as LGBTQ+?
Cushman: With increased risk and rate of eating disorders and disordered eating, body dysmorphia and health care discrimination, my first recommendation is to take a weight-neutral approach to diabetes care for LGBTQ+ people. In their resource inventory, “Diabetes Prevention Programs: Equity Tailored Resources,” CMS recommends emphasizing overall health improvement instead of weight loss when tailoring services for the LGBTQ+ community. Such strategies include promoting increased physical activity, decreased consumption of sugar-sweetened beverages, and increased fruit and vegetable intake, rather than focusing on BMI and weight loss. More research has been focusing on Health at Every Size-based approaches, and a 2022 analysis suggests that weight-neutral lifestyle modification interventions may improve health- and wellness-related markers even in the absence of weight loss.
Other recommendations include starting within and assessing your own biases. You can start by referring to the Association of Diabetes Care & Education Specialists “Self-Assessment of Cultural Competency for Sexual and Gender Minorities Seeking Diabetes Education and Care.” Openly discuss common conditions or health risks within the LGBTQ+ community with colleagues and self-identified LGBTQ+ people, and check regularly for best practices and the latest research.
Weiner: From your experience working with people living with diabetes, what might those who identify as LGBTQ+ like health care providers to know about their experience?
Cushman: As an LGBTQ+ individual and through my work of providing inclusive diabetes care, I can speak directly from experience. People are open to sharing their experiences once trust and rapport are established. If you don’t know something, admit that and be open to asking questions. It is far more important to create a safe and inclusive environment than it is to know all of the answers.
Joining an online community, such as inclusivediabetescare.com, with like-minded professionals can advance your knowledge and credibility as a practitioner. Immersing yourself in LGBTQ+ culture and being an active ally through actionable steps — such as developing specific diabetes management programming or advocating for an inclusive care space — will push the collective further along the spectrum of achieving health equity for all.
References:
- CMS. Diabetes Prevention Programs: Equity Tailored Resources. Published Jan. 18, 2023. www.cms.gov/files/document/culturally-and-linguistically-tailored-type-2-diabetes-prevention-resource.pdf. Accessed June 13, 2023.
- Dimitrov Ulian M, et al. Front Nutr. 2022;doi:10.3389/fnut.2022.598920.
- Garnero T. Association of Diabetes Care and Education Specialists. Inclusive Care for LGBTQ People with Diabetes. www.diabeteseducator.org/docs/default-source/practice/educator-tools/inclusive-care-for-lgbtq.pdf?sfvrsn=d9d78658_7. Published 2021. Accessed June 13, 2023.
- Medina C, et al. Protecting and Advancing Health Care for Transgender Adult Communities. Center for American Progress. www.americanprogress.org/article/protecting-advancing-health-care-transgender-adult-communities/. Published Aug. 18, 2021. Accessed June 13, 2023.
- Savin K and Garnero T. ADCES In Practice. 2022. doi.org/10.1177/2633559X211070024.
For more information:
Tessa Cushman, RDN, (she/her) is a food security specialist at Adams County Health Department. She is a 2022 Bloomberg Food Systems for Health Fellow and part-time master of public health student with the Johns Hopkins Bloomberg School of Public Health. She worked for 2 years as a diabetes educator specializing in LGBTQ+ diabetes prevention. She can be reached at tcushman@adcogov.org.
Susan Weiner, MS, RDN, CDN, CDCES, FADCES, is co-author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@susanweinernutrition.com; Twitter: @susangweiner.
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