Sitting on an exam table in a flimsy gown can intimidate anyone. And if you happen to be gay, lesbian or bisexual, the experience can be even worse.
As a woman of sexual minority, Nicole Flemmer has encountered medical misinformation and false assumptions. She was once diagnosed with "ego dystonic homosexuality" - a long-discredited term - without her knowledge or an appropriate discussion with the doctor. She discovered the notation years later when she happened to glance at her medical chart.
Such experiences left her hesitant to access health care and afraid to be honest with caregivers.
Today Flemmer, a family nurse practitioner in Seattle, is working with educators at Washington State University Vancouver to alleviate similar distress in others.
A paper detailing their work was published in The Journal for Nurse Practitioners in September and presented at the international conference for the Society for Clinical Nurse Specialist Educators in Vancouver, BC in October.
Flemmer has created a new model for health care called empathic partnership - a framework designed to help primary care practitioners create safe, effective partnerships with all of their patients. The model is influenced by the work of sociologist Brene Brown.
Empathy from health care providers has been shown to improve clinical outcomes such as better control of blood sugar levels in diabetics and shorter, less severe symptoms in patients with the common cold, she said.
Empathic partnership encourages caregivers to adopt six key elements:
1. Reflection - An awareness of one's own beliefs and biases, which can help the provider recognize a range of cultures and beliefs in others.
2. Environment - An affirming environment, as suggested by artwork, photographs, reading material and posted nondiscrimination policies.
3. Language - The use of inclusive and open-ended language by providers, staff and in medical forms.
4. Knowledge - Understanding the unique health concerns and disparities common to minority populations.
5. Partnership - Recognition and softening of the inherent power imbalance in the provider-patient relationship.
6. Empathy - Attempting to understand, share and accept another person, thereby helping them feel understood and not alone.
Safety for marginalized populations
Flemmer said empathic partnership can be used with all patients but is particularly valuable for marginalized individuals and families. She used the example of women who have sex with other women or WSW, a term she said is more inclusive than lesbian or bisexual.
"WSW have historically faced invisibility, mistrust and abuse - and have suffered various degrees of stigma, not only within society but also within the health care system," she said.
"Accessing health care and being sick are incredibly vulnerable times in a person's life," said Flemmer. "Creating the empathetic partnership framework is one way I am trying to make it safer for people of both LGBT (lesbian-gay-bisexual-transgender) and other minority populations to have access to safe care and partnerships with their clinicians if they so wish."
Empathic partnership builds on the idea of cultural safety - defined as "the effective nursing care of a person or family from another culture." It also encourages care providers to temper the inherent power imbalance between patient and practitioner.
A 2012 literature review by Flemmer suggests that WSW may have higher rates of certain mental, emotional, substance abuse and physical health and cancer risks than the general population.
For example, "many providers are under the assumption that WSW do not need regular Pap smears because of perceived low risk," she said. "However, human papillomavirus - believed to cause 90 percent of cervical cancers - can be transmitted between women."
She said some studies indicate depression occurs at higher rates than in heterosexual women. Research has shown a significantly elevated suicide risk among the LGBT population.
Suggestions for caregivers
In addition to adopting the empathic partnership program, Flemmer suggests care providers use health questionnaires and educational brochures that are inclusive of same-sex relationships, ask open-ended questions and adopt a nonjudgmental approach to client questions.
She developed the idea for empathic partnership as a student in the WSU College of Nursing in collaboration with associate professor Dawn Doutrich and clinical associate professor Lida Dekker.
Flemmer is also the founder of "The We Belong Project," an online resource and blog for women of sexual minority and those who provide care for them.