LGBTQIA+ is an umbrella term referring to people whose sexual orientations, gender identity, gender expression, or sex characteristics differ from conventional cisgender and heterosexual norms. A burgeoning number of international research endeavours have collated evidence on health inequities between LGBTQIA+ people and their cisgender and heterosexual counterparts. Health implications of LGBTQIA+ identities result primarily from people’s experiences of social environment rather than related to biology, as studies have documented the effect of cisheterosexism manifesting as minority stressors (i.e., the discrimination and rejection that LGBTQIA+ people face) that contribute to heightened rates of depression and suicidality. 

The concept of “cultural competence” remains prevalent in the current LGBTQIA+ healthcare literature. LGBTQIA+ cultural competency entails health providers having a requisite understanding of sexuality and gender diversity and sociocultural factors that affect LGBTQIA+ health in order to provide culturally appropriate care. However, there are a few critiques for the individual-level focused positioning of cultural competency; these include the placing of health professionals at the centre of the provider–patient relationship, the deficit-framing process that “others” LGBTQIA+ people, and the risk of accidentally lulling health providers into a falsely confident space to speak for the perceived needs of LGBTQIA+ people after acquiring LGBTQIA+ knowledge through a tick-box approach.

Nonetheless, the concept of “cultural competency” serves as a crucial first step towards achieving “cultural safety”, a concept that was coined by Dr Irihapeti Ramsden in Aotearoa/New Zealand to address the long-term impact of colonisation and racism on Indigenous Māori health outcomes.^[1] The Nursing Council of Aotearoa/New Zealand^[2] commissioned Dr Ramsden to write the guidelines for cultural safety in nursing and midwifery education which defined cultural safety as:

A key difference between the concepts of cultural competency and cultural safety is the notion of “power”, where the latter accentuates the experience of the recipient of care. Health providers working on a culturally safe framework engage in reflexivity by examining the inherent power dynamics when providing care and allow patients to determine whether a clinical encounter is safe. Rather than practising a blinded approach that treats all clients as equal regardless of their cultural differences, a culturally safe health provider adopts a multiculturalist approach that consciously and carefully explores paradoxes of apparent differences in social positions. Indeed, the understanding of health inequities affecting LGBTQIA+ people require to address the differential power in healthcare interaction and the broader health structures that are often informed by cisheterosexist norms. With a commitment to achieve health equity, the application of cultural safety also expands beyond the provider–patient interface to challenge unjust policies and institutions that create unsafe healthcare environments.

As cultural safety focuses on the differences in the distribution of social power, this concept is pertinent to advance health equity for LGBTQIA+ people as a marginalised population. In 2022, Mukerjee and colleagues introduced the 5 "P" tenets for health providers to practice culturally safe care.^[3] These comprise (1) partnerships: Providers to provide collaborative care and transfer power to patients by respecting their knowledge and experiences; (2) personal activities of daily living (ADLs): Providers to explore and understand daily activities of life and survival that LGBTQ individuals engage in as they face marginalisation within society and incorporate these experiences into clinical care; (3) prevention of harm: Providers to engage in mutual learning and understand what the patient needs to stay safe; (4) patient centring: Providers to provide the means to achieve healthcare as decided by the patient and help to move towards goals that fit into patients’ lives; and (5) purposeful self-reflection: Providers to involve in a process of uncovering one’s own biases and blind spots that may interfere with the provider–patient relationship and take accountability to deal responsibly with these internal processes.

Premising on Mukerjee et al.’s culturally safety framework that aspires to provide a comprehensive approach to care through challenging the status quo power relations, the present research discussed five components of culturally safe care: power-enhancing care (addressing power imbalance); inclusive healthcare institutions (dismantling institutional barriers); continuous education and research (improving access to LGBTQIA+ knowledge); promotion of visibility (increasing LGBTQIA+ representation), and individualised care (centering the voices of LGBTQIA+ people). 

However, the implementation of cultural safety framework ought to account for the specific local context. As LGBTQIA+ remains a criminalised identity in Malaysia, the collection of data on sexuality and gender identity information may be a less justifiable option if LGBTQIA+ people have no intention to disclose their identity or when confidentially cannot be guaranteed. Misgendering in health care is also a common issue affecting transgender and non-binary people in Malaysia due to barriers in changing gender marker on identity documents. A health provider can initiate the conversation by disclosing their name and pronouns and then enquiring about patients’ preferred pronouns. Likewise, while the benefits of increasing LGBTQIA+ representation in decision-making boards of healthcare institutions have been described in Western literature, this is not always a feasible option in Malaysia given the limited number of healthcare providers who are proudly out as LGBTQIA+. In this regard, leaders in healthcare institutions are recommended to form a partnership with local LGBTQIA+ community groups to design a culturally safe guideline of care.

Health institutions are not value-neutral and the present research argues that a blinded approach of the care (i.e., to treat everyone the same) is an apparent example that healthcare structures and providers continue to uphold power over LGBTQIA+ people who are marginalised by cisheterosexism. There is an urgent need to increase awareness on culturally safe care for LGBTQIA+ people, which aligns with the affirmative approach of empowering LGBTQIA+ individuals who have been long affected by social injustices.