By Carl G Streed Jr, MD
March 1, 2018
According to a recent national survey by the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, 18 percent of lesbian, gay, bisexual, transgender, and queer (LGBTQ) Americans do not seek medical care for fear of discrimination. The results highlight an ongoing dilemma in healthcare; we cannot provide competent and compassionate care for those who fear us.
Presently, there are approximately 9 million US adults who identify as LGBTQ, including approximately 1.4 million who identify as transgender. And yet, health care providers remain unprepared to provide the care they need; approximately 50% of transgender individuals report having to teach their health care providers about transgender care.
To provide complete and appropriate care for patients requires an open dialogue built on trust and understanding of the unique needs of these populations. Doing so requires thinking about the entire patient experience, from registration to clinical encounter:
- Clinical staff and registrars need to be welcoming of LGBTQ individuals and their families
- Clinic facilities must include gender-neutral restrooms
- Clinic environment must reflect the diversity of the patient community
- Intake forms must offer patients the opportunity to provide their sexual orientation and gender identity
- Electronic health records must have fields for sexual orientation and gender identity data
Assuming the clinic staff and intake process are culturally competent and appropriately matched to the patient, it then falls to the health care provider to ensure adequate and complete care for LGBTQ patients. For any of their patients, health care providers should be aware of how personal bias can affect the patient-provider relationship. Heterosexist attitudes and homophobic beliefs inculcated by the majority culture influence interactions between patients and providers from either’s perspective; heterosexist bias affects how providers communicate and internalized homophobia may prevent patients from disclosing their sexual orientation and/or gender identity in even the most welcoming of clinics.
|Helpful Hints When Starting the Clinical Encounter|
Use Preferred Name
This should be addressed on intake and noted in all future visits
Do Not Assume Gender
Do not refer to the patient as “Mr. Smith” or “Ms. Smith”
Use the patient’s preferred full name or preferred first name
If the patient notes that they are not single, do not assume the gender of their significant other.
Avoid “girlfriend, “boyfriend,” “wife,” and “husband” unless the patient uses these terms.
Do Not Make Assumptions About Relationships
Do not say, “and is this your sister [brother/mother/father]?”
Say, “and who has joined you today?” and allow the companion to identify themselves and their relationship to the patient
Though it may seem unnecessary to mention, greeting the patient and whomever may be accompanying them sets the tone for the entire clinical encounter. First, the gender identity or sexual orientation of the patient should never be assumed based on name or outward appearances or even name in the medical chart; transgender patients may still be in the process of aligning their legal name with their gender identity. It is therefore important that until the patient’s preferred gender pronoun or preferred name is known, they should be addressed by their preferred full name, not as “Mr. Smith” or “Ms. Smith.” Secondly, never presume to know the relationship of anyone accompanying the patient; too often are significant others mistaken for “brother” “sister” or “friend.” Making an assumption, no matter how benign and unintentional, can signal to the patient that the health care provider is at best not trained to manage LGBTQ patients and at worst intolerant or hostile. If the provider unintentionally makes an assumption, providing an immediate apology often corrects the faux pas and can allow the provider and the patient to set the encounter on the right path.
After greetings, introductions, and establishing rapport, the clinical encounter can transition to eliciting the chief concern of the patient. Providing undivided attention and exhibiting interest with nonverbal cues will signal engagement, and maintaining an appropriate level of eye contact will allow the patient to feel more welcome; too often have LGBTQ patients have been dismissed by providers who looked at the patient with a degree of disgust or judgment or never looked them in the eye.
Beyond making health care more welcoming, from registration to the encounter, health care providers must understand the unique health care needs of LGBTQ patients and families. What is the confluence of cancer-risks for lesbian and bisexual women? What are the cardiovascular concerns when starting gender-affirming hormone therapy? Which vaccines are prudent for gay, bisexual, and other men who have sex with men? How does discrimination affect the health of sexual and gender minority youth? To know the answers to these clinical questions often requires seeking education beyond what was provided in medical school, residency, or fellowship.
We must not rely on our patients to know what care they need, we must seek additional training to provide the most up-to-date and competent care to our patients.
Learn more from Dr. Streed and his colleagues in a CME program designed to help primary care physicians, specialists, and other health care professionals who work with LGBTQ patients to provide gender-sensitive and inclusive care: LGBTQ Health Issues.
Additional resources to provide compassionate and competent care for LGBTQ patients:
- ACP Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health
- Lesbian, Gay, Bisexual, and Transgender Healthcare: A Guide to Preventive, Primary, and Specialty Care
- Physician Education and Assessment Center
- Trauma, Resilience, and Health Promotion in LGBT Patients: What Every Healthcare Provider Should Know
- UCSF Center of Excellence for Transgender Health
Carl Streed Jr, MD is a fellow in the Division of General Internal Medicine & Primary Care at Brigham and Women’s Hospital. His research focuses on the health and well-being of sexual and gender minorities, particularly transgender and gender nonconforming individuals. Nationally, he has most recently chaired the American Medical Association Advisory Committee on LGBTQ Issues.
*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.