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Expert Insights: Providing Equitable, Affirming Care for LGBTQ+ Patients

Op-Med is a collection of original articles contributed by Doximity members.

It is well known in the medical community that LGBTQ+ patients face unique health care disparities and barriers to equitable care. The AMA’s longstanding policy on LGBTQ+ care has remained clear for years: “Our AMA continues (1) to support the dignity of the individual, human rights and the sanctity of human life, and (2) to oppose any discrimination based on an individual's sex, sexual orientation, gender identity, race, religion, disability, ethnic origin, national origin or age and any other such reprehensible policies.”

For this edition of Expert Insights, Doximity asked clinician members who work extensively with LGBTQ+ patients to offer their best advice for providing high-quality, equitable care for this vulnerable population. Here’s what a few of them had to say:

Doximity: In your daily practice, how do you build trust and rapport with new LGBTQ+ patients? What are some of the strategies you use in consultations or initial appointments to help LGBTQ+ patients feel comfortable?

Tymberly Seim MD, Child & Adolescent Psychiatry: Have options for patients to self-identify gender in screening forms/general intake forms. [I] prefer to have them write in their response as opposed to having to choose a pre-selected option. I always ask patients what their preferred name is, preferred pronoun, and how they would like to be addressed. And if you make a mistake in gendering, acknowledge, apologize, and move on.

Elyse Pine MD, Pediatric Endocrinology: I ask open-ended questions. I introduce myself and use my pronouns. I ask people what their goals are when they come to discuss gender-affirming care without making assumptions.

Gretchen Frey MD, Obstetrics & Gynecology: [My] patient intake form includes options to self-describe as transgender, gender fluid, or gender neutral [and] asks for preferred pronouns.

Elizabeth Eaman MD, Family Medicine: To establish rapport, it's important to ask open-ended questions and not make any assumptions on sexuality or gender identity. Instead, ask the patient their preferred pronouns. I only ask about sexual activity and partner gender-identity if it's relevant or [an] organic part of rapport-building. An important caveat: when talking about sexual health specifically (and health risks), it's sexual behavior, not sexuality, that matters to physical health, so I try to ask specific questions (e.g., do you engage in receptive penetrative intercourse) not about sexual organs and genders (e.g., do you have "vaginal" sex with "men").

Dox: Have you ever had an experience in your practice where you feel you "messed up" or offended an LGBTQ+ patient? How did you resolve it in the moment? What advice would you give to clinicians who strive to be LGBTQ+ allies but are afraid of offending someone?

TS: I have definitely made mistakes, and it's all in how you handle it. In order to build/maintain rapport, you must acknowledge your mistake, apologize, and move on. Most everyone is [understanding] and is generous towards your fallibility. It starts by making your space supportive to folks who may not identify as cisgender/nonbinary. Be cognizant of the photos you have up in your office. If the pictures are constantly showing straight couples, how is that perceived by those in same-sex relationships? Be aware of how you're coming off. Train your staff!

EP: I have used the wrong pronoun. I have apologized and moved on. I would say that being an ally means acknowledging when you have made a mistake and trying to do better next time. 

GF: Early on, I, several times, inadvertently forgot to use the appropriate pronouns for a transgender individual, especially one who had not yet [medically] transitioned and was presenting as their sex assigned at birth. I always apologized and explained I was doing my best to train myself but that I was still learning. I have also had the opportunity to correct medical students or residents who are working with me, in the presence of the patient (always gently).

EE: Absolutely! Even as someone who identifies as part of the community, I make mistakes. I have misgendered patients accidentally in documentation. Or used the incorrect name or pronoun as someone transitions. I immediately apologize and strive to improve. To those afraid of offending: Making mistakes is human, it's what we learn from our slip-ups that makes us better doctors. Being open to making mistakes, apologizing immediately, and showing you are eager to learn from them will make you a better ally and, in my opinion, a better compassionate human being!

Dox: Is there a particular population you work most closely or most often with that you wish more clinicians knew more about? What would you tell colleagues about this population that they absolutely need to know or understand before treating them?

TS: I am a psychiatrist who specializes in working with LGBTQ+ youth. They are at extreme high risk for suicide and self-harm. Be aware of this, and I encourage you to be as nonjudgmental as possible. Be aware that their gender identity might not be solidified, but it doesn't mean that what they are telling you is not important.

EP: I work with transgender youth. I wish people knew that when these kids are well-supported, they are a resilient group, and that they have bright futures. I want other physicians to know that transitioning is not a fad, and that all medical issues should not be blamed on hormones (just as one would not blame most medical issues on natal pubertal hormones).

GF: I do a lot of work with menopausal women (as a gynecologist, this is the biggest part of my practice) and I think they have a harder time admitting even to being gay or bisexual, probably even less to being transgender. It's a generational lack of comfort with discussing the topic. I'd tell colleagues not to forget to ask gender identity and sexual orientation questions, no matter the patient's age or what they think they know about them already.

EE: The transgender population is really my niche, my area of expertise, so to say. Cis-women and peri- and post-menopausal women may be my next big population I teach about (sexual and pelvic health, specifically). I give lectures and talk routinely on the topic of caring for gender non-conforming patients and  teach or have round tables with all levels of education — medical or general ed, college students, or medical school preceptors and professors. If there's one thing to let people know about my population of patients, it's that helping people transition is one of the most rewarding things you can do for a patient.

Dox: What do you feel is the most pressing issue in LGBTQ+ health care today? How are you working to spread the word about it, trying to solve it, or simply seeing it in the population?

TS: I see a lot of fear from other providers for treating this population. I see fear and rejection by support staff and other medical professionals. Education around this topic is essential. If you are an affirming health care provider, please make sure your staff [members] are, too. Be up to date with how to treat this minority population in your particular specialty.

EP: Insurance access and coverage. If the ACA is dismantled and discrimination legalized, this will be devastating. I am seeing more denials for hormone coverage.

GF: The same as for everyone: affordability of health care. We absolutely have to solve this. It is breaking the back of our nation. 

EE: Unfortunately, I think politics is the most pressing issue. Politicizing people's health and wellbeing is atrocious, but is also a very American trait where health care is a privilege more than a right. I try to support organizations that work to eliminate health, racial, gender, sex, etc. disparities and talk openly about these threats with my patients when I can. I also try to help bring to light minority stress and create a safe place where my patients can process the damage that institutionalized discrimination can cause to their minds and bodies.

If you are a clinician who identifies as LGBTQ+ or works to provide LGBTQ+ patients with safe, affirming, equitable care, experts recommend joining the OutList, part of OutCare, to reach vulnerable communities and to show you care.

Do you want to see more LGBTQ+ content on Doximity? Tell us here. 

Image: Oxana Bazarova / shutterstock

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