Anthony, the LGBTQ community is one that many practitioners may not be that familiar with. Can you give us some sense of the scope of the community?
Absolutely! Before I go into details I’d like to say that the information I’m going to provide was researched by a group of us brought together by the Long Island Health Collaborative including Hofstra University, Stony Brook University, Pride for Youth, PULSE, The LGBT Network, and The Transgender Resource Center of Long Island.
The LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning) community is more widespread than people might think, and becoming much more open. According to the Williams Institute, a think tank focusing on sexual orientation and gender identity public policy, at UCLA:
- In the New York area, almost 5% of the population describe themselves as LGBT
- Of those, 42% are male and 58% are female
- 58% are white, 21% are Latino/a, and 12% are black
- The average age of a member of the LGBT community is 37 years old
How can we try to better understand LGBTQ persons?
It’s important to understand what members of the community regularly face. Implicit or unconscious bias is defined as a positive or negative mental attitude/thought toward a person, thing, or group that an individual has. In simple terms, our brains are always quietly drawing conclusions, many of which are based on incomplete information and completely invisible to our conscious minds. The good thing is, these biases can change with conscious effort, such as heightened awareness; identifying and acknowledging biases, or challenging and refuting them. Prejudice is also an issue, which is harder to change.
Just like with all communities that people aren’t familiar with, an important first step is understanding and acceptance. Truly understanding some of the common terms helps. Briefly and succinctly:
- Your sexual orientation is who you are attracted to.
- Your gender identity is who you feel you are.
- How you present your gender is your gender expression. The physical manifestation of one’s gender identity through clothing, hairstyle, voice, body shape, etc. may or may not conform to socially defined behaviors and characteristics typically associated with being either masculine or feminine.
- Not everyone conforms to society’s gender expectations, which is the stereotypical role that society associates with gender that includes personality traits, domestic behaviors, occupations, and physical appearances
- Transgender is an umbrella term used to describe people whose gender identity differs from the sex they were assigned at birth. Transgender people may or may not have had gender reassignment procedures.
- Cisgender is a term for people whose gender identity matches the sex that they were assigned at birth
- Queer means having a sexual orientation that is something other than heterosexual. Although queer has traditionally been an insult, many use this term with pride. However, the term queer is not embraced or used by all members of the LGBT community
What are some of the key issues in health disparities for members of the community?
Access is an important issue, and not always by choice. LGBT persons experience the same barriers to care as others. However, because of many of the issues I’m describing here, LGB adults are more likely to delay or not seek medical care; more likely to delay or not get needed prescription medicine, and more likely to receive health care services in emergency rooms. These data aren’t available on transgender persons.
Here are just a few examples of disparities extensive research has shown:
Access to Care
- Over 30% of transgender individuals have forgone preventative care due to fear of discrimination
- 8% of LGB individuals and 27% of transgender and gender-nonconforming persons reported being denied needed health care
- 11% of LGB patients reported that a healthcare provider that a health professional had refused to touch them or used excessive precautions
- LGBTQ individuals are almost 3 times more likely than others to experience a mental health condition
- 40% of transgender adults reported having made a suicide attempt.
- 92% of these individuals reported having attempted suicide before the age of 25
- An estimated 20-30% of LGBTQ people abuse substances, compared to 9% of the general population
- More than half of gay and bisexual men say that they have never discussed HIV with their doctor
- 1 in 6 gay and bisexual men will get HIV if current incident rate persists
- Nearly 1 in 5 black transgender women are living with HIV
- LGB youth report 2x higher rates of certain venereal diseases than heterosexual men
- LGB individuals are more likely to have chronic conditions and earlier onset disabilities than heterosexual individuals
- LGB people report more asthma diagnoses, headaches, allergies, osteoarthritis, and gastro-intestinal problems than heterosexual individuals
- LB women are less likely to receive mammograms
- LGB youth are more likely to be overweight
You can see that this community is similar to others that do not feel part of “mainstream” society. This borders on an epidemic, and costs the country much more of the health care dollar.
What are some best practices you’re aware of that can reduce apprehension and provide greater access?
I believe one of the keys to better access and improve health equity is to provide more inclusive and welcoming healthcare environments so LGBTQ persons won’t feel so apprehensive.
Communication is key! Here are a few best practices I’ve come across:
Avoid making assumptions:
- Don’t assume you know a person’s gender identity or sexual orientation based on how they look or sound
- Don’t assume you know how a person wants to describe themselves or their partners
- Don’t assume all of your patients are heterosexual and cisgender (not transgender)
Use patients’ preferred names and pronouns:
- Often, when speaking of a singular human in the third person, pronouns have a gender implied — such as “he or him” to refer to a man or “she or her” to refer to a woman. These associations are not always accurate or helpful
- “They,” “them,” and “their” are gender-neutral and can be used as singular gender-neutral pronouns
- Transgender people often change their name to affirm their gender identity. This name is sometimes different than what is on their insurance or identity documents. Transgender people also want others to use pronouns that affirm their gender identity
- Here’s a good approach under these circumstances:
- If you are unsure about a patient’s preferred name or their pronouns:
- “I would like be respectful—what name and pronouns would you like me to use?”
- If a patient’s name doesn’t match insurance or medical records:
- “Could your chart/insurance be under a different name?”
- “What is the name on your insurance?”
- If you accidentally use the wrong term or pronoun:
- “I’m sorry. I didn’t mean to be disrespectful.”
- If you are unsure about a patient’s preferred name or their pronouns:
Use forms that LGBT persons are comfortable completing so you get complete background
- Ask not only legal name but for the name you prefer to use
- Check boxes for “Do you think of yourself as: -Lesbian, gay or homosexual; -Heterosexual; -Bisexual; -Not Sure”
- Marital Status: -Married; -Partnered; -Single; -Divorced; -Other
- Ask “What is your gender?” and “What gender were you assigned at birth?”
Set up the office, practice, or waiting area so that:
- Initial Contact is positive.
- Frontline staff need to be educated on sensitivity to gender variance and sexual orientation when answering the phone/scheduling appointments
- Do not assume a caller’s gender based on the sound of their voice or name; use their name, not their pronoun
- Do not make a big deal out of someone using a name/gender that may not match their legal documentation and/or insurance records
- Make space (or set an alert) for clear notes on any names or pronouns a caller specifically asks your staff to use when they come in for their appointment
- Use language that assures them they are being taken seriously, and that they are not a burden in any way
- Intake is comfortable
- Ask sexual orientation
- In obtaining parental medical history, this should read “Parent #1/Parent #2”, rather than “Mother/Father”
- Obtain sexual history information to determine risk factors
- Discuss what body parts are used for sex & how
- Discuss realistic ways of protecting one’s sexual health & alternatives for sexual pleasure (harm reduction)
- Become educated on PEP & PrEP (FDA-approved pills to prevent HIV transmission)
- Educate patients on getting tested for HIV
- Know what types of STD screenings a person should receive
- All of this said, if a patient is visiting for a “routine” visit such as a cold or sprained ankle, a conversation about sexual health may not be warranted
- Office environment is welcoming
- Visible signs of support in entry and waiting areas
- LGBTQ-inclusive imagery (posters, brochures, etc)
- Anti-discrimination policy posted
- All-gender Restrooms & Other Accommodations
- Frontline staff need to be educated on sensitivity when greeting the patient:
- Do not ask unnecessary questions about name or gender at the reception desk
- If there are questions regarding how to bill insurance, discuss this in a private setting away from other patients
- Make a habit of looking at notes (or alerts) to see how the patient would like to be addressed BEFORE calling their name in the waiting room
- Communication with the patient is judgment-free:
- Use name & pronouns the patient wants
- Ask the two basic questions:
- What sex were you assigned at birth?
- What is your gender?
- Also important for patient safety and insurance coding
- When you are uncertain of a term… “Tell me what that means for you”
- Do not assume everyone is straight or cisgender (i.e. never start a conversation about sexual history or behaviors by asking a female patient “do you have a boyfriend”?)
Any further thoughts to help practitioners ensure their LGBTQ patients feel welcome?
Here are some comments to make sure are avoided:
- Don’t laugh or gossip about a patient’s appearance or behavior
- Don’t use stereotypes or ask questions that are not necessary for care.
- “You’re so pretty! I cannot believe you are a lesbian.”
- “Are you sure you’re bisexual? Maybe you just haven’t made up your mind yet.”
- “I see you checked ‘gay’ on your registration form. How’s the club scene these days?”
- “Wow. You look just like a real woman!”
Creating an environment of accountability and respect requires everyone to work together.
Don’t be afraid to politely correct your colleagues if they make a mistake or make insensitive comments.
People ultimately want to be treated with respect. If you think about how you set up an environment for patients, you’d want to make sure everyone would feel comfortable in your practice. That’s the best way to make sure access is available to all.
- Transgender Resource Center of Long Island, https://trcli.org/, (631) 306-4TRC
- Pride for Youth, https://longislandcrisiscenter.org/prideforyouth/, Nassau: (516) 679-9000 Suffolk (631) 940-1964
- The LGBT Network, https://lgbtnetwork.org/, Nassau: (516) 323-0011, Suffolk: (631) 665-2300, Queens: (718) 514-2155
- AIDS Center for Queens County (ACQC), https://acqc.org/, (718) 896-2500
- Northwell Health Center for Transgender Health, https://www.northwell.edu/doctors-and-care/lgbtq-services/clinical-services, (516) 622-5195
- Centers for Disease Control and Prevention, LGBT Health: https://www.cdc.gov/lgbthealth/index.htm
- Healthy People 2020 LGBT, https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health
- New York State LGBT Health and Human Services Network: https://gaycenter.org/recovery-health/health/lgbt-health-network/#join
- New York State Health Department, LGBT Health: https://www.health.ny.gov/diseases/aids/consumers/lgbt/
- The National LGBT Health Education Center: https://fenwayhealth.org/the-fenway-institute/education/the-national-lgbt-health-education-center/