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Strategies For Improving Patient Care In The LGBTQ + Community
As health care providers, we must be prepared to treat individuals of various races, ethnicities, religions, ages, and backgrounds. Implicit bias and racial disparities in the health care community exist, with more research and literature emerging confirming this fact annually.1 This same system-wide deficit is especially obvious in relation to the LGBTQ+ community. LGBTQ+ individuals experience increased health risks, including high rates of psychiatric disorders, substance abuse, and suicide.2-5 Creating an affirming and inclusive environment where the LGBTQ+ community can find trust and open communication with health care providers can go a long way towards improving their overall health. This article details some strategies that we as health care professionals can employ to help facilitate inclusive care and awareness for the LGBTQ+ community in our practices, therefore hopefully contributing to improved outcomes.
The LGBTQ+ community faces discrimination in their personal lives, workplace, the public sphere, and in access to critical health care.3,6 Many LGBTQ+ people report altering their lives to avoid this discrimination and the resultant trauma.5,7 Younger generations report higher levels of discrimination than older generations, with increased incidence among transgender individuals, individuals of color, and disabled individuals.6 This discrimination can manifest as negative health care encounters that can range from refusal of care, to insensitive criticisms about appearance and behavior, to overheard inappropriate jokes or slurs.These continuous hurtful emotions can then lead to increased unhealthy coping behaviors with an associated broad range of health-related issues.10 The list below outlines some of the alarming health issues in the LGBTQ+ community as described by Healthy People 2020 and the Institute of Medicine:5
• the LGBTQ+ population is two-to-three times more likely to attempt suicide;
• 20 to 40 percent of homeless youth identify as LGBTQ;
• they more likely to experience bullying in school;
• they are at a higher risk of developing sexually transmitted diseases (STDs);
• they are at higher risk of smoking, drug use, alcohol use, depression, and anxiety;
• they are less likely to get preventative services for cancer;
• they experience higher rates of behavioral issues;
• there is a higher prevalence of HIV/STD and victimization; and
• they are at an increased risk of isolation, diminished levels of family support, and reduced availability to social services.
Nearly 16 percent of LGBTQ+ adults have experienced discrimination while at a physicians’ office, while 20 percent have avoided medical care out of fear of such discrimination.2,6,8 This affects the willingness of the individual to seek medical care in the future. Below are some practical and effective steps that may make your practice more LGBTQ+ friendly.
Broadening One’s Knowledge And Employing Inclusive Language
Familiarizing oneself with general concepts and terminology will help develop understanding and open lines of communication between a provider and patient.5 The two most basic concepts to understand are sexual orientation and gender identity. Sexual orientation is how a person characterizes their sexual and emotional attraction to others.5,9 For example, a heterosexual person is attracted to an individual of the opposite sex, while a homosexual person is attracted to an individual of the same sex. Bisexuality characterizes a person attracted to both sexes.5
Gender identity, on the other hand, is a person’s internal sense of being a man/male, woman/female, both, or neither. Individuals who have a parallel gender identity, that is, the same as the sex assigned at birth, are cis-gender (eg, a person born male and who identifies as a man).5,9 However, some people have a gender identity that does not correspond to their sex assigned at birth. This is where the term transgender derives. For example, a person born male and who identifies as female, is a transgender woman. Some may have gender identities outside of the traditional gender binary of male and female.4 They may identify as both male and female, or their gender identity may change over time, termed gender-fluid.5 These definitions and terms are important concepts, however, understand that not every LGBTQ+ individual will fit neatly into one of these categories.5,10
When addressing patients for the first time, all physicians and staff should avoid making assumptions regarding gender identity and sexual orientation. Only use gender pronouns when certain of the patient’s gender identity and/or preferred pronouns. Not using the patient’s preferred name may cause embarrassment and confusion. This is also true regarding racial identity, age, and other such characteristics. One way to address this is to add identifiers to the patient registration form and other relevant documents.5 If your organization does not collect this information, then it is quite acceptable to simply ask patients privately for their preferred name and pronouns, documenting immediately for future reference. This allows other medical professionals and staff to see and use these preferences.
It is also wise to reconsider how we greet and interact with patients. For example, most of us use the terms “ma’am” and “sir” to be polite. Try removing these terms from your vocabulary. Instead of “How may I help you, sir?” instead, try “How may I help you today?” You can also avoid using “Mr./Mrs./Miss/Ms.” It is a perfectly acceptable practice to use a person’s first name or simply ask them how they would like to be addressed.
Using correct verbiage can help establish relationships, while the wrong wording can increase the risk of negative health care provider encounters. To help decrease this risk, ask more open-ended questions. For example, while taking a history, do not assume an individual has an opposite sex partner. Instead of, “Do you have a boyfriend/girlfriend/wife/husband?” ask, “Are you in a relationship?” These kinds of open-ended questions allow patients to communicate freely, which helps them to better discuss their needs and thoughts.9
Creating A Welcoming And Non-Judgemental Practice Environment
Helping patients feel comfortable in the clinical setting is an important step in establishing a constructive dialogue about their specific health care needs.9 You are probably not the first provider this person has encountered. If the patient had a negative experience in the past with a health care provider, they may be on guard or anticipate the same from you. LGBTQ+ patients are used to scanning their environments for welcoming signs that demonstrating inclusion. Consider creating marketing material that communicates an inclusive, LGBTQ+ friendly environment. For example, post your organization’s non-discrimination policy; display the rainbow flag or pink triangle; set out magazines and/or health education literature that includes diverse images and inclusive language. This simple act communicates that you are an LGBTQ+ ally and inherently begins to encourage trust.
It is important for practitioners to not show any signs of disapproval or surprise during medical visits, usually in the form of body language, including facial expressions. Ensure you are not sending unintended messages and maintain a neutral demeanor. The transgender population is the most at risk for experiencing this behavior.4 These individuals often transition their appearance to affirm their gender identity by changing hairstyles, names, clothes, hormone therapy, surgical re-assignment, etc. As a health care provider, it is important to be respectful and not let curiosity interfere with your professional relationship.
Transgender individuals also face unique obstacles when accessing health care and express or report more problems and negative encounters than any others in the LGBTQ+ community.4 According to the Center of American Progress and NORC, who conducted an online survey in 2020, 38 percent of transgender Americans say that their doctors or other providers have been visibly uncomfortable with them because of their gender identity.4,6 While 25 percent state their health care professional refused to give medical treatment related to their gender transition. These statistics drastically increase if the transgender individual is a person of color.4,6
Many transgender Americans face health insurance-related discrimination as well, with 34 percent stating that their insurance company would not change their records to reflect their current name or gender.4 Currently there are 27 states and four territories in the United States that do not have inclusive insurance protections for the LGBTQ community (see chart on page 46).11 Changing one’s name and gender on medical records and insurance resources can be complicated and lengthy, which can make it difficult for transgender individuals to seek timely necessary medical treatment.4 Therefore, physicians and staff must be prepared for this possibility without embarrassing or “outing” the patient. Acknowledge that there is a discrepancy, understand the problem, and reflect that you will do everything possible to try to correct the issue.
Understanding Diversity And Fluidity Of Patient Gender Expression
As stated above, some patients in the LGBTQ+ community will not fit into a specific, neat category and may not identify in a way that you will understand. Gender identity develops within multiple social contexts, including: a person’s family; their larger community; and the society and historical time in which they live.4 Each of these social contexts may have very different norms and expectations about gender expression and gender identity. Some individuals do not have a fixed gender identity and present as different genders during their lifetime for any number of cultural or personal reasons. This is more common in younger and adolescent individuals. Youth who identify as gender-fluid may face increased discrimination compared to the cisgender community.5,11
Gender-fluid and transgender individuals are two-to-three times more likely to develop depression, anxiety, self-harming behavior, and suicidal ideations within the LGBTQ+ community.2,4,5 Learning to make patients feel comfortable during health care interactions would decrease the risk of these health issues developing. Mastering this takes time and does not happen overnight. Don’t be surprised if an honest mistake occurs during interactions. Mistakes happen, and simply apologizing can help defuse a difficult situation and re-establish communication.
Most people are curious about LGBTQ+ individuals, which can lead to irrelevant questions and sometimes unnecessarily probing into a person’s life. Most people want to keep their personal life and medical life private and separate. Focus on why the patient is there. Before asking personal questions ask yourself, “Is my question necessary for the patient’s current or future care?”
Becoming A Resource Connected To The Community
Educating oneself about the LGBTQ+ community as well as being aware of local LGBTQ+ health care resources will help facilitate awareness.9 Some ideas would be to create a portal on your practice website to provide information about available programs, initiatives, and services designed to meet specific LGBTQ+ patients’ needs.7 Also, provide a directory of any staff physicians specializing in LGBTQ+ health care. Your office can also connect with various LGBTQ+ organizations to solicit feedback regarding your facility’s policies to ensure they are non-discriminatory and fully inclusive.5
Establishing partnerships with community health centers or hosting educational programs to raise awareness about services are other examples. This conveys you care enough to be informed about the community’s specific needs. See the table on page 45 for a brief list of informative resources health care providers can consult for more information regarding the LGBTQ+ community.
In Conclusion
Don’t be afraid to politely correct colleagues that make insensitive comments or use incorrect pronouns. Creating an environment of accountability and respect requires everyone to work together. Again, mistakes will happen, and it is not always possible to avoid errors. However, acknowledging the error is a right step to correct these wrongs. If this is an ongoing issue, education and discussion is one solution. The National LGBTQ Education Center helps health care providers and staff provide quality, inclusive and welcoming care to the community through training via webinars, publications, and other various platforms.8
We as health care professionals must gather more data to help identify specific health needs of the LGBTQ+ population to better serve this community. The above-discussed strategies are based on researched literature and personal experience by the author. We need to better address ongoing disparities amongst LGBTQ+ individuals in the workplace, public sector, and health care settings, and it starts with us as practitioners. By learning to care for these individuals with sensitivity and understanding, providers can help avoid and decrease the risk of further health-related issues.
Support and accommodation will increase market share with the LGBTQ+ community and allies, contributing to a greater overall push for better access to care and positive health outcomes. Positive and affirming interactions with providers and staff can be lifesaving. By taking these steps, we as physicians can help ensure that LGBTQ+ patients receive the excellent level of care that they deserve.
Dr. Wilder is a fellowship-trained foot and ankle surgeon in practice in Atlanta, GA.
1. Bridges KM. Implicit Bias and Racial Disparities in Health Care. Human Rights. 2018;43(3). Available at: https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-state-of-healthcare-in-the-united-states/racial-disparities-in-health-care/ . Accessed January 4, 2022.
2. Nurse.org staff. 10 Tips For Caring For LGBTQIA+ Patients. Nurse.org. Available at: https://nurse.org/articles/culturally-competent-healthcare-for-LGBTQ-patients/ . Published June 3, 2021. Accessed January 4, 2022.
3. Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health care disparities among lesbian, gay, bisexual, and transgender youth: a literature review. Cureus. 2017;9(4):e1184.
4. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. (2016). The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality. Available at: https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf . Accessed January 4, 2022.
5. LGBTQIA+ Health Education Center. Providing inclusive services and care for lgbt people. LGBTQIA+ Health Education Center website. Available at: https://www.lgbtqiahealtheducation.org/wp-content/uploads/Providing-Inclusive-Services-and-Care-for-LGBT-People.pdf . Published August 19, 2020. Accessed January 4, 2022.
6. Cusick J, Seeberger, C, Woodcome T, et al. (2021, November 7). The state of the LGBTQ community in 2020. Center for American Progress. Available at: https://americanprogress.org/article/state-lgbtq-community-2020/#Ca=10 . Published November 7, 2021. Accessed January 4, 2022.
7. Walker B. How to make your healthcare facility LGBTQ-friendly. Patient Bond website. https://www.patientbond.com/blog/how-to-make-your-healthcare-facility-lgbtq-friendly. Published September 17, 2015. Accessed January 4, 2022.
8. Mohan A. 5 ways to improve LGBTQ+ patient access. Radix Health. Available at: https://www.radixhealth.com/blog/lgbtq-patient-access . Published June 1, 2021. Accessed January 4, 2022.
9. Kabel K. 7 teaching strategies for treating LGBTQ patients. Simtalk blog. Available at: https://blog.simtalkblog.com/blog/7-teaching-strategies-for-treating-lgbtq-patients . Published June 21, 2018. Accessed January 4, 2022.
10. Pineiro M, LeGrande K, Pitts R, et al. Creating an LGBTQ affirming clinic resource guide: a guide for practice managers and providers. Available at: https://hhinternet.blob.core.windows.net/uploads/2020/02/creating-an-lgbtq-affirming-clinic-resource-guide.pdf . Accessed January 4, 2022.
11. Movement Advancement Project. Equality maps: healthcare laws and policies. Available at: https://www.lgbtmap.org/equality-maps/healthcare_laws_and_policies . Accessed January 4, 2022.
