Creating A Welconing Clinical Environment For Lesbian, Gay, Bisexual, and Transgender (LGBT) Patients
Background
Studies show that lesbian, gay, bisexual, transgender populations, in addition to having the same basic health needs as the general population, experience health disparities and barriers related to sexual orientation* and/or gender identity or expression. Many avoid or delay care or receive inappropriate or inferior care because of perceived or real homophobia, biphobia, transphobia, and discrimination by health care providers and institutions.
Homophobia in medical practice is a reality. A 1998 survey of nursing students showed that 8 - 12% "despised" lesbian, gay, and bisexual (LGB) people, 5-12% found them "disgusting," and 40 - 43% thought LGB people should keep their sexuality private.1
Health care providers can take positive steps to promote the health of their LGBT patients by examining their practices, offices, policies and staff training for ways to improve access to quality health care for LGBT people.
There are some simple ways to make your practice environment more welcoming and safe for your LGBT patients. Here are a few ideas to update your physical environment, add or change intake and health history , form questions, improve provider-patient discussions, and increase staff's knowledge about and sensitivity to your LGBT patients. We hope you find this tool useful.
Create A Welcoming Environment
Lesbian, gay, bisexual, and transgender (LGBT) patients often "scan" an office for clues to help them determine what information they feel comfortable sharing with their health care provider.
Participating in provider referral programs through LGBT organizations (e.g., www.glma.org, www.gayhealth.com, or local LGBT organizations) or advertising your practice in LGBT media can create a welcoming environment even before a patient enters the door.
If your office develops brochures or other educational materials, or conducts trainings, make sure that these include relevant information for LGBT patients.
Open dialogue with a patient about their gender identity/expression, sexual orientation, and/or sexual practices means more relevant and effective care.
You may want to implement some of the following suggestions as appropriate for the type and location of your office:
- Post rainbow flag, pink triangle, unisex bathroom signs, or other LGBT-friendly symbols or stickers.
- Exhibit posters showing racially and ethnically diverse same-sex couples or transgender people, or posters from non-profit LGBT or HIV/AIDS organizations.
- Display brochures (multilingual when possible and appropriate) about LGBT health concerns, such as breast cancer, safe sex, hormone therapy, mental health, substance use, and sexually transmitted diseases (STDs - also called sexually transmitted infections or STIs such as HIV/AIDS, Syphilis, and hepatitis A and B).
- Disseminate or visibly post a non-discrimination statement stating that equal care will be provided to all patients, regardless of age, race, ethnicity, physical ability or attributes, religion, sexual orientation, or gender identity/expression.
- Acknowledge relevant days of observance in your practice such as World AIDS Day, LGBT Pride Day, and National Transgender Day of Remembrance.
- Display LGBT-specific media, including local or national magazines or newsletters about and for LGBT and HIV-positive individuals.
General Guidelines For Forms and Patient-Provider Discussions
Filling out the intake form gives patients one of their first and most important impressions of your office. The experience sets the tone for how comfortable a patient feels being open about their sexual orientation or gender identity/expression.
At the end of this section are recommendations for questions you may want to consider adding to your standard intake and health history forms, or ideally - discuss with the patient while taking an oral history. Examples include more inclusive choices for answers to questions, open-ended questions, and adding "partner" wherever the word "spouse" is used. The following are additional topics for possible inclusion in health history forms or to help a provider with in-person discussions with LGBT patients:
- Intake forms should use the term "relationship status" instead of "marital status," including options like "partnered." When asking - on the form or verbally - about a patient's significant other, use terms such as "partner," in addition to "spouse" and/or "husband/wife."
- Adding a "transgender" option to the male/female check boxes on your intake form can help capture better information about transgender patients, and will be an immediate sign of acceptance to that person.
- As with all patient contacts, approach the interview showing empathy, open-mindedness, and without rendering judgment.
- Prepare now to treat a transgender patient someday. Health care providers' ignorance, surprise, or discomfort as they treat transgender people may alienate patients and result in lower quality or inappropriate care, as well as deter them from seeking future medical care.
- Transgender individuals may have had traumatic past experiences with doctors causing fear or mistrust. Therefore, developing rapport and trust with transgender patients may take longer and require added sensitivity from the provider.
- When talking with transgender people, ask questions necessary to assess the issue, but avoid unrelated probing. Explaining why you need information can help avoid the perception of intrusion, for example: "To help assess your health risks, can you tell me about any history you have had with hormone use?"
- Be aware of additional barriers caused by differences in socioeconomic status, cultural norms, racial/ethnic discrimination, age, physical ability, and geography. Do not make assumptions about literacy, language capacity, and comfort with direct communication.
- When talking about sexual or relationship partners, use gender-neutral language such as "partner(s)" or "significant other(s)." Ask open-ended questions, and avoid making assumptions about the gender of a patient's partner(s) or about sexual behavior(s). Use the same language that a patient does to describe self, sexual partners, relationships, and identity.
- When discussing sexual history, it is very important to reflect patients' language and terminology about their partners and behaviors. Many people do not define themselves through a sexual orientation label, yet may have sex with persons of their same sex or gender, or with more than one sex. For example: some men who have sex with men (MSM), especially African American and Latino men, may identify as heterosexual and have both female and male partners.
- When assessing the sexual history of transgender people, there are several special considerations:
- Do not make assumptions about their behavior or bodies based on their presentation;
- Ask if they have had any gender confirmation surgeries to understand what risk behaviors might be possible; and
- Understand that discussion of genitals or sex acts may be complicated by a disassociation with their body, and this can make the conversation particularly sensitive or stressful to the patient.
- Ask the patient to clarify any terms or behaviors with which you are unfamiliar, or repeat a patient's term with your own understanding of its meaning, to make sure you have no miscommunication.
- It is important to discuss sexual health issues openly with your patients. Non-judgmental questions about sexual practices and behaviors are more important than asking about sexual orientation or gender identity/expression.
- For additional information on sexual risk assessment for LGBT populations, see Resources section.
- Be aware that sexual behavior of a bisexual person may not differ significantly from that of heterosexual or lesbian/gay people. They may be monogamous for long periods of time and still identify as bisexual; they may be in multiple relationships with full knowledge and consent of their partners. However, they may have been treated as confused, promiscuous, or even dangerous. They may be on guard against health care providers who assume that they are "sick" simply because they have sexual relationships with more than one sex. Yet they may also, in fact, lack comprehensive safer-sex information that reflects their sexual practices and attitudes, and may benefit from thorough discussions about sexual safety.
- When discussing sexual practices and safer sex avoid language that may presume heterosexuality or discriminate.
There are so few trained experts in transgender health that you will often have to become that expert. Likewise, providers who treat transgender patients often have to build the base of specialty care referrals by pre-screening other providers for sensitivity or guiding them to educational resources. Do not be afraid to tell your patient of your inexperience. Your willingness to become educated will often stand out from their previous healthcare experiences.
Confidentiality
Encourage openness by explaining that the patient-provider discussion is confidential and that you need complete and accurate information to have an understanding of the patient's life in order to provide appropriate care. Ensure that the conversation will remain confidential and specify what, if any, information will be retained in the individual's medical records.
Developing and distributing a written confidentiality statement will encourage LGBT and other patients to disclose information pertinent to their health knowing that it is protected. Key elements of such a policy include:
- The information covered.
- Who has access to the medical record.
- How test results remain confidential.
- Policy on sharing information with insurance companies.
- Instances when maintaining confidentiality is not possible.
Display the confidentiality statement prominently and provide it in writing to every patient. Consider having staff agree to the statement in writing.
Some Specific Issues To Discuss With LGBT Patients
Homophobia, biphobia, transphobia, discrimination, harassment, stigma and isolation related to sexual orientation and/or gender identity/expression can contribute to depression, stress and anxiety in LGBT people. Conduct depression and mental health screening as appropriate, and do not discount these sources of stress for your LGBT patients.
Explore the degree to which LGBT patients are "out" to their employers, family, and friends, and/or the extent of social support or participation in community. One's level of identification with community in many cases strongly correlates with decreased risk for STDs (including HIV) and improved mental health.
Understand that LGBT people are particularly vulnerable to social stresses that lead to increased tobacco and substance use. A recent large study showed GBT men smoked 50% more than other men, and LBT women smoked almost 200% more than other women. Emphasis on other health issues may leave many people unaware of the disproportionate impact of tobacco in this population. Be prepared to intervene and provide treatment options. Likewise, explore whether LGBT patients are dealing with social stress through alcohol or drug use and be prepared to present treatment options. Social stress may also contribute to body image, exercise, and eating habits.
Discuss safer sex techniques and be prepared to answer questions about STDs and HIV transmission risk for various sexual activities relevant to LGBT people.
If a female patient identifies as lesbian, or indicates a female sexual partner, do not assume that she has never had a male sexual partner, has no children, has never been pregnant, or has little or no risk of STDs. If a male patient identifies as gay or bisexual, or identifies a male sexual partner, do not assume that the patient has never had a female sexual partner or has no children. Do not make assumptions about past, current, and future sexual behavior.
Rates of Syphilis are rising among MSM in some areas. Other STDs among MSM continue to be of concern to public health officials. The Centers for Disease Control and Prevention now recommends screening of MSM at least annually for Syphilis, Gonorrhea, Chlamydia, HIV, and immunization against hepatitis A and B for those MSM who are not already immune. For MSM at highest risk (e.g., drug use or multiple partners), screening is recommended every 3-6 months, regardless of condom use. If patients do not have coverage for vaccination, refer them to a community clinic or STD clinic offering free or low cost vaccination.
Transgender people are sometimes subject to the most extreme levels of social exclusion. This can destabilize individuals and create a host of adverse health outcomes. Risks and response behaviors to watch out for include: cycling in and out of employment (and therefore health insurance); having a history of interrupted medical care; avoiding medical care; pursuing alternate gender confirmation therapies (like injecting silicone or taking black market hormones); engaging in survival sex; interrupted education; social isolation; trauma; and extreme poverty. Health interventions will need to consider the aggregate impact of health risks resulting from this stigma.
Conduct violence screening: LGBT people are often targets of harassment and violence, and LGBT people are not exempt from intimate partner/domestic violence. Individuals being battered may fear being "outed," i.e., that if they report the violence to providers or authorities, their batterer could retaliate by telling employers, family, or others that they are gay. Assure the patient of confidentiality to the extent possible depending on your state laws regarding mandatory reporting.
Ask all patients-men and women-violence screening questions in a gender neutral way:
- Have you ever been hurt (physically or sexually) by someone you are close to or involved with, or by a stranger?
- Are you currently being hurt by someone you are close to or involved with?
- Have you ever experienced violence or abuse?
- Have you ever been sexually assaulted/raped?
Transgender people who are visibly gender variant may be exposed to a very high routine level of violence. For this population, the assessment of risk should be much more in-depth. If a person reports frequent violence, be sure to explore health issues related to long-term and post-traumatic stress.
Regardless of whether a transgender person is visibly gender variant, they may experience trauma, increased stress, and direct grief as a result of violence against other community members. Asking about possible associative trauma can help identify health risks.
Language
Listen to your patients and how they describe their own sexual orientation, partner(s) and relationship(s), and reflect their choice of language. Be aware that although many LGBT people may use words such as "queer," "dyke," and "fag" to describe themselves, these and other words have been derogatory terms used against LGBT individuals. Although individuals may have reclaimed the terms for themselves, they are not appropriate for use by health care providers who have not yet established a trusting and respectful rapport with LGBT patients. If you are in doubt as to how to refer to a patient, ask what word or phrase they prefer.
Avoid using the term "gay" with patients even if they have indicated a same-sex or same gender sexual partner. If patients themselves have not indicated a particular identity or have indicated a sexual orientation other than "gay," using this term may cause alienation and mistrust that will interfere with information gathering and appropriate care. The key is to follow the patient's lead about their self description (which builds respect and trust) while exploring how this relates to their current and potential medical needs.
Young people as well as adults may be unlikely to self-identify using traditional sexual orientation labels such as gay, lesbian, or bisexual. While some may identify as "queer," others may not choose any label at all.
Respect transgender patients by making sure all office staff is trained to use their preferred pronoun and name. Clearly indicate this information on their medical record in a manner that allows you to easily reference it for future visits.
Staff Sensitivity And Training
When possible, it is helpful to have openly lesbian, gay, bisexual, and transgender people as staff. They can provide valuable knowledge and perspectives about serving LGBT patients, as well as help patients feel represented and comfortable.
It is especially important to train all front-line staff in office standards of respect towards transgender people, including: using their chosen name, and referring to them by their chosen pronoun.
Circulate these Guidelines to all administrative, nursing, and clinical staff. Training for all staff is critical to creating and maintaining practice environments deemed safe for LGBT patients. Training should be periodic to address staff changes and keep all staff up-to-date. Designate an on-site LGBT resource person to answer any questions that arise in the interim.
Topics to include in a staff training program should include:
- Use of appropriate language when addressing or referring to patients and/or their significant others.
- Learning how to identify and challenge any internalized discriminatory beliefs about LGBT people.
- Basic familiarity with important LGBT health issues (e.g., impacts of homophobia, discrimination, harassment, and violence; mental health and depression; substance abuse; safe sex; partner violence; HIV/STDs).
- Indications and mechanisms for referral to LGBT-identified or LGBT-friendly providers. Developing resource lists and guidelines for patient interactions can reduce possible staff anxiety in dealing with LGBT patients.
All employees need to understand that discrimination against LGBT patients, whether overt or subtle, is as unethical and unacceptable-and in many states as illegal-as any other kind of discrimination. Employers should make it clear to employees that discrimination against LGBT patients "will not be tolerated." It is also important to monitor compliance and provide a mechanism for patients to report any disrespectful behavior.
Some of your employees may have longstanding prejudices or negative feelings about LGBT patients due to ignorance or lack of familiarity with LGBT issues. Some may also feel that their religious beliefs require them to condemn LGBT people.
Some employees may need individual training and counseling.
Other Suggestions
A universal gender-inclusive "Restroom" is recommended. Many transgender and other people not conforming to physical gender stereotypes have been harassed for entering the "wrong" bathroom, so at least one restroom without Men or Women labels would help create a safer and more comfortable atmosphere.
Be aware of other resources for LGBT individuals in your local community, as well as national/internet resources, and build collaborative relationships between your office and local lesbian, gay, bisexual, and transgender organizations and support groups.
References and Resource Documents
Endnotes
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Kaiser Permanente National Diversity Council and Kaiser Permanente National Diversity Department.
A Provider’s Handbook on Culturally Competent Care: Lesbian, Gay, Bisexual, and Transgender Population, 2nd ed. 2004.
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Gay Men’s Health.
Small Effort, Big Change.
Resource Documents
Dean, L., et. al.
Lesbian, Gay, Bisexual, and Transgender Health: Findings and Concerns.
Journal of the Gay and Lesbian Medical Association, Vol. 4, No. 3, 2000.
Feldman J, Bockting W.
Transgender Health.(review) Minn Med 2003;86(7):25–32.
Available online at www.mmaonline.net/publications/MNMed2003/July/Feldman.html.
Gay and Lesbian Medical Association and LGBT HealthExperts.
Healthy People 2010 Companion Document for LGBT Health (2001).
Harry Benjamin International Gender Dysphoria Association.
The Standards of Care for Gender Identity Disorders, Sixth Version. Dusseldorf: Symposion Publishing, 2001.
International Journal of Transgenderism
Kaiser Permanente National Diversity Council and Kaiser Permanente National Diversity Department.
A Provider’s Handbook on Culturally Competent Care: Lesbian, Gay, Bisexual and Transgender Population (2nd ed., 2004). 510-271-6663
Lombardi E.
Enhancing Transgender Health Care. Am J Public Health 2001;91(6):869–72.
National Coalition of Anti-Violence Programs (NCAVP).
Lesbian, Gay, Bisexual, Transgender Domestic Violence: 2003 Supplement.
Oriel, Kathleen A.
Clinical Update: Medical Care of Transsexual Patients, Journal of the Gay and Lesbian Medical Association, Volume 4, Issue 4, Dec 2000, Pages 185–194
Schatz, B, O’Hanlan, K.
Anti-Gay Discrimination in Medicine: Results of a National Survey of Lesbian, Gay and Bisexual Physicians (1994). Copies available from the Gay and Lesbian Medical Association www.glma.org or 415-255-4547
Scout.
Social Determinants of Transgender Health.
Dissertation at Columbia University. New York, NY. 2005.
Available online at www.scoutout.org
Telex, C., et. al.
Attitudes of Physicians in New Mexico Toward Gay Men and Lesbians. Journal of the Gay and Lesbian Medical Association, Vol. 3, No. 3, 1999.
U.S. Department of Health and Human Services Administration, Center for Substance Abuse Prevention.
CSAP Substance Abuse Resource Guide: Lesbian, Gay, Bisexual, and Transgender Populations (2001).
www.health.org/referrals/resguides.aspx?InvNum=MS489
U.S. Department of Health and Human Services Administration, Center for Substance Abuse Treatment.
A Provider’s Introduction to Substance Abuse Treatment forLesbian, Gay, Bisexual, and Transgender Individuals (2000). Inventory No. BKD392.
www.kap.samhsa.gov/products/manuals/pdfs/lgbt.pdf
Medline Plus Gay and Lesbian Health Webpage.
Accessible at www.nlm.nih.gov/medlineplus/gayandlesbianhealth.html
Wolfe D, Gay Men’s Health Crisis Inc.
Men like us: the GMHC complete guide to gay men’s sexual, physical, and emotional well-being. 1st ed. New York: Ballantine Books; 2000.
Acknowledgements
Staci Bush, PA-C
Howard Brown Health Center
Lisabeth Castro-Smyth, B.A.
Lesbian Health Research Center at University of California San Francisco (UCSF)
Pete Chvany, Ph.D.
Bisexual Resource Center
Ryan Clary
Project Inform
Suzanne Dibble, D.NSc., R.N.
Lesbian Health Research Center at University of California San Francisco (UCSF)
Tri Do, M.D., M.P.H.
UCSF Department of Medicine
Center for AIDS Prevention Studies
SFGH Positive Health Program
Board Member, Gay and Lesbian Medical Association
Patricia Dunn, J.D., M.S.W.
Amphora Consulting
Lead Author and Editor
Jessica Halem
Lesbian Community Cancer Project (LCCP)
Lynn Hunt, M.D.
Lesbian Health Fund Board Member, Gay and Lesbian Medical Association Department of Pediatrics, University of California, Irvine
Marion (Mhel) H. E. Kavanaugh-Lynch, M.D., M.P.H.
California Breast Cancer Research Program University of California, Office of the President Lesbian Health Fund
Anne Lawrence, M.D., Ph.D.
Private practice, clinical sexology
Harold S. Levine
Levine & Partners, Inc.
Ana Maldonado PA-C/MPH
Fenway Community Health
Amari Sokoya Pearson-Fields, M.P.H.
Doctoral Candidate
Mautner Project, the National Lesbian Health Organization
Leigh Roberts, M.D.
Howard Brown Health Center
Laurie Safford, M.S.W.
Survey and Evaluation Research Laboratory
Virginia Commonwealth University
Jason Schneider, M.D.
Division of General Medicine
Department of Medicine Emory University School of Medicine
Policy Chair, Gay and Lesbian Medical Association
Lead Author, Caring for Gay and Bisexual Men: Additional Considerations for Clinicians
Scout, Ph.D.
Health Consultant
Associate Author and Editor
Shane Snowdon
University of California San Francisco
Edgework Consulting
Jodi Sperber, M.S.W., M.P.H.
Health Dialog
Jennifer S. Taylor, M.P.P., M.P.H.
Associate Author and Editor
Bianca Wilson, Ph.D.
Lesbian Health Research Center at University of California San Francisco (UCSF)
The Gay and Lesbian Medical Association
A national organization committed to ensuring equality in health care for lesbian, gay, bisexual, and transgender (LGBT) individuals and health care professionals. GLMA achieves its goals by using medical expertise in professional education, public policy work, patient education and referrals, and the promotion of research. To join GLMA or for more information, please visit www.glma.org.
Gay and Lesbian Medical Association (GLMA)
459 Fulton Street, Suite 107
San Francisco, CA 94102
Phone: 415-255-4547
Fax: 415-255-4784
Excerpted from: "Creating a Safe Clinical Environment for Men Who Have Sex With Men," created by the Gay and Lesbian Medical Association. May 2005. www.glma.org
* the term sexual orientation is used in this document to mean sexual orientation identities, behaviors, and/or attractions, all of which are important in the health care context.