Population Care

How to take an LGBTQ-inclusive social history to improve care

Brendan Murphy , Senior News Writer

Health inequities prevail among LGBTQ youth, making them more prone to depression and suicidality, substance-use disorder, and altered body image, among other mental health issues. Addressing and, eventually, eliminating those inequities begins with physicians who have the proper training, starting in medical school.

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Identified by the World Health Organization as the period of development between ages 10 and 19, adolescence is a critical stage in human development. Organizations such as the American Academy of Pediatrics identify healthy sexuality as an important aspect of development during this period. Physicians can play a key role in the development of healthy routines, behaviors and relationships that can carry into their adult lives.

Adolescence breaks into three stages—early adolescence (10–13 years old), mid-adolescence (14–16) and late adolescence (17–21). Knowing which stage of adolescence a patient is in, and what characteristics might be associated with that stage, are important to taking a social history, according to Priya Bui, DO.

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“As we talk about some of our tools to obtain a social history, I keep these stages in mind. “Where is my patient at based on their age and what I know about them,” said Dr. Bui, clinical chief of pediatrics at the University of North Texas and assistant professor at Texas College of Osteopathic Medicine. She recorded a presentation on the topic for medical students gathering virtually at the November 2020 AMA Sections Meeting.

Find out more about the AMA Medical Student Section, which gives voice to—and advocates for—issues that impact medical students.

One tool Dr. Bui touted for taking an effective social history is the HEADSS screen—which stands for Home, Education, Activity, Drugs, Sexuality, Safety, Suicide/Homicide. She recommends using it in a one-on-one setting with a patient independent of a parent. To do that, it’s imperative to make a parent understand that the child is the patient and there is a benefit to their health in having a private conversation.

“A lot of people think of this as asking [patients] pointed questions,” Dr. Bui said. “Are you doing drugs? Are you having sex? How many partners have you had? It really shouldn’t be that. You should think of it as a conversation to obtain your social history.”

To make it more of a conversation, Dr. Bui recommends keeping the questions more open-ended by using prompts such as, “Tell me about home.”

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Sexuality is an important point in getting to know your adolescent patients. A frank conversation about sexuality can reveal potential risk factors. Dr. Bui cited survey research showing that LGBTQ youth, for instance, were twice as likely to have considered suicide in the past year.

When it comes to the sexuality part of the screening, Dr. Bui highlighted that it’s “sexuality, not sex.” She recommends asking patients how they feel about changes in their body, and how they feel about potential changes during puberty, and if they have had feelings of attraction for others. It’s also appropriate to ask if a patient is attracted to men, women or both.

“Flowing in this way will allow you to not assume someone’s sexuality, to allow for changes in sexuality during conversations, and to really have this conversation without going too far for the patient,” Dr. Bui said.

Depending on how the conversation goes, a physician might follow up those initial questions by inquiring about a patient’s physical relationships.

In instances of a HEADSS screen that reveals a patient needs help, Dr. Bui breaks the intervention down into four steps:

  • Discuss management options with the patient and determine the best course of option. Promote the teen’s confidence that the plan can work.
  • Discuss potential barriers to the management plan by having the patient identify them and plan ways to overcome those barriers.
  • Develop a verbal agreement or contract with the patient regarding joint expectations.
  • Follow up with identified actions, offering the patient a method to make contact directly as needed.

The entire process, Dr. Bui said, is about building trust.

“Even if nothing comes up, if you are confidential about their questions about body odor or changes to their body, they will notice that. And that builds their confidence in understanding that you are taking care of them and they will feel more comfortable about letting you know about more sensitive things on future visits,” she said.

Learn more about the AMA Advisory Committee on LGBTQ Issues, which highlights LGBTQ news and topics related to patients and physicians.