Population Care

Q&A: How to build a nationally recognized LGBTQ+ clinic

Andis Robeznieks , Senior News Writer

A student-sponsored seminar held in 2011 and attended by a senior physician who graduated from medical school in 1982 and another who was just finishing her residency sparked a professional partnership that led to the opening of a specialty clinic and national recognition for the doctors’ academic health system 10 years later.

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Katherine Imborek, MD
Katherine Imborek, MD

The chance meeting between internist Nicole Nisly, MD, and family medicine resident Katherine Imborek, MD, at a transgender student group-produced program led to the founding of the University of Iowa (UI) Health Care LGBTQ Clinic. In the beginning, the clinic was only open one night a week. But now it offers a full spectrum of services delivered in a welcoming and affirming environment for some 14,000 patients in the LGBTQ+ community, including many who travel long distances to get there.

The clinic serves as the catalyst for efforts to advance equitable treatment and inclusion of LGBTQ+ patients, visitors and employees across the University of Iowa Health Care enterprise, which includes University of Iowa Hospitals & Clinics, a member of the AMA Health System Program.

These efforts were recognized by the Human Rights Campaign Foundation, which named UI Health Care as an LGBTQ+ Health care Equality Top Performer for earning a score of 95 (out of 100) on its 2022 Health care Equity Index.

The index measures the LGBTQ+ inclusiveness of a system’s patient, visitation and employee nondiscrimination policies. It also requires staff training on LGBTQ+ cultural competency and includes points for whether there are equal health insurance benefits for employees, resource groups for employees, LGBTQ+ inclusive hiring efforts and support for employees undergoing transgender transition.

Three other AMA Health System Program members—Atlantic Health, Henry Ford Health and Virginia Mason Franciscan Health—also earned the Human Rights Campaign Foundation honor. The AMA Health System Program equips leadership, physicians and care teams with resources to advance programs to help drive the future of medicine. Also, find out more about the AMA LGBTQ Advisory Committee, which addresses many important issues of interest to LGBTQ+ medical students, resident and fellows, LGBTQ+ physicians, patients and their straight allies.

Dr. Imborek, co-director of the LGBTQ+ Clinic and a University of Iowa clinical professor of family medicine, took time to reflect on the success of the clinic, the growth of gender-affirming care that has created more options and access for transgender patients, and the political climate that threatens to reverse those gains.

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AMA: Can you explain the significance of the Human Rights Campaign Foundation’s recognition?

Dr. Imborek: Our clinic gives us a lot of momentum as an organization and is, in some ways, the driving factor—but this recognition is for our entire University of Iowa Health Care enterprise. It makes it more meaningful because it is clear that UI Health Care—from all our individual clinics to all of our individual units at the hospital—that we have folks from top to bottom that have embraced our stance and our commitment to providing welcoming and affirming care.

AMA: Can you tell the story of the LGBTQ Clinic’s origins and how you and Dr. Nisly joined forces?

Dr. Imborek: It was a fortuitous meeting. Dr. Nisly is quite humble—so I'll toot her horn. Dr. Nisly is an exemplar ally of this community. You can ask: “How does an idea become reality?” Sometimes, it's having those allies who are in positions of privilege or power who jump on as a champion and make something happen.

That's the role Nicole played. She had been a general internal medicine physician for, oh my gosh, more than 20 years at the time we met, and had a panel of probably more than 2,000 patients. She had one patient who identified as a transgender woman. And Nicole personally felt ill-equipped to care for that patient, and because of that one patient, she attended that program to learn more.

I went to that panel because I identify as a lesbian, and I was just finishing my residency and knowing that I was joining faculty here and starting my own practice at one of our outlying clinics. I went to go to the source to figure out what sort of intake demographic questions we should be asking all of our patients. We both went up to the mic during the Q&A, and she grabbed me afterward and said: “Hey, I’m thinking about starting an LGBTQ+ clinic. Would you want to do that with me?” As somebody who hadn't joined the faculty yet, who hadn't even graduated from residency, I was skeptical if this could happen because the university is a large and slow-moving machine.

You must have persistence, diligence and support to make things happen. I had no idea of just how much political capital and personal effort that Nicole was willing to put in. I think we made a great team in terms of her knowing how to navigate the system, and me having lived experience as a member of the queer community and also having the time and energy that goes along with being fresh out of residency..

AMA: Dr. Nisly said the way the LGBTQ Clinic operates comes from asking patients what they want to hear from their doctors. What did you hear from patients that you didn’t learn in residency or medical school?

Dr. Imborek: The most important thing that we learned was the power of language, and the intentionality that needs to be done upfront with training all of your staff—this really has to go beyond the physicians. A patient can finally make it into the part of the visit where they're face to face with their physician or other health professional, who may be passionate, educated, , and ready to give that patient a wonderful, respectful, medically expert, culturally appropriate visit.

But the patient has already had to interact with three to four other members of the health care team. And if they haven't received some foundational training on LGBTQ+ terms, the use of pronouns, and calling patients by the name that they identify with, then that entire encounter could already be ruined. Some of the important things we learned was just about how traumatizing it can be for patients—especially those who identify as transgender or nonbinary—to be misgendered by being referred to by the wrong pronouns or to be referred to by what is called their “dead name.” That's usually their given name, which is not the name they use.

We knew how important it was to make sure we had cultural competency training for all our staff, but we also knew how important it was to put things in place to operationalize some common things we do. We knew that we had to get the preferred name on labels that we use at the different spots you go in the health system. We were able to do things like that across the whole enterprise, which has been a game changer. We've been able to incorporate someone's preferred name and someone's pronoun, and information about sexual orientation or gender identity, or “SOGI”, directly into the medical record. This information about pronouns, preferred name, gender identity, and assigned sex at birth are captured as discrete data fields in the electronic medical record and follows patients as they traverse the health system. , Physicians and other clinical staff can quickly access information like whether a person has ovaries and a uterus, where you need to be worried about whether they're pregnant. These things are important, not just for establishing rapport and being respectful, but also when making medical decisions.

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AMA: Where do your patients live?

Dr. Imborek: The majority of our facilities are located within Johnson County and I would say that the majority of our patients come from outside of this county. So people think that of course an LGBTQ+ clinic will work in Iowa City because it's full of all these queer folks.

But there are also a lot of queer folks in rural Iowa and that haven't been able to reliably receive gender-affirming and/or LGBTQ+-affirming care, so they come to our system. Pre-COVID, they would drive, and now that we—like many other places have incorporated telemedicine—we've been able to offer that option.

It's something that, specifically, our LGBTQ+ patients really love. About half of my patient visits are via video.

AMA: How has this field of medicine changed?

Dr. Imborek: When we started this 10 years ago, we were probably one of the first academic institutions to set up an LGBTQ+ clinic. Since then, there have been more and more clinics that have started, in academics and outside, which is wonderful.

There's been an ever-widening acceptance, and we have many more physicians who prescribe hormones and more surgeons doing gender-affirming care. We've seen more insurance companies cover these procedures and align with what the AMA stated years ago: that gender-affirming care—including hormones and procedures—were medically necessary. 

Then, at the same time, we have recently seen an exponential, horrific increase in the amount of anti-LGBTQ+ and, specifically, anti-trans and anti-trans youth bills proposed and passed in state legislatures.

There are some that are really scary that do things like criminalize the care of transgender children. This is a scary trend and, hopefully, one where science and proven medical evidence about the benefit of gender-affirming care wins out.