Inclusion is more than a buzzword. It can be an important way to develop trust and provide care for vulnerable groups, such as LGBTQ patients. Due to stigma surrounding sexual orientation and gender identity, some LGBTQ patients may hesitate before seeking medical treatment, or, even worse, they may not seek it at all.
In an episode of the “AMA Moving Medicine” podcast, Erick A. Eiting, MD, MPH—vice chair of operations for emergency medicine at Mount Sinai Downtown, in New York City, and former vice chair of the AMA Advisory Committee on LGBTQ Issues—discusses ways to provide more inclusive experiences and improve health care quality for LGBTQ patients.
Dr. Eiting: I'm just going to spend a little bit of time talking about a few definitions. We'll talk about why it's important to think a little bit differently about your LGBTQ patients. Then we'll go through a little bit of clinical cases and scenarios, just to sort of highlight some issues that I want you to think about as you're taking care of your LGBTQ patients.
Just a broad overview, Gates in 2011 released a survey. The estimate that he provides was that 3.5% of the U.S. population identifies as either lesbian, gay or bisexual. Then about .3% of the population identifies as transgender. …[I]t relies on self-reporting, so there may be some under reporting in this because patients may not always feel comfortable disclosing this information. The point is, these patients are out there, and we're certainly taking care of them.
In Chandra's survey in 2011 … from ages 18 to 44, 8.8% responded that there was some sort of same-sex behavior, and 11% supported some sort of same-sex attraction. The reason why I think it's important to think about this too is because I think we often assign labels to what we think something is. But what somebody is and how they identify doesn't necessarily describe their behavior, and I think that's a really important point when taking care of LGBTQ patients.
I just want to go over what some of these terms mean. A lot of times they sort of just brush through this slide, but I think it's important to spend a little bit of time thinking about how the words that we use in the LGBTQ community have an impact.
Some of the more important ones: Gender identity means this is your internal perception of an individual's gender. So, this is how they label themselves. That can be different from your anatomical sex or the gender when you were born. So, it's important to think about patients and how this can impact them and how they define themselves. But that doesn't necessarily give you an adequate picture every time that we're dealing with patients of what disease entities we need to be thinking about.
We use the terms transgender and cisgender. Transgender is a blanket term. It encompasses a lot of things. We're hearing a lot more about transgenders, but I think the point that I really want to stress about the term transgender is that it is so heterogeneous. There could be transgender patients who are on medical therapy, including hormones. There are transgender patients who may be post-op, who may have had gender confirmation surgery, but there also may be patients who identify as transgender who are not taking any hormones, who are not undergoing any sort of medical therapy that we assume that our transgender patients have done. They may not ever have any intention of ever having surgery. So, there is a big heterogeneity to it.
Transitioning is an important term because that sort of talks about this movement from the anatomical sex with which you were born and moving towards, or in the direction, of the gender with which you identify.
I don't want to belabor the point here, but I do think it's important to make sure we talk about the word advocate, because I would go so far as to say that probably everybody in this room is an advocate. This is a person who works actively to end intolerance, to educate others, and supports social equity for a group, so a very important person in the LGBTQ community.
Carl Streed, who is on the Massachusetts delegation and was a previous chair of the advisory committee, shared this slide with me. I think it really captures the essence of how complex all of this. So, there's gender identity, how you feel that you are the gender that you identify with, and then there's gender expression, and those two things may be different.
The way that you see somebody, and how they present themselves, may be totally different from how they identify. Obviously, it can be different from the sex you were assigned at birth, and getting back to what we sort of talked about, that there's sexual attraction and romantic attraction, and there may be discord amongst all of these things. So, it just sort of gets to the heterogeneity of the population and how complex this can be.
This is a story. So, I practice emergency medicine. I think that this is a story that many of my emergency physician colleagues can relate to, where there was a lack of sensitivity which was truly problematic. This is a picture of Jacob Rumble. This is a case that happened in Minnesota a few years back. Jacob is a female-to-male transgender patient … came in with a fever of 104, had an elevated heart rate, was having pelvic pain and ultimately required an examination including a pelvic exam.
Then, according to the legal documents, the physician came in and lacked professionalism. The accusation was that there was an approach to the physical exam that the patient felt was consistent with assault. That there were many staff members who had made very concerning comments about the patient saying, “This is a woman,” even though this patient clearly identified as a man. The outcome of this … is a patient who presented with sepsis. He required hospital admission and didn't require any surgical intervention but had quite a traumatic hospital stay. This is sort of the entry point to the emergency room.
The courts in Minnesota decided that this was a case that could be proceeded. They are deeming this as a potential malpractice case. I think it really highlights the importance of reminding ourselves that we need use appropriate terminology, we need to treat patients for who they are, and we need to make sure that patients feel comfortable with the approach that we're using to provide them with good care.
I also think that it's important to remind people that the entire LGBTQ community, but particularly our transgender patients, are often times avoiding care. This is an article that came out in Annals of Emergency Medicine back in 2012, talking about the number of people who identify as LGBTQ, and had reported that either they delayed seeking emergency care when they felt that they truly had an emergency, or they avoided the emergency department altogether because they were concerned about the stigma. They were concerned about the experience that they were having.
So, I think that when we talk about patient experience, it sort of comes to a heightened and very different level. We just have to think about the approach a little bit differently, but really, these are some concerning statistics.
I’d like to talk about how you can create a practice that is friendly to your LGBTQ patients, and I really think that it starts from the time that you hit the door. Part of that means that you need to train your registration staff, making sure that they're using terminology that's inclusive.
One of the first things that our patients receive when they walk in to see us for the first time, regardless of our practice setting, is usually some kind of form that asks for some demographic information. So, it's really important that when you have that form, that you're including things that include a gender that is something with which they identify.
It really just sort of starts in rethinking this entire approach. It's not just about the clinical interactions that we have, it's not just about the care that we provide, or whatever therapies we assign to them. The experience starts in the beginning and it's comprehensive and lasts throughout.
The AAMC [Association of American Medical Colleges] has provided some recommendations on how we should approach taking care of our LGBTQ patients. I think that some of these are obvious. I don't want to read through each one of these because it is obvious. But it means a lot to me that this is an issue that the AAMC and the Joint Commission and CMS and all of these sort of regulatory bodies that remind us what's important and help us prioritize certain issues, that this is something that they've given some thought to and they’ve provided some guidelines.
Talking about the patient environment and what it is that we can do to make an area and make an environment that's more comfortable and inclusive, as I said, it starts with the intake forms. So, making sure that you have something that is inclusive.
Ensuring confidentiality. I think that we sort of take it for granted. We assume that patients believe that we are going to maintain their confidentiality, but I think that when I talk to my LGBTQ colleagues, I think that the concerns about confidentiality are even more heightened. I think it's appropriate to spend even a little bit more time talking about the importance of confidentiality.
Training all of your staff. And like I said, this starts with your registration staff, but it should be anyone who's having any sort of patient encounter, and even the people who aren't having patient encounters. It is really important to make sure that you are setting a tone that is inclusive of your LGBTQ patients, and so it really has to be a comprehensive approach.
One of the things that I did in my urgent care is we posted a rainbow flag. It's very subtle, but the thing is, I know there are patients who look at that and they say, "Wow I can really relate to this." They're looking at, like, if you have a sign and it is a same sex couple. It's just not about getting HIV tested or anything we sort of associate with that, but just sort of being there, I think it really resonates with them and they say, "Wow, this is a place that I really can mesh with."
The last thing that I have on this list is unisex bathrooms. I know that this is hard, but this is a really important issue. You have to sort of think about it. I think we take for granted that going to be the bathroom, it's just such a normal behavior, but for some people that can be a traumatic event. So, moving in that direction of providing unisex bathrooms is really important.
It's important also to make sure you're doing an assessment of your current environment. These are some questions that I would encourage you to ask and I'm happy to share this slide deck. PrEP is a very important conversation. Pre-exposure prophylaxis is something that is become increasingly common in the community of men who have sex with men, as an important way to reduce risk of HIV. The CDC has just amended their guidelines last month on the recommendations for who should be getting PrEP and what the recommendations should be.
I know that you guys can access that easily, but it's all online. These are the guidelines that we're using to decide who should be on PrEP [preexposure prophylaxis]. I do like to make sure that we're thinking about when we have our men-who-have-sex-with-men patients, some things that I just want you to think about: obviously HIV and STI screening are very important, and that also needs to be comprehensive. But a big part of how we decide what testing needs to be done is you have to have a good conversation about what sexual behaviors are occurring and then help to risk stratify and make some decisions.
I'm going to skip through the post-exposure prophylaxis because I think that there's a lot of overlap, but just some quick points that I want to bring up.
So, this is a 32-year-old female who came into the emergency department. She had epigastric discomfort. She also had some nausea and vomiting for four days. She's unable to tolerate PO and she denies fever or sick context. She identifies as lesbian and is with her female partner. The one test that I want you to order—and the point that I'm trying to make here right, obviously—a pregnancy test. This is a patient who's positive.
Again, the point of this case is to stress that how you identify does not necessarily reflect your behavior. We need to make sure that we're being mindful of this. You get the scenario and you think, obviously, "This is a woman who's telling me she's a lesbian, and she's with her female partner, so I don't need to think about pregnancy.” Just keep in the back of your mind that behavior is not always something that is going to be disclosed, and you can sort of see how in this scenario, maybe this patient wouldn't have wanted to disclose some behavior that may have become problematic or troublesome if her partner had heard it.
The last case that I want to talk about is a 56-year-old male-to-female transgender patient who presents to the emergency department with a complaint of chest pain. She's had several episodes over the past few days with occasional shortness of breath. She's a smoker. Family history is uncertain. She denies any relevant medical history. She's currently unemployed and admits to taking Premarin but not additional medications. So we get the EKG, we get a troponin, and it's 1.32. So, very positive. I think it just sort of stresses the fact that risk factors are a little bit different, and we need to think about how we profile our patients in terms of risk stratification a little bit differently.
This was a woman where she's transgender, she's taking Premarin, but we have to remember that often times these are patients who are taking medications that are not prescribed by a doctor or being supervised by a clinician. They're medications that they're getting on the street. So, they may be taking inappropriately high doses.
We also talked about how the family history was unknown, which is not uncommon in the transgender population. These are people who are often estranged from their families. They spend some time, or are more likely to spend some time, being homeless or incarcerated. So, we just have to think about the social determinants of health and how it's just a little bit different. Also, one of the things that I think it's really important to stress, particularly this week, is the higher suicide rate that we're seeing in these patients.
Any time we're taking care of a LGBTQ patient, you need to give a little bit more thought to, “Do I need to do more of some kind of depression screening? Or are you at risk here for any ill outcomes?”