and community members have identified the need for improved data collection and gender-inclusive intake forms, signage, and education of providers. 20 One study introduced an intervention over the course of one year to train staff at federally qualified health centers on culturally affirming practices, increase the collection of sexual orientation and gender identify information, and improve targeted screening. Post-
intervention, the percentage of sites collecting sexual orientation and gender identity information had increased from 13.5% to 50.8%. Screening practices also indicated improvement. The authors note, however, that some of the centers felt the staff needed more training in culturally affirming care to better collect data and perform screening. 78
TREATMENT RECOMMENDATIONS
This course has discussed some of the general recommendations for creating a welcoming, nonjudgmental environment and incorporating intake and sexual history forms that provide more inclusive and open-ended questions. The Gay and Lesbian Medical Association recommends discussing patient confidentiality and developing a written statement to explain how their information is protected, how it remains confidential, who can access it, and what circumstances may require sharing of information. The preventive care topics are no different than for any client and, as always, we must take the time to determine which is a specific risk for each patient. Each new patient visit should assess sexual risk, safety related to lifestyle (e.g., seatbelts, firearms, sunblock), domestic violence, and substance use. 79 As many as 45% of lesbian and bisexual women are not out to their providers, which reinforces the need to obtain a nonjudgmental sexual history and reinforces the need for confidentiality. Social and behavioral risk factors include stress and failure to seek care, being overweight, as well as smoking and substance use. 79 Completing screening for substance use, interpersonal violence, depression, and anxiety are important to identify these possible risks. Consideration should be given for breast cancer screening at age 40 in women who are nulliparous or experienced early menarche, and in those with a positive family history. Do not assume a lesbian or bisexual woman does not plan to have children. Pap smears should be completed on all individuals with Recommendations There are several additional suggestions in the literature to decrease disparity and improve access to care among LGBTQ persons. Although there has been some increase in acceptance of sexual minority individuals, there is still much work needed to reduce the health disparities and identify risks: Seek resources for continuing education An increase in knowledge and understanding on topics of concern for the LGBTQ population improves patient outcomes. Effective communication Using correct pronouns will increase a patient’s comfort level. Do not gossip or joke about any patient. Encourage coworkers in their communication with patients. If you are uncertain, avoid the use of gender-related terms until you have confirmed this information with the patient. Apologize if you make an error and if there is a discrepancy with names or
a uterus, including HPV testing at the recommended intervals, since transmission of HPV can occur among WSW. Additional screening and health concerns should be age-appropriate and focused on the actual behaviors of each client. Gay and bisexual men should receive the same screenings as any male (i.e., colon, prostate, and testicular cancers; coronary artery disease) with consideration for the increased risk of anal HPV, anal cancer, domestic violence, mental health issues, and substance use. 79 Healthcare for transgender individuals has been lacking in much of the US because of the insufficient number of healthcare providers with adequate training, because of discrimination, or negative behaviors experienced during healthcare utilization, and insufficient insurance or ability to pay for care. 80,81 Screening should be based on anatomy and behaviors that are present. Cervical and prostate screenings, for anyone with a cervix or prostate respectively, should be conducted at recommended intervals for trans and cisgender individuals. Transgender men may experience anxiety or distress during pelvic examinations, and healthcare providers should be sensitive to this possible reaction and attempt to maximize comfort during the examination. 81 Likewise, mammography is recommended for trans men who have not undergone chest reconstruction. Desire for birth control and fertility should also be discussed without assumptions by the provider. 81 records. Ask what the name on the insurance card is or if the chart may have a different name. Confirm identity with date of birth. Increase data collection on transgender individuals As previously mentioned, there is minimal data available, lack of provider knowledge, and hesitancy to disclose this information to others. Four focus groups, with self-identified transgender individuals, explored the feasibility of asking about transgender identity in the Current Population Survey sponsored jointly by the U.S. Census Bureau and the U.S. Bureau of Labor Statistics (BLS). 9 Feedback revealed some concerns about accuracy of responses since answers may be made by household proxy and because it would be difficult to create adequate response options to capture group diversity. 9 General recommendations were to develop and test a variety of questions to test with other trans focus groups.
Book Code: CT24CME
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