District of Columbia Physician Ebook contains8 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
District of Columbia Continuing Medical Education
District of Columbia Medical Licensure Program
LGBTQ Cultural Competency 2 HOURS 1 HOUR Pharmacology 5 HOURS Public Health Priorities (10% Rule)
Need to complete the DEA’s new one-time MATE requirement? See page i for more details.
CME FOR:
AMA PRA CATEGORY 1 CREDITS ™ MIPS MOC STATE LICENSURE
DC.CME.EDU
InforMed is Accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
DISTRICT OF COLUMBIA
01
IMPROVING ACCESS TO CARE FOR LGBTQ PATIENTS COURSE ONE | 2 CREDITS*
16
ANTIBIOTIC STEWARDSHIP COURSE TWO | 1 CREDIT**
26
ALTERNATIVES TO OPIOIDS FOR PAIN MANAGEMENT COURSE THREE | 2 CREDITS+
42 EFFECTIVE MANAGEMENT OF ACUTE AND CHRONIC PAIN WITH OPIOID ANALGESICS COURSE FOUR | 3 CREDITS+
72
LEARNER RECORDS: ANSWER SHEET AND EVALUATION REQUIRED TO RECEIVE CREDIT
*Satisfies Mandatory Requirement for two (2) credits on LGBTQ Cultural Competency **Satisfies Mandatory Requirement for one (1) course on Pharmacology +Satisfies Mandatory Requirement on Current Public Health Priorities (Opioids/Pain Management)
Program Options
Book Option
Price Credits
Code
ENTIRE PROGRAM
$100 8 Credits MDDC0824
Improving Access to Care for LGBTQ Patients
$50 $50 $50 $50
2 Credits MDDC02LG
Antibiotic Stewardship
1 Credit
DC22CME-2
Alternatives to Opioids for Pain Management
2 Credits DC22CME-4 3 Credits DC22CME-3
Effective Management of Acute and Chronic Pain with Opioid Analgesics
DATA REPORTING: Federal, State, and Regulatory Agencies require disclosure of data reporting to all course participants. InforMed abides by each entity’s requirements for data reporting to attest compliance on your behalf. Reported data is governed by each entity’s confidentiality policy. To report compliance on your behalf, it’s mandatory that you must achieve a passing score and accurately fill out the learner information, activity and program evaluation, and the 90-day follow up survey. Failure to accurately provide this information may result in your data being non-reportable and subject to actions by these entities. CME that counts for MOC Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities (see page iii for further details). InforMed currently reports to the following specialty boards: the American Board of Internal Medicine (ABIM), the American Board of Anesthesiology (ABA), the American Board of Pediatrics (ABP), the American Board of Otolaryngology–Head and Neck Surgery (ABOHNS), and the American Board of Pathology (ABPath). To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting.
InforMed has the solution. Scan the QR code or go to https://uqr.to/deamate to get started. Effective June 27, 2023 , renewing DEA-registered practitioners must complete 8 hours of one-time training on the treatment and management of patients with opioid or substance use disorders. Get the training you need in a self-paced, convenient format with a course specifically designed for physicians to meet the Drug Enforcement Administration (DEA)’s new requirement under the Medication Access and Training Expansion (MATE) Act. Need to complete the DEA’s new requirement under the Medication Access and Training Expansion (MATE) Act? InforMed has joined the Elite Learning family Two of the nation’s top healthcare education providers have joined forces with one goal in mind: to offer physicians a state-of-the-art learning experience that fulfills your state requirements and empowers you with the knowledge you need to provide the best patient care. Here’s what you can expect from our new partnership: • COURSES: In addition to the mandatory courses you need to renew your state license, you’ll now have access to dozens of hours of elective courses and an expanded content library. • ACCOUNTS: You’ll also have access to a personalized learner account. In your account you can add, organize, and track your ongoing and completed courses. For instructions on how to set up your account, email us at office@elitelearning.com. • BOOK CODES: You may notice a book code on the back cover of the latest InforMed program you’ve received in the mail. When entered on our new site, this code will take you directly to the corresponding self-assessment. See more information below.
How to complete
Please read these instructions before proceeding. Read and study the enclosed courses and answer the self-assessment questions. To receive credit for your courses, you must provide your customer information and complete the mandatory evaluation. We offer two ways for you to complete. Choose an option below to receive credit and your certificate of completion. Scan this QR code to complete your CE now !
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• Go to BOOK.CME.EDU . Locate the book code MDDC0824 found on the back of your book and enter it in the box then click GO . • If you already have an account created, sign in to your account with your username and password. If you do not have an account already created, you will need to create one now. • Follow the online instructions to complete your self- assessment. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online evaluation. • To find elective hours, please visit DC.CME.EDU ONLINE FASTEST AND EASIEST!
Enter book code
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MDDC0824
If you need help finding your code, Browse Book Code FAQs
• Fill out the answer sheet and evaluation found in the back of this booklet. Please include a check or credit card information and e-mail address. Mail to InforMed, PO Box 2595, Ormond Beach, FL 32175-2595 . • Completions will be processed within 2 business days from the date it is received and certificates will be e-mailed to the address provided. • Submissions without a valid e-mail will be mailed to the address provided. BY MAIL
BOOK CODE: MDDC0824
1-800-237-6999
BOOK.CME.EDU
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INFORMED TRACKS WHAT YOU NEED, WHEN YOU NEED IT
District of Columbia Professional License Requirements
LGBTQ CULTURAL COMPETENCY (MD/DO/PA) In accordance with the Code of the District of Columbia § 3–1205.10, any continuing education requirements for the practice of any health occupation licensed, registered, or certified under this section must include two (2) credits of instruction on cultural competency or specialized clinical training focusing on patients who identify as lesbian, gay, bisexual, transgender, gender nonconforming, queer, or question their sexual orientation or gender identity and expression (“LGBTQ”), unless exempt. The instruction required shall, at a minimum, provide information and skills to enable a health professional to care effectively and respectfully for patients who identify as LGBTQ. PHARMACOLOGY (MD/DO) In accordance with the Code of the District of Columbia § 3–1205.10, as a condition for renewal of licenses for the practice of medicine, continuing education requirements must include instruction on pharmacology, which shall: (a) Be evidence-based; (b) Provide physicians with information regarding the cost-effectiveness of pharmacological treatments; and (c) Not be financially supported by any pharmaceutical company or manufacturer. EXISTING CME REQUIREMENTS Physicians (MD/DO) and Physician Assistants (PA) are required to complete at least 10% of their required total continuing education hours in topics identified by the Director of the Department of Health as public health priorities. For physicians (MD/DO), who have a fifty (50) hour requirement (per D.C. Municipal Regulations §4614.2), at least five (5) hours must be in a topic designated as a public health priority. For PAs, who have a one-hundred (100) hour requirement (per D.C. Municipal Regulations § 4906.4), at least ten (10) hours must be in a topic designated as a public health priority. This new requirement is part of the existing CE requirements. For more information regarding this requirement, see page 70. UPDATED CONTINUING MEDICAL EDUCATION REQUIREMENTS (NEW 10% RULE)
Department of Health Board of Medicine 899 North Capitol Street, NE Washington, DC, 20002 P: (877) 672-2174 We are a nationally accredited CME provider. For all board-related inquiries please contact:
COMPLETION DEADLINE: 12/31/2024
LICENSE TYPES: MD/DO & PA
Disclaimer: The above information is provided by InforMed and is intended to summarize state CE/CME license requirements for informational purposes only. This is not intended as a comprehensive statement of the law on this topic, nor to be relied upon as authoritative. All information should be verified independently.
ii
MOC/MIPS CREDIT INFORMATION
In addition to awarding AMA PRA Category 1 Credits TM , the successful completion of enclosed activities may award the following MOC points and credit types. To be awarded MOC points, you must obtain a passing score and complete the corresponding activity evaluation.
Table 1. MOC Recognition Statements Successful completion of certain enclosed CME activities, which includes participation in the evaluation component, enables the participant to earn up to the amounts and credit types shown in Table 2 below. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit. Board Programs ABA American Board of Anesthesiology’s redesigned Maintenance of Certification in Anesthesiology TM (MOCA®) program, known as MOCA 2.0®
ABIM
American Board of Internal Medicine’s Maintenance of Certification (MOC) program
ABOHNS American Board of Otolaryngology – Head and Neck Surgery’s Continuing Certification program (formerly known as MOC)
ABPath
American Board of Pathology’s Continuing Certification Program
ABP
American Board of Pediatrics’ Maintenance of Certification (MOC) program
Table 2. Credits and Type Awarded
AMA PRA Category 1 Credits TM 2 AMA PRA Category 1 Credits T M 1 AMA PRA Category 1 Credit T M 2 AMA PRA Category 1 Credits T M
Activity Title
ABA ABIM ABOHNS ABPath
ABP
Improving Access to Care for LGBTQ Patients
2 Credits LL 1 Credits LL 2 Credits LL 3 Credits LL
2 Credits MK 1 Credits MK 2 Credits MK 3 Credits MK
2 Credits SA 1 Credits SA 2 Credits SA 3 Credits SA
2 Credits LL 1 Credits LL 2 Credits LL 3 Credits LL
2 Credits LL+SA 1 Credits LL+SA 2 Credits LL+SA
Antibiotic Stewardship
Alternatives to Opioids for Pain Management Effective Management of Acute and Chronic Pain with Opioid Analgesics
3 AMA PRA Category 1 Credits T M 3 Credits LL+SA Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, LL+SA = Lifelong Learning & Self-Assessment, PS = Patient Safety
Table 3. CME for MIPS Statement Completion of each accredited CME activity meets the expectations of an Accredited Safety or Quality Improvement Program (IA PSPA_28) for the Merit-based Incentive Payment Program (MIPS). Participation in this Clinical Practice Improvement Activity (CPIA) is optional for eligible providers.
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IMPROVING ACCESS TO CARE FOR LGBTQ PATIENTS
COURSE DATES:
MAXIMUM CREDITS:
FORMAT:
Release Date: 3/2022 Exp. Date: 2/2025
2 AMA PRA Category 1 Credits ™
Enduring Material (Self Study)
TARGET AUDIENCE This course is designed for all physicians (MD/DO), physician assistants, and nurse practitioners. The purpose of this course is to help improve care and health outcomes of the LGBTQ population by recognizing the existing disparities and increased health risks present in this population. This course will examine system and provider/client barriers to equality in healthcare. COURSE OBJECTIVE
HOW TO RECEIVE CREDIT:
• Read the course materials.
•
Complete the self-assessment questions at the end. A score of 70% is required.
• R eturn your customer information/ answer sheet, evaluation, and payment to InforMed by mail or complete online at BOOK.CME.EDU .
Completion of this course will better enable the course participant to: 1. Discuss concepts regarding healthcare disparities of the LGBTQ population. 2. Identify strategies to improve healthcare access of the LGBTQ population. 3. Describe health risks within the LGBTQ community resulting from healthcare disparities. 4. Identify strategies to improve health outcomes in the LGBTQ community. LEARNING OBJECTIVES
ACCREDITATION STATEMENT InforMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. DESIGNATION STATEMENT InforMed designates this enduring material for a maximum of 2 AMA PRA Category 1 Credits ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. IMPLICIT BIAS IN HEALTHCARE Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics.
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FACULTY Sarab Sodhi, MD, MAUB Assistant Professor Cooper Medical School of Rowan University Margaret Salinas, PhD, MS, APRN, FNP-C Lead APRN Planner and Editor Colibri Healthcare
COURSE SATISFIES
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LGBTQ CULTURAL COMPETENCY
ACTIVITY PLANNER Michael Brooks CME Director InforMed
SPECIAL DESIGNATION
This course satisfies two (2) credit hours of instruction on LGBTQ Cultural Competency in accordance with DC law 21-95.
DISCLOSURE OF INTEREST In accordance with the ACCME Standards for Integrity and Independence in Accredited Continuing Education, InforMed implemented mechanisms, prior to the planning and implementation of this CME activity, to identify and resolve conflicts of interest for all individuals in a position to control content of this CME activity.
D.C. Law 21-95 requires that any continuing education requirements for the practice of any health occupation licensed, registered, or certified by a Health Occupation Board include two (2) credits of instruction on cultural competency or specialized clinical training focusing on LGBTQ patient, unless exempt.
FACULTY/PLANNING COMMITTEE DISCLOSURE The following faculty and/or planning committee members have indicated they have no relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients: • Sarab Sodhi, MD, MAUB • Margaret Salinas, PhD, MS, APRN, FNP-C • Michael Brooks
STAFF AND CONTENT REVIEWERS InforMed staff, input committee and all content validation reviewers involved with this activity have reported no relevant financial relationships with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
DISCLAIMER *2024. All rights reserved. These materials, except those in the public domain, may not be reproduced without permission from InforMed. This publication is designed to provide general information prepared by professionals in regard to the subject matter covered. It is provided with the understanding that InforMed, Inc is not engaged in rendering legal, medical or other professional services. Although prepared by professionals, this publication should not be utilized as a substitute for professional services in specific situations. If legal advice, medical advice or other expert assistance is required, the service of a professional should be sought.
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To date, the available research has mainly focused on lesbian, gay, and bisexual individuals with limited information on transgendered individuals. Findings vary among different sources, primarily because of differing methodologies for data collection. 1 Sexual orientation is a multidimensional construct that consists of sexual identity, sexual and romantic attraction, and sexual behavior. Sexual orientation describes a person’s identity in relation to the gender(s) that they are attracted to and how they act on that attraction. This orientation includes heterosexuality (attraction to the opposite sex), homosexuality (attraction to the same sex), bisexuality (attraction to both male and female sexes), pansexuality (attraction to all sexes), and asexuality (no attraction to any sex). 3 Similar to sexual orientation, significant changes have occurred over time in the scientific understanding of gender. Gender is a ubiquitous and multi-faceted social category. When discussing the concept of gender, scientists distinguish between biological sex, gender identity, and gender expression. Though one’s biological sex, gender identity, and gender expression are distinct constructs, society expects that they will align. For most individuals this is true – that is, most individuals who are assigned female at birth identify as girls or women and adopt a feminine gender expression, while most individuals who are assigned male at birth identify as boys or men and adopt a masculine gender expression. 4 However, for some individuals, these constructs do not align. The term transgender refers to individuals whose gender identity is not consistent with their sex assigned at birth. The terms gender nonconforming or gender incongruence refer to individuals whose gender expression does not conform to the stereotypical norms in their culture for any assigned sex at birth. 3,5 Infants’ biological sex is labeled at birth, almost always based solely on external genital appearance; this label given at birth is referred to as one’s assigned sex at birth. Sex assigned at birth helps to determine health risk factors and the need for screening, particularly if there are remaining natal organs (i.e., breasts, ovaries, testes). 6 Gender identity refers to a person’s deeply felt, inherent sense of being. A person can identify as a girl, a woman, or female; a boy, a man, or male; a blend of male or female; or an alternative gender. Gender expression refers to the ways a person communicates their gender within a given culture, such as clothing choices and communication patterns. A person’s gender expression, the ways in which a person demonstrates their gender, including naming conventions, social presentation, and pronouns, and often aligns with gender identity. 5 In the past, diverse sexual orientation has been considered pathologic or a medical condition in need of treatment. The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) listed homosexuality as a sociopathic disorder. Homosexuality was not removed as a diagnostic category until 1973 when the American Psychiatric Association (APA) decided that homosexuality did
not fit the criteria of mental disorder. However, until 1987, the APA continued to include a diagnostic category for individuals who were unhappy with their sexual orientation, which supported the development of conversion therapies. 7 Since that time, many organizations, including the American Medical Association, the American Academy of Pediatrics, and the American Counseling Association, have issued statements condemning conversion therapy and supporting gender- affirming care. Furthermore, scientists and clinicians now understand that identifying with a gender that does not align with sex assigned at birth, as well as a gender expression that varies from that which is stereotypical for one’s gender or sex assigned at birth, is not inherently pathological. 4 However, people may experience distress associated with discordance between their gender identity and their body or sex assigned at birth (i.e., gender dysphoria) as well as distress associated with negative social attitudes and discrimination. This shift in the understanding of gender identities and expressions was reflected in the replacement of the category “Gender Identity Disorder” with “Gender Dysphoria” in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders . 8 The diagnosis of Gender Dysphoria, which is marked in children and adolescents by clinically significant distress associated with the discordance between biological sex and gender identity that disrupts school or social functioning, depathologizes diverse gender identities and expressions. This newer definition focuses instead on the potential psychosocial challenges associated with gender diversity. Sexual orientation questions are included in 11 federal surveys and, of these, seven also have an inquiry regarding gender identity. 9 Gender identity questions were added to the National Health Interview Survey (NHIS), a principal source of US population health, beginning in 2013, 3 and in the National Survey on Drug Use Abuse and Health (NSDUH) in 2015. It is important for healthcare providers to understand the differences between gender identity, sexual orientation, and sex assigned at birth and how these factors are important. The 2020 census was the first census that included a question specifically about same-sex relationships. Optional answers included opposite OR same-sex husband/wife/spouse and opposite OR same-sex unmarried partner. 10 Use of census data assists in determining federal funding to states. In 2015, $175 million in funding for Housing Opportunities for Persons with AIDs, $312 billion for Medicaid, and $71 billion in money for food stamps was received through census data. 11 LGBTQ people are among those most likely to rely on these programs, and under-representation may affect financial assistance. 11 Unfortunately, a single question is unable to reflect this diverse population.
Introduction People who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) come from all walks of life, including people of all races and ethnicities, all ages, all socioeconomic statuses, and from all geographic regions. The Centers for Disease Control and Prevention (CDC) and many professional organizations assert that the perspectives and needs of LGBTQ people should be routinely considered in all medically related interactions to improve overall health and eliminate health disparities. 1 To have productive and health-promoting interactions with LGBTQ patients, clinicians need to recognize the differences among sexual orientation, gender identity, and gender role, understand the health disparities faced by people who identify as LGBTQ, be able to identify specific health risks, and ensure they create a welcoming environment for all people. The purpose of this course is to discuss the disparities in healthcare and increased health risks that exist in the LGBTQ population; identify system, provider, and client barriers; and examine ways to provide better care. In addition, this CME learning activity is designed to improve the care and health of LGBTQ patients by educating providers on the perspectives and needs of LGBTQ patients as well as ways to improve practices, office settings, policies, and staff training to make them welcoming and supportive for everyone. The author would like to emphasize there is no single definition of the LGBTQ community. Instead, just as any other group or community, the LGBTQ community is made up of a group of individuals from a variety of racial/ ethnic backgrounds, cultures, incomes, religions, and many other characteristics, resulting in unique diverse groups of individuals. 2 Stigma is a commonly shared experience among the groups.
A Note About Acronyms
This learning activity uses LGBTQ as the acronym for discussing the entire range of sexual orientation, gender, and sexual behavior, with the acknowledgement that there are some variations not captured explicitly by the terms “Lesbian,” “Gay,” “Bisexual,” “Transexual,” and “Queer.” (“Queer” and “genderqueer” are non-pejorative terms describing people whose sexual orientation is not exclusively heterosexual or homosexual.) LGBTQ is the acronym currently used by the Human Rights Campaign, the Gay and Lesbian Medical Association, and many (but not all) other organizations focused on sexual minority/gender non-conforming individuals. Still, language and usage are constantly changing. In the future, variations that attempt to be more inclusive such as LGBTQ+ or LGBTQ* may become more standard.
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If the healthcare community in general or individual caregivers have a preconceived concept of gender as male or female, sexual orientation as based on gender at birth, or sexual activity as between heterosexual individuals, and do not venture from this idea, information will be missed that may affect the health of an individual. Provider discomfort with inquiry into sexual orientation, gender identity, and sexual activity may inhibit an open discussion on sexual risk factors. There also may be a lack of awareness of the risks of LGBTQ patients or a desire to remain impartial and avoid cultural discussions. 18 In both cases, providers may potentially miss important information. In examining disparities in healthcare, it is crucial to consider patient factors such as access to care. Is the population (or person) able to receive care? There are a variety of factors that can affect the ability to access care, including the following: insurance coverage or the financial means to pay for care; ability to access the care, which can relate to location, transportation, finances, and/or desire; and locating a qualified provider one feels comfortable with, which may vary according to culture, gender, race, and sexual identity to name a few. Additional difficulties can arise in small tight- knit communities and rural areas where decreased access to care, lower incomes, and lack of public transportation may already exist. 19 Transgender people in particular report difficulty finding gender- affirming healthcare. 20,21 While these examples are mainly interpersonal/ relational, there are also system/institutional barriers. Smith and Turell 22 identified several themes in their study, including substandard care, lack of determinants for quality care, heteronormativity in forms, extra documentation for partner participation in care, geographic barriers to LGBTQ-friendly care, and inadequate insurance. Under the Winsor & Obergefell ruling, federal and state employees with same-sex married spouses are guaranteed the same benefits as heterosexual married couples. 2 However, 45% of the LGBTQ population lives in states that do not have LGBTQ- inclusive insurance protection. 23
Epidemiology The most accurate and current information about LGBTQ demographics is based on independent polling and survey organizations. The most recent large-scale survey was a 2021 Gallup report based on interviews with a random sample of approximately 15,000 U.S. adults, which showed that the proportion of American adults identifying as LGBTQ increased to 5.6% from 4.5% in 2017. Millennials (born 1981-1996) and Generation Z (born 1997-2002) are more likely to identify as bisexual compared to lesbian, gay, transgender, or other. 12 As the general population ages, the number of older LGBTQ adults will increase as well. By 2030, there will be an estimated 2 million to 6 million LGBTQ adults ≥65 of age in the United States (vs. an estimated 1 million to 2.8 million in 2000), approximately 120,000 of whom are projected to be living in nursing homes. 13 These individuals will have distinct healthcare needs and face well-documented health-related disparities including disability, poor mental health, smoking, and increased alcohol consumption. In addition, older lesbians have a higher risk of developing metabolic syndromes and cardiovascular disease (CVD). Older transgender adults are at significantly higher risk of poor physical health, disability, depression, and perceived stress compared with cis-gender patients. 13,14 Risk Identification To identify risk, healthcare providers need to see, talk to, and examine patients. This point sounds obvious, but there are many barriers that may prevent this examination and communication from occurring. One of the most common barriers in caring for LGBTQ people is the lack of provider training and experience in caring for sexual minority persons. 15,16 This lack of training may cause a fear of missing or doing something wrong or result in inadvertently doing or saying something offensive. Provider implicit bias can also prevent risk identification in the LGBTQ population. Bias can stem from religious or cultural backgrounds, fear of the unknown or unfamiliar, 16,17 and preconceived ideas from media representation.
Healthy People Goals
A goal of Healthy People 2020 was to increase the health, safety, and well-being of LGBTQ people. 24 Progress has focused on population- based data systems to increase their collection on Healthy People objectives, or recommendations for LGBTQ or states and territories to increase their data collection in the Behavioral Risk Factor Surveillance System. 25 Additional important goals are to increase the quantity and uniformity of data collected on transgender individuals. The inclusion of sexual orientation and gender identity questions on health history forms is an excellent beginning to open discussions in the healthcare setting. LGBTQ objectives for Healthy People 2030 fall under the major goal of improving the health, well- being, and safety of LGBTQ people. 26 The objectives are then classified under the following categories: adolescents, drug and alcohol use, mental health, infrastructure, and sexually transmitted infections. Within these categories, there are a variety of objectives including reducing bullying, illicit drug use, and increasing the number of entities collecting data on LGBTQ health. 25 The focus of the adolescent objectives is to reduce bullying, both in-person and cyberbullying. The 2019 Youth Risk Surveillance Survey found that 32% of adolescents who identify as a member of a sexual minority group report they were bullied at school and 26.6% report being cyberbullied. Almost twice as many students who are lesbian, gay, or bisexual compared to their heterosexual peers reported missing school because of concerns for their personal safety. 27 Accessing or Avoiding Healthcare Quality of care is important for all patients and providers and is paramount to achieving positive outcomes. Part of the healthcare experience results from the patient-provider relationship along with the general experience of the patient in the healthcare setting, whether clinic, hospital, or community. A qualitative study by Smith and Turell 22 examined the differences in expressed needs of different groups (lesbian, trans woman, gay, and HIV+ gay men) seeking healthcare in the LGBTQ community. Participants had a wide range of feelings on topics and several areas of agreement.
Terms to Avoid These terms may have been used in the past but are now considered outdated and may be offensive. In addition, while patients may use these terms, when in doubt, the provider should ask the patient which terms they prefer. Unacceptable Acceptable Berdache (to describe gender non-conforming indigenous people) Two-spirit Gender reassignment surgery Gender assignment surgery Homosexual Gay or lesbian Intersex/hermaphrodite Disorders of sex development Sex change Gender affirmation surgery Sexual preference Sexual orientation Transgendered/a transgender Transgender
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First, there were differences regarding identity disclosure to providers, with the HIV+ group noting the importance of informing the clinician on their positive status. Levels of comfort on disclosure varied from no concern “for the straight people’s discomfort” 22(p643) to great concern about how one’s healthcare would be affected by disclosure and how the information would be stored and shared. 22 Participants also shared that they experienced lapses in confidentiality such as using incorrect pronouns, physician sharing HIV+ status with family at bedside rounds after surgery, and other situations that eroded patient trust. Although this study has several limitations, including small sample size (n=26) and exclusion of persons of color/trans men, similar findings were identified in other studies. 2,28,29 Participants also perceived discomfort and heteronormative expectations of healthcare professionals. These examples ranged from unfamiliarity with terms of address, lack of knowledge of LGBTQ health needs, too much focus on sexual health, and implicit bias such as assuming that a woman needed birth control because she is sexually active, that a lesbian’s partner is her “husband,” or that gays or lesbians do not have children. Participants also identified overt discrimination, homophobia, and transphobias and discussed being made to feel like a “freak” by staff and providers through refusal of care, excessive use of personal protective equipment inappropriate for the situation, and putting the LGBTQ person on display. 22,28 Overall, findings revealed general heteronormativity in healthcare, lack of knowledge of LGBTQ healthcare needs, and microaggressions or phobias of clinicians and staff. These experiences led to patients feeling stressed and stigmatized. 22 Nondiscrimination in Access to Healthcare The Affordable Care Act (ACA) implemented in 2010 and the expansion of Medicaid in 2014 increased the rate of LGBTQ adults who have insurance. In states that have adopted the expansion, 8% are uninsured and 25% have Medicaid compared to states that did not adopt the expansion where rates are 20% uninsured and 13% have Medicaid. 21,30 The ACA set nondiscrimination protections for LGBTQ people, which included prohibition of discrimination or refusal of care based on sexual orientation and gender identification in any ACA health plan as well as any health program receiving federal funds (including Medicare and Medicaid). 21 These protections and the removal of limits on chronic or pre-existing conditions mean an increase in access to care. However, there are still problems for transgender individuals, especially people of color, desiring transition-related care. A Center for American Progress study 21 found that 43% of transgender individuals and 48% of transgender people of color were denied transition surgery, with 38% of transgender individuals and 52% of transgender people of color being denied hormone therapy for transition. 21
No Judgment
A note about conversion therapy
The National LGBTQIA+ Health Education Center has published suggestions for improving healthcare environments for LGBTQ patients. 33 One suggestion includes posting a nondiscrimination policy, signed by the staff, in plain view of patients. A nondiscrimination policy helps ensure commitment to an environment in which all people are valued and respected and provides an opportunity for staff members to examine their own beliefs and assumptions about race, age, sex, gender, and marital relationships. Another suggestion is to provide an area to display local LGBTQ resource information. Using an intake form that allows a patient to provide personal information in a nonjudgmental manner will set the tone for quality patient-provider interactions. The inclusion of domestic partnership under the “relationship status” of a history form as well as options for transgender individuals, such as male-female or female-male, may help patients feel more comfortable sharing this information. Additional suggestions include providing more inclusive options for screening questions, using open-ended questions, and using the term “partner” rather than “spouse.” It is dangerous to assume how others may behave. When a provider believes a particular person, group, or community has a characteristic or action, they risk overlooking potential conditions. Asking the patient about their definition of behavior, sexual activities, language, or terminology helps prevent misperceptions that endanger health. An example may be a person who does not consider themselves in terms of sexual orientation, that is, they do not identify as heterosexual, homosexual, bisexual or asexual, and may have sexual partners of both genders; Providers should avoid assuming that a lesbian, or her female partner, has never had intercourse with a male or has never been pregnant. Focus on questions about anatomy and behavior to gain information about potential health risks and opportunities for health promotion.
Conversion therapy—the effort to change an individual’s sexual orientation, gender identity, or gender expression—is not supported by credible evidence and has been disavowed by behavioral health experts and associations. Conversion therapy perpetuates outdated views of gender roles and identities as well as the negative stereotype that being a sexual or gender minority or identifying as LGBTQ is an abnormal aspect of human development. Most importantly, it may put young people at risk of serious harm. 31
Importance of History
Health disparities and unidentified risks exist for many reasons, including poverty, inadequate access to healthcare, environmental threats, and individual factors. One important potentially unrecognized weakness is obtaining the appropriate health history in a nonjudgmental manner. Each provider should act as a concerned practitioner, looking out for the well-being of each patient. Providers should ask open-ended questions, encourage patients to share important information about potentially risky behaviors, and listen in a nonjudgmental manner. While a provider may be aware that certain patients are lesbian or gay, or that certain heterosexual patients have high-risk sexual practices, social discomfort regarding the topics may lead to avoidance. It is important for a provider to talk openly and objectively with these patients about potential risk factors. In addition, health history forms may contain presumptive language about sexual partners. Staff members may exhibit a bias based on a patient’s appearance or way of speaking. A patient’s perception of bias may lead to a reluctance to discuss symptoms or may even cause them to avoid seeking additional care. This could lead to missed opportunities for screening, consideration, diagnosis and treatment of potential disease processes.
Obtaining a sexual history—questions to consider and use 6 :
Evidence-Based Practice
To obtain pertinent health-related information, it is important to ensure confidentiality and gather a complete sexual history during a nonjudgmental discussion. This sexual history form should be used with all patients in the healthcare practice. If staff members are obtaining this information, practitioners should display a privacy statement in the office and/or provide such a policy to patients. Ensuring privacy is important and should be guaranteed for everyone. • Are you sexually active? • With whom do you have sex? • What parts of your body do you use when having sex? • What do you do to practice safe sex?
A 2017 national survey showed that LGBTQ patients experienced discrimination in healthcare settings because of their sexual orientation, and this discrimination keeps them from seeking care or may lead to trouble finding care if turned away. 32 This study demonstrates the discrimination that still exists against the LGBTQ population and the need to educate healthcare providers to mitigate such disparity.
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Many forms used today assume heterosexual and monogamous behavior. Changing the form to include gender rather than sex, and providing the options “male,” “female,” “transgender,” or “both” to questions about recent sexual partners, recognizes that alternative relational patterns exist. This use of an inclusive form provides patients with the opportunity to provide accurate information. Creating a welcoming environment LGBTQ patients often assess a clinical practice for clues to help determine what information they feel comfortable sharing with a healthcare provider. The following are among the measures that can promote a more welcoming environment and encourage patients who are LGBTQ to access care: • Post a rainbow flag, pink triangle, unisex bathroom signs, or other LGBTQ-friendly symbols or stickers. • Exhibit posters showing racially and ethnically diverse same-sex couples, transgender people, or posters from nonprofit LGBTQ or HIV organizations. • Display brochures (multilingual when appropriate) about LGBTQ health concerns. • Distribute or visibly post a nondiscrimination 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. • Display magazines or newsletters about and for LGBTQ and HIV-positive individuals. • When possible, diversify staff. Hire openly lesbian, gay, bisexual, and/or transgender staff, who can provide valuable knowledge and perspectives about serving LGBTQ patients, as well as help patients feel comfortable. Ensure non-discrimination statements are included in job postings. • Review and consider rooming and visitation policies to ensure they are inclusive. • Physicians communicate an impression of their practice and can set a positive tone with patient • intake forms. These inclusive forms can help patients feel more comfortable and open about their sexual orientation or gender identity/expression. • Ensure that clinic staff is aware of the process for responding and reporting discrimination. • The following ideas may improve the inclusivity of forms and help clinicians with in- person discussions: • Intake forms and electronic medical records/ patient portals should include questions about sexual orientation, gender identity, and sex assigned at birth. °
• Ensuring that gender options include “transgender” and “nonbinary” allows for people to choose the option that most applies to them and offers an initial sign of acceptance. It may also be helpful to include a body map for patients to identify anatomic elements of their bodies. There should also be a space about how they would like to be referred to including asking about preferred pronouns. • Train front desk staff to avoid assumptions about identity and teach techniques to clarify ambiguity in a patient-centered way. Front desk staff should not make assumptions about patients’ gender or sexual identity or the gender of their spouses/ partners, and they should use gender-neutral terms whenever possible. When it is unclear or a staff member is unsure, she or he should ask the patient how they would like to be addressed. By anticipating the event where there may be a discordance between names/ genders on official identifications or insurance forms and what a patient is currently using, staff members can more effectively address the situation. Another strategy might be adding a name/identity reconciliation box or form. This strategy is particularly relevant for transgender patients in the process of transitioning from one gender identity to another. • Clinicians can encourage openness by explaining that patient-provider discussions are confidential and that they, the clinicians, need complete and accurate information to provide optimum and appropriate medical care. • Developing and distributing a written confidentiality statement will encourage people who identify as LGBTQ and other patients to disclose information pertinent to their health. The statement should be prominently displayed and distributed to each patient. Consider careful communication: Clinicians should always ask patients how they identify and wish to be addressed. Patients may use words that are considered derogatory like “dyke” to describe themselves. Although individuals might have reclaimed the terms for themselves, they are not appropriate for use by healthcare providers. The key is to follow the patient’s lead about self- description while exploring how this self-description relates to their current and potential medical needs. For example, avoid using the term “gay” with a patient even if they have indicated a same- sex or same gender sexual partner because if the patient has not indicated a particular identity or has indicated a sexual orientation other than gay, using this term may cause alienation and mistrust that can interfere with the patient-provider relationship. Therefore, clinicians need to elicit and understand all three aspects of sexual orientation: attraction, self-described identity and behavior, as well as gender identity.
Respect transgender patients by making sure all office staff are trained to use their preferred pronouns and names. Clearly indicate this information in their medical record for easy reference for future visits. Traditional personal pronouns are based on a binary she/he framework. An inclusive approach to addressing both gender nonconforming and transgender patients is to use non-binary personal pronouns. An optimal approach is to first provide your own personal pronouns and then ask patients how they would like to be called. For transgender patients, their answers may include pronouns such as “they,” “ze” (pronounced “zee”), or “xe (also pronounced “zee”). Some clinicians may be challenged using a pronoun that they learned in English classes as a plural now as a singular noun. However, this accommodation may improve rapport with patients. Tips for clinical encounters: • Don’t make assumptions about a patient’s body or behavior based on their initial visual presentation. • Get in the habit of assessing preferred pronouns at every visit. The most common format used is to introduce yourself and state your preference, as in “I’m Dr. Jones, and I use the pronouns she/her; how about you?” • Understand that discussing genitals or sex may be very sensitive, stressful, or possibly traumatic for certain patients. Therefore, always ask permission before any physical contact and clearly explain all processes, tests, or examinations before they are done. For more information, visit the National LGBTQIA+ Health Education Center at www.lgbtqiahealtheducation.org . Clinical consideration: Used the wrong pronoun or name? Overheard your staff? A simple apology and dedication to do better may make the difference in your patient staying with your practice or not. “I’m sorry I used the incorrect pronoun. I did not intend to be disrespectful.” BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 1 ON THE NEXT PAGE. Health Risks for LGBTQ Patients LGBTQ patients have the same risk factors as any patient, but they also have risk factors and healthcare disparities that require special consideration. Healthy People 2020 targeted health disparities for elimination among LGBTQ people. 34 Research showed that negative health outcomes of LGBTQ individuals are often related to stigma, discrimination, and denial of human rights. 34 Eliminating disparities and improving LGBTQ health are important in contributing to increased longevity, decreased expenditure for healthcare, reduced disease transmission, and increased physical and mental wellness. 34
Use neutral terms on forms such as “relationship status” instead of “marital status.” Avoid referring to questions as “female only” or “male only” and instead leave a box for “not applicable.”
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Case Study 1 - Part 1
Instructions: Please read through the case study below and consider the questions that follow, then do the same for Part 2.
Sam had been searching for a primary care provider for months. He wanted to find someone who would treat him like a person, not a freak. In the previous primary care clinic where he received care, he overheard a front desk person commenting it was a shame that such a pretty girl was going to be a male. Fortunately, that was a different place, and he was now away at graduate school in a liberal arts college with a Campus Pride Index of 4.5. Someone in the resource center recommended this office, and he had a few things he hoped to find once he arrived. Sam called to inquire and received a package of information electronically that already gave him some comfort. Instead of the questions Sam had normally seen, these forms had options for gender that included transgender and relationship questions that did not assume married or single but allowed for partnered.
1. From the information in the case study, how does Sam identify?
2. What type of barrier to care did Sam experience in his previous primary care practice?
Discussion for Question 1: Gender identity is a personal feeling or idea that one has of themselves. One may choose to express their gender identity through the way they dress, behave, and mannerisms they use. They may also select pronouns they feel express who they are. The most identified genders are male, female, intersex, non-binary, trans, and non-conforming. Gender identity may or may not conform to assigned sex at birth. At birth Sam was identified as female according to anatomy and now identifies as male and is referring to himself as “he.” Gender transition occurs when a person begins to live their gender identity. This transition is different for each individual and may include changing clothing, appearance, name, pronoun, identification, and for some, may include hormone therapy and/or surgery. Discussion for Question 2: Multiple barriers can affect a person’s access to healthcare. Relational or interpersonal interactions and system or institutional functions can present barriers impeding or serving as a discouragement for individuals needing or desiring healthcare. Sam purposefully left a previous healthcare provider because of insensitivity and bias from an employee who commented on his male identification. This is an example of a personal or relational barrier that created a stressful situation for Sam and resulted from the bias of another person. The experience of stigma is common among LGBTQ people and is a cause for stress and avoidance of healthcare. Insensitivity and/or discomfort of providers and office staff and occasionally refusal of care are also in this personal/relational category. System or institutional barriers are issues like transportation, distance, access to appropriate care, insurance restrictions, and assumed heteronormativity.
Case Study 1 - Part 2
Sam entered the office and scanned the waiting room/reception area. There were several areas for literature around the room, with one section dedicated to sexual minorities. The receptionist greeted Sam, and he handed her his previously filled out forms. The receptionist asked for a preferred first name and pronoun. Sam felt relieved that he could tell the office his preferred pronouns were he/him/his because the legal-name- change paperwork was not finalized. He grabbed a brochure and had a seat to wait for his appointment. In about 10 minutes, he heard someone call his name and he stood to walk in the back. After having his height and weight measured, he was led to an exam room. The nurse introduced herself, and Sam noticed a framed print on the wall titled “We Promise.” The nurse saw him looking at it and explained the people who worked here felt very strongly that each person deserved respect and privacy for who they were and what they believed, and that everyone signed it. She asked a few questions and then handed him a form, saying they have all adult patients complete it and that the nurse practitioner would go over it with him. He turned it over and saw it was a sexual history form.
3. What are some methods the office used to provide a welcoming environment for LGBTQ people?
Discussion for Question 3: This office provided a section in the waiting room for literature relating to local resources and information for LGBTQ individuals. The intake form included preferred gender and pronoun, which was reinforced by the receptionist. Instead of asking only for marital status, it included additional options. In the exam room there was a nondiscrimination policy statement signed by employees, which showed their support for all individuals. Finally, the use of a sexual history form to be reviewed with a provider serves as a starting point for a discussion related to sexual practices and assists with risk identification. There are additional methods including displaying sexual minority couples, displaying a rainbow flag or sticker, providing a gender-neutral toilet facility, and listing your office on the Gay and Lesbian Medical Association (GLMA) directory.
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