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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