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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