People who are transgender or gender diverse have expressed difficulty in finding culturally affirming medical care, especially in rural areas. Both healthcare providers 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 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 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 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.
Address one’s own bias. Explicit bias is conscious; the person is aware of their feelings, which may be expressed in words or actions. Implicit bias is unconscious and can reflexively interfere with assessments, decision-making, and provider- patient relationships. 82 Both explicit (conscious) and implicit (unconscious) bias should not be in healthcare. The former will take significant time and effort to overcome. Implicit bias must be uncovered and identified by the individual who must then desire to change their thoughts and behavior. 81 Several versions of the Implicit Association Test 82 can be accessed online (https://implicit.harvard. edu/implicit /takeatest.html). Consider taking the Sexuality IAT, Transgender IAT, and Race IAT to assist with your self-evaluation. Use of screening tools and guidelines. Guidelines and screening tools exist for general wellness in primary care practice and for specialty diagnosis in multiple settings. Additional research is needed to provide consistent care and optimize outcomes for our LGBTQ clients, including adequately developed guidelines that are evaluated and revised as information is updated. BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 2 ON THE NEXT PAGE. Resources Many online sites provide education and CME credit related to sexual minority healthcare. The following list represents just a few of the hundreds of available resources. You can search by state and even locally to determine what is in your area . The National LGBTQQ+ Health Education Center (https://www.lgbtqiahealtheducation. org/resources/) provides free publications, videos, webinars, and learning modules, many with continuing education credits, on multiple topics including providing inclusive healthcare, understanding disparities, and understanding health needs among others. The CDC (https://www.cdc.gov/stophivtogether/ hiv-prevention/) provides a variety of healthcare provider trainings along with some clinical care protocols and resources for HIV prevention and treatment. The American College of Obstetricians and Gynecologists (https://www.acog.org/ clinical/clinical-guidance/committee-opinion/ articles/2012/05/healthcare-for-lesbians-and- bisexual-women) provides recommendations for the healthcare of lesbian and bisexual women.
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