Medical Grand Rounds

Ending LGBT invisibility in health care: The first step in ensuring equitable care

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ABSTRACTLesbian, gay, bisexual, and transgender (LGBT) individuals experience health care disparities that will be eliminated only if clinicians elicit information about sexual orientation and gender identity from their patients through thoughtful, nonjudgmental discussion and history-taking.

KEY POINTS

  • LGBT people are represented in most medical practices, and their health issues, including sexually transmitted diseases such as human immunodeficiency virus, can generally be managed in traditional health care settings rather than in special clinics.
  • Physicians need to become more comfortable asking patients about sexual health, identity, and behavior, and make such queries more routine.
  • Sexual behavior is not always congruent with routine understanding of sexual identity. For example, many men who do not identify themselves as gay occasionally have sex with men, as do many self-identified lesbians. It is important to know this to provide appropriate preventive screening and care.


 

References

In speaking about lesbian, gay, bisexual, and transgender (LGBT) health, it is not uncommon for me to be asked what is so unique about the health care needs of lesbians, gay men, bisexuals, and transgender individuals that it warrants focused attention in the training of health professionals and while providing care.1 Although it is true that most health issues affecting LGBT individuals parallel those of the general population, people who are LGBT have been shown to have unique health needs and to experience disparities in care.

There is a growing if limited number of good studies of LGBT health. The Institute of Medicine2 reported on lesbian health in 1999, concluding that enough evidence of disparities exists to support more research and to develop better methods of conducting the research. Healthy People 2020 actually recognizes significant health care disparities.3 Finally, the Institute of Medicine recently formed a committee on LGBT health issues to identify gaps in our knowledge and priorities for research. Their findings were expected to be published in late March 2011, after this article went to press.

MAKING A DIFFERENCE

While this article will not attempt to discuss all the disparities, the focus will be on how physicians can take the first critical step to helping LGBT individuals feel comfortable seeking care, ie, by being proactive in taking a history that includes discussion of sexual orientation and gender identity. Only by knowing this about patients will clinicians appropriately care for specific health needs, and will patients feel comfortable discussing their concerns in clinical settings.

While some feel this is relevant only in select areas of the country, recent data show that the LGBT population is both spread throughout the country and diverse in how they might present themselves in clinical settings.1,4 In the United States, 1.4% to 4.1% of people identify themselves as lesbian, gay, or bisexual.5 About 3% of women and 4% of men say they have had a same-sex sexual contact in the last year, and 4% to 11% of women and 6% to 9% of men report having ever had one.

Everyone who practices clinical medicine needs to understand whether patients are LGBT and how to engage in conversation about sexual orientation and gender identity.

GETTING TO KNOW LGBT PATIENTS

What questions should a clinician ask to get this information? In thinking about what to ask, it helps to realize that patients generally do not mind being questioned about personal matters if the provider approaches the topic and the patient with genuine respect, empathy, and even curiosity.

On the other hand, providers often feel ill-prepared to discuss intimate issues, or feel uncomfortable doing so. Successfully achieving a change in clinical practice involves learning an approach to doing so and becoming comfortable with discussions that may follow. One question to consider is how you will feel and how you will follow up if a patient tells you that he or she is LGBT.

The core comprehensive history for LGBT patients is the same as for all patients, keeping in mind the unique LGBT health risks and issues. Clinicians may begin by getting to know each patient as a person (eg, ask about partners, children, and jobs). I like to begin a session with a patient who is otherwise in good health with an open-ended question such as “Tell me a bit about yourself.” This provides an opportunity for patients to raise a range of issues without any additional focused questions being asked. In this context, if a patient brings up issues regarding sexual orientation or gender identity, ask permission to include this information in the medical record and assure the patient of its importance and that it will be confidential.

If these issues do not come up in response to general questions, they can be embedded in the sexual history, which should be more than a history of risk behaviors and should include a discussion of sexual health, sexual orientation (including identity, behavior, and desire), and gender identity. One can start by simply asking, “Do you have any concerns or questions about your sexuality, sexual orientation, or sexual desires?”

When it is necessary to ask more directed questions, it helps to provide some context so patients do not wonder why you are asking questions they may never have been asked by a physician before. It is best to explain that these are questions you ask all patients, as the information can be important in providing quality care. Patients should be told that discussion of sexual identity, behavior, and desire, as well as gender identity, is routine and confidential. For example, you might say: “I am going to ask you some questions about your sexual health and sexuality that I ask all my patients. The answers to these questions are important for me to know to help keep you healthy. Like the rest of this visit, this information is strictly confidential.”

One usually need not be too probing to get answers; people are often very forthcoming. During such conversations, patients often tell me that it is the first time a doctor has shown any interest in talking about these topics.

In having these conversations, initially it is best to use gender-neutral terms and pronouns when referring to partners until you know which to use: for example, “Do you have a partner or a spouse?” “Are you currently in a relationship?” “What do you call your partner?” Even if you make an incorrect assumption, and the patient corrects you, you can always apologize if a mistake is made and ask which term the patient prefers. Once you know it, use the pronoun that matches a person’s gender identity.

In order to get more information from the patient, the physician can engage in a series of questions, such as:

  • Are you sexually active?
  • When was the last time you had sex?
  • When you have sex, do you do so with men, women, or both?
  • How many sexual partners have you had during the last year?
  • Do you have any desires regarding sexual intimacy that you would like to discuss?

In general, it is best to mirror the patient’s language. If patients use the term “gay” or “lesbian” to describe themselves, it would be off-putting to the patient to use a more clinical term, such as homosexual, in response. Some patients may use terms such as “queer” to indicate that they do not choose to identify as gay or straight. If terms like this are unclear to you, you may simply ask what this term means to the patient.

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