Providing an Inclusive Environment for LGBTQIA+ Patients in Healthcare

PracticeUpdate: What are the common barriers for patients from the LGBTQIA+ community when accessing healthcare services?

Dr. Hayon: Access is a huge issue. Barriers to access can come in many forms—lack of insurance coverage; no clinicians who are local and/or in-network who are knowledgeable about providing the care they need; legislation that impedes access. 

If a letter of support from a therapist is required for surgical care, there is an additional barrier of finding a therapist who has experience caring for trans and nonbinary patients. It's not uncommon for patients to have to wait for 6 to 9 months to get in with a therapist who can write them a letter. 

LGBTQIA2S (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, Two-Spirit) couples who would like to be parents face unique challenges as well. 

• Many insurance plans won't cover assisted reproduction unless very specific criteria are met. Often these criteria don't apply to LGBTQ+ couples (eg, actively trying to get pregnant without medical intervention for a certain amount of time; clinical evidence of "male factor" infertility).

• Legal factors are a concern for LGBTQ+ families as well. Legal considerations are usually impacted by the state someone lives in since laws differ by state, plans for parenthood (ie, insemination vs adoption vs gestational carry vs fostering), and relationship status (single vs married vs in an unmarried relationship).

• The costs of medical care for assisted reproduction as well as legal fees to help protect the parental rights of both parents can sometimes mean that parenthood is financially out of reach for some couples.

Laws around parentage and family-building are not the only legal worries facing LGBTQIA2S people in the U.S.  So far this year, 491 anti-LGBTQ bills have been introduced into state legislatures across the country.  Of these, 77 have been passed into law and 209 are currently advancing through the legislative process. 

PracticeUpdate: What are the challenges being faced currently by physicians in treating the LGBTQIA+ patient category?

Dr. Hayon: With all of the legislation that is attacking gender-affirming care, doctors are often finding themselves in the position of trying to interpret legal rulings, which frequently have very confusing language. Sometimes it feels easier or safer to just stop providing gender-affirming care if the medicolegal risks are not immediately clear, but making that choice has obvious implications for the patients who need care.

Misinformation about transgender and nonbinary people is rampant right now, and it can be hard to know not only what information is accurate but how to clearly and compassionately correct misinformation.

PracticeUpdate: What strategies can physicians incorporate in their practice to make healthcare inclusive and unbiased towards patients from the LGBTQIA+ community?

Dr. Hayon:

• Schedule some CME that focuses on LGBTQIA2S healthcare. There are many regional and national conferences, as well as free online self-directed learning. It is essential that we take on the responsibility for educating ourselves rather than asking our patients to educate us.

• Do a walking tour of your clinic space and take note of the physical space and workflows that patients encounter when they come to the clinic.

  • What sort of artwork and reading materials are in the waiting room?

  • What is the bathroom access like? Are there any gender-neutral bathrooms with signs designating them as such?

  • What do your patient intake forms look like? Are there multiple options for patients to self-identify their sexual orientation, gender identity, and relationship status?

  • What systems are in place to help prevent staff from using the wrong name/pronouns for patients?

• Learn some new frameworks for taking a sexual history. Asking someone if they "have sex with men, women, or both" is not enough.

• It is important to remember that you don't have to be an expert in LGBTQIA2S healthcare to provide excellent, compassionate care. Being kind, using the right name and pronouns for your patient, and avoiding unnecessary questioning about someone's body and/or surgical history are relatively easy but enormously effective ways to create a welcoming clinic experience. If you don't know how to provide a specific kind of care (eg, gender-affirming hormones), it's very appropriate to refer patients to another clinician locally who can help. 

• We all make mistakes; so, it can be really helpful to have a plan for how to respond if/when you use the wrong name or pronouns or make an assumption about someone's relationship that turns out to be wrong.

  • Apologize and thank the patient. This should be short but heartfelt (eg, I'm so sorry I used the wrong pronouns. Thank you for bringing that to my attention. I'm sure that was hurtful, and I'll try hard not to let it happen again).

  • Move on. Sometimes we can feel awkward after making a mistake and end up spending a lot of time trying to explain ourselves, but this often makes things more awkward in the long run.

  • Strategize for the future. Are there reminders or flags that you can put in place in the EMR to alert you to someone's name or pronouns? If you huddle with nursing staff before your clinic session, make it a habit to review names, pronouns, and relationship status as part of that huddle.

PracticeUpdate: Are there any resources focused towards providing inclusive healthcare which the physician can access easily?

Dr. Hayon:

• The National LGBTQIA+ Health Education Center is one of my favorite resources.  They offer tons of free CME activities: https://fenwayhealth.org/the-fenway-institute/education/the-national-lgbtia-health-education-center/
• This is a document that they put out about creating inclusive health care environments : https://www.lgbtqiahealtheducation.org/wp-content/uploads/2021/05/Ten-Strategies-for-Creating-Inclusive-Health-Care-Environments-for-LGBTQIA-People-Brief.pdf
• UCSF's Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People: https://transcare.ucsf.edu/guidelines
• The Philadelphia Trans Wellness Conference: https://www.mazzonicenter.org/gender-affirming-care/philadelphia-trans-wellness-conference
• The World Professional Association for Transgender Health has a yearly conference for medical and mental health professionals: https://www.wpath.org/
• GLMA: Health Professionals Advancing LGBTQ+ Equality annual conference: https://www.glma.org/conference.php
• Gender Spectrum: https://genderspectrum.org/
• A podcast that I produce along with historian Dr. Rebecca Davis has a whole episode about taking a sexual history: https://www.reallyweirdquestion.com/