Photo Credit: ADragan
To celebrate Pride Month, here are the seven LGBTQ+ health topics physicians should know about from Drs. McDonald and Nass’s conversation.
Physician’s Weekly editorial board member Alex McDonald, MD, CAQSM, FAAFP, spoke with Scott Nass, MD, MPA, FAAFP, AAHIVS (Aledade), about LGBTQ+ healthcare for a podcast episode. Since 2019, Dr. Nass has served as Chief Medical Officer for the transgender community-founded and led Transgender Health and Wellness Center in Palm Springs, Riverside, and San Diego, CA. Additionally, he is a past president of GLMA: Health Professionals Advancing LGBTQ Equality. To celebrate Pride Month, here are the seven LGBTQ+ health topics physicians should know from their conversation.
1. Who are LGBTQ+ patients, and what encompasses that term?
“As we start to see more role models in the media, we’re beginning to understand how expansive sexual orientation and gender identity can be,” says Dr. Nass. “Traditionally, we used LGBT to stand for lesbian, gay, bisexual, and transgender. That probably captured then, and still does, most folks who are members of the larger community. However, over the years, several other letters have been added: “Q” for queer, gender queer, and queer in terms of sexual orientation, so that’s a more encompassing letter. And then the ‘+’ to be inclusive, but we understand that not everyone will see themselves in ‘+.’ In some places, you might see “I” for intersex. Often, intersex folks are excluded when we have conversations around LGBTQ+ health. “A” can stand for asexual or aromantic. “P” could be for pansexual, polyamorous, or any number of things. It’s important to realize that when we try to be inclusive by using indications like “+,” we may still be somewhat exclusive because we aren’t deliberately and intentionally naming someone. I think the convention will continue to evolve as our definitions and understanding of what sexuality and gender identity continue to evolve.”
2. What’s the difference between sexuality versus gender identity versus sex?
“This is a challenging conversation. The place to start is when we’re in medical school or other health profession schools,” offers Dr. Nass. “I use the gender unicorn graphic to teach medical students and residents. The important part is trying to understand where people are coming from. Identity is foundational to how we begin to describe ourselves. So, knowing:
- What sex do we consider ourselves
- What gender do we consider ourselves
- Who we’re attracted to
These can be interrelated, but they can also be very different things. Sexual orientation and gender identity are very different things. We must be careful not to conflate those things for sure. Traditionally, sexual orientation has been heterosexual and homosexual. Either you were attracted to the opposite sex or the same sex. We now know that sex is not binary. If folks are bisexual, it means rather than being attracted to male and female, which historically is what we understood that to be. But this is now classified as attracted to its own sex and another sex. And pansexual would be all the sexes, including one’s own. It’s kind of broad, but again, who we’re attracted to is different than our sex and gender identity, but very much related. One thing to know about this topic is things are always changing. When it comes to sex, historically, one is referencing biological sex, which can now be a politicized term. Traditionally, folks are male or female appearing, intersex, or some variation that doesn’t quite appear to be specifically male or female at birth. And as we grow, we understand more about ourselves and identify in various ways. Some begin to feel that they don’t necessarily fit into the binary. And so that’s more of an identity they begin to develop that can then be compared to their physical traits, and that helps us understand a little bit more about where they came from and where they want to go.”
“How I explain it in very general terms,” explains Dr. McDonald, “is sexuality is who you’re attracted to. Gender identity is in your head; who do you feel like, a boy or a girl or neither or both? And then sex is sort of your anatomy between your legs.”
3. What health challenges face the LGBTQ+ community?
“I think there are two main issues the LGBTQ+ community faces. One issue is that we aren’t teaching about LGBTQ+ health, the importance of recognizing someone’s sexual orientation, and gender identity, in medical school,” says Dr. Nass. “We talk about people’s families and their jobs, and a lot of times, if we don’t know sexual orientation or gender identity, patients won’t feel comfortable sharing those things. Then, we can’t have full conversations, especially in primary care. I want to treat the whole person, I want to know the whole person, and I want to build that relationship over the years. For me, that’s a critical piece to know who’s in their life, how they see themselves, and how they want to identify in the world. However, we aren’t teaching that in a lot of medical schools or other health profession schools. I think that’s the biggest challenge: we aren’t putting a lot of clinicians out there who understand the importance of someone’s identity and how that can impact their interest in engaging in care or their comfort.
“We know that looking across preventable conditions, something like breast cancer, lesbians or women who otherwise identify as a sexual minority are much less likely to get screened for breast cancer. And when breast cancer is detected, it is more likely to be an advanced stage. There’s no reason for that. If we’re using universal screening, every person with breast tissue coming into a practice should be getting screened at the right age. But that doesn’t happen because there is a misconception about whether people need the same screenings. The same happens for people who identify as a sexual minority with HPV screening. If they’ve never had sex with someone with a penis, then are they really at risk of having HPV on the cervix? The answer is absolutely.
“The second issue is the stigma against LGBTQ+ folks in the healthcare system. Many emergency departments, hospitals, and health systems have not caught up to the idea that all their staff members from the front and back offices, clinicians, and everybody who comes in contact with patients need to have an understanding of what it means to treat someone with respect and in an affirming way. Your job is to take good care of folks, and you probably went into healthcare to ensure people had a good experience in the healthcare system.”
4. How can we overcome the stigma and create a more welcoming hospital environment for our LGBTQ+ patients?
“I think that’s a great way for any health system, organization, or facility to think about what they can do specifically,” explains Dr. Nass. “There are plenty of models out there. There are places to go and see LGBTQ+ health centers or transgender centers of excellence where folks stand out as welcoming. And there’s a need for that in many communities because there isn’t universal affirming care wherever you go. Leadership in organizations needs to lead, find educational opportunities, and train everybody at every level. The goal is to provide a welcoming environment, not doing anything different for folks who are LGBTQ+ than they would anybody else. There must be respect for who they’re married to, who they date, and how they see themselves. For those not in leadership, it’s important to lead around you and create change in your unit or department. I think that as patients and people in the community, there’s a lot we can do to advocate. We can engage with our local clinics or other organizations to help them understand how much is out there in terms of training. The Healthcare Equality Index from HRC is a great way for hospitals to look at how well they’re doing. If you are a clinician, seeing folks be open, inquisitive, listen, repeat what you hear, speak to understand, and appreciate where they’re coming from. I think that’s the most important thing we can do individually.”
“When I started caring for LGBTQ+ patients, I had done some training modules and spoke to some colleagues, but I was fumbling through it,” says Dr. McDonald. “I relied on my patients. I would say, ‘Hey, you know what? I’d like to ask a question. I apologize if this is not the right way. Tell me how I should ask this question.’ My patients taught me a huge amount, but it was sort of by me asking them and not just relying on them to tell me when I was using the wrong term or not asking a question appropriately. By asking, we open the door and help them be the teacher as opposed to us teaching them about their health.”
“Practicing humility with patients is absolutely something I would recommend,” adds Dr. Nass. “For example, a typical scenario would be if you use the wrong name or the pronouns they don’t use, they may not correct you because they suddenly identify this as an unsafe space. They may think that if they correct you, they may not get the care they need that day. Watch the patient’s body language. I’ll do my best to watch folks, and anytime they look away, if they’re looking at me or I see a grimace on their face, I can tell that’s a topic they are uncomfortable with. And as soon as I see that shift in comfort level, I’ll say, ‘I’m sensing something here. What am I sensing?’ I hope they’ll open up with me and say, ‘Actually, these are my pronouns. I wish you wouldn’t have assumed that.’”
5. How can physicians ask patients about gender, orientation, or pronouns?
“Lead by example,” emphasizes Dr. Nass. “I would start with, ‘Hi, I’m Dr. Nass. I use he/him pronouns. Tell me about yourself or who I am meeting with today. Or tell me about everybody who’s in the room today.’ That gives them a chance to use their language to describe themselves, their names, and their language to describe their relationship with the other people in the room. Use open-ended questions all the time. If you have a Sexual Orientation and Gender Identity (SOGI) module in the EHR, be careful not to make assumptions or force people into the binary. If it’s not as broadly set up as it could be, for example, if you cannot put in open-ended responses from folks, don’t pick the thing that matches the closest. You want to ensure you’re always honoring the patient’s language. And even if you can’t click the right box, put it in your free text or your own thinking note. Any information that’s critical to the patient should be accessible when you look at their chart.”
“In my EHR, there’s a SOGI module, which is robust,” explains Dr. McDonald. “I can put preferred names, pronouns, and other items in there. There’s also sort of a little sticky note where you can just put private comments for me. And I’ll often put little tidbits or information in the private comment that help remind me for future visits.”
6. There is a significant lack of data regarding LGBTQ+ health, particularly when it comes to screening measures. What evidence do we have? How can we continue to build this evidence? How do we make sure we’re treating patients based on data and science?
“It’s critical that we talk about this and have this conversation in an ongoing way because this community can resist getting healthcare,” says Dr. Nass. “And having LGBTQ+ folks participate in clinical trials or medical studies has been a challenge for a couple of reasons. Until recently, nobody thought of asking those questions as part of enrollment in trials. So even when we find out that a cancer drug works well for men over 50, what else might be different about those men? Could we look at that even further and see if there’s a differentiation between sexual orientation, for example? At the population level, it’s challenging to sort out these data sets if there are differences based on sexual orientation and/or gender identity. Then we have questions like who should get pap smears and who is more at risk? And we tend to focus on men who have sex with men. But there’s a little conjecture there. But the question is if we did mass universal screening for that within pap smears, for everybody who says, ‘Yes, I have receptive intercourse,’ what kind of a difference are we going to make? We don’t know what the cost-benefit analysis fully is, but I think finding out that information in a larger study is critical for anything that disproportionately affects anyone within the LGBTQ+ community. But again, a lot of stigma remains for folks coming into trials.”
7. Where can physicians get information about how to provide better care for LGBTQ+ patients?
“There are many local and regional conferences that talk about LGBTQ+ health,” says Dr. Nass. “I’m partial to GLMA’s educational offerings, including its annual conference. There is also the National LGBTQIA+ Health Education Center out of the Fenway Institute, where you can find a lot of free online modules. Then, find folks in your organization who are experts or leading in this area. If you have somebody that patients are mentioning to you or hear about through the grapevine, become their friend.”
