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Feb 2019

Knowing Patient Sexual Orientation & Gender Identity Important to Improving Community Health

Roughly eight percent of lesbian, gay, bisexual and queer patients have reported that healthcare providers refuse to see them because of their actual or perceived sexual orientation.  Twenty nine percent of transgender patients reported not being seen by a healthcare provider because of their actual or perceived gender identity. These patients also reported doctors or other providers using harsh or abusive language towards them.

Lesbian, gay, bisexual, transgender and queer (LGBTQ) patient concerns about bias in healthcare are, unfortunately, not unfounded.  This group experiences both implicit and explicit discrimination ranging from harassment and humiliation by hospitals and doctors.

There are inherent health risks to patients who, to avoid possible discrimination, are not transparent about their sexual orientation or gender identity (known as SO/GI) with their doctors or who avoid seeing healthcare professionals all together.  This latter number is not insignificant. There is evidence that up to eight percent of all LGBTQ people, and 14 percent of this community who had experienced some form of bias, avoid or postpone necessary medical care. This number increases to over 20 percent of transgender people who avoid care.

By delaying or denying care as a result of this type of bias, providers may be putting patient health and lives at risk.  In one case, a patient who disclosed his HIV status was not provided HIV medication. In another well-publicized case in Michigan, a pediatrician refused to treat a child of same-sex parents.  Other patients report being refused prophylaxis treatments for HIV and other STIs, while a transgender woman told of being refused antibiotics for a yeast infection because of her gender identity.

In situations where a patient decides to not disclose their SO/GI, providers will have a more difficult time in identifying and meeting health care needs specific to LGBTQ patients.  For example, they may not receive appropriate preventative screenings or information and assessment for sexually transmitted diseases. One study, for example, suggests that with lower screening rates, lesbian and bisexual women have higher rates of cervical and breast cancer than their heterosexual counterparts.  

What Providers Can Do

Many providers may be uncomfortable to simply ask patients about their sexual orientation or gender identity.  They sometimes feel that such questions are an invasion of privacy or that some patients may find them insulting or offensive. However, research clearly points to the opposite.  

One study recently published in the Canadian Medical Association Journal, indicates that patients are very open to being asked about their SO/GI.  Of 15,221 patients surveyed, a full 90 percent answered questions about both sexual orientation and gender identity.   It was interesting that these patients not only answered such questions, but they also reported appreciating the variety of options on the survey to indicate their SO/GI.  In fact, some even suggested additional descriptors and terms to be included in future surveys. Another study showed that 97 percent of patients who were asked about sexual SO/GI were fine with being asked.

It is also important to keep this patient information in their electronic health records (EHRs) and to ensure that EHR portals and other interfaces offer questions and data capture of sexual orientation and gender identity.  The system should also include questions regarding the pronoun and name a patient wishes to be called by the provider’s staff. While collecting this information, the provider should explain why it is being asked as well as state its confidentiality and nondiscrimination policies.  Some providers may ask for this information only once during a patient’s lifetime unless the patient requests an update. It may, however, be more prudent to confirm a patient’s initial responses on a periodic basis given that sexual orientation and gender identify are fluid with some individuals.

Knowing this information is essential for providing the best care possible to LGBTQ patients and collecting it has been endorsed by a variety of entities including the U.S. Centers for Disease Control and Prevention (CDC), the National Academy of Medicine and the Joint Commission.  Academic institutions such as the University of California, San Francisco, offer providers examples of the types of questions to ask patients, how to talk with patients about their SO/GI, and what the EHR should include for best recording SO/GI data.  

It is also good to remember that the Health Resources & Services Administration (HRSA), which is part of the U.S. Department of Health & Human Services, requires HRSA-funded providers to collect and report SO/GI data. For its part, the Centers for Medicaid and Medicare Services (CMS) require providers to have a variety of nondiscrimination policies in place, including for hospital visitations.

Other steps a provider can take may include the following:

  • Educate and train all provider team members who have any interaction with LGBTQ patients – from registration and billing to doctors and nurses – on how to provide affirming services to LGBTQ patients
  • Update new-hire packets and stand-alone items, such as internal notices and educational pamphlets for staff, to include provider policies of non-discrimination against LGBTQ patients
  • Be sure to have all appropriate staff updated on relevant local, state, federal and accrediting bodies’ regulatory requirements related to LGBTQ patients, including collection of data, name/gender changes and confidentiality
  • Work with local medical schools and in-house training to develop LGBTQ competency courses for doctors and nursing staff (almost half of providers have no LGBTQ-competency training at all)
  • Use gender-neutral and inclusive language in day-to-day interactions with patients (independent of their SO/GI)

By taking these simple steps and overcoming their own possible bias and discomfort with LGBTQ patients, providers can go far in addressing and remedying the disparities in healthcare that continue to threaten the health and wellbeing of this patient group.

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