Ryan is a 15-year-old transmale patient (natal sex female who identifies as male and prefers male pronouns, he/him/his) who presents to the emergency department (ED) with suicidal thoughts that have increased with his period this month. His father explains to the registration staff that Ryan is transgender and while his legal name is still Rachel, he prefers to be addressed as Ryan and uses male pronouns. The registration person passes this on to the nurse who will be caring for Ryan. While in the ED, Ryan is frequently referred to by his birth name, Rachel, and female pronouns by various staff members. Dad corrects them, and staff are responsive to his feedback, but the continued misgendering increases Ryan’s suicidality to the point that dad considers leaving the ED.

Nakeia is a 2-month-old infant female brought to the clinic by her parents Shayla and Marie, who are a married lesbian couple. When the doctor walks in, she introduces herself to Shayla and when she sees Marie, she says, “It’s so nice that your mother came with you to the appointment today.” Marie is taken aback and wonders if they should search for another pediatrician who has experience working with LGB couples.

The two cases above are fictional cases created from a collection of experiences shared by patients and families that have presented to our clinics. While unintentional, the assumptions of staff and providers resulted in distress for the patient and families being cared for. What could have been done differently?

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are less likely to access health care than are their non-LGBTQ peers for a variety of reasons. Perceived discrimination within the health care system, and health care providers’ lack of awareness and knowledge of LGBTQ specific health issues are factors that lead to decreased use of health care services.1 In a 2009 survey of LGBT adults, 56% of LGB respondents and 70% of transgender and gender nonconforming respondents reported experiencing at least one incident of discrimination in the health care setting.2 The Institute of Medicine (IOM), the Association of American Medical Colleges (AAMC), and the Joint Commission recommend specific training of health care providers on issues of LGBTQ health as one way of addressing these barriers.2,3,4 Despite these recommendations, many providers report that they are not adequately trained to provide care for LGBT patients.1

A number of resources are available to help health care providers and staff increase their competency in caring for LGBTQ patients and families. The National LGBT Health Education Center is one easy-to-use resource that has information on disparities in the LGBT community and strategies that can be implemented in practice to address these disparities. These strategies are not expensive to implement, but do require time, effort, and dedication from staff and providers to provide best quality care to all patients. Below are a few suggestions to create an inclusive health care environment adapted from the center’s guide on creating inclusive health care environments for LGBT people5:

All staff receive training on culturally affirming care for LGBT people.

• Training on terminology, health disparities, and how to avoid assumptions and stereotypes is important for all staff members. A positive or negative encounter with one staff member can set the tone for the whole visit.

• Respectful, nonjudgmental communication can help patients and families feel safe and comfortable and increases the likelihood that they remain engaged in care.

Processes and forms reflect the diversity of LGBT people and their relationships.

• Preferred names/pronouns. Many transgender patients have insurance cards and legal documents that do not reflect their current identity. Having a process where preferred names and pronouns can be recorded in the chart and easily communicated to other staff members is important. It is equally important that staff members are trained to recognize and use this information.

• Relationship questions. All staff members should ask the relationship of people accompanying patients to visits and not assume relationships.

• Sexual history questions. When asking or collecting information about sexual history, do not assume heterosexuality.

All patients receive routine sexual health histories.

• A confidential sexual health history should be part of the comprehensive history for all adolescent patients.

• Discussions should be broad, not only focusing on sexual behaviors and risks, but also addressing attraction, readiness for sex, health of relationships, sexual satisfaction, and history of trauma or abuse.

• Ask open-ended and inclusive questions, such as “Are you in a relationship?” “Are you attracted to men, women, both, neither?”

• Ask patients and parents if they have any concerns about gender identity. This offers an opportunity for patients and parents to discuss these issues.

•  Avoid assumptions by asking these questions of all patients.

Clinical care and services incorporate LGBT health care needs.

LGBTQ youth in general have the same health and wellness needs as those of all patients. There are, however, health disparities that exist in this community related to stigma and minority stress. Clinicians should be aware of these disparities so they can provide targeted, individualized care.

• Gay men, bisexual men, and transgender women face higher rates of HIV and STIs. Culturally responsive prevention and testing is important, including availability of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) therapy for HIV as appropriate.

• Smoking and substance use rates are higher in LGBTQ youth; assessing for this and providing appropriate support is important.

• LGBTQ youth are at higher risk of depression, anxiety, suicidality, and bullying. Assessing for family and social support is important as these can be protective. Connecting parents and youth to support groups can be helpful.

• Transgender youth may require specialized services including counseling, psychiatric services, pubertal suppression, and cross-sex hormone therapy. Knowledge of where patients can be appropriately referred is important.

The physical environment welcomes and includes LGBT people.

Studies have shown that many LGBTQ youth and parents look for signs or clues that a clinic or facility is welcoming or safe. Below are some easy ways to communicate openness through the physical space.

• Signs and brochures. Prominently display clinic or institutional nondiscrimination policies. LGBT-friendly symbols such as the rainbow flag or safe zone signs can be displayed on placards, bulletin boards, or staff badges.

• Reading materials. Brochures, magazines and décor that contain images of couples and families should include same-sex couples and LGBT families. Reading materials should include topics relevant to the LGBTQ patients. Information about local LGBTQ resources should be available.

• Restrooms. Transgender and gender nonconforming youth often experience anxiety using public restrooms in part due to fear of harassment. Health care spaces should have policies that allow patients to use restrooms based on their gender identity rather than birth sex. If possible, it is helpful to provide access to single occupancy unisex restrooms.

Creating a space that is safe, welcoming, and respectful of LGBTQ patients and families is one way to begin addressing the health disparities that exist in this community. Below are resources to help your clinic or institution become one of these spaces.

1. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding . (National Academies Press: Washington, 2011).

2. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV (New York: Lambda Legal, 2010).

3. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Non-Conforming, or born with DSD: A Resource for Medical Educators . (AAMC: Washington, 2014).

4. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. (The Joint Commission: Oak Brook, Ill. 2011)

5. Ten Things: Creating Inclusive Health Care Environments for LGBT People. National LGBT Health Education Center ( www.lgbthealtheducation.org ).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

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