Caring for LGBTQ patients

[otterxavier]

This thread is a designated space to ask questions and discuss issues related to clinical care of LGBTQ patients. Please remember to follow SDN guidelines, discuss patients with respect, and omit any potentially identifying information. The resources threads here and here link to additional materials about developing clinical and cultural competence with LGBTQ patients.

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[deleted480308]

During an initial patient encounter....what's the respectful way to verify if identified gender differs fron gender of birth?

(I.e. Someone identifying as a man but biologically a woman could still need a pregnancy test or have ovarian issues that wouldn't be part of a workup in a biological male)

 

[Ceke2002]

During an initial patient encounter....what's the respectful way to verify if identified gender differs fron gender of birth?

(I.e. Someone identifying as a man but biologically a woman could still need a pregnancy test or have ovarian issues that wouldn't be part of a workup in a biological male)

From discussions I've had with friends in the trans community I would probably use the term 'gender assigned' when enquiring if gender identity differs from birth gender - so rather than saying 'born male' or 'born female' you would say 'gender assigned as female' or 'gender assigned as male'.

 

[Ceke2002]

(I.e. Someone identifying as a man but biologically a woman could still need a pregnancy test or have ovarian issues that wouldn't be part of a workup in a biological male)

Sorry, I got distracted by my cat and hit post before I'd finished. In terms of physical examinations that may need to be done, specific to FtM, use gender specific or neutral terms where possible - so regardless of whether they've had top surgery or not, for example, you would always refer to an examination of that area as a 'chest exam' not a 'breast exam'. If they have had top surgery, and it's unclear what other gender reassignment surgery they may have had (hysterectomy for example) you could enquire by asking something like 'besides chest surgery, have you had any other gender reassignment surgery done?' This avoids the use of terms like ovaries, womb, hysterectomy, which some, not all, but some FtM trans folks may have difficulty with. Also if an internal examination is necessary it's probably best to give the person the option of booking a separate appointment - some of my FtM friends are very matter of fact about the necessity of looking after their gynaecological health and would handle the need for an internal examination accordingly, others would need time to prepare themselves mentally/emotionally and/or wish to bring a friend or advocate with them to the appointment.

(*disclaimer, I'm not trans, and I'm not claiming to speak specifically for anyone in the trans community itself)

 

[Guero]

During an initial patient encounter....what's the respectful way to verify if identified gender differs fron gender of birth?

(I.e. Someone identifying as a man but biologically a woman could still need a pregnancy test or have ovarian issues that wouldn't be part of a workup in a biological male)

Great question! If the you're unsure, or if the pt discloses during your encounter that they identify outside of the gender binary or as transgender, simply ask "What pronouns do you prefer?" It's safe to assume that the vast majority of pts identifying as such will welcome such a question with a huge smile and receive the question as an attempt at respecting their identity. In more conservative areas, I like to say go with your gut, especially if someone is clearly presenting with clothes consistent with a certain gender (e.g., skirt and blouse versus a suit and short trim). But even then, assumptions can get you into trouble. Begining with "Hi, I'm so and so. What name and pronouns do you prefer?" is always the safest bet.

 

[Guero]

Also, @sb247, we've added more LGBTQ clinical care links for medical students today: here.

 

[deleted480308]

Also, @sb247, we've added more LGBTQ clinical care links for medical students today: here.

I appreciate it. Despite what I believe is good intentions my school could beef up on this topic

 

[Guero]

I appreciate it. Despite what I believe is good intentions my school could beef up on this topic

The fact that you asked, and so many other students ask in person, is a great sign. We're working our best to spread accurate and appropriate information, including at our respective schools. Our hope is that this forum's accessibility and visibility will help expedite the spread of essential information like this. It takes time for each school to meet the LCME's growing LGBTQ Med-Ed criteria. Thank you for taking the time to ask.

 

[otterxavier]

During an initial patient encounter....what's the respectful way to verify if identified gender differs fron gender of birth?

(I.e. Someone identifying as a man but biologically a woman could still need a pregnancy test or have ovarian issues that wouldn't be part of a workup in a biological male)

This is a great question and @Ceke2002 and @Guero's responses are totally on point! One other thing to consider, if you're in a position to do so, is advocating for intake forms that ask about patients' assigned sex at birth and gender identity, and give space to list a preferred name and pronouns. It signals to trans patients that this is a respectful and trans-savvy environment, takes some of the onus off of providers to figure out when and how to ask about those things, and heads off some awkward mistakes. Institutional inclusion ftw.

I'd also add that many trans folks going into a healthcare encounter will have thought carefully about whether and how to come out to the doctor and other staff. I'd wager (no data here) that we are generally pretty good about disclosing proactively when we know that it's relevant, and can say for sure that many of us choose not to disclose if we think it's not necessary. For example, establishing care with a new PCP = probably... popping into urgent care with nausea and vomiting = quite possibly not. Not saying that this is ideal from a medical perspective, but it's a strategy for self-protection after past experiences of discrimination in healthcare.

So, the best way to ask will be mindful of that context: ask in a way that's open-ended and non-judgmental, at a logical point in the encounter (toward the beginning if you're asking about preferred name and pronouns; if you're asking more detailed questions about transition-related medical history, maybe further in once you've had a chance to establish some rapport). Normalize by emphasizing that this is something you discuss with every patient to make sure that you're providing the most comprehensive and respectful care. And if you ask for further details, stick to questions that are truly necessary for their care, and explain how they're relevant. (If a trans man shows up to urgent care with a sinus infection, no need to ask whether he's thinking about a hysterectomy any time soon, etc.)

 

[Guero]

This is a great question and @Ceke2002 and @Guero's responses are totally on point! One other thing to consider, if you're in a position to do so, is advocating for intake forms that ask about patients' assigned sex at birth and gender identity, and give space to list a preferred name and pronouns. It signals to trans patients that this is a respectful and trans-savvy environment, takes some of the onus off of providers to figure out when and how to ask about those things, and heads off some awkward mistakes. Institutional inclusion ftw.

I'd also add that many trans folks going into a healthcare encounter will have thought carefully about whether and how to come out to the doctor and other staff. I'd wager (no data here) that we are generally pretty good about disclosing proactively when we know that it's relevant, and can say for sure that many of us choose not to disclose if we think it's not necessary. For example, establishing care with a new PCP = probably... popping into urgent care with nausea and vomiting = quite possibly not. Not saying that this is ideal from a medical perspective, but it's a strategy for self-protection after past experiences of discrimination in healthcare.

So, the best way to ask will be mindful of that context: ask in a way that's open-ended and non-judgmental, at a logical point in the encounter (toward the beginning if you're asking about preferred name and pronouns; if you're asking more detailed questions about transition-related medical history, maybe further in once you've had a chance to establish some rapport). Normalize by emphasizing that this is something you discuss with every patient to make sure that you're providing the most comprehensive and respectful care. And if you ask for further details, stick to questions that are truly necessary for their care, and explain how they're relevant. (If a trans man shows up to urgent care with a sinus infection, no need to ask whether he's thinking about a hysterectomy any time soon, etc.)

"I agree with the above findings and plan."
Addendum and attestation signed 20:04, 6/30/16, Guero, MS3.



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[fantasty]

"I agree with the above findings and plan."
Addendum and attestation signed 20:04, 6/30/16, Guero, MS3.



Sent from my iPhone using SDN mobile

See how easy it is to be an attending?

 

[fantasty]

Great question! If the you're unsure, or if the pt discloses during your encounter that they identify outside of the gender binary or as transgender, simply ask "What pronouns do you prefer?" It's safe to assume that the vast majority of pts identifying as such will welcome such a question with a huge smile and receive the question as an attempt at respecting their identity. In more conservative areas, I like to say go with your gut, especially if someone is clearly presenting with clothes consistent with a certain gender (e.g., skirt and blouse versus a suit and short trim). But even then, assumptions can get you into trouble. Begining with "Hi, I'm so and so. What name and pronouns do you prefer?" is always the safest bet.

Yeah, I don't really have any better insights to add. But, I'll just throw in that most patients will just be glad to know that you made the effort to make them feel comfortable, and once you've made them feel welcome and unjudged, they'll be open to telling you about how they'd like to be addressed. It might be a little more hit or miss as to whether they might be defensive about you making assumptions about their current anatomy, but clearly that's an important medical conversation to have they will still want you to understand what is or isn't appropriate for them so it's better to just ask if you aren't sure.

 

[Guero]

See how easy it is to be an attending?

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[JustPlainBill]

Thank you for starting this thread/topic --- My current patient panel consists of about 1% transgendered patients both pre/post surgery. I had an encounter the other day and was able to spend about a half hour with 2 ladies both of whom were involved in the local community/resource center. They brought up an interesting point in that after they had dealt with the legal aspects of reassignment they had run into problems with insurance companies. For example -- being diagnosed with prostatitis yet having already undergone reassignment both physically/legally to female status caused some insurance companies to balk at reimbursement depending upon physician coding. They were both very helpful in that area and I'm trying to get some time to go visit them at the resource center to see if/how we can help in that area. Anyone have any experience with this or similar situations? How did you deal with it?

 

[Guero]

I lack time to elaborate, but I, too, recently treated a transwoman and her transman boyfriend for heat exhaustion at our local pride parade. The transwoman was suffering from heat exhaustion. As soon as they realized we were MS3s and I was a trans girl myself, they allowed me to treat, comfort, and get them home safely without a hospital stay because she was THAT scared of physicians. I hope @JustPlainBill receives some help. GL


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[Ceke2002]

Just a tip for dealing with bisexual patients. If a patient discloses their bisexuality to you, the next words out of your mouth really shouldn't be anything along the lines of, 'We should do some STD tests then'. Maybe ascertain what the patient's sexual history, and current sexual activity is first, before jumping straight to 'Womp, better break out the STD kit'.

 

[beautifulrobot]

...some insurance companies to balk at reimbursement depending upon physician coding. They were both very helpful in that area and I'm trying to get some time to go visit them at the resource center to see if/how we can help in that area. Anyone have any experience with this or similar situations? How did you deal with it?

This is also a big issue for transmen who are getting routine gynecological care done, i.e. their gender is listed as M with health insurance but they still have a uterus, and will be denied by the insurance for any codes related to pap smears or cervical cancer screenings. Usually a call to the insurance company will resolve the issue (either by the patient, the medical office, or both) - clarifying that it was not a miscoding, and the patient is indeed male and required a pap smear. With ACA, insurance companies that receive any government funding (pretty much all major private insurance companies) are not allowed to discriminate against transgender patients, so they can't legally deny coverage for these services just because the person is transgender. It will likely require some additional policy work to get to the point where we have codes that have a modifier to indicate transgender status, or health insurance companies stop blanket denials for "gender incongruent" procedures, or start collecting data on the customer's anatomy/sex assigned at birth. Once any of those things happen, we will hopefully end this hassle for both transwomen and transmen (and non-binary people as well). In the meanwhile, the only solution I know of is having to follow up individually with the insurance company if/when the claim is denied. Granted, medical coding is not my area of expertise, so I would be happy to learn if anyone knows of a more proactive way to handle this issue.

 

[fantasty]

Just a tip for dealing with bisexual patients. If a patient discloses their bisexuality to you, the next words out of your mouth really shouldn't be anything along the lines of, 'We should do some STD tests then'. Maybe ascertain what the patient's sexual history, and current sexual activity is first, before jumping straight to 'Womp, better break out the STD kit'.

True. But no one has time to actually talk to patients. But, once your patient changes into a different risk group, your screening guidelines change.

(There's no time for thinking, let alone talking. It's all about compliance. )

(I'm not jaded, really...)

 

[Guero]

True. But no one has time to actually talk to patients. But, once your patient changes into a different risk group, your screening guidelines change.

(There's no time for thinking, let alone talking. It's all about compliance. )

(I'm not jaded, really...)

We do have time, though a very limited time especially depending on the encounter type (rounds in hospital vs primary care visit). Screening guidelines indicate regular STI screening for all sexually active persons, not just those identifying as a sexual or gender minority. Although risks do change depending upon the sexual activity, frequency, and mode of contraception (if any), it doesn't change whether or not you test. It changes a few items on the panel that you order. So rather than eschewing the issue by blaming lack of time, I recommend maintaining compassion and briefly explaining that the STI panel is routine for all sexually active patients regardless of gender identity and sexual orientation (a mere 5 second preface before moving on and completing the visit). That might save your patient and many more from contracting an STI and/or waiting too long for treatment down the road because your initial encounter so alienated or humiliated the patient that they felt too anxious to return for regular visits and testing.


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[y0ssarian87]

It sounds like a no-brainer, but if someone comes in asking for an STI screening, there should be a discussion about sexual behavior to guide appropriate testing.

One day a couple years ago, my cousin (who's also gay) quickly developed some joint pain, and since he couldn't afford to take time off of work, he didn't go to his doctor immediately. Over the next day and a half the joint pain got worse, and he developed a high fever and chills. He ended up needing to be hospitalized for disseminated gonococcemia that had led to septic arthritis. He ended up needing to get Rocephin infusions daily, and it took a couple weeks for him to be able to move around comfortably after the entire thing. He was frustrated because he got tested regularly, used condoms, and his last tests were negative despite his last exposures being prior to his tests. It turned out that his provider was only doing urine samples and didn't do pharyngeal swabs. He didn't know that he needed to ask for throat testing if he was engaging in oral sex.

 

[fantasty]

It sounds like a no-brainer, but if someone comes in asking for an STI screening, there should be a discussion about sexual behavior to guide appropriate testing..

I'm sorry that happened to your cousin but thank you for sharing - it's an important reminder, and not necessarily something that everyone thinks of.

 

[Guero]

I'm sorry that happened to your cousin but thank you for sharing - it's an important reminder, and not necessarily something that everyone thinks of.

I'd just like to echo the condolences for enduring that suffering and some gratitude for sharing. I'll never forget this and will use it in future teaching moments.


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[y0ssarian87]

This is old, but still useful. Not sure if there's a more recent set of recommendations: http://www.aafp.org/afp/2004/0501/p2149.html


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[FlameBroiledDoc]

Be polite, be humble, and if you blurt something that seems insensitive, apologize sincerely and thank the patient for correcting you. It's a little bit easier nowadays because there are resources out there - I had more than a few double-takes when I started practice - but if you're approachable a patient isn't likely to chastise you for an honest mistake.

Sexual health is something of a different story, and I would highly recommend students spend time in a public health clinic. Nurses in public health clinics are absolute pros at taking a sexual history, and they don't shy away from anything.