Mandatory 'Sexual Orientation' Annual Screening

[Fan_of_Meehl]

So I just became aware that the VA now has a new annual clinical reminder to question/discuss/document every patient's sexual orientation on an annual basis.

Question: what is the actual base rate of an adult experiencing a spontaneous and undetected change in sexual orientation in a 12-month period? Is there any articulable rationale for doing this based in the scientific literature? Why annually? Why not monthly...or weekly...or every clinical encounter? Thoughts on this?

Edit: I've just looked through some training docs on this but cannot determine if it's meant to be a one-time thing (which makes sense) to be updated as needed or a mandated annual 'check in.' Does anyone know for sure?

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[PsyDConvert]

Like many things, our longitudinal data could be much better in this area (to answer why 12-months), but work from Lisa Diamond and others may be of interest to you (such as the below article).

Diamond, L.M. Sexual Fluidity in Male and Females. Curr Sex Health Rep 8, 249–256 (2016). https://doi.org/10.1007/s11930-016-0092-z​

 

[Shiori]

I browsed through the related policy and there doesn't appear to be any specific guidance on how often it should be done. That makes me feel like individual sites are going to make that decision for better or worse. It looks like it's stemming from GAO recommendations about better data collection to evaluate disparities since identify information hasn't been consistently collected. The clinical reminder has been piloted at some sites since 1/22, so hopefully others have more insight.

 

[Fan_of_Meehl]

Like many things, our longitudinal data could be much better in this area (to answer why 12-months), but work from Lisa Diamond and others may be of interest to you (such as the below article).

Diamond, L.M. Sexual Fluidity in Male and Females. Curr Sex Health Rep 8, 249–256 (2016). https://doi.org/10.1007/s11930-016-0092-z​

I'll look into it...thank you for the citation!

 

[texanpsychdoc]

Yeah I saw the email yesterday from our LGBTQ+ coordinator. Yay...one more damn clinical reminder to do. Alternatively, I usually ignore most of those reminders and let the LPNs or RNs do them.

 

[cara susanna]

I was gonna say, the VA sure loves its reminders.

 

[Fan_of_Meehl]

I was gonna say, the VA sure loves its reminders.

If it is an annual requirement I'm just gonna say it...I'm having flashforwards to sitting down to start a therapy session with a grizzled 79 year old Vietnam Vet who hears me start my annual spiel about the screening and he interrupts me abruptly only to say, 'Nope, doc. Still not gay! Try again next year!'

 

[Sanman]

If it is an annual requirement I'm just gonna say it...I'm having flashforwards to sitting down to start a therapy session with a grizzled 79 year old Vietnam Vet who hears me start my annual spiel about the screening and he interrupts me abruptly only to say, 'Nope, doc. Still not gay! Try again next year!'

So, what happens if someone can't find their sexual orientation amongst the options? Is there a 'nunya damn bidness' check box because I think most of my vets fall into that category?

 

[futureapppsy2]

So, what happens if someone can't find their sexual orientation amongst the options? Is there a 'nunya damn bidness' check box because I think most of my vets fall into that category?

There's usually a prefer not to disclose option on these, so probably, yes.

 

[Fan_of_Meehl]

So, what happens if someone can't find their sexual orientation amongst the options? Is there a 'nunya damn bidness' check box because I think most of my vets fall into that category?

I think we have to hand them a pair of anatomically correct dolls, an Etch-a-Sketch, and a PHQ-9 and await the results.

 

[Sanman]

There's usually a prefer not to disclose option on these, so probably, yes.

Something tells me that most of my clients will not be responding so politely. I wish they just allowed clients the ability to identify themselves and put an indicator in the chart.

 

[Fan_of_Meehl]

Something tells me that most of my clients will not be responding so politely. I wish they just allowed clients the ability to identify themselves and put an indicator in the chart.

That would be an appropriately discreet yet effective solution that would actually treat veterans like responsible adults. It'll never happen.

 

[WisNeuro]

That would be an appropriately discreet yet effective solution that would actually treat veterans like responsible adults. It'll never happen.

To be fair, there's a small portion of them who simply refuse to act like adults no matter how you treat them.

 

[texanpsychdoc]

If it is an annual requirement I'm just gonna say it...I'm having flashforwards to sitting down to start a therapy session with a grizzled 79 year old Vietnam Vet who hears me start my annual spiel about the screening and he interrupts me abruptly only to say, 'Nope, doc. Still not gay! Try again next year!'

Like..."you sure, are you really sure? If you haven't tried, you may not be sure." Alternatively, my favorite clinical reminder to-date is the intimate partner violence reminder....the responses I get from older vets makes my day.

 

[futureapppsy2]

To be fair, a good number of people do "realize" their sexual orientation and gender identity later in life, especially if they come from a context where anything other "straight and cisgender" (e.g., "normal," "right", "not fruity," "not [insert slur here]") was never accurately discussed or discussed at all. and there was no safe way to explore that that wouldn't get you beat up, made homeless, and/or killed.

 

[texanpsychdoc]

To be fair, a good number of people do "realize" their sexual orientation and gender identity later in life, especially if they come from a context where anything other "straight and cisgender" (e.g., "normal," "right", "not fruity," "not [insert slur here]") was never accurately discussed or discussed at all. and there was no safe way to explore that that wouldn't get you beat up, made homeless, and/or killed.

I'm aware...I was one of those people when I became aware of my being gay later in life. I'm not sure if I am totally on board with a lot of the stuff that has been implemented lately, but that's just me. For the record, I am a person with multiple physical and intellectual disabilities, and I am gay.

 

[smalltownpsych]

I almost always ask about my patients about their sexual orientation and I tend to fall on the none of their damn business side of this. I am very individualistic and protective of the therapeutic relationship and how we work through the nuances of self discovery. I don’t like my patients being pressured to check a box. In lots of contexts it might make sense, but in my office it is a safe space to explore all aspects of choice of how to be in the world and in relationships. I am very careful about how I even ask the questions because it is so difficult to not impose a worldview around this topic in particular.
On a more humorous note, I remember a scene in the movie Stripes where the new recruits are asked about whether or not they were homosexual and the answer was “no, but we‘re willing to try. “. Not sure why, but I’ve always liked that line maybe because it was during that ridiculous time of “don’t ask don’t tell”.

 

[texanpsychdoc]

I almost always ask about my patients about their sexual orientation and I tend to fall on the none of their damn business side of this. I am very individualistic and protective of the therapeutic relationship and how we work through the nuances of self discovery. I don’t like my patients being pressured to check a box. In lots of contexts it might make sense, but in my office it is a safe space to explore all aspects of choice of how to be in the world and in relationships. I am very careful about how I even ask the questions because it is so difficult to not impose a worldview around this topic in particular.
On a more humorous note, I remember a scene in the movie Stripes where the new recruits are asked about whether or not they were homosexual and the answer was “no, but we‘re willing to try. “. Not sure why, but I’ve always liked that line maybe because it was during that ridiculous time of “don’t ask don’t tell”.

Indeed - for me...it's more-so a matter of how, if, and when to broach the subject. It's a delicate balance vs. the VA's check-box clinical reminder approach: "how are we doing Mr. X, any domestic violence in the past month; have you smoked in the past month; how about any same-sex encounters in your life time?" Just doesn't roll off the tongue so well.

 

[Shiori]

For me, I imagine I'll tie it to its purpose. It's for data collection.

"We update demographic information annually to ensure its accuracy. I have that you identify as x. Is this accurate?"

This reminds me of a story. I had a client during my PCMHI rotation who presented as Black, but was marked as White in CPRS. People identify all sorts of ways, but something seemed weird. I took a look at the note history before I approached the client about it. It became very clear that folks were having a hard time with it. They either wrote it as it appeared in the chart, made their own assumption, or avoided it altogether. I asked the individual about it and they had a hearty laugh. They definitely did not identify as White. This person was in the system as White literally for years because no one felt comfortable following up.

As a clinician to individuals, I think about the weirdness of having these conversations in inorganic ways and clicking literal checkboxes. As an advocate in a massive, complicated hospital system, I also consider how we can better serve marginalized groups who may not have many options outside the VA for healthcare. I think about how the VA moves the needle on some of these goals. I also hope (naively, I know) that with data, the political folks will have more leverage to remove at least some basic healthcare needs out of the realm of partisan jockeying. The VA seems so numbers driven (unless someone with political clout is on their neck) that I think about how we justify the allocation of funds without numbers. Beans must be counted to matter, it seems.

 

[cara susanna]

I definitely think there's value to being able to asking about sexual orientation at least once since they enter care. I don't think an annual screening would be worth it, for the reasons mentioned above. I also just hate reminders.