INTRODUCTION
Lesbian, gay, bisexual, and transgender (LGBT) people have become more openly accepted into the framework of society. Likewise, the medical literature has expanded its discussion of the health needs of LGBT people, though often addressing the issues from a strictly sexual behavior perspective (e.g., “men who have sex with men”). Specific knowledge and skills are essential for the health care provider to be able to ascertain the sexual orientation and gender identity of patients; communicate acceptance and understanding of LGBT health issues; screen for conditions amenable to behavioral interventions; and provide information and resources specific to the needs of LGBT patients. Providers can use these skills to provide access to competent medical care for LGBT patients.
Lesbians and gay men make up anywhere from 1% to 10% of the general population—depending on the source quoted and the sampling method used in the study. In most studies, self-identified bisexuals are a small fraction of the lesbian or gay population. Whatever the exact percentage, however, in absolute terms, LGBT persons constitute a significant group of patients with unique medical, psychological, and social needs. Sexual orientation and gender identity are generally invisible. Consequently, many health care providers caring for LGBT patients do not recognize or acknowledge their unique needs.
DEFINITIONS & CONCEPTS
Sexual orientation refers to sexual attraction to another person, including fantasies and the desire for sex, affection, and love. Sexual orientation is distinct from and not necessarily predictive of sexual behavior or activities. Being gay, lesbian, or bisexual assumes awareness of this sexual attraction to people of the same gender or both genders, respectively, and development of an identity based on this awareness. Emotions, psychological responses, societal expectations, individual choices, and cultural influences are all factors that form this identity. Most lesbians and gay men prefer the terms lesbian and gay, because such terms incorporate emotions, behavior, and a cultural system, as well as sexual orientation. Compared to the term homosexual, often interpreted as more clinical and sometimes pejorative, gay and lesbian are more accepted terms.
Sexual orientation, sexual behavior, and identity are interrelated but function independently. Most self-identified lesbians and gay men are sexually active with a partner of their own gender. However, despite this identity, some lesbians and gay men are celibate or have sexual partners of the opposite gender. In fact, most lesbians have had at least one sexual experience with a man, but would not self-identify as bisexual. On the other hand, some men and women who identify as bisexual enter into and codify long-term relationships with a partner of the opposite gender while maintaining sexual relationships with partners of the same gender. Because of the variable relationship between orientation, behavior, and identity, physicians must remain sensitive, open-minded, and nonjudgmental (see section “Provider–Patient Interactions”).
Race and ethnicity have a strong influence on sexual identity and behavior. “Down low,” a colloquial term coined in African American hip-hop culture, refers to nondisclosure of same-sex sexual behavior among men who identify as heterosexual. Sexual behavior in conflict with sexual identity is not unique to African American men. Men and women from racial and ethnic minority communities are less likely to identify as gay, lesbian, or bisexual because of the complex interactions of homophobia (see section “Homophobia and Transphobia”), religious institutions and influences, and cultural norms. As an example, the concept of machismo or masculinity is highly valued in Latino culture. A gay male Latino identity runs counter to this norm.
Gender identity refers to the deep-seated beliefs, emotions, and thoughts that create the self-perception of being male or female. A person is considered transgender when gender identity conflicts with biological or genetic sex. Many in the transgender community use the terms cis-gender (referring to a gender unchanged from birth) and trans-gender, (referring to a gender that changes from a gender assigned at birth), although these terms are relatively new. Gender expression is the behavioral manifestation of gender identity. Toddlers and school-age children often engage in sex-discordant gender expression normally. In transgender individuals, this conflict between sex and gender is pervasive and long lasting. The current edition of the Diagnostic and Statistical Manual defines transgender as “Gender Dysphoria”, replacing the previous “gender identity disorder”, an imperfect but important move away from characterizing transgender individuals as diseased.
The gender expression and roles that transgender people exhibit vary widely, influenced by personal preference and access to health care resources. Some transgender men and women may only desire an outward physical appearance (e.g., hair style, cosmetics, clothing) consistent with their identity. Others may seek cosmetic and/or full sex reassignment surgery. Many transgender individuals interact with the health care system actively in transition from one gender to another.
The spectrum of gender identity is distinct from sexual orientation and identity. A transgender person can have either same-gender sexual attraction, opposite-gender sexual attraction, or both. Regardless of the gender of sexual partners, transgender individuals do not necessarily identify as gay, lesbian, or bisexual.
Many LGBT patients are not comfortable identifying as one specific “letter,” that is L, G, B, or T, and prefer broader terms like “Queer” or “Gender Queer.” “Queer,” which was formerly used as a derogatory term for LGBT people, has now been reclaimed by portions of the LGBT community as an inclusive term. Queer is often used by younger members of the LGBT community to refer to a sexual orientation outside of the usual binary. Others will still consider this an offensive term, so it is important for providers to consider an individual’s feelings when using such terms and not assume one term fits each patient.
Homophobia is defined as an irrational fear of or prejudice against gay men, lesbians, and bisexuals. Transphobia is a more recent term reflecting a similar fear or prejudice against transgender individuals. In daily life, LGBT individuals experience homophobia and transphobia as interpersonal, workplace, societal, or political bias. In other words, homophobia and transphobia reflect prejudice or hatred based solely on perceptions of sexual orientation and gender identity. LGBT people often find it difficult to act in accordance with their identity for fear of bias, discrimination, or violence.
The stigma that accompanies attitudes of homophobia and transphobia contributes to chronic stress (sometimes called “minority stress”) and negative health outcomes for LGBT persons. Societal discrimination both creates a disparity in social support and resources and limits access to appropriate health care resources. Internalized homophobia (i.e., self-hatred) and self-concealment can create adverse mental health outcomes. Conversely, disclosure of LGBT identity often leads to better psychological adjustment. However, if self-disclosure by an LGBT individual is not supported, it can lead to its own stressor and risk behaviors (see section “Coming Out”).
LGBT patients frequently report detrimental experiences with health care providers. In a survey of its members, the Gay and Lesbian Medical Association reported that more than 50% of respondents were aware of substandard care delivery because of a patient’s sexual orientation. In an earlier survey of nursing students, 8–12% of those responding “despised” gays and lesbians. Several studies document negative reactions after patients self-disclose their identity to a provider and such reactions have been shown to lead to worsened health outcomes for these patients.
Each negative experience with a health care provider decreases the likelihood that LGBT patients will continue to seek health care. Providers must work to overcome judgmental attitudes and biases toward LGBT patients. The Code of Ethics of the American Medical Association states that professional obligation limits a physician’s prerogative to choose whether to enter into a relationship with a patient, in that “physicians cannot refuse to care for patients based on race, gender, [or] sexual orientation ….” Health care providers must recognize that they will likely encounter patients of all orientations and identities in the daily practice of medicine (see section “Provider–Patient Interactions”).
PROVIDER–PATIENT INTERACTIONS
CASE ILLUSTRATION 1
Robert, a middle-aged high school teacher, comes to the doctor’s office. This is his first visit, and he has not completed the intake history form. After the introductions, the physician looks at the form and prepares to take a social history.
The doctor starts the social history:
Doctor: Are you single, partnered, married, widowed, or divorced?
Robert: I’m divorced, with a 20-year-old son, and I’m partnered now. His name is Tim.
Doctor: How long have you been together? How’s the relationship?
Robert: Six years, and going well.
Further questioning reveals that Tim is younger than Robert—and openly gay. Although openly gay with his friends and family, Robert is uncomfortable being that open at work; he is afraid of a scandal at school and the loss of his job. As the history taking continues, the physician asks how Robert feels about having the fact that he is gay documented in the chart. After some discussion, the two decide on a coded entry of the information. At the end of the visit, Robert thanks the doctor for being so understanding; he especially appreciates the advice to establish a durable power of attorney for health care, something that he and Tim have not discussed yet. The doctor is also happy with the visit because he has been able to screen the patient appropriately and provide him with his first physical examination in 6 years.
The provider–patient relationship is the key to providing competent and respectful care to LGBT patients. Without a good provider–patient relationship, patients may avoid medical care. Providers who are uncomfortable working with LGBT patients, or who fail to recognize the sexual orientation of a patient, will not provide quality care. Patients who do not obtain competent primary care services, including screening and health risk and psychosocial counseling are likely to have a lower health status than their heterosexual counterparts. Providers can develop a good relationship with LGBT patients by showing an understanding of their health needs and communicating a nonjudgmental attitude.
Many LGBT persons are reluctant to share their sexual orientation with health care providers for fear of negative judgments and homophobic responses. Some fail to share this information even when asked directly. Unpleasant experiences with health care providers have made LGBT people more likely to avoid health care and routine screening. Even sympathetic health care providers are often uncomfortable with the interaction. They may lack experience with LGBT health issues or feel unsure as to what language to use to elicit information respectfully from these patients. When both patient and provider are uncomfortable, important information is not shared.
Gathering information about a patient’s sexual orientation or sexual practices is often a challenge for health care providers. Asking about orientation only while taking a sexual history and not at other times can limit the opportunity to learn important details about the patient. The initial focus should be on sexual behavior, not identity, as many people with same-sex partners do not identify as gay or lesbian, and sexual orientation is a complex, multifaceted concept. Therefore, the provider should avoid questions that presume behavior or identity. Examples include: “What form of birth control do you use?” “Are you married, single, widowed, or divorced?” “When was the last time you had intercourse?” Because the options given do not necessarily pertain to them, the patient must either provide false information or awkwardly stop and explain. Needing to give such explanations can make obtaining an already challenging sexual history even more difficult for both parties. To avoid this awkwardness, or to avoid negatively impacting the provider-patient relationship, patients may play along with the assumption of heterosexuality, which may negatively impact their health care.
This may be a more comfortable part of the interview in which to raise issues of sexual orientation. By asking questions that do not have heterosexual assumptions, the provider can increase the opportunities for, and comfort level in, discussing these issues. Providers learn about the patient’s family structure, any stressors the patient might have, and personal and community resources on which patients would be likely to draw.
Because LGBT people come in all shapes, sizes, ages, and colors, providers need to use questions that avoid bias with all men and women, not just those they suspect of being LGBT. Sensitive questions make no assumptions about sexual orientation and are easily phrased: “Are you single, partnered, married, widowed, or divorced?” “Who is in your immediate family?” “Over your lifetime, have your sexual partners been men, women, or both?”
In the initial visit with the patient, it is important to discuss explicitly the documentation of sexual orientation in the chart. Many LGBT persons keep their sexual orientation hidden for legal, employment, or child custody reasons. A direct question, such as, “How do you feel about my documenting your sexual orientation on the chart?” may be asked. When an LGBT patient does not want sexual orientation documented, providers can use a coded entry. The code serves to remind providers of the patient’s sexual orientation for medical purposes but will prevent inadvertent breaches of confidentiality.
As a relationship develops between the patient and the provider, it is appropriate to inquire more deeply about a patient’s gender identity or sexual practices. For example, a provider may use one of the following questions: “If you become ill, is there someone important whom I should involve in your care?” or “What percentage of the time do you practice safer sex?” Transgender individuals very early in a transition to another gender may have an appearance that is discordant from the intended gender. Others may have not yet changed the assigned sex or name on legal documents or the medical record. It is perfectly acceptable to inquire about the preferred use of personal pronouns: “What name do you prefer? Would you prefer I address you as he or she?”
Providers who show a nonjudgmental attitude are much more likely to develop trusting relationships with gay and lesbian patients. Providers can improve the relationship in several simple ways: offering to include a partner in the discussions, ensuring that an LGBT patient’s partner is treated as a spouse in the office and the hospital, including partners in discussions of next-of-kin policies and advance directives, and using office and hospital forms with words that do not assume a heterosexual family structure.
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