Clinicians and the care of sexual minorities

An excerpt from “The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health,”� new from ACP Press.


Elimination of health disparities among lesbian, gay, bisexual, and transgender (LGBT) individuals, also collectively called sexual minorities, was highlighted as a major goal in Healthy People 2010, a document prepared by the Department of Health and Human Services to serve as a roadmap for improving the health of the U.S. population during the first decade of this century.

There is a critical need for this focus. Studies suggest that LGBT populations are disproportionately at risk for violent hate crimes, sexually transmitted infections including HIV/AIDS, a variety of mental health conditions, substance abuse, and certain cancers. However, LGBT patients frequently encounter problems with access to quality health services, experience disparities in screening for chronic conditions, and report a lack of counseling pertinent to actual lifestyle behaviors.

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Among the many factors that contribute to disparities in LGBT health, several deserve emphasis: negative societal attitudes that persist even within the medical community, lack of appropriate education for health professionals, and communication shortfalls during clinical encounters. Indeed, a major reason why clinicians do not offer appropriate guidance is that they fail to identify their LGBT patients; that is, they do not know the right questions to ask about gender identity and sexual orientation, or how to create safe environments in which patients feel comfortable volunteering this information.

LGBT health is a topic of particular importance to clinicians for a number of reasons. Clinicians not only have a duty to “do no harm” but, according to the standards of care published by all of the major health profession organizations today, are obligated to educate themselves appropriately to be able to provide culturally competent health services to diverse patients, including LGBT patients.

Some clinicians may sidestep becoming better educated about the needs of LGBT patients because they do not believe they provide care to any of these individuals in their practices. However, data suggest that the failure of clinicians to recognize their LGBT patients is an ascertainment issue (we don't ask and they don't tell) rather than a demographic issue (LGBT people do not exist). While the exact number of people who identify themselves as LGBT is not known, the best designed study of sexual behavior and orientation in the U.S. to date, published by the University of Chicago Press in 1994, found that 1.4% of women and 2.8% of men identify themselves as bisexual or homosexual; 4.3% of women and 9.1% of men report some “same-sex behavior since puberty”; and 7.5% of women and 7.7% of men report experiencing same-sex desire or attraction. There are no reliable data on the numbers of transgender people; prevalence estimates vary widely and tend to include only transsexual persons who have undergone sex reassignment surgery.

How can we do better?

Sustained behavioral change is generally accomplished only after a thorough process of self-questioning, in which a person explores his or her feelings, thoughts, and values, as well as the reasons why he or she does and does not want to change. With respect to increasing competency in LGBT health, clinicians may find it helpful to start by asking: “How do I feel about learning more about LGBT health?” “What factors are motivating me?” “What factors are holding me back?” “What are my short- and long-term goals?” and “Do I have the resources and support I need to reach these goals?”

Clinicians should try to develop awareness of and respect for a patient's difference(s) and a willingness to listen empathically to that person's experience. This is not always easy to do. Negative attitudes toward LGBT people are common: Clinicians—regardless of whether they are lesbian, gay, bisexual, transgender, or heterosexual—are subject to the same societal influences as everyone else and are vulnerable to believing stereotypes and making assumptions. A helpful exercise in examining one's own beliefs is to quickly write down all the labels and stereotypes, both negative and positive, one associates with the terms “gay man,” “lesbian,” “heterosexual woman,” “heterosexual man,” “bisexual,” and “transgender.” Exercises such as this can stimulate us to think about our deepest internal reactions to people of difference. It is easy to see how personal biases, even the ones we wish to dispose of, can interfere with the process of truly understanding a patient and establishing empathy during a clinical encounter.

The more “different” clinicians perceive themselves to be from their patients (and vice versa), the more likely it is that either or both parties will feel uncomfortable during clinical interactions. Numerous factors affect the quality of the clinician-patient relationship, including externally observed and internally inferred characteristics of both the clinician and the patient (gender, age, race or ethnicity, social class, education, disability, sociocultural beliefs, religious attitudes and values, and sexual orientation). Clinician-patient dyads that seek to become more comfortable with difference must attend to all of these variables. The greater the number of disconnects, the more complicated and lengthy the process is likely to be.

Depending on personal comfort level with gender and sexual diversity, clinicians may experience a wide variety of emotions when patients disclose that they might be or are lesbian, gay, bisexual or transgender. Surprise, anxiety, guilt, fear, confusion, anger, disgust and delight are all possible emotional reactions. A clinician's response to the multitude of feelings that can arise can have either a negative or a positive impact on the therapeutic relationship. Clinicians who avoid acknowledging and examining their emotions are likely to have limited or incomplete understanding of their subsequent motivations and actions. Avoidance also makes it more likely that these emotions will affect the patient in ways that are counterproductive or even harmful. Discriminatory reactions on the part of health care personnel, including hostility, denial of care, violation of confidentiality, and refusal to acknowledge a patient's partner, have been reported in the literature, though most of these studies are over 10 years old. On the other hand, clinicians who take the time to examine their responses in detail are more likely to be able to negotiate, accept and perhaps even take pleasure in the differences between themselves and their patients. These clinicians are much more likely to create a trusting and nonjudgmental atmosphere in which to conduct care.

Clinicians have a professional duty to examine the basis of their emotional reactions toward patients and the assumptions they make about patients. We are trained not to casually accept the first diagnosis that pops into our heads. Instead, we ask ourselves: “What evidence supports this diagnosis?” or “Is there anything else that could be going on?” Similarly, we should not automatically accept our personal biases without question. When we have a particularly strong reaction to a patient, we might ask: “Why am I responding this way?” “What is the evidence that my assumption is correct?” “Is there any other possible interpretation?” or “How can I take care of this patient in as nonjudgmental a manner as possible?”

In addition to the value of questioning in challenging bias, stereotypical attitudes can also be changed through experience. Research studies show that the more contact clinicians have with patients who are “different,” the more comfortable they are likely to feel during clinical interactions and the more positive their attitudes toward these patients will become. This holds true for the majority view of various minority populations, including racial and ethnic groups as well as sexual and gender minorities. Therefore, clinicians who are particularly interested in changing their attitudes about people with nontraditional gender identity and sexual orientation are advised to attend LGBT-focused continuing education conferences and to seek out training experiences in settings where they are likely to encounter large numbers of LGBT patients.

Creating a safe environment

There are many things clinicians can do to create a safe health care environment for LGBT patients. First and foremost, it is important to resist making assumptions about a person's gender identity, sexual orientation and lifestyle behaviors based on his or her appearance, demeanor or any other characteristics. It is important to provide nonverbal (visual and environmental) cues that signal acceptance, as well as to attend carefully and respectfully to verbal and written communication. Examples of the former include posting a nondiscrimination policy in the office; displaying educational brochures that are pertinent to LGBT populations; including demographic categories on intake forms that honor LGBT identities and lifestyles; and ensuring availability of a unisex restroom. Examples of the latter include learning how to ask sensitive, open and direct questions about gender issues, sexual orientation, risk behaviors and overall life adjustment and explicitly discussing and maintaining confidentiality.

Learning how to communicate sensitively and effectively requires that we develop an appreciation for the variety of ways in which people define and express their sexuality and gender. Sexual orientation can be seen as comprising three dimensions: behavior, identity, and desire. Lesbian, gay, and bisexual populations are those who have “an orientation toward people of the same gender in sexual behavior, affection, or attraction, and/or self-identify as gay or lesbian or bisexual.” People who identify themselves as gay or lesbian tend to have romantic and sexual relationships with members of the same gender, while those who self-identify as bisexual have the potential for experiencing such relationships with members of any gender. Bisexuals may feel equally attracted to both men and women or have a stronger preference for one gender. It is important to note, however, that sexual identity, behavior, and attraction are fluid and may change over time, and sexual identity does not always align with sexual behavior and attraction. For example, a married man who identifies as heterosexual may be exclusively attracted to men and have sexual and emotional relationships with other men as well as with his wife. Similarly, a woman who identifies as a lesbian and has a female partner may have had relationships with men in the past.

Understanding the “T” in LGBT can be more confusing. The definition of transgender has changed over time and continues to be used inconsistently. Most broadly, the term includes anyone who does not conform to traditional gender norms for men and women. When used in this sense, it includes people who do not identify as either male or female, as well as people who experience and choose to express their gender identity as opposite to their biological (birth) sex. Importantly, transgender refers to gender identity and is therefore distinct from sexual orientation; transgender individuals may seek relationships with men, women, or other transgender individuals and may identify as gay, lesbian, straight, or bisexual.

Some people object to the traditional labels of gender or sexuality and may choose to use nontraditional identity terms, such as “same-gender-loving man” or “woman-loving woman.” Others reject labels altogether and describe themselves as gender neutral. In recent years, the term “queer” has become increasingly popular as a term of both sexual and gender identity, especially among adolescents and young adults, although it has not been embraced by all LGBT individuals or communities.

Finally, it is important to realize that some people who have same-gender relationships, particularly men from racial and ethnic minority communities, self-identify as heterosexual. Reasons for adopting a straight rather than gay identity are multiple. Some racial or ethnic minority men view gay culture and identity as white, Western, and classist, and they do not feel welcome in the LGBT community. Others believe that to embrace a gay identity would be to reject family and religious values, or ethnic culture, and could lead to estrangement from family and community.

Providing training for everyone

Patients' experiences in a health care facility are impacted by all of the individuals they encounter during the process of care. These people include the person who makes their initial appointment on the telephone, the valet in the parking garage, the receptionist who greets them on arrival, the nursing assistant who takes their vital signs, and so on. Therefore, it is vital that everyone who works in the health care arena, including administrative and janitorial staff, receive training. A physician or nurse may be very sensitive to LGBT issues, but if, for example, a receptionist makes an even remotely insensitive comment, the patient may develop a negative impression of the practice. Staff development regarding LGBT-specific, culturally competent language and interactions will not only help ensure a safe, welcoming, nonjudgmental experience for patients, but may also relieve anxiety and confusion among employees who are unfamiliar with and do not feel prepared to serve LGBT patients.

For clinicians who seek to improve care for sexual and gender minorities, developing the ability to communicate sensitively and effectively with LGBT patients is a skill of paramount importance. Attention to identification and examination of personal biases, as well as learning about cultural characteristics that impact risk factors and disease incidence, sets the stage for clinicians to communicate more productively. However, attitudes and knowledge are not enough: Developing skills requires practice. Clearly, the best way to practice is through actual experience interacting with LGBT patients. However, since opportunities for concentrated exposure to LGBT patients are limited, it may be more practical to experiment with different communication techniques in hypothetical situations, through role-play exercises (see ). The educational value of both real and contrived scenarios is greatly enhanced when feedback is provided; therefore, clinicians are encouraged to ask a trusted colleague to serve as an observer.

Strategies for educating others and effecting change

All clinicians, both LGBT and non-LGBT, who seek support to challenge prevailing views about gender or sexual identity may be interested in joining a professional organization committed to improving health for sexual minority populations. A number of professional organizations are devoted to this purpose; in addition, many mainstream organizations have special interest groups that are similarly dedicated (see ).

Hopefully many clinicians will choose to become active at the institutional level to create an appropriate context in which to offer high-quality care to LGBT patients. It is difficult to sustain an office culture that celebrates and protects diversity without having policies that clarify and support the principles of that culture. Therefore, we recommend that clinicians who are in management roles create and implement antidiscrimination policies for both employees and patients. Clinicians who do not have direct managerial responsibility themselves can advocate for adoption of these same policies with institutional leadership.

The manner in which antidiscrimination policies are disseminated has a strong influence on uptake. They should be written in languages appropriate to the populations served at the health care facility, posted in strategic areas, and included in informational or promotional materials about the facility. Policies geared toward employees should be discussed during the interview process, presented in the employee handbook, and reviewed during orientation programs. All staff should be aware of all policies. It is crucial to communicate clearly to all employees that discrimination in the delivery of services based on gender identity or sexual orientation violates standards of good care and will be subject to disciplinary action.

Some clinicians will also feel moved to become active in regional and national advocacy efforts. Small steps, such as starting a working group or becoming involved in an interest group, can mean a lot both to LBGT patients and LGBT employees.