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Gender minorities face additional barriers to health care
Health care providers may feel ill-equipped to handle the unique issues that some patients of a gender or sexual minority face, but many small shifts in the atmosphere of the office, clinic or visit can make a big difference for these patients.
“There is a baseline set of signals that can be sent to a patient that a particular office is welcoming,” Sheryl Kingsberg, PhD, chief of the division of behavioral medicine, department of OB-GYN, University Hospitals Cleveland Medical Center, and professor in the departments of reproductive biology and psychiatry at Case Western Reserve University School of Medicine, told Endocrine Today.
Some simple ways to make an environment more welcoming include offering gender-neutral bathrooms; using diverse gender identity options on patient intake forms; ensuring a diverse representation in posters, brochures and magazines in the waiting room; designating an office as a safe space; promoting visible nondiscrimination policies; and adopting an affirming (patient facing and provider facing) electronic medical record.
“Sending messages to patients that inform them that a particular setting [is inclusive of their identity] is very important and reassuring, especially since many people have had negative experiences in the past,” Lisa Simons, MD, attending physician at The Potocsnak Family Division of Adolescent and Young Adult Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, and assistant professor of pediatrics at Northwestern University, Feinberg School of Medicine, told Endocrine Today.
Gender identity, pronouns
The first step to ensure patients feel safe and welcome is to learn each patient’s gender identity and pronouns.
Although the terms “gender minority” and “sexual minority” do not cover all-inclusive lists of identities, the physicians interviewed for this piece agreed that these tend to include anyone who does not fit into a cisgender — that assigned at birth — identity. Other terms that may be used interchangeably include “gender expansive,” “gender nonconforming” or “gender diverse.” This patient population can also include anyone who is part of the LGBTQIA community.
The language around gender and sexual identity continues to change rapidly, and labels can be important to some but eschewed by others, Kingsberg said.
“We want patients to know that we are aware of the limitations of labels, and we want to affirm them and their identity,” Kingsberg said. “We are more likely to ask patients to take the lead in how they self-identify.”
Simons said she likes to begin a session by introducing herself and sharing her pronouns with the patient, which can then prompt them to reciprocate and feel comfortable doing so.
Jeremi Carswell, MD, director of the gender management services program at Boston Children’s Hospital, recommends training front desk staffers to ask each patient what name and pronouns they would like to use, noting that cisgender individuals, too, may prefer a nickname or go by their middle name.
Challenges to care
Patients of a gender or sexual minority — particularly those whose outward appearance may not indicate their identity — can face hurdles throughout their health care journey and may continually be unsure about how they will be received.
Some common questions, according to Kingsberg, may include, “Will my insurance cover it? Will I get time off to see the health care provider? Will the front desk staff be welcoming? Will the physical environment be open and affirming? Will the back office staff and the provider be welcoming? Will they be knowledgeable about needs that are specific to my identity? Will they hear me and listen to me as a person? Are they able to check their implicit or unconscious biases at the door? Are there follow-up supports/services that I will be able to access?”
Patients may also face challenges around billing and insurance, particularly if their name on billing documents is not the name they use to fit their gender identity — an issue that is common for transgender patients. According to the 2015 U.S. Transgender Survey (USTS), the largest survey to examine experiences of transgender people in the United States with 27,715 respondents, 68% of respondents reported that none of their identity documents (such as driver’s license, social security records, student records, passport and birth certificate) had the name and gender they preferred.
In addition, 25% of respondents reported a problem with insurance in the past year related to being transgender, such as being denied coverage for care related to gender transition or for routine care because they were transgender.
Carswell noted that not all states have mandates against nondiscrimination in health care based on gender and recommended practitioners to refer their patients to the National Center for Transgender Equality for help dealing with these issues.
Understanding bias
One difficulty to creating a positive atmosphere for patients of diverse gender and sexual identities is the lack of training and education available, both for clinicians and for office staff.
The USTS found that 33% of those who had seen a health care provider in the past year reported having at least one negative experience related to being transgender, and 23% of patients had avoided visiting a provider in the past year for fear of being mistreated as a transgender person.
“This number, unfortunately, is higher when an individual is of another minority, such as ethnicity or race,” Carswell told Endocrine Today.
Kingsberg said health care providers must examine their own biases and how those might affect how they interact with patients.
While trying to make patients feel welcome, Simons and Kingsberg said, providers must avoid making assumptions about an individual’s gender identity or sexuality.
“Use gender-neutral and inclusive language, open-ended questions, show respect, affirm the dignity of the patient,” Kingsberg said. “Additionally, reflect an understanding of the unique challenges they may face as a gender minority patient while at the same time, do not assume they face all of those challenges the way you might imagine they do.”
“When I ask about gender identity,” Simons said, “I like to understand more about how they use [a particular] term, what it means to them, especially when people use terms that reflect nonbinary identities. When I ask about sexuality, I keep it open-ended and ask patients to describe their partners.”
Although keeping up on terminology can be tricky, asking questions is OK. “If someone uses a term that you are unfamiliar with, it is always appropriate to ask what that term means to them, and if that is the term they would like to use,” Carswell said. “Most importantly, if you have made a mistake in terminology or pronouns, acknowledge, apologize and then move on.
“Taking care of gender expansive patients is not something that most practicing physicians have been trained in, but something that is definitely worth educating [themselves] about,” Carswell said. “On the whole, taking care of this population has been the most rewarding part of my career, and I know I’m not alone in this sentiment.” – by Amanda Alexander
Reference:
James SE, et al. The Report of the 2015 U.S. Transgender Survey. Washington, D.C.: National Center for Transgender Equality. Available at: https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf.
For more information:
Jeremi Carswell, MD, can be reached at jeremi.carswell@childrens.harvard.edu.
Sheryl Kingsberg, PhD, can be reached at sheryl.kingsberg@uhhospitals.org.
Lisa Simons, MD, can be reached at lsimons@luriechildrens.org.
Disclosures: Carswell, Kingsberg and Simon report no relevant financial disclosures.