NEW ORLEANS -- Medical practices that want to make their offices welcoming and inclusive for lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals can signal their intention with subtle indicators, Jesse Ehrenfeld, MD, MPH, said here Monday.
"Take inventory," Ehrenfeld, who is director of the Advancing a Healthier Wisconsin Endowment at the Medical College of Wisconsin, in Milwaukee, said at the annual meeting of the Medical Group Management Association. "Have something rainbow-flavored somewhere," such as a "safe space" sticker or a flag on the desk, or subscribe to LGBTQ-themed magazines and leave them in the waiting room. He noted that in his prior job at Vanderbilt University, the staff put up signs on all of the single-stall bathrooms indicating that they were gender-neutral. "Straight patients won't notice, but it will mean the world [to others]."
Ehrenfeld, who is the first openly gay chair of the American Medical Association's board of trustees, said he himself always looks at the non-discrimination language that healthcare facilities are required to post in their waiting rooms, to see if information about gender identity has been added. "It's just one of those subtle things I kind of notice." At his current facility, the pediatric unit used to have paperwork with spaces for information about "Mom" and "Dad," and they have changed it to "Parent 1" and "Parent 2," which works for all kinds of families, he added.
Such reminders can be welcome to a significant portion of your patient population, said Ehrenfeld. "Every day, no matter where you work or what you do, you'll be taking care of LGBTQ folks." He cited a survey showing that:
- 4.1% of U.S. adults -- 10 million people -- identify as LGBT
- 8.2% report same-sex behavior in their lifetimes
- 11% report having had same-sex attraction at some point
Transgender numbers are a little harder to pin down, but one survey estimated transgender individuals as about 0.6% of the U.S. population. Furthermore, almost 2% of high school students in the U.S. identify as transgender, and 27% of them feel unsafe at school; 35% say they are bullied because of being transgender, and 35% have attempted suicide. In addition, almost 40% of homeless adolescents are LGBT, said Ehrenfeld.
Access to care is also more difficult for this population, with LGBT patients twice as likely to be uninsured as other patients. "And when people do have coverage and come see us, they often don't get the best care," he added, with 56% of LGB and 70% of transgender patients reporting that they encounter bias or discrimination when accessing care. "If you come to the doctor's office and are told, 'I don't take care of people like you,' what do you do? Well, you don't go back."
Even in urban areas where more acceptance might be expected, "it's really hard to find knowledgeable, friendly providers," said Ehrenfeld. He spoke with one endocrinologist in the Washington, D.C., area who said he had a transgender patient who had previously gone to six other endocrinologists -- none of whom had been willing to take him as a patient.
He reviewed questions that should and shouldn't be asked of LGBTQ patients. Those that should be asked include, "Is there a name you use that is different from what is on your chart?" and "Is there a gender pronoun that you use that is different from what is on your chart?" Inclusive policies can also be incorporated into the patient intake workflow -- for instance, many facilities have stopped putting gender on patient armbands because it's not clinically relevant, but have added patients' preferred names.
Questions not to ask include anything that is clinically irrelevant and those that are just to satisfy your personal curiosity. He gave an example of a senior leader at Vanderbilt who was openly gay; one day, his secretary said to him, "I just don't quite understand. You and your husband -- who's doing what?" He responded, "I think you just asked, am I the insertive or receptive partner. Is that what you really wanted to ask?"
"She said, 'Oh my God -- I'm so sorry,'" Ehrenfeld said. "People unfortunately are asked these inappropriate things lots of times.... Just be thoughtful about the questions you're asking."
On the other hand, LGBTQ patients do want to be asked clinically relevant questions, he said. One study by researchers at Johns Hopkins University found that while patients don't mind being asked about their sexual orientation -- whether it's by a registration clerk, an RN, or a physician -- "on the staff side, we are afraid," Ehrenfeld said. "The vast majority of patients want to be asked, and the vast majority of healthcare workers think that we shouldn't ask because I'm going to, like, turn someone off."
One way to improve the way your practice treats LGBTQ patients is to use the Healthcare Equality Index, a free tool developed by the Human Rights Campaign (HRC), an organization that promotes LGBTQ rights, Ehrenfeld said. The index allows practices and health systems to rate themselves on their policies in areas such as patient non-discrimination, equal visitation, and employment non-discrimination. Of the 680 facilities who participated in the index in 2019, 408 earned a score of 100 points, giving them a designation of "Leader in Healthcare LGBTQ Equality," according to the HRC website -- a designation that facilities can post on their website to further indicate their inclusive policies.
Another way to make your practice more inclusive is through a Trans Buddy Program, such as the one Vanderbilt implemented in 2015 for its transgender patients. The program involves using community-driven trained volunteers to accompany patients to appointments, he explained.
"It is so hard to be a male-presenting trans man in ob/gyn clinic -- to show up to women's health to get your Pap smear and you've got a beard -- it's just awful." Ehrenfeld said the program has been very successful, is free, and anyone can be referred to it.