Working near New York City, Tochi Iroku-Malize, MD, MPH, MBA, the chair of family medicine for Northwell Health, cares for many patients in the LGBTQIA (lesbian, gay, bisexual, transgender, queer, intersexual or asexual) community. She has given serious thought and effort into making each one of these patients feel accepted, valued and welcomed in her practice.
“People in this special population of patients may feel that the healthcare system, including providers and institutions, is not up to recognizing their culture or their needs,” she says.
Research supports that feeling. A large literature supports the finding that people who depart from traditional heterosexual norms feel disrespected and marginalized in healthcare settings. The literature also shows that these patients do in fact receive poorer quality care than people who fit prevailing norms.
Stigma leads to avoidance of healthcare encounters, the research has found, and such avoidance of primary care takes its toll.
“When patients feel there is stigma, this can increase depression among them,” says Iroku-Malize. “The patients, especially the youth among them, are at increased risk of both depression and suicide.” If patients sense that there is stigma against them, that can also lead to increased substance abuse, in terms of alcohol, smoking, and other drugs, all of which leads to more long-term chronic illness, explains Iroku-Malize.
Physicians do not have to become experts in caring for patients in this population, says Iroku-Malize. “You just need to be aware of this population and get the basics of how to approach the patient.”
Here are four ways Iroku-Malize suggests physicians can make clear that LBGTQIA patients will be treated with the same respect and high-quality care any other patients receive. (Note: Many LBGTQIA people also use “queer” as an umbrella term for the entire group, and in the rest of this article that will be the term used.)
Questions to ask
Start with two fundamental questions you can ask on intake forms. They are:
What is your current gender identity? Check all that apply:
- Female-to-male (FTM)/transgender male/trans man
- Male-to-female (MTF)/transgender female/trans woman
- Genderqueer, neither exclusively male nor female
- Additional gender category/(or other), please specify
- Decline to answer,please explain why
What sex were you assigned at birth on your original birth certificate? Check one:
- Decline to answer,please explain why
You will need to do basic preventive screenings based on the assigned sex at birth. This means that a person who had been assigned male gender at birth and who now identifies as a transgender woman still needs to have the health of their prostate monitored. Likewise, a person assigned female gender at birth and who now identifies as a transgender man will need pap smears done.
Other physical exams and tests may be called for depending on whether or not the person has had surgery as part of their transition, and the stage of any such surgery.
Addressing the patient
“The biggest thing healthcare providers don’t know about is what to call these patients,” says Iroque-Malize. Ask the patient what pronoun they prefer–he/she/they/ze or some other pronoun. (“Ze” is one of several relatively new pronouns. It is preferred by some transgender people and by some who consider themselves neither male nor female, and therefore find “he” and “she” inappropriate and hurtful.
Use the patient’s preferred pronoun consistently, and make sure that other staff members do so as well. Place a big note in the patient’s chart in such a way everyone who cares for that person will see it and know how to address them.
In a related matter of language, if you need to do an exam that involves the genitals, ask the patient how they refer to those areas of their body. In that kind of situation, if you need to do a cervical exam, go slowly and be circumspect.
“You have to gain trust and make this exam as comfortable as possible acknowledging that they identify as male,” says Iroku-Malize. You might need to gently explain each step of the exam. “Okay, I am about to approach x and I will do this and do that.”
Taking the time to respect their sensitivities and use their preferred words affirms the patient’s identity, she explains. “Everything I do as a primary care provider acknowledges who they are as a person,” she says.
“Be honest with the patient,” says Iroku-Malize. “Say, ‘I am not experienced with this and I need you to guide me in what is appropriate and not appropriate.’” Tell them that you need their help to gain their trust and be as helpful as possible.
Own your limitations
Be self-aware enough to recognize if your own discomfort or disapproval disqualifies you from caring for a gender-nonconforming patient. If so, be prepared to refer those patients to clinicians who will welcome and care for them well. If there is no one in your area that seems appropriate, you may need to learn about good telemedicine options.
Iroku-Malize says that her healthcare system, Northwell Health, has established a dedicated referral service for members of the queer community. This simplifies the patients’ search for quality care.
If you have pictures of happy families in that area, include families of different sorts. “Even having a small rainbow flag in the waiting room says to patients, ‘You are welcome here,’” says Iroku-Malize.
Make sure that your staff understands the basics of serving queer patients. “Anyone working in primary care has to be culturally sensitive to the gender identities of patients coming in,” says Iroku-Malize. Training resources are available. For instance, the Human Rights Campaign Foundation offers resources to healthcare providers. Be curious and willing to keep learning.
Queer patients are likely to have had unwelcoming encounters elsewhere. In fact, you may be the third or fourth primary care provider that a gender-nonconforming person has turned to, and the first three or four may have been condescending, dismissive or judgmental says Iroku-Malize.
She emphasizes that being willing to listen and learn and wanting to help are all that it takes to make a big difference in the lives of these vulnerable patients.