Know thy patient: Providing a welcoming environment and better care for LGBTQIA+ patients

Every patient wants their needs met in a friendly and respectful manner, which should serve as the baseline when treating patients functionally, emotionally and socially. Christine Kalish, MBA, CMPE, president/CEO, Brittain-Kalish Group, and Penny Crow, MS, SHRM-SCP, RHIA, principal/compliance officer, Brittain-Kalish Group, said it’s no different with LGBTQIA+ patients.

“Regardless of what gender identity or sexual orientation is practiced by anybody, we’re not going to be able to meet that patient’s health care as a whole person if we don’t respect them for where they are,” Crow stressed during her presentation with Kalish at MGMA20 | The Operations Conference Online.

The colloquialism, “a picture paints a thousand words,” comes to mind when instituting a gender-neutral and welcoming culture for all patient groups. Regardless of unconscious biases — stereotypes or beliefs that affect our actions in a discriminatory manner — providers and staff should strive to support every patient and foster a holistic and inclusive environment.

Respecting gender identity

Defined as “a person’s internal sense of being male, female, some combination of male and female, or neither male nor female,” gender identity should be understood and respected prior to providing care to patients. Sadly, this is an ongoing issue in healthcare. As reflected in recent studies, LGBTQIA+ patients often experience discrimination, which can affect their desire to seek care. 

For example, a 2018 study by the Center for American Progress reported that 8% of lesbian, gay, bisexual and queer respondents and 29% of transgender respondents said that a doctor or healthcare provider had refused to see them because of their sexual orientation or gender identity. The study also revealed that 9% of LGBQ respondents and 21% of transgender respondents stated that a provider used harsh or abusive language when treating them.¹ In a 2019 survey of oncologists from National Cancer Institute (NCI)-designated Comprehensive Cancer Centers, only 66% of respondents said it was important to them to know their patients’ gender identity.² Another study in the Journal of Adolescent Health reported that 46% of patients surveyed at a gender clinic in southwestern Pennsylvania said that they avoided disclosing their gender identity outside of gender clinics.³ 

Whether the bias is conscious or unconscious, it’s apparent that the healthcare industry has room for improvement when it comes to inclusiveness with LGBTQIA+ patients. As such, there are several actions practices can take to respect gender identity, including: 

• Create a welcoming environment: Regardless of the patients’ gender identity, age, skin color, etc., everyone should feel equal.
• Do not assume: When in doubt, ask patients their preferred name and pronoun(s).
• Treat individuals consistent with their gender identity: This is particularly relevant regarding patient access to healthcare facilities, programs and activities. When separated or labeled by gender, treat patients according to their self-identified gender.
• Discuss sexual orientation or gender identity when collecting healthcare information: By doing so, practices can help address health disparities and meet specific healthcare needs.
• Avoid one-and-done questions: Gender fluidity — when gender identity is not fixed — precludes providers and staff from making assumptions about gender identity. For example, a patient may have started life as a female but now identifies as a transgender male. However, the patient may decide that he wants to get pregnant.
• Change technology to capture data in a community that’s not binary: Because there are patients who are transitioning, they do not fit into the fixed binary system established in early computer systems. As a result, many EHRs don’t allow for patients to identity as nonbinary, transgender, genderqueer or other LGBTQIA+ identities.

Employing best practices

Establishing processes for promoting inclusiveness is vital for all practices, Kalish noted, to ensure positive interactions every time when caring for LGBTQIA+ patients. “I always say in healthcare that we never seem to have time to do it right the first time, but we always find the time and money in the budget to do it over and over again to fix it,” Kalish said about the benefits of prioritizing best practices from the start.

To help address patients’ concerns, the Fenway Institute’s National LGBT Health Education Center assembled a resource to assist frontline healthcare staff in developing an affirming environment for transgender and gender non-conforming patients. When implementing best practices, the center recommends using the script in Table 1.*

Although it may be difficult to follow a script the first few times, according to Crow, it helps staff and providers get in the habit of addressing patients in the manner they would like to be addressed. After all, patients would prefer to be asked a question rather than have someone make an assumption. “This is just good people skills that we provide to these patients so that all patients are treated the same,” Crow maintained.

Scripts are particularly helpful for frontline staff, whom Kalish refers to as air traffic controllers, because patients encounter them first and they can make patients feel welcome straightaway. “What we don’t do for these folks is we don’t give them sufficient training to be able to be successful for being that air traffic controller and managing all of the stuff that they have to manage,” Kalish said.

Kalish noted that training needs to be inherent to help staff refrain from using gender-specific pronouns. “Rather than saying, ‘she is in the waiting room,’ ‘he is doing this,’ if you don’t know … either use the patient name or use something that is not gender specific,” Kalish said.

Enhancing patient engagement

There are many ways practices can enhance patient engagement, including emphasizing active patient participation in care, optimizing healthcare technologies and stressing the importance of patient surveys and feedback. However, with LGBTQIA+ patients specifically, some of the most important considerations that can lead to better patient engagement include: 

• Partner/spouse rights: Ensure spouses and partners complete HIPAA consent forms, as it’s often a primary concern for LGBTQIA+ patients.
• Birth certificate policies: Be knowledgeable of state laws; for example, states such as California include mother-mother and father-father fields when listing parent information. 
• Patient registration: To maintain privacy, patients should be able to register through the practice’s patient portal. 
• Inclusive content: Beyond being able to list legal name and gender, patients should be able to list a preferred name and gender. This will affect how medications and procedures are noted in the patient portal. For example, if a patient is undergoing gender reassignment surgery, they should be able to review the hormones they’ll need to take. In addition, some EHRs are still binary, but gender identity is not. When selecting an EHR, ensure that it offers fields for sex assigned at birth, legal sex, gender identity and sexual orientation. Additionally, there should be fields for names and pronouns used.
• Nondiscrimination notice: Clearly display a notice of nondiscrimination and include pictures of nontraditional families in the office. 
• Reference ranges for lab results: Patients who have received lab results should have access to reference ranges tied to gender. For example, if a patient is going through a female-to-male gender reassignment, their “normal” range may be different than someone born male.

According to Kalish, the notion of respecting gender identity should be ingrained in a practice’s culture. “The more comfortable the patient is, the more you’re going to get the information you need,” Kalish expressed. “Everything really needs to be inclusive, but it needs to be inclusive of all of your patients all of the time, depending on who it is that you’re caring for.”

Notes:

1. Mirza SA, Rooney C. “Discrimination prevents LGBTQ people from accessing health care.” Center for American Progress. Available from: ampr.gs/2WabYLN.
2. Schabath MB, Blackburn CA, Sutter ME, et al. “National survey of oncologists at National Cancer Institute-designated Comprehensive Cancer Centers: Attitudes, knowledge, and practice behaviors about LGBTQ patients with cancer.” J Clin Oncol 37:547-558, 2019. Available from: bit.ly/3b4tLZ6.
3. Sequeira GM, Ray KN, Miller E, Coulter RWS. “Transgender youth’s disclosure of gender identity to providers outside of specialized gender centers.” Journal of Adolescent Health. Feb. 20, 2020. Available from: bit.ly/3fkoO1w.