“Do you know anything about the father? What is his history? You know how important the father is, right?”
“PLEASE STOP SAYING FATHER,” I desperately screamed internally as my wife and I held our newborn son, my hormones raging and sleep deprivation already apparent. “HE HAS TWO MOMS” is what I wanted to shout to the attending, but I had no energy for the teachable moment and quietly said “No, he has no such history.” He left the room, never realizing the mistake he made.
However, this was not the first or last time the heteronormativity of medicine crept into our lives. Months later, an ED visit for an allergic reaction prompted “Which one of you is the real mother?” Since then, countless forms asking for the “Father’s Name.”
Unfortunately, these microaggressions are often experienced by lesbian, gay, bisexual, transgender, queer, intersex, and other sexually and gender diverse people (lesbian, gay, bisexual, transgender, intersex, and “+” [LGBTQI+]; Table 1) in daily life including when interfacing with the medical community. There are an estimated 11 million people in the United States who identify as LGBT, but this is an underestimation of the true population because data are not collected consistently to capture the diversity of sexual orientation and gender identity (SOGI), especially in transgender and intersex populations (1).
This review will discuss the important terms relevant to the LGBTQI+ population and the history of the LGBTQI+ community, highlight top health disparities, and offer concrete action steps to create a more inclusive and welcoming environment for our LGBTQI+ patients.
It is imperative to understand and use the proper language when interacting with the LGBTQI+ community. There are differences between sex, gender, sexual orientation, and gender identity (Table 2). Sex is biologically determined by chromosomes, endogenous hormones, and reproductive organs that one is born with. Gender is a social construct that is culturally defined. Gender identity is how one sees themselves and may be cisgender, transgender, or nonbinary (Table 2). Importantly, one’s gender identity does not imply any specific sexual orientation.
UNDERSTANDING LGBTQI+ HISTORY
Members of the LGBTQI+ community have a history of experiencing discrimination, violence, and oppression that has affected nearly every aspect of their lives. Figure 1 depicts a timeline of important historic events that have shaped the narrative of many in the LGBTQI+ community. Specifically, as it relates to health care, several instances have affected health-seeking behavior and access to care. Up until 1973, the Diagnostic and Statistical Manual of Mental Disorders pathologized homosexuality as a mental disorder (2). In 1983, the US Food and Drug Administration banned blood donation from gay and bisexual persons. This practice has been revised, but its ramifications have been felt throughout the community, especially after the Pulse nightclub shooting in Orlando, Florida, where there was an urgent need for blood donors, but gay men could not donate unless they were celibate for 1 year (3). More recently, a tsunami of anti-LGBTQI+ legislation is flooding state legislatures with bills allowing denial of health care based on religious or moral objections in addition to those jeopardizing the health care of our transgender patients, specifically youth (4). As a result, many LGBTQI+ patients do not reveal their sexual orientation or gender identity to their providers, despite the importance of such information in their medical care (5).
Reviewing the LGBTQI+ narrative illustrates that there are many social determinants of health based on discrimination that affect LGBTQI+ individuals and their health outcomes (6). Many in the LGBTQI+ community have learned that identifying as LGBTQI+ can be dangerous and ostracizing and such feelings intensity in the healthcare setting. Although some may feel outright homophobia, there are many subtle instances of discrimination in the form of heteronormativity (where heterosexuality is woven into society as the expected sexual orientation). The latter is seen in gender binary structures of medical intake forms and patient interactions (i.e., assuming a patient has 1 mother and 1 father) (7). In addition, one’s SOGI intersect with ethnicity, age, socioeconomic status, culture, class, and religion and also affect health outcomes (8).
THE SCOPE OF LGBTQI+ HEALTH DISPARITIES
In 2016, the LGBTQI+ population was identified as a “health disparity population” by the National Institute on Minority Health and Health Disparities (6). Higher rates of cardiovascular disease, psychiatric illness (anxiety, depression, and suicide), human immunodeficiency virus, and other sexually transmitted infections are seen in the LGBTQI+ population (9). From a gastroenterology and hepatology lens, lesbians and bisexual women are more likely to be obese, rates of anal cancer are increased among gay and bisexual men, and there is decreased utilization of preventative cancer screenings including colorectal, anal, and breast (6). These disparities are, in part, believed to be related to decreased access to employer-sponsored health insurance benefits for same-sex partners (10).
Part of this health disparity is also seen in the amount of dedicated LGBTQI+ content that is taught in medical schools in the United States. One study reported a median of 5 hours across the entire curriculum with a specific paucity related to transgender health care (11). Not surprisingly, a survey conducted in 2009 with 4,916 LGBT patients found that up to 89% of transgender and 49% of LGB patients did not think there were enough trained providers to care for sexual minorities (12). The same survey also found that 52% of transgender patients feared they would be refused medical care and 73% feared medical providers would treat them differently. As such, efforts to increase LGBTQI+ health education and teaching are of paramount importance.
WHAT CAN WE DO?
Outlined below are critical steps that we can take to improve the health and well-being of our LGBTQI+ patients. This is by no means an exhaustive list but concrete actions that can be taken today to help our patients.
Create a welcoming and inclusive environment
LGBTQI+ patients report scanning their environment for subtle signs that signify their acceptance (5). Having a sign at the door welcoming everyone (Figure 2a) or the 2018 redesigned progress pride flag by Daniel Quasar that adds pink, light blue, black, and brown stripes (representing transgender, black, and brown people, respectively) to the existing rainbow (Figure 2b) can demonstrate inclusivity. In addition, visibly displaying patient nondiscrimination policies that include sexual orientation and gender and designating all-gender bathrooms can also help.
Obtain SOGI data from all patients
Intake forms (10) and electronic health records should be revised to be inclusive to a range of sexual orientations and gender identities (13). At our institution, we have launched a “We Ask Because We Care” campaign because we initiate SOGI data collection so that patients may understand why it is important to capture these data and how it allows us to provide better care.
Our language is important
It is important to ask our patients how they identify themselves and their preferred pronouns (Table 3). In addition, having our pronouns displayed on our badges (in addition to our e-mail signatures, Zoom identities, and social media profiles) can also create a welcoming environment. Use of pronouns extends beyond transgender and nonbinary equality and serves to normalize discussions surrounding gender. When we ask and use preferred pronouns, there are no assumptions or misgendering; it demonstrates inclusivity and creates a safe space for not only our patients but for our colleagues, trainees, and staff.
Increase LGBTQI+ health-related education and training
As discussed above, there is a lack of education regarding LGBTQI+ health in medical schools. Increasing not only time spent in the formal curriculum but also access to LGBTQI+ patients is needed. In addition, training all hospital and clinic staff is necessary.
Cultivate cultural competency and cultural humility
Although this does not solely apply to the LGBTQI+ population, we know the importance of cultural competency in medicine—having knowledge about our patient’s culture and traditions—allows us to avoid stereotypes (14). However, it is important to have cultural humility in knowing that things will change and being open to adapt. Know that we will all make mistakes. Acknowledge them, apologize, and be humble.
Moving forward, let no well-intentioned healthcare provider fixate on missing fathers. Although the breadth and complexity of LGBTQI+ health disparities are vast, we have the ability to shift them with changes in our behaviors, education, and language. My son (now aged 6 years) is delighted to see the rainbow flag on the door to his doctor’s office; “Look Mama, they care about us.” Let all of our patients feel as welcome as my son does. Although the comprehensive strides of change transcend a simple rainbow decal, our small actions can reverberate this call for change.
CONFLICTS OF INTEREST
Guarantor of the article: Sonali Paul, MD, MS.
Specific author contributions: S.P. planned and drafted the entire article and has approved the final draft submitted.
Financial support: There was no financial support in the writing of this article. Dr. Paul has grant and research support from Target PharmaSolutions, GENFIT, and Intercept Pharmaceuticals, but this work was independent of that support.
Potential competing interests: None to report.
I wish to acknowledge the following people for their thoughtful review and commentary: Dr. Sarah Hoehn, Ms. Julia Karol, Ms. Catherine Lazatin, and Ms. Raykayle Martinez.
1. National Academies of Sciences, Engineering, and Medicine. Understanding the Status and Well-Being of Sexual and Gender Diverse Populations. Washington, DC: National Academies Press, 2020 (https://www.nationalacademies.org/our-work/understanding-the-status-and-well-being-of-sexual-and-gender-diverse-populations
). Accessed March 23, 2021.
2. Drescher J. Out of DSM: Depathologizing homosexuality. Behav Sci 2015;5:565–75.
3. Stern M. There’s an Urgent Need for Blood Donors in Orlando. Most Gay Men Still Can’t Donate. SLATE (https://slate.com/human-interest/2016/06/orlando-pulse-gay-nightclub-shooting-gay-men-cant-donate-blood.html
). Published June 12, 2016. Accessed March 12, 2021.
4. Ronan W. 2021 Slated to Become Worst Year for LGBTQ State Legislative Attacks as Unprecendented Number of States Poised to Enact Record-Shattering Number of Anti-LGBTQ Measures into Law. Human Rights Campaign Press Release (https://www.hrc.org/press-releases/2021-slated-to-become-worst-year-for-lgbtq-state-legislative-attacks
). Published April 22, 2021. Accessed April 25, 2021.
5. Eliason MJ, Schope R. Original research: Does “don’t ask don’t tell” apply to health care? Lesbian, gay, and bisexual people’s disclosure to health care providers. J Gay Lesbian Med Assoc 2001;5:125–34.
6. Healthy People 2020. Disparities. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion: Washington, DC (https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities
). Accessed March 26, 2021.
7. Goins EaP D. Check the box that best describes you: Reflexively managing theory and praxis in LGBTQ health communication research. Health Commun 2013;28:397–407.
8. Ng HH. Intersectionality and shared decision making in LGBTQ health. LGBT Health 2016;3:325–6.
9. Lim FABD, Kim SMJ. Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: A review of best practices. Am J Nurs 2014;114:24–34.
10. AKaM HJ. Improving the Healthcare of Lesbian, Gay, Bisexual, and Transgender (LGBT) People: Understanding and Eliminating Health Disparities. The Fenway Instituite (https://www.lgbtqiahealtheducation.org/wp-content/uploads/Improving-the-Health-of-LGBT-People.pdf
). Published January 26, 2016. Accessed March 15, 2021.
11. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender–related content in undergraduate medical education. JAMA 2011;306:971–977.
12. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV. New York: Lambda Legal, 2010 (www.lambdalegal.org/health-care-report
). Accessed March 25, 2021.
13. Baker KE, Streed CG Jr, Durso LE. Ensuring that LGBTQI+ people count - collecting data on sexual orientation, gender identity, and intersex status. N Engl J Med 2021;384:1184–6.
14. Nguyen PV, Naleppa M, Lopez Y. Cultural competence and cultural humility: A complete practice. J Ethnic Cult Divers Soc Work 2020;30:273–81.