Learning to be LGBT-friendly

Three years ago, Brandyn Gallagher moved from Fayetteville, Ark., to Seattle seeking to start hormone replacement therapy as part of his transition from female to male.

Gallagher, 27, said many transgender people he knew in Arkansas who sought care from their healthcare providers for their transition were refused care or told to seek mental health counseling or psychiatric hospitalization. Transitioning “was not really an option,” said Gallagher, who now works as an advocate for HIV prevention and sexual health education. “All of the trans people I knew in Arkansas were getting their hormones illegally on the Internet and self-medicating.”

Gallagher felt that moving to a city with one of the highest percentages of people who identify as lesbian, gay, bisexual or transgender would make it less likely that he would face the discrimination and harassment that he saw transgender people face in Fayetteville. And he thought it would give him access to high-quality healthcare for his particular needs.

But Gallagher said he still found it challenging to find high-quality, specialized care. And he's had some grating experiences with providers in Seattle. He recalls a nurse who kept referring to him as a woman even though he already had changed his gender and name.

LGBT people like Gallagher say too many healthcare providers are not sensitive to or knowledgeable about their healthcare needs. Even for basic primary-care services, many LGBT patients say they're reluctant to visit providers that do not offer services specific to the LGBT population. As a result, many LGBT people may delay or forgo seeking care to avoid what they fear will be an uncomfortable experience with clinical staff.

A few hospital systems, such as Mount Sinai Health System in New York City, have launched specialized medical and sensitivity training for healthcare professionals and staff. But this type of intensive training for physicians and other healthcare professionals remains uncommon.

Tari Hanneman, deputy director of health and aging for the Human Rights Campaign, the nation's largest LGBT civil rights advocacy group, said hospitals considered leaders in addressing LGBT healthcare needs generally integrate LGBT healthcare into broader continuing medical education, which is better than offering one or two seminars on sensitivity training. Still, most health professionals receive little or no training on LGBT healthcare needs either in their professional training or in the hospital setting.

“Most people are not taught even some of the basic communication issues, like learning what someone's preferred name and pronouns are, not to make assumptions, or not to use pronouns unless you know the right ones to use,” said Dr. Harvey Makadon, a Harvard University professor of medicine and director of the National LGBT Health Education Center at the Fenway Institute in Boston.

Even providers who focus on care for LGBT patients can find these issues challenging. “We're still very much learning about the transgender community,” acknowledged Dr. Christopher Konstantelos, an internal medicine physician with Northwestern Medical Group, a subsidiary of Chicago-based Northwestern Medicine, who works in an outpatient clinic as part of a group specializing in LGBT health needs.

“A lot of times, the legal forms that people complete on intake will have a legal name, but maybe the person is in transition and would prefer to be called by a different name,” he said. “So we're modifying forms to not only include the legal name, but to include the name you prefer to be called by.”

A 2010 survey of some members of the LGBT community by the civil rights group Lambda Legal found nearly 56% of respondents reported having at least one experience where they were refused care, had a healthcare professional refuse to touch them or take excessive precautions before doing so, been verbally or physically abused by a healthcare professional, or been blamed for their health status.

Nine percent of lesbian, gay and bisexual respondents reported reluctance to seek medical care because of the concerns, while up to half of transgender and gender non-conforming respondents reported such reluctance.

Experts say it's important for healthcare providers to become more knowledgeable, sensitive and welcoming to LGBT patients because that population suffers from a disproportionate burden of chronic illness. LGBT individuals tend to have higher rates than heterosexuals of various chronic conditions such as asthma, hepatitis B and C among lesbian and bisexual women, and a higher prevalence of cancer and cardiovascular disease in gay men, according to a Kaiser Family Foundation research brief published in July.

LGBT individuals also are more likely to have health risks such as obesity, smoking, alcohol and substance abuse compared with national averages. For transgender individuals, the statistics are even worse. A 2010 study conducted by the National Center for Transgender Equality and the National Gay and Lesbian Task Force found transgender people had an HIV infection rate that was more than four times the rate of the general population, as well as a higher prevalence of behavioral health issues and suicide.

“One of the main barriers to overcoming (health) disparities is creating an inclusive and affirming environment so that LGBT people come and feel safe in a space where they are getting healthcare,” Makadon said. “Most disparities that are experienced are really the result of stigma and discrimination, and a lot of that has occurred in the context of getting healthcare.”

Discrimination against LGBT patients by healthcare professionals and institutions has a long history that continues to shape many people's attitudes about seeking care. The problem was highlighted during the HIV/AIDS epidemic in the early 1980s, when fear of the disease led to blatant discrimination against gay men, who were becoming infected at a higher rate than the rest of the population at the time.

“A lot of LGBT folks are sort of used to this history of discrimination in healthcare,” Hanneman said. “In fact, a lot of people will say a lot of the (health) disparities are because we don't seek healthcare because we're afraid of being discriminated against.”

Since that time, however, healthcare services for the LGBT population have grown, and they've evolved from focusing primarily on HIV/AIDS to a broader range of care, said Dr. Henry Ng, clinical director for Cleveland-based MetroHealth System's PRIDE Clinic, which serves LGBT patients “But there is still a strong stigma associated with being a sexual minority,” he said.

Dr. Barbara Warren has overseen the LGBT health services program at Mount Sinai in New York City since its inception in 2013. It's recognized as a leader in the field of addressing LGBT people's health needs.

The program teaches primary-care providers, residents and medical students how to initiate and manage hormone therapy for transgender patients, as well as how to provide reproductive and family care for LGBT patients who are starting families. Such efforts led to Mount Sinai two years ago creating the nation's first mandatory LGBT care curriculum for internal medicine and family medicine residents. Warren said her system has been sharing the curriculum with other systems around the country. Plans are underway to publish the curriculum online this fall as an open-access resource.

Mount Sinai providers are trained to take into consideration the patient's sexual orientation as a part of their basic clinical approach, whether or not the condition being treated is directly related to sexual orientation. Warren said identifying patients who are LGBT allows providers to screen for other conditions they might not have checked for a straight patient.

A Mount Sinai physician performing a routine exam on a gay man, for example, may inquire about his eating habits, since distorted body image and eating disorders are more common among gay men. If a woman visiting the emergency department for a broken arm identifies as being lesbian, the provider also may conduct a precautionary breast cancer screening as lesbian women are more likely to have risk factors for the disease but tend not to get screened as frequently as straight women. Transgender patients may be asked whether they have experienced chest pain or shortness of breath, since they are at increased risk for heart attack if they are taking hormones.

A major part of any good LGBT care program is training health professionals in counseling and treating patients for sexually transmitted diseases, including administering pre-exposure prophylaxis, a medication given to prevent those exposed to HIV from becoming infected.

Two Northwestern University facilities were among more than 400 hospitals recognized by the Human Rights Campaign in 2014 as being a “Leader in LGBT Healthcare Equality” as part of the group's annual Healthcare Equality Index. The HEI is a survey that grades participating facilities on whether they meet certain criteria in providing LGBT patient-centered care. Those criteria include having non-discrimination policies that specifically include LGBT patients and staff, as well as providing training to employees on LGBT-patient care.

Northwestern's Konstantelos said many of the challenges in addressing LGBT health needs could be solved by simply asking patients the right questions in the right tone, making them feel more at ease. “When you have an open dialogue that is started from day one, people are going to be more open with you,” he said. “Then you can get into the meat and potatoes and actually address the problems.”

“It is not just about being nice to the gay people,” Warren said. “There are special healthcare sensitivities and needs that folks who interact with patients want to be aware of.”

Despite advances by some providers in addressing LGBT health needs, hospitals and physicians lack adequate data to determine best clinical practices. Historically, information on sexual orientation or gender identity was not collected, Warren explained. In response, Mount Sinai is planning a pilot program in September that will include a patient's sexual orientation and gender identity within their electronic health record, joining several other providers such as University of California at Davis Health System and Partners HealthCare in Massachusetts.

Even with such broader system efforts, Hanneman said improving care of LGBT patients still comes down to greater knowledge and sensitivity among individual healthcare professionals. That determines whether LGBT people feel comfortable using the healthcare system. “It only takes one person to create a really bad experience for somebody and create that atmosphere of discrimination,” she said.