According to the most recent Gallup poll, 5.6% of American adults identify as LGBT2QIA+. The U.S. Office of Disease Prevention and Health Promotion (ODPHP) has highlighted multiple social determinants that impact the health of the LGBT2QIA+ community, some relating to issues of discrimination by uninformed or intolerant providers. A simple internet search can tell a compelling story: accounts of LGBT2QIA+ patients searching for healthcare, probing and inappropriate questions, unfair treatment, or outright hostility. That means in 2020, more than 18.4 million LGBT2QIA+ adults could have walked out of a healthcare encounter underserved or untreated. The good news is that there is compelling evidence that targeted, education-based interventions can help organizations address these health disparities.
The therapeutic alliance between doctor and patient can make or break a healthcare interaction. An encounter can quickly become sub-optimal or even inappropriate if the provider is not culturally competent in LGBT2QIA+ issues. On the other hand, a provider that gives compassionate and informed care earns the trust of their patients, who are then more likely to come back in the future. However, quality care isn’t just how a patient is treated at the clinic or hospital, it is also based in how a patient’s information is documented. Gaps in documentation can negatively affect treatment and ultimately health outcomes.
The ODPHP has found that there is a shortage of healthcare providers who are knowledgeable and culturally competent in LGBT2QIA+ health, which leads to less-than-ideal health outcomes for LGBT2QIA+ patients. A 2019 Center for American Progress (CAP) survey found that one in three transgender people reported having to “teach their doctors about transgender people to get appropriate care” and nearly half of transgender people surveyed reported having experienced mistreatment at the hands of a medical provider, including refusal of care as well as verbal and/or physical abuse. Furthermore, an NPR poll found that one in five LGBT2QIA+ adults have avoided medical care due to fears of discrimination.
The ODPHP names the collection of SOGI (sexual orientation and gender identity) data as one way to combat the care disparities that LGBT2QIA+ patients face. Putting a patient’s gender identity, preferred name, and pronouns in their medical record can help to avoid instances of misgendering, while documenting sexual orientation can give insight into what specific tests may need to be run for preventative care. If a provider “isn’t comfortable” asking patients about sexual orientation or gender identity or doesn’t know what to do with the information once received, critical data that informs a patient’s overall health is being excluded from the medical record. Clinicians need a well-rounded picture of who their LGBT2QIA+ patients are, understand unique considerations for their care, and how to document patient information in an accurate, informed way.
Healthcare providers are not being given the tools they need to create positive interactions with LGBT2QIA+ patients. Studies have shown that medical schools are doing an inadequate job at preparing future doctors to address LGBT2QIA+ healthcare needs. Even at schools that consider themselves on the forefront of LGBT2QIA+ care, many classes about these issues are elective, taught over lunchtime, or scheduled at night. Often, these classes are taught by students who volunteer and not by professional educators who are knowledgeable about both the subject and didactics. While the students involved are passionate about knowledge-sharing, such informal classes lack the rigor, attendance, and organization that a true curriculum integration of these topics could provide.
A 2011 study found that the average time spent in medical school learning about LGBT2QIA+ patients was five hours. Less than one-quarter of respondents rated their school’s overall coverage of LGBT2QIA+ topics as “good” or “very good.” Further, almost all schools taught students to ask about the gender of a patient’s sexual partners, but far fewer taught students to relate that information to identity. The authors conclude, “it is possible that students are taught to initiate sensitive conversations but lack the breadth of training to continue them in meaningful ways.”
Education is one of the most direct paths to address SOGI data gaps and provider cultural competence shortcomings. Targeted training can combat LGBT2QIA+ healthcare disparities and doesn’t require new legislation or nationwide change. Just as healthcare organizations roll out training on new hospital policy or teach staff how to use a new EHR, training and education can be leveraged to make a positive impact in LGBT2QIA+ patients’ lives and health. Clinical care teams can be given the tools to engage with their LGBT2QIA+ patients in a training setting, without worrying about “saying the wrong thing” and receiving valuable information that they may have missed out on in medical school. By combining classic classroom or e-learning with facilitated discussions, clinicians can leave training confident in their competency to treat all their patients, whether they be cisgender or transgender, gay or straight.
Education enhances both the comfort of the providers and the health outcomes of the patient. As more medical schools and healthcare organizations begin to incorporate focused LGBT2QIA+ content into educational offerings, studies have shown that providers feel better equipped to treat their patients. After Boston University School of Medicine added a transgender health section to their endocrinology course, second-year students reported an almost 70% decrease in discomfort with providing transgender care. By integrating LGBT2QIA+ specific information into standard class curriculum, and not just leaving it to a lunchtime elective, physicians start to combat SOGI data gaps and make connections with their LGBT2QIA+ patients from the start.
Everyone has the right to feel safe, respected, and affirmed when seeking out healthcare. Organizations can turn talk of “inclusion” into concrete action and results by focusing on education for the individuals that set the tone for encounters. Inclusive and affirming healthcare is possible for all, and it starts with heading back to the classroom.