Improving Care for LGBT+ individuals in an Imperfect System | Allison Asante, PA-C
“Hi! I’m calling to do a sleep apnea screening before your surgery with us next week.” I sit back in my chair; it is the middle of a busy clinic day and this sounds like a reason to relax for a few minutes. We roll through the questions, and it is taking longer than I expected. I am happy when the pre op nurse finally says, “Ok, I will tally your score and let the anesthesiologist know.” I sigh, relieved, until I hear her continue, “Oh, wow, I don’t know how to score this for you. My only options are male and female. I’ve never had this happen before. Guess I’ll just hand it in without a score. Sorry, this is how the world is, you know.”
I take a deep breath, instantly feeling marginalized, different, other. My instinct is to keep my feelings to myself, and get back to my day; instead I take a few minutes to tell her how sex and gender are different things, and that my medical risks are probably determined by my biologic sex. I was nicer than I needed to be, my voice an octave higher than my normal speaking voice, but she is now hopefully more knowledgeable. We hung up, I moved on, but my mind did not.
Her words, “this is how the world is,” kept replaying in my mind. All I could think about was how I do not fit. How do I reconcile being a non-binary health care provider in a gendered specialty knowing that the system was not intended for someone like me? Most institutions, but certainly the US health care system, were built for the rich, the white, the cisgender, the heterosexual, the privileged. While it was not built for me, it was also not built for my patient who speaks an uncommon Chinese dialect, it was not built for my homeless patient trying to avoid infection while on chemotherapy. Thinking of this helped me to find comfort in not fitting. So, what can we do to improve care for LGBT+ people in an imperfect system?
The first step is to educate oneself about sexual and gender minorities. Currently, there is no requirement to include LGBT+ cultural competency in medical school, residency or fellowship training, physician assistant or nursing school. It has only been six years since the Association of American Medical Colleges even recommended its inclusion in medical education. It is necessary to learn the correct language to discuss sexual minorities and transgender identified people from the beginning of training.
While correct language is important, respect and inclusion are paramount when treating LGBT+ patients. Our patients do not expect perfection, and you should not expect yourself to be perfect. Sexual and gender identities are continuously evolving. We must prioritize seeing the humanity in our patients, and they will see the humanity in us. Misgendering happens, mistakes in terminology happen. Apologize if you have made an error and keep working to improve. Your patient will remember your intention was to validate their identity.
As we try to create inclusive and equitable environments, “othering” is something we must actively avoid. Making LGBT+ people feel “othered” often results in them not seeking care. Being a lesbian is a risk factor for cervical cancer, simply because they are less likely to have adequate cervical cancer screening. In a 2016 study by the National Center for Transgender Equity, a quarter of transgender identified people reported not seeking medical care for fear of transphobia.
Robert Eads was the man who exposed gynecologic oncology’s transphobia in the 1990s. Robert was a female to male transgender man diagnosed with cervical cancer. Because of his gender, he was denied treatment by over two dozen oncologists. By the time he found a physician to treat him, his cervical cancer had metastasized, and he died of his disease in 1999. This is an extreme example, but it is especially relevant today.
In June of this year, the Trump administration removed protection from sexual discrimination in health care and health insurance for LGBT+ individuals, worsening the community’s fear of health care. Because of this, it is even more important for health care providers to make LGBT+ patients feel included in health care settings.
For this reason, I think it is important to implement the practice of “Do Ask and Do Tell” with our patients. As with the current practice of collecting race and ethnicity data, we must begin to collect data regarding sexual orientation and gender identity. Collecting this information is the first step to identifying disparities.
Below are some suggestions for your daily practice to be more inclusive of LGBT+ people in health care.
- Look at your office and cancer center and consider the experience if you were there for the first time as a LGBT+ identified patient.
- Consider how things are gendered in your institution. Is it necessary to have a “women’s” cancer center? Do single stall bathrooms need to be gendered? Do your medical intake forms only allow traditional gender and sexual orientation choices?
- Use signage to show you are an inclusive institution.
- Do ask your patients if they have a preferred name or pronoun so that you can refer to them in an affirming way.
- Do learn how to take an inclusive sexual history and educate yourself about sexual practices outside of cisgender heterosexual relationships.
- Do not assume every patient you meet is heterosexual. LGBT+ people likely represent 12% of your patients and peers.
For those wondering where to start, I recommend an article from the June issue the Journal of Clinical Oncology by Quinn et al, titled, “What Oncologists Should Know About Treating Sexual and Gender Minority Patients with Cancer.” Keep an eye out for future announcements, as SGO and the Diversity, Inclusion and Health Equity Committee are actively exploring training options to make gynecologic oncology practices more LGBT+ affirming.
Allison Asante is a non-binary identified Gynecologic Oncology Physician Assistant at Northwell Health in New York City. They specialize in survivorship care, chemotherapy management, cervical dysplasia and LGBT+ affirming gynecologic care. They are currently getting their MBA in Strategic Healthcare Administration hoping to move into cancer care administration.