GUIDELINES FOR CARE OF LESBIAN, GAY, BISEXUAL, AND ...

1 GUIDELINES FOR CARE OFLESBIAN, GAY,BISEXUAL, ANDTRANSGENDERPATIENTST able of ContentsChapter 1 Creating a Welcoming ClinicalEnvironment for LGBT Patients..1 Background .. 1 Create a Welcoming Environment .. 2 General GUIDELINES for Formsand Patient-Provider Discussions .. 4 Confidentiality .. 8 Some Specific Issues to Discusswith LGBT Patients .. 9 Language .. 12 Staff Sensitivity and Training .. 13 Other Suggestions ..15 Sample Recommended Questionsfor LGBT-Sensitive Intake Forms .. 15 References and OtherResource Documents .. 19 Chapter 2 Caring for Lesbian and BisexualWomen:Additional Considerations forClinicians..23 Chapter 3 Caring for Gay and Bisexual Men:Additional Considerations for Clinicians..37 Appendices..53 Resources ..53 Acknowledgments ..60 CREATING A WELCOMINGCLINICAL ENVIRONMENT1cREATING A WELCOMINGCLINICAL ENVIRONMENT FORLESBIAN, GAY, BISEXUAL, ANDTRANSGENDER (LGBT)PATIENTSjBackgroundStudies show that lesbian, gay, BISEXUAL, transgender and (LGBT) populations, inaddition to having the same basic healthneeds as the general population, experiencehealth disparities and barriers related tosexual orientation* and/or gender identity orexpression.

2 Many avoid or delay care orreceive inappropriate or inferior care becauseof perceived or real homophobia, biphobia,transphobia, and discrimination by health careproviders and in medical practice is a survey of nursing students showed that8 12% despised lesbian, gay, and bisexual(LGB) people, 5 12% found them disgusting, and 40 43% thought LGB people should keeptheir sexuality care providers can take positive steps topromote the health of their LGBT patients byexamining their practices, offices, policies andstaff training for ways to improve access to qualityhealth care for FOR CARE OF LGBT PATIENTSk1*the term sexual orientation is used in this documentto mean sexual orientation identities,behaviors, and/orattractions, all of which are important in the healthcare FOR CARE OF LGBT PATIENTSk3uPost rainbow flag, pink triangle, unisexbathroom signs, or other LGBT-friendlysymbols or posters showing racially and ethnicallydiverse same-sex couples or transgenderpeople.

3 Or posters from non-profit LGBT orHIV/AIDS brochures (multilingual whenpossible and appropriate) about LGBT healthconcerns, such as breast cancer, safe sex,hormone therapy, mental health, substanceuse, and sexually transmitted diseases(STDs also called sexually transmittedinfections or STIs such as HIV/AIDS, syphilis,and Hepatitis Aand B).See Resources section for where to findbrochures and other or visibly post a non-discriminationstatement stating that equal care will beprovided to all patients, regardless of age, race,ethnicity, physical ability or attributes, religion,sexual orientation, or gender relevant days of observancein your practice such as World AIDS Day,LGBT Pride Day, and National TransgenderDay of LGBT-specific media, including localor national magazines or newsletters aboutand for LGBT and HIV-positive Resources sectionCREATING A WELCOMING CLINICAL ENVIRONMENTj2 There are some simple ways to make your practiceenvironment more welcoming and safe for yourLGBT patients.

4 Here are a few ideas to updateyour physical environment, add or change intakeand health history form questions, improveprovider-patient discussions, and increase staff sknowledge about and sensitivity to your LGBT patients. We hope you find this tool a Welcoming EnvironmentLesbian,gay, bisexual, and transgender (LGBT)patients often scan an office for clues tohelp them determine what information theyfeel comfortable sharing with their health in provider referral programs throughLGBT organizations ( , , , or local LGBT organizations)or advertising your practice in LGBT media cancreate a welcoming environment even before apatient enters the door. If your office develops brochures or othereducational materials, or conducts trainings,make sure that these include relevant informationfor LGBT dialogue with a patient about their genderidentity/expression, sexual orientation, and/orsexual practices means more relevant andeffective may want to implement some of the followingsuggestions as appropriate for the type andlocation of your office: GUIDELINES FOR CARE OF LGBT PATIENTSuPrepare now to treat a transgender patientsomeday.

5 Health care providers ignorance,surprise, or discomfort as they treat transgenderpeople may alienate patients and result in lowerquality or inappropriate care, as well as deterthem from seeking future medical individuals may have had traumaticpast experiences with doctors causing fear ormistrust. Therefore, developing rapport andtrust with transgender patients may take longerand require added sensitivity from the talking with transgender people, askquestions necessary to assess the issue, butavoid unrelated probing. Explaining why youneed information can help avoid the perceptionof intrusion, for example: To help assess yourhealth risks, can you tell me about any historyyou have had with hormone use? uBe aware of additional barriers caused bydifferences in socioeconomic status, culturalnorms, racial/ethnic discrimination, age,physical ability, and geography. Do not makeassumptions about literacy, language capacity,and comfort with direct talking about sexual or relationshippartners, use gender-neutral language suchas partner(s) or significant other(s).

6 Askopen-ended questions, and avoid makingassumptions about the gender of a patient spartner(s) or about sexual behavior(s). Use thesame language that a patient does to describeself, sexual partners, relationships, and A WELCOMING CLINICAL ENVIRONMENTj4jGeneral GUIDELINES for Forms andPatient-Provider DiscussionsFilling out the intake form gives patients oneof their first and most important impressionsof your office. The experience sets the tonefor how comfortable a patient feels being openabout their sexual orientation or page xx are recommendations for questionsyou may want to consider adding to your standardintake and health history forms, or ideally discuss with the patient while taking an oralhistory. Examples include more inclusive choicesfor answers to questions, open-ended questions,and adding partner wherever the word spouse is used. The following are additional topics forpossible inclusion in health history forms or tohelp a provider with in-person discussions withLGBT patients:uIntake forms should use the term relationshipstatus instead of marital status, includingoptions like partnered.

7 When asking on theform or verbally about a patient s significantother, use terms such as partner, in additionto spouse and/or husband/wife. uAdding a transgender option to themale/female check boxes on your intakeform can help capture better informationabout transgender patients, and will be animmediate sign of acceptance to that person. uAs with all patient contacts, approach theinterview showing empathy, open-mindedness,and without rendering FOR CARE OF LGBT PATIENTSare more important than asking about sexualorientation or gender additional information on sexual riskassessment for LGBT populations, seeResources aware that sexual behavior of a bisexualperson may not differ significantly from that ofheterosexual or lesbian/gay people. They maybe monogamous for long periods of time andstill identify as bisexual; they may be in multiplerelationships with the full knowledge andconsent of their partners. However, they mayhave been treated as confused, promiscuous,or even dangerous.

8 They may be on guardagainst health care providers who assume thatthey are sick simply because they have sexualrelationships with more than one sex. Yet theymay also, in fact, lack comprehensive safer-sexinformation that reflects their sexual practicesand attitudes, and may benefit from thoroughdiscussions about sexual discussing sexual practices andsafer sex avoid language that may presumeheterosexuality or are so few trained experts in transgenderhealth that you will often have to become thatexpert. Likewise, providers who treat transgenderpatients often have to build the base of specialty-care referrals by pre-screening other providers forsensitivity or guiding them to educationalresources. Do not be afraid to tell your patient ofyour inexperience. Your willingness to becomeeducated will often stand out from their previoushealthcare experiences. k7 CREATING A WELCOMING CLINICAL ENVIRONMENTj6uWhen discussing sexual history, it is veryimportant to reflect patients language andterminology about their partners and people do not define themselves througha sexual orientation label, yet may have sexwith persons of their same sex or gender, orwith more than one sex.

9 For example: somemen who have sex with men (MSM), especiallyAfrican American and Latino men, may identifyas heterosexual and have both female andmale assessing the sexual history oftransgender people, there are severalspecial considerations:1do not make assumptions about theirbehavior or bodies based on theirpresentation;2ask if they have had any gender confirmationsurgeries to understand what risk behaviorsmight be possible; and3understand that discussion of genitalsor sex acts may be complicated by adisassociation with their body, and thiscan make the conversation particularlysensitive or stressful to the the patient to clarify any terms or behaviorswith which you are unfamiliar, or repeat apatient s term with your own understandingof its meaning, to make sure you have is important to discuss sexual health issuesopenly with your patients. Non-judgmentalquestions about sexual practices and behaviorsGUIDELINES FOR CARE OF LGBT PATIENTSjSome Specific Issues to Discusswith LGBT PatientsHomophobia, biphobia, transphobia,discrimination, harassment, stigma andisolation related to sexual orientation and/orgender identity/expression can contributeto depression, stress and anxiety in LGBT people.

10 Conduct depression and mental healthscreening as appropriate, and do not discountthese sources of stress for your LGBT the degree to which LGBT patientsare out to their employers, family, andfriends, and/or the extent of social support orparticipation in community. One s level ofidentification with community in many casesstrongly correlates with decreased risk for STDs(including HIV) and improved mental that LGBT people are particularlyvulnerable to social stresses that lead toincreased tobacco and substance use. A recentlarge study showed GBTmen smoked 50%more than other men, and LBT women smokedalmost 200% more than other women. Emphasison other health issues may leave many peopleunaware of the disproportionate impact oftobacco in this population. Be prepared tointervene and provide treatment , explore whether LGBT patients aredealing with social stress through alcohol ordrug use and be prepared to present treatmentoptions. Social stress may also contribute tobody image, exercise, and eating safer sex techniques and be preparedto answer questions about STDs and HIVtransmission risk for various sexual activitiesrelevant to LGBT A WELCOMING CLINICAL ENVIRONMENTj8jConfidentialityEncourage openness by explaining that thepatient-provider discussion is confidentialand that you need complete and accurateinformation to have an understanding of thepatient s life in order to provide appropriatecare.