Keeping patient care as priority one

Medical professionals who understand the diverse and unique health care needs of LGBTQ patients are key to competent, compassionate health care.
isn’t that the goal?

Shai Feingold, D.O.’11, acknowledges he heard “inappropriate and even hurtful” anti-gay comments by fellow students and some faculty when he was at DMU. He points out the lack of education both in medical school and during his residency on caring for patients who identify as lesbian, gay, bisexual or transgender and those questioning their sexual orientation or gender identity (LGBTQ populations). More important than any of that, though, is the primary reason he and his colleagues chose to pursue health care careers.

“We’re all here to serve patients; it doesn’t matter what their orientation is,” he says.

That said, Feingold and others note the importance of understanding the diverse and unique health care needs of LGBTQ patients. That’s a challenge for many health care professionals: A recent report of the Institute of Medicine noted that a scarcity of research on LGBTQ populations “yields an incomplete picture” of their health status and needs, “which is further fragmented by the tendency to treat sexual and gender minorities as a single homogeneous group.”

Adding to that challenge is the “stigma experienced by gender and sexual minorities can make them reluctant to disclose their orientation,” the report stated.

“That [stigma] affects their health care, their ability to get health insurance and their mental health,” Feingold says. “It affects their ability to establish healthy relationships, so they may engage in risky behaviors.”

That can compound the health problems of LGBTQ individuals.

“Among these populations is a high risk of drug addiction, alcohol abuse, depression and suicide. You have to find out that history,” says Andrew Adair, D.O.’98, FACOS, a physician with Henry Ford Macomb Family Medicine in Chesterfield, MI, and president of the Michigan Association of Osteopathic Family Physicians. “You have to look at the situation from each patient’s point of view. If they had a rough time coming out, they’ve had trust issues.”

Adair seeks to establish the trust of his patients, who include LGBTQ individuals, by combining compassion and honesty.

“When they say, ‘I’m X, Y or Z,’ I don’t blink,” he says. “I ask frank questions about sexual partners: ‘Do you have sex with men, women or both?’ I don’t care if they’ve been married for 20 years. If you don’t ask the questions, you won’t know the answers.

“Patients want honesty,” Adair adds. “I tell them, ‘I want to help you, but I need your help in guiding your health care.’”

A GOOD START: A GOOD FORM

Asking about a patient’s sexual orientation and sexual behavior isn’t easy for many physicians. They may feel uncomfortable or too pressed for time to ask open-ended questions about those topics. They may simply assume their patients are heterosexual. And since patients don’t want to face discrimination or be judged, their sexuality may never be discussed, says Roberta Wattleworth, D.O.’81, M.H.A.’99, M.P.H.’04, FACOFP, FNAOME, professor of family medicine.

“I’ve practiced in four states and seldom does it happen that patients share revealing, intimate details on the first visit,” she told approximately 60 DMU students who attended her presentation on how to take a sexual health history. “I try to give off the impression I’m receptive and accepting.”

Wattleworth says the patient history form is a good way to demonstrate openness and obtain
patient information. She suggests it include options for patients to indicate their gender, the gender/s of their current and past sexual partner/s, the form/s of sexual activity in which they participate and their exposure to and concerns about violence and abuse.

“The fact you have those questions on your form opens the dialogue for people to feel comfortable in discussing things with you,” Wattleworth told the students. She also emphasized that other clinicians in the practice must embrace those questions.

“If you’re going to share the form and somebody in the practice is not comfortable discussing those issues, what are you going to do about it?” she queried. “You’ve got to decide you’re going to be unified in caring for these populations, because you can’t have one clinician alienating patients so they don’t come back.”

Wattleworth says physicians also must advocate for their patients. With LGBT patients, that may involve communicating with health insurance carriers when gender-related procedures – such as hormone replacement therapy, sexual reassignment surgery and the counseling required beforehand – are medically necessary.

Health care providers may need to advocate for patients within their families, too. Wattleworth shared with students her experience with a young male who came to her after being diagnosed as HIV-positive.

“He burst into tears and said, ‘I’m scared,’” she recalled. She offered to go with him to talk with his parents. “I could see the color drain from his mother’s face. The father stood up and started yelling. I said, ‘Sir, your son needs your support, not your condemnation, so please sit down and listen.’

“It was a difficult, difficult conversation, but that was a time to advocate for that young man,” she added.

EDUCATED AND ‘OUT’ AS LGBTQ-FRIENDLY

Joe Freund, M.D., came out as a gay male at age 40 but admits he’d had “very little education on providing care to LGBTQ patients.” The Des Moines physician, who spoke on gender and sexual orientation issues during a recent campus panel discussion, decided to join the Gay and Lesbian Medical Association (GLMA), which works to ensure equality in health care for LGBT individuals and health care professionals. GLMA provides resources for patients, including a provider directory and suggested issues to discuss with one’s physician, and resources for providers, such as online continuing education and annual scientific meetings.

Affiliating with such organizations lets LGBTQ patients know whether a provider is accepting as well as informed about their health care needs. Andrew Adair, the DMU graduate, joined the LGBT-friendly health provider list maintained by Affirmations, a multi-service nonprofit organization near Detroit that serves persons of all sexual orientations and gender identities. To be added to the directory, Adair agreed to uphold the organization’s “community standards of practice,” which include maintaining an inclusive, nondiscriminatory environment for LGBTQ patients, having a “basic familiarity” with their health care issues, and including in their care those patients’ domestic partners and/or other chosen family members the same as for heterosexual patients.

“Once these individuals find out a physician is friendly, they come to that physician in flocks,” Adair says. “If you’ve got a patient whom you don’t like, for whatever reason, you can’t provide effective care. If you can’t deal with this population, you’d better make it really well known.”

John Carstensen, M.D., a GLMA member and internal medicine physician with Iowa Health in Des Moines, says letting patients know he’s accepting of LGBTQ patients, whether through conversations or printed materials in his waiting room, fosters the trust needed for effective health care. So does understanding the diverse needs across LGBTQ populations.

“The care they need depends on whether the patient is a gay male, a gay female, a transgender person who either has or has not undergone surgery, etc.,” says Carstensen, who has participated in campus discussions hosted by DMU’s Gay Straight Alliance. “Physicians need to be comfortable in asking those questions and researching solutions based on the patients’ needs.”