Continuing Education

Seeing our invisible patients: The importance of providing inclusive sexual and reproductive healthcare to LGBTQ populations

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Statement of the problem

Women who identify as lesbian or bisexual (also known as sexual minority women, or SMW), as well as those who were assigned female gender at birth but identify as transgender, gender-queer, or gender non-conforming (TQ), represent subsets of the LGBTQ population. These groups have historically experienced discrimination and stigma in healthcare. As a result, they may be less likely than heterosexual women or cis-gender women (those whose gender identity matches the female sex they were assigned at birth) to seek sexual and reproductive healthcare. Even if they seek this type of care, they may not be properly assessed, managed, or educated if their healthcare providers (HCPs) lack the knowledge and communication skills they need to provide inclusive sexual and reproductive care to SMW and TQ patients. In a video from the National LGBT Education Center, LGBT individuals share some of the experiences, both bad and good, that they have had with HCPs.

Dearth of research

Perpetuating this healthcare disparity is a dearth of research on LGBTQ-specific healthcare needs (with the exception of HIV/AIDS and mental health problems in gay men). Only in the past 5 years have the many health disparities experienced by LGBTQ individuals and the need for LGBTQ-specific research become a topic of conversation on a national level. From 1989 until 2011, 0.5% of studies funded by the National Institutes of Health (NIH), the largest funder of medical research in the world, pertained to LGBTQ health, and of that 0.5%, only 13.5% was allocated to SMW and 0.2% to transgender men.1 In 2011, the CDC identified health disparities related to sexual orientation as one of the main gaps in current health disparities research.2 In the same year, the Institute of Medicine reported the inadequacy of LGBTQ health research, identified challenges in conducting research on these populations, and established recommendations for the NIH, including implementation of a research agenda designed to advance knowledge and understanding of LGBTQ health.3

Dearth of educational programs

The curricula in most clinical education programs do not include adequate LGBTQ-related content. One study that specifically assessed inclusion of LGBTQ-related content in medical school curricula in the United States and Cana da found, on average, 5 hours of instruction in this area.Although corresponding studies assessing nursing school curricula have not been reported, they would likely reveal similarly discouraging findings. Educating future HCPs, through both classroom instruction and clinical experiences, to care for LGBTQ patients will help increase the number of HCPs who are competent and comfortable in this area.

Ways to provide competent and inclusive healthcare for LGBTQ populations

As a basic foundation in this regard, HCPs must understand the differences among the terms sex assigned at birth, sexual orientation, and gender identity. Sex assigned at birth, also referred to as biological sex, is based objectively on genital appearance, hormones, and chromosomes. Sexual orientation refers to the object of a person’s physical and/or emotional attraction. Gender identity represents how one perceives oneself—as female, as male, or somewhere in between.

Both U.S. society and the healthcare community within it are hetero-normative and cis-normativeinadvertently creating an environment that is a source of implicit discrimination toward LGBTQ populations.In a heteronormative society, heterosexuality is the expected and “normal” sexual orientation. Similarly, in a cis-normative society, being cis-gender—having a gender identity that matches one’s sex assignment at birth—is expected and “normal.” By these definitions, anyone who lives/behaves as anything other than heterosexual or who identifies as anything other than cisgender is considered “abnormal.”

Recognize and aim to overcome health disparities

Although the literature has been sparse, newly emerging studies provide information about the sexual and reproductive health behaviors of young SMW populations. In general, researchers have found that SMW (and/or sexual minority teens), compared with their heterosexual counterparts:

• display a greater number and range of sexually risky behaviors (e.g., younger age at sexual debut, greater number of sex partners, greater use of alcohol or drugs during sexual encounters, greater likelihood of having unprotected sex)6-11;

• with the exception of lesbians11 have higher rates of sexually transmitted infections (STIs)7,8,10;

• have similar rates of unwanted pregnancy and higher rates of abortion6,8,10;

• have lower rates of contraceptive and gynecologic care seeking, including a lesser likelihood of getting Pap tests and the HPV vaccine series12-15;

• have a greater likelihood of being subjected to intimate partner violence (IPV)6-8; and

• may have an elevated risk for breast cancer because of their increased rate of nulliparity, older age at first live birth, and greater rates of obesity and alcohol consumption.16

Fewer studies have addressed the sexual and reproductive health disparities that affect TQ populations, which also include gender non-binary individuals, who reject the assumption that gender is strictly an either/or option of male/female that matches the sex they were assigned at birth.17 Instead, these individuals view gender identity as a spectrum of possibilities. No epidemiologic studies on transgenderism in the U.S. have been published, and demographic studies based on national surveys have been limited because of a lack of questions about gender identity.18

About 0.3% of adults in the U.S. (~1 million persons) are thought to identify as transgender.18 Most of the available literature concerns transgender females (i.e., persons who are assigned the male sex at birth but who identify as female). In studies conducted in countries outside the U.S., the prevalence of transgender males (i.e., persons who are assigned the female sex at birth but who identify as male) has been reported as 1:30,400 to 1:200,000.19

Many transgender individuals have experienced discrimination in healthcare, particularly after disclosing their gender identity to their HCP. Experiences of hostility and/or insensitivity from their own HCP can cause mistrust of HCPs in general.20 This cycle can lead to a lack of utilization of healthcare services, particularly when care is not critical for survival.

Despite the lack of research, transgender males do express concerns related to their sexual and reproductive healthcare, particularly with respect to discrimination, lack of validation of their gender identity, physical discomfort during examinations, fertility preservation, and pregnancy. Another fact to keep in mind: Although a person born with a uterus and ovaries may not identify as female, this person may wish to have biological children. In a cross-sectional Web-based survey of transgender males who had been pregnant and delivered a baby, two-thirds of the pregnancies were planned, and pregnancy, delivery, and birth outcomes did not differ according to whether or not the patient had used testosterone prior to pregnancy.21

Avoid faulty assumptions

Not all patients are heterosexual and cis-gender. If a reproductive-aged patient states that she is sexually active, an HCP should not necessarily follow up with the question “What type of birth control are you using?” First, the HCP needs to determine the patient’s sexual orientation; she may not need to practice birth control. Instead of giving patients two gender options—“male” and “female”—on intake forms, the HCP can provide a box labeled “other” that can be filled in with the patient’s stated identity.

These concepts also apply to the way that visit types are labeled in the office. Visits related to contraception care are often termed family planning visits, and those that occur yearly are often termed well-woman exams. The terminology for these visit types can be off-putting to persons, including staff members, who may not use contraceptives for birth control and for those who may not identify as women even though they have female genitalia and reproductive organs. HCPs should aim to create an inclusive office atmosphere so that SMW and TQ patients can build trust in their provider and receive healthcare that meets their needs.

Create an inclusive environment

Providers should not assume that a patient coming into the office for contraceptive care or for a yearly checkup is heterosexual and cis-gender. One of the first things any patient does in an office visit is complete intake and health history forms. Forms are more inclusive when the term partner or spouse is used instead of husband or wife and when transgender and other identitywith a write-in area, are added to the cis-gender options of male and female. HCPs need to ask patients who identify as transgender, gender-queer, or gender non-conforming about their preferred names and which gender pronouns they use (e.g., he, she, they). Preferred names may differ from the legal documentation on their driver’s licenses and insurance cards; HCPs must avoid using a name that the patient no longer uses or that may cause distress. Questions about preferred names and gender pronouns are appropriate and polite, and demonstrate from the outset of the professional relationship that the HCP and the staff acknowledge and validate all their patients’ sexual orientations and gender identities.

Non-discrimination policies need to be posted in check-in areas and/or waiting rooms where they are easily visible. Information about and examples of patient non-discrimination policies are available through the Human Rights Campaign Healthcare Equality Index website. Staff members need to know these policies and adhere to them. After all, the first person with whom a patient has contact in a healthcare setting is usually not the HCP but, rather, the office reception staff. The National LGBT Health Education Center, a program of The Fenway Institute, offers online webinars and video training sessions that can be used to help educate clinical and administrative office staff members.

Follow health screening and preventive health recommendations

Recommendations are implemented for SMW and TQ patients within the same parameters as for heterosexual and cis-gender female patients. Screening for STIs and HIV is based on behaviors and risk factors, not on sexual orientation or gender identity. HCPs need to ask patients about the types of sexual behaviors in which they engage so that the types of STI screenings and the sites of sampling can be determined. HCPs also need to advise patients to catch up on their HPV vaccinations if they have not completed them.

Providers need to ask patients whether they have a partner with whom it would be possible to get pregnant, and whether they are having penetrative vaginal sex with this partner. If so, and if the patient does not desire a pregnancy, HCPs need to discuss and offer all available and appropriate contraceptive options. HCPs need to inform SMW and TQ patients that, even if they are not engaging in what is typically considered heterosexual or cis-normative sex, they could still be at risk for cervical dysplasia or cancer and should undergo cervical cancer screening according to current guideline recommendations. Screening for a history of or current IPV needs to be included.

Clinical breast exams need to be performed and screening mammography recommendations followed, even in patients who have had “top surgery” or a bilateral mastectomy because these individuals may have residual breast tissue. Because this topic may be a sensitive one, HCPs must allow adequate time to communicate openly and compassionately about it.

Enhance competence and understanding

Conferences and webinars on providing healthcare to LGBTQ patients, many with continuing education credit, are available from organizations such as the World Professional Association for Transgender Health, UCSF Center of Excellence for Transgender Health, The Fenway Institute, and Health Professionals Advancing LGBT Equality (formerly the Gay and Lesbian Medical Association). These organizations and others have developed vetted lists of articles, publications, and online training sessions that can be used as resources (Table). For HCPs seeking more intensive education in LGBTQ health, graduate certificate programs are available through institutions such as Drexel University in Philadelphia, The George Washington University in Washington, DC, and New York University in New York City.

Conclusion

Healthcare providers who manage the sexual and reproductive health concerns of heterosexual and cisgender women are used to providing sensitive and compassionate care during vulnerable stages throughout the lifespan. They need to expand their knowledge and understanding, and acknowledge their implicit assumptions and biases, if they exist, in order to provide the same quality of care to SMW and TQ patients. These populations are often overlooked or “invisible” in healthcare settings, or they experience discrimination, stigma, and hostility, precluding their full access to and utilization of routine and preventive care.

Nationally representative research is needed to fully reveal the health disparities and risk factors that burden these populations. Curricula must be expanded to prepare future HCPs to adequately address these concerns and provide competent and inclusive sexual and reproductive healthcare. HCPs need to use available evidence, create inclusive office environments, and commit to continuing education that expands knowledge about LGBTQ healthcare needs for themselves and their staff to help make a meaningful difference and have a beneficial effect in caring for these populations.

References

1. Coulter RWS, Kenst KS, Bowen DJ, Scout. Research funded by the National Institutes of Health on the health of lesbian, gay, bisexual, and transgender populations. Am J Public Health. 2014;104(2):e105-e112.

2. CDC. CDC Health Disparities and Inequalities Report – United States, 2011. MMWR Suppl. 2011;60(1):1-2.

3. The National Academies Press. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. March 31, 2011.

4. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306(9):971-977.

5. Morrison S, Dinkel S. Heterosexism and health care: a concept analysis. Nurs Forum. 2012;47(2):123-230.

6. Tornello SL, Riskind RG, Patterson CJ. Sexual orientation and sexual reproductive health among adolescent women in the United States. J Adolesc Health. 2014;54(2):160-168.

7. Oshri A, Handley ED, Sutton TE, et al. Developmental trajectories of substance use among sexual minority girls: associations with sexual victimization and sexual health risk. J Adolesc Health. 2014;55:100-106.

8. McCauley HL, Silverman JG, Decker MR, et al. Sexual and reproductive health indicators and intimate partner violence victimization among female family planning clinic patients who have sex with women and men. J Womens Health (Larchmt). 2015; 24(8):621-628.

9. Matthews AK, Cho YI, Hughes T, et al. The relationships of sexual identity, hazardous drinking, and drinking expectancies with risky sexual behaviors in a community sample of lesbian and bisexual women. J Am Psychiatr Nurses Assoc. 2013;19(5):259-270.

10. Herrick A, Kuhns L, Kinsky S, et al. Demographic, psychosocial, and contextual factors associated with sexual risk behaviors among young sexual minority women. J Am Psychiatr Nurses Assoc. 2013;19(6):345-355.

11. Estrich CG, Gratzer B, Hotton AL. Differences in sexual health, risk behaviors, and substance use among women by sexual identity: Chicago, 2009-2011. Sex Transm Dis. 2014; 41(3):194-199.

12. Lindley LL, Barnett, CL, Brandt HM, et al. STDs among sexually active female college students: does sexual orientation make a difference? Perspect Sex Reprod Health. 2008; 40(4):212-217.

13. Waterman L, Voss J. HPV, cervical cancer risks, and barriers to care for lesbian women. Nurse Pract. 2015; 40(1):46-53.

14. Charlton BM, Corliss HL, Missmer SA, et al. Influence of hormonal contraceptive use and health beliefs on sexual orientation disparities in Papanicolaou test use. Am J Public Health. 2014;104(2):319-325.

15. McRee A-L, Katz ML, Paskett ED, Reiter PL. HPV vaccination among lesbian and bisexual women: findings from a national survey of young adults. Vaccine. 2014;32(37):4736-4742.

16. Clavelle K, King D, Bazzi AR, et al. Breast cancer risk in sexual minority women during routine screening at an urban LGBT health center. Womens Health Issues. 2015;25(4):341-348.

17. Green ER, Maurer, L. Teaching Transgender Toolkit: A Facilitator’s Guide to Increasing Knowledge, Decreasing Prejudice and Building Skills. Ithaca, NY: Planned Parenthood of the Southern Finger Lakes; 2015.

18. Stroumsa D. The state of transgender health care: policy, law, and medical frameworks. Am J Public Health. 2014;104(3):e31-e38.

19. World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, Version 7.

20. Bradford J, Reisner SL, Honnold JA, Xavier J. Experiences of transgender- related discrimination and implications for health: results from the Virginia Transgender Health Initiative Study. Am J Public Health. 2013; 103(10):1820-1829.

21. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120-1127.

Web resources (Table)

E. lgbt.ucsf.edu/lgbt-education-and-training

F. http://transhealth.ucsf.edu/

G. glma.org/index.cfm?fuseaction=Page.viewPage&pageId=534

H. fenwayhealth.org/the-fenway-institute/

I. mazzonicenter.org/training-and-resources

J. straightforequality.org/Healthcare

K. wpath.org/site_page.cfm?pk_association_webpage_menu=2577&pk_association_webpage=6633

L. hrc.org/hei/the-national-lgbt-health-education-center#.VttJLVKzWu4

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