LGBTQI+: Special considerations for reproductive health care

Health care and the LGBTQI+ community

The LGBTQI+ community has a history of experiencing societal discrimination and stigma, which stems from medical mistrust often due to a lack of understanding of their medical and psychosocial needs.^8,9 A 2019 survey of US LGBTQ adults, found that about 50% of people who identified as transgender reported having negative or discriminatory experiences with a health care clinician.¹⁰ About 18% of transgender people anticipated being refused medical care due to their gender identity.¹⁰ About 18% of LGBTQ individuals avoid any type of medical care, fearing discrimination.¹⁰ Lesbian women are 3 times more likely to have not seen an ObGyn than women who identify as straight.¹¹ Sixty-two percent of lesbian women have biological children and received prenatal care; however, of those, 47% do not receive routine cancer screenings.^10,11 Only 45% of age-eligible lesbian women have received at least 1 dose of the HPV vaccine, compared with 60% of straight women.^10,11

Due to societal stigma, more than 40% of transgender people have attempted suicide.¹² Felt or perceived stigma is also associated with risky health behaviors that contribute to health disparities. LGBTQI+ people are more likely to use substances,¹³ lesbian women are more likely to be obese,¹⁴ and 19% of transgender men are living with HIV/AIDS.¹⁵ Rates of unintended pregnancy among lesbian women and transgender men are 28%, compared with 6% in straight women, and 12% in heterosexual teens.^15,16

In addition to real or perceived discrimination, there are medical misperceptions among the LGBTQI+ community. For instance, sexual minority women (SMW) are less likely to receive regular screening for cervical cancer. In one survey of more than 400 SMW, about 25% reported not receiving regular screening. SMW may mistakenly believe they do not need Pap testing and pelvic exams because they do not have penile-vaginal intercourse.^17,18 Transgender men may not identify with having a cervix, or may perceive ObGyns to be “gendered” toward people who identify as women.¹⁸

Embracing cultural humility

Cultural humility expands upon the term cultural competence, with the idea that one can never be fully competent in the culture of another person.^19,20 The National Institutes of Health defines cultural humility as “a lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of his/her own beliefs and cultural identities.”²¹

Having cultural humility is the recognition that, in order to treat your ObGyn patient as a whole person and engage in shared medical decision making in the office setting, you need to know their sexual orientation and gender identity. Treating each patient the same is not providing equitable care (equality does not equal equity) because each patient has different medical and psychosocial needs. Embracing cultural humility is the first step in creating safe and welcoming spaces in the ObGyn office.²⁰

CASE Ways to better introduce yourself

To revisit the case, what options does the clinician have to start off on a best foot to create a safe space for Alex?

• Open with your own preferred pronouns. For instance, for an introduction, consider: “I’m Dr. X, my pronouns are she/her.”
• Don’t assume. Do not make assumptions about the relationship between Alex and the person accompanying them.

4 ways for creating welcoming and affirming spaces in ObGyn

1. Make sure your intake form is inclusive. Include a space for pronouns and the patient’s preferred name (which may differ from their legal name). Also allow patients to choose more than 1 sexual orientation and gender identity.²⁰ (An example form is available from the LGBT National Health Education Center: https://www.lgbtqiahealtheducation.org/publication/focus-forms-policy-creating-inclusive-environment-lgbt-patients/.)
2. Create a safe environment in the waiting area. Try to ensure that at least 1 bathroom is labeled “All Gender” or “Family.” Gendered bathrooms (eg, Ladies’ or Men’s rooms) are not welcoming. Make sure your non-discrimination policy is displayed and includes sexual orientation and gender identity. Review the patient education and reading materials in your waiting room to ensure they are inclusive. Do they show people with varied gender expression? Do they show same-sex couples or interracial couples?
3. Use a trauma-informed approach when taking a sexual history and while conducting a physical exam. Determine if a pelvic exam is necessary at this visit or can it be postponed for another visit, when trust has been established with the patient. Explain each part of the pelvic/vaginal exam prior to conducting and again while performing the exam. Before taking a sexual history, explain why you are asking the questions and be sure to remain neutral with your questioning. For instance, you can say, “It’s important for me to understand your medical history in detail to provide you with the best health care possible.” Instead of asking, “Do you have sex with men, women, or both?” ask, “Do you have sex with people with a penis, vagina, or both? Do you have anal sex?” Recognize that some patients may be in a polyamorous relationship and may have more than 1 committed partner. For sexually active patients consider asking if they have ever exchanged sex for money or other goods, making sure to avoid judgmental body language or wording. Patients who do engage in “survival sex” may benefit from a discussion on pre-exposure prophylaxis to reduce HIV transmission.²²
4. Provide appropriate counsel based on their feedback.

• Explain their risk for HPV infection and vaccination options.
• Respectfully ask if there is a need for contraception and review options appropriate for their situation.
• Ask about the use of “toys” and provide guidance on sanitation and risk of infection with shared toys.
• Determine current or past hormone use for patients who identify as transgender and nonbinary (although many do not take hormones and have not had gender-affirming procedures, some may be considering these procedures). Be sure to ask these patients if they have had any surgeries or other procedures.

The receipt of gynecologic care can be traumatic for some LGBTQI+ people. Explain to the patient why you are doing everything during your examination and how it might feel. If a pelvic exam is not absolutely necessary that day, perhaps the patient can return another time. For transgender men who have been taking testosterone,vaginal atrophy may be a concern, and you could consider a pediatric speculum.

Personal introspection may be necessary

In summary, the number of people who identify as lesbian, gay, bisexual, transgender/nonbinary, queer/questioning, intersex, or asexual is not insignificant. Many of these patients or their partners may present for ObGyn care at your office. Clinicians need to understand that there is a new language relative to sexual orientation and gender identity. Incorporating cultural humility into one’s practice requires personal introspection and is a first step to creating safe and welcoming spaces in the ObGyn office. ●