CASE A new patient office visit
A new patient is waiting for you in the exam room. You review the chart and see the sex demographic field is blank, and the patient’s name is Alex. As an ObGyn, most of your patients are female, but you have treated your patients’ partners for sexually transmitted infections. As you enter the room, you see 2 androgynously dressed individuals; you introduce yourself and ask,
“What brings you in today, and who is your friend?”
“This is my partner Charlie, and we are worried I have an STD.”
Estimates suggest that between 7% to 12% of the US population identifies as lesbian, gay, bisexual, transgender/non-binary, queer/questioning, intersex, or asexual (LGBTQI+).1 If you practice in an urban area, the odds are quite high that you have encountered an LGBTQI+ person who openly identified as such; if you are in a rural area, you also likely have had an LGBTQI+ patient, but they may not have disclosed this about themselves.2 Maybe you have had training in cultural relevance or are a member of this community and you feel confident in providing quality care to LGBTQI+ patients. Or maybe you think that, as a responsibly practicing health care clinician, you treat all patients the same, so whether or not you know their sexual orientation or gender identity does not impact the care you provide. As the proportion of US adults who identify as LGBTQI+ increases,1 it becomes more important for health care clinicians to understand the challenges these patients face when trying to access health care. To start, let’s review the meaning of LGBTQI+, the history of the community, what it means to be culturally relevant or humble, and how to create a welcoming and safe practice environment.
LGBTQI+ terms and definitions
The first step in providing quality care to LGBTQI+ patients is to understand the terminology associated with sexual orientation, gender identity, and gender expression.3–5
Sexual orientation refers to whom a person is sexually attracted. The term straight/heterosexual suggests a person is sexually attracted to a person of the opposite gender. Lesbian or gay refers to those who are attracted to their same gender. Some people use bisexual (attracted to both the same and opposite gender) and pansexual (attracted to all humans regardless of gender). Still others refer to themselves as queer—people who identify as someone who is not heterosexual or cisgender. A variety of other terms exist to describe one’s sexual attraction. There are also some people who identify as asexual, which suggests they are not sexually attracted to anyone.
Gender identity relates to how one views their own gender. If you were assigned female at birth and identify as a woman, you are cisgender. If you were assigned male at birth and identify as a woman, you may identify as transgender whether or not you have had gender transitioning surgery or have taken hormones. Some people do not identify with the terms male or female and may view themselves as nonbinary. The terms gender queer, gender fluid, gender diverse, and gender non-conforming also may be used to describe various ways that an individual may not identify as male or female. We also can refer to people as “assigned female at birth” or “assigned male at birth”. People with intersex conditions may require taking a unique medical history that includes asking about genetic testing (eg, 46,XX congenital adrenal hyperplasia or 46,XY complete gonadal dysgenesis).
Gender expression refers to how one pre-sents themselves to others through appearance, dress, and behavior. A person may be assigned female at birth, dress in a conventional male fashion, and still identify as a woman. Still others may choose to express their gender in a variety of ways that may not have anything to do with their sexual orientation or gender identity, such as dressing in ways that represent their culture.
People may be fluid in their sexual orientation or gender identity; it may change from day to day, month to month, or even year to year.6,7
*The term LGBTQI+ is not used consistently in the literature. Throughout this article, the terminology used matches that used in the cited reference(s).
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