In doctor’s offices across America, medical professionals often provide care based on the assumption that patients are cisgender and heterosexual. But LGBTQ+ patients—especially those who are trans, gender non-conforming, or nonbinary deserve better, and experts say improvements will only come when LGBTQ+ and gender-affirming health care becomes commonplace.
This type of care—which caters to the needs of these individuals without stigma or shame, and affirms patients’ sexuality and gender identity—is especially important given the significant health disparities the LGBTQ+ community faces, including increased risk for sexually transmitted infections (STIs) and HIV/AIDS, higher rates of mental health disorders, and an increased prevalence of houselessness and intimate partner violence.
While there are many factors that contribute to these disparities, a major one is that many LGBTQ+ folks avoid seeking medical care because they’ve experienced transphobia or homophobia in the past, or because they believe they’ll be discriminated against or don’t think they’ll receive adequate care because of provider ignorance. But the sooner affirming care becomes the standard, the less likely that is to happen.
What is gender-affirming care?
One of the first things Andrew Goodman, MD, does when he sees a patient is say his own pronouns to create a welcoming environment so patients know that their identity and needs matter. Practicing gender-affirming care is about, “not walking in with any assumptions, and understanding that knowing someone’s sex doesn’t mean you know things about their gender identity, who they have sex with, or the care they might need,” says Dr. Goodman, who is the medical director at Callen-Lorde, a health center for New York’s lesbian, gay, bisexual, and transgender communities. “It means that you ask and you’re open. It’s treating a patient like they are the expert of their own experience.”
Affirming care means that patients get the treatment they need for the bodies they have, not what the medical community presumes is appropriate based on the gender they were assigned at birth.
Some medical professionals presume that only women need pap smears, or that a man can’t get pregnant, but affirming care recognizes that certain services aren’t just for cisgender men and women and that trans men, nonbinary people, and intersex people are in need of reproductive care, too. It also acknowledges that patients’ sexual experiences might include people of all genders, and that hormone therapy, STI testing and treatment, contraception, and abortion are important health services for many people, regardless of sexual orientation, gender expression, or gender identity. In short: Affirming care means that patients get the treatment they need for the bodies they have, not what the medical community presumes is appropriate based on the gender they were assigned at birth.
Daria*, a nonbinary survivor of female genital mutilation (FGM), did not receive gender-affirming care when they sought help for FGM-related health care. “My heart dropped when I saw that all of the support information only mentioned women and girls. While they served people regardless of gender, the FGM department only seemed to cater to women and girls,” Daria says. “So in order to receive services, I signed up as a cis woman.” Despite the fact that they got some of the mental health care they needed, and were even offered a free gynecological exam to examine the physical effects of FGM, everything was in the context of womanhood. “Having gender-affirming health care means that as a nonbinary survivor of FGM I don’t have to compromise my gender identity in order to receive the help I need.”
Why education and advocacy are important
Bhavik Kumar, MD, MPH, the medical director of primary and trans care at Planned Parenthood Gulf Coast, explains that making a commitment to providing affirming care means educating and training staff to ensure “all the people involved in a patient’s health-care experience understand and value LGBTQ+ people.” For example, providers are taught to use neutral language and ask what body parts a patient’s sexual partners have, rather than asking if they’re sexually active with men or women. “We strive to make our health centers affirming spaces that are mindful of the indirect messages that can be so important to building trust and making our patients feel comfortable,” Dr. Kumar says.
It’s also important that patients of all ages receive this type of care, says Armonté Butler, the senior program manager of LGBTQ health and rights at Advocates for Youth, a nonprofit advocacy group dedicated to sexuality education and the prevention of HIV and sexually transmitted diseases. LGBTQ+ youth should learn from an early age that they deserve—and can receive—quality treatment, because it will help them feel comfortable seeking medical treatment later in life. Providers should also make it clear to all patients that they offer services like HIV testing and prevention, and they should be transparent about the way their practices handle insurance and confidentiality procedures. “It’s also crucial for health-care organizations to update their websites and social media to include imagery and resources for LGBTQ+ young people, including youth of color and youth living with HIV,” says Butler.
And it shouldn’t be the job of the patient to educate their health-care providers, either. “Finding affirmative and inclusive health care is like finding a needle in a haystack,” says Grey*, a nonbinary student who has received affirming care and also had negative experiences seeking health care. “Many doctors rely on their patients for education and that can cause more harm than healing,” Grey says.
At the bare minimum, providers should make sure they use inclusive language and visuals and that forms provide space for patients to list their names and pronouns. And it would be beneficial if they also offered access to hormone treatments and inclusive screenings for all gender orientations, says Jessica Halem, former Harvard Medical School LGBTQ+ outreach and engagement director.
Above all else, health-care providers should be advocates for their LGBTQ+ patients. “A primary care provider might not be comfortable with HIV care or hormone therapy, but it’s important not to say, ‘I’m not familiar with this and don’t think you should get it.’ Affirming care is, ‘I’m not familiar with this but let me go find out more about it and get you the resources you need,’’ says Dr. Goodman. This type of advocacy is a huge part of Dr. Goodman’s practice. For example, when he knows that he has to send a prescription to an external pharmacy that might use a transgender patient’s legal name instead of their chosen name, he prepares the patient so they aren’t caught off-guard. He’s even helped patients navigate the process of a legal name change so that they don’t have to worry about being deadnamed in official settings outside of health care.
And it’s important to recognize that affirming care goes beyond the front-office and patient-facing aspects of health care; the technology that powers the medical system needs updating as well. Many software systems display a patient’s legal name and sex assigned at birth, which could clash with their identity. Some software also forces doctors to make medical decisions based on assigned sex at birth and that can influence dosage amounts for prescribed medications or prompt the doctor to make improper preventative-care recommendations, explains Susanne Fortunato, founder of Wingspan Health, an inclusive patient portal. But things are changing. New software makes it possible to provide a better experience, by capturing a patient’s legal name and assigned sex and birth for insurance purposes but displaying their correct name to front desk staff, incorporating all gender markers and pronouns, and using displays that look the same for all patients in order to protect their privacy.
Making affirming care the new standard
Often, without the proper systems in place, LGBTQ+ people are left to fend for themselves or accept being misgendered or improperly treated. But it doesn’t need to be this way. “You might think you’re not in the position to question an experience, but you can give feedback to your provider,” Dr. Goodman says. And if you feel comfortable doing so, it might help bring about change. That said, if you’re not getting the care you deserve, you can leave and find a new provider. The Gay and Lesbian Medical Association (GLMA) specifically has a provider directory that lists the affirming and competent practices in the United States.
If you work in health care or feel comfortable sharing resources with your medical providers, you can be a driving force for change. Some resources to consult include the University of California San Francisco’s transgender care guidelines and Essential Access Health’s guide to Providing Inclusive Care for LGBTQ Patients. These guides explain how to avoid stereotypes and assumptions about patients’ sexual orientations and gender identities and offer samples of inclusive intake forms and updated ways of keeping health records. And they don’t just cover the ways that doctors treat patients; they touch on why it’s critical for all staff, especially those who have contact with patients (such as outreach workers, front-desk staff, assistants, and those who handle billing and insurance) to have LGBTQ+ affirming training. Ultimately, any and every interaction in health care sets the foundation for patients to feel cared for.
As things change, there will be providers who worry that implementing inclusive care will push some patients away. But Dr. Goodman explains it’s necessary for health-care professionals to understand that patients who don’t like the changes will probably have access to care elsewhere, while marginalized patients often don’t have that option. That’s why creating a welcoming space for the people who are the least likely to have access to those spaces must be the priority.
“A lot of change starts small and is incremental,” Dr. Goodman says. “Maybe right now all you can change is what happens in your exam room, but that can be so powerful.”
*Name was changed to protect privacy.
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