Research has proven that race, sex, ethnicity, and socioeconomic status all are factors that can affect health care outcomes, and that knowledge has led health policy makers to make significant chances to how doctors, clinical staff, and administrators interact with patients from marginalized populations. Sexual orientation and gender identity are also traits that are susceptible to bias within the health care system, causing reduced access to care among LGBTQ patients and limiting treatment.
“The argument I try to make to people who say, ‘Why should I care about this, why shouldn’t I just treat everyone the same?’ is that there’s really different health outcomes that we’re seeing,” says Bláz Bush, director of the LGBT Center at the University of Louisville’s Health Sciences Center. “And the reason we believe those health outcomes are happening is because through societal stigma, through discrimination, less and less LGBTQ people feel comfortable accessing medical care. And that’s due to really negative experiences when they do access medical care.”
The LGBT Center at U of L’s Health Sciences Center has developed a curriculum designed to educate current and future health care providers about the unique care needs of this community. The work started before Bush came on board about a year ago, and he feels privileged to continue its mission.
“A study that was done found that across all medical colleges in the nation, there’s only about five hours of curriculum on average focused on LGBTQ health care issues, despite these alarming health care disparities,” he says. “And so the University of Louisville really found both a lot of interest on the Health Sciences campus in learning, and the community support to come in and say, ‘Yes, we will teach you.’”
Improved Communication, Improved Treatment, Improved Health Outcomes
Bush explains that the doctor-patient relationship is one where openness and complete honesty are essential. If a physician and his or her staff are not comfortable in dealing with a patient’s self-identification with regards to gender and sexuality, then a bond cannot be formed leading to quality health care.
“In my life, if I want to talk about my partner, and my partner being involved in my health care, I want a provider who is going to be able to hear that and support that,” Bush says. “Those are the kinds of issues that make people say, ‘I don’t want to go back to that health care provider, now I’ve got to find a new one. Or maybe I’m just tired of going into the health care system in general.’
“And so that’s what we see: more and more LGBTQ-identified people, especially transgender [and] non-binary folk, are choosing not to engage in the medical system,” he continues. “Which means they’re not getting their screenings for their health outcomes. They’re not getting checkups regularly. Maybe they’re accessing medical care in other ways, by going to friends that they feel safe with. And all of these pieces add up to negative long-term health care outcomes.”
Bush describes a hypothetical situation where a patient is engaging in sexual practices that may put them at risk for getting human immunodeficiency virus (HIV). If that patient does not feel that their provider is welcoming and therefore does not bring up the behavior during the visit, crucial information relating to prevention and treatment won’t be communicated.
Making assumptions during a first meeting can have a negative impact on a patient, Bush says. For example, a patient may appear based on traditional societal norms to be a man, having facial hair and a muscular build, but “male” may not be the gender the patient identifies as. The patient may be fearful to fully present as their preferred identity, especially if they have not taken hormonal treatment and still appear on the outside to be conforming to societal conventions regarding gender.
“People are beginning to find the confidence and the places to come out and say, ‘I have a different gender identity than how I present, or how I was assigned at birth,’” Bush says.
Recognizing and Embracing Personal Preferences in the Medical Setting
If a physician is willing to re-think the way he or she welcomes patients into care and develops relationships, the process needs to begin at the first consultation – and to be even more specific, at the initial greeting.
“The best thing to do is to try to talk to somebody and ask them” about how they’d like to be addressed, Bush says. “For example, whenever I meet somebody new, I do my best to try to say, ‘Hi, I’m Bláz Bush, so nice to meet you, I use he/him pronouns. Can I get your name and pronouns?’”
Bush says that this method of introduction is actually commonplace throughout society – it’s just that people whose gender identity conforms to traditional, appearance-based norms never think about how they prefer to be addressed.
“Pronouns are he, him, his; she, her, hers. Those are the most common pronouns that we hear,” Bush says. “There are gender-neutral pronouns like they, them, theirs. I know you might be thinking that’s plural, but Merriam-Webster dictionary actually added they/them pronouns as individual singular pronouns.”
A person may have been assigned as male or female by physiology at birth, and that is what’s on their medical records, but Bush points out that many people develop a different gender as they move into adolescence and adulthood. They could identify as non-binary (neither completely male nor completely female, as defined by societal norms) or even as fluid (moving from one identity to the other).
As a person matures, “there’s an internal gender identity development that’s going on for this individual,” Bush says. “And as they progress, and what we see for transgender identified folks and non-binary identified folks, is that that sex assignment really didn’t reflect how they felt inside. It’s vitally important to affirm this aspect of this individual. What we see when we don’t affirm these aspects of the individual – the internal sense of their gender identity which they may like to express externally – we see high rates of suicidality, very high rates of depression, other coping skills like substance use, and again the lack of engagement with the health care system.”
In addition to being aware of a patient’s preferences and improving communication, the medical provider can also make changes in how their office is organized, from placing a wider variety of magazines in the waiting room to adding signage that acknowledges gender diversity, Bush says.
“If (patients are) more comfortable, they’ll keep coming into care,” he explains, “and they’ll learn to trust you and they’ll open up to you, which is what we want in the people that we’re working with. And then maybe if we can keep them engaged in care, we can help them offset some of these negative health care issues.”
