Running head: IMPROVING THE LGBT PATIENT EXPERIENCE

Improving the LGBT Patient Experience Ashton Layne MGMT 5530 Physician Practice Management December 3rd, 2012

IMPROVING THE LGBT PATIENT EXPERIENCE Abstract The LGBT community is one that has specific health care needs that are often left unaddressed

but with a growing population the health care community must begin to resolve these disparities. This paper will first take a look at the general experience of the LGBT patient and the issues of inequality and invisibility in their health care experience and access. Also the paper will look into communication between the patient and provider including disclosure of ones sexual preference or gender identity. Lastly under the umbrella of general health care experience we will address language and the powerful influence it can have over the LGBT patients experience. After looking at the subject from a generalized perspective we will then turn towards specific minority groups within the LGBT community and their specific health needs as well as how providers can ensure these needs are met. Then we will explore the specific health care needs of the lesbian woman and how health care professionals can be sensitive to these needs. Lastly, we will look at the health care experiences of the transgender community. Within each of these topics this paper hopes to provide suggestions and insight as to how to improve this communitys patient experience and address the specific needs of these minority groups.

IMPROVING THE LGBT PATIENT EXPERIENCE Improving the LGBT Patient Experience Lying on the table waiting to be passed through the MRI machine, the patient was now explaining to the third member of the staff that although she had not had a period for three months there was in fact no way that pregnancy was a possibility. The clinician was left confused and the patient irritated by a situation that could have been avoided through patient specific sensitivity. She was in fact a pre-op transgender man who had been on testosterone

injections for the past three months preventing any menstruation. This incident is an example of a patient experience specific to the LGBT community that could have been avoided if there wasnt such a high level of invisibility and lack of provider sensitivity in the health care community. In their research of The National Library of Medicine, Boehmer(2002) states that LGBT persons are estimated to constitute between 1% and 10% of the total population. Only 3777 articles, the equivalent of 0.1% of the MEDLINE database, focused on LGBT individuals over the past 20 years. (p. 1128). This statistic is a direct indicator of the lack of recognition the LGBT community has by health care industry and in turn the disparities that exist in regards to medical care specific to the LGBT patient. This paper intends to looks at this issue first in a broad context by looking at the LGBT community as a whole and then turning attention to a few of the sub-communities that exist within the LGBT population. Once the scope has been narrowed, I then intend to explore the needs specific to these smaller populations. While identifying the disparities is necessary, ultimately the goal is provide possible solutions to reducing the inequalities and improving the LGBT patients experience.

IMPROVING THE LGBT PATIENT EXPERIENCE Broad Scope Analysis of the LGBT Patient Experience Invisibility The assumption of heterosexuality or a gender conforming identity is most likely the initial error by practitioners that precedes numerous negative patient experiences and/or the providing of insufficient medical care. In his article entitled Ending LGBT Invisibility in Health Care: The First Step in Ensuring Equitable Care, Makadon (2011) asserts physicians can take the first critical step to helping LGBT individuals feel comfortable seeking care, ie, by being proactive in taking a history that includes discussion of sexual orientation and gender identity (p. 220). This assumption not only occurs by the medical provider but also at the administrative level in a medical practice. Most documentation in a medical office does not inquire as to a patients sexual orientation or gender identity. The request for additional information during the new patient process could result in obtaining this information which is essential to providing the best care possible for patient medically as well as interpersonally. McWayne (2010) declares The intake forms could include questions that have appropriate responses for gender identity, sexual orientation, and same-sex partners as well as other sex

partners (p. 277). The story in the introduction is an example of how modification of the intake form could have prevented several uncomfortable conversations and a negative patient experience for that particular individual. While altering the intake forms may be a viable option, this solution will be of no service if the patient does not feel at ease disclosing their sexual orientation or gender identity. Doctors and staff must work towards providing a comfortable environment in which the LGBT patient is secure discussing their identity and sexual history. This includes the space where the patient first

IMPROVING THE LGBT PATIENT EXPERIENCE enters the practice, the waiting room. Bonvicini and Perlin (2003) affirm One of the primary steps in creating a safe environment for patients is to examine the practice environment and the messages sent through verbal and non-verbal behavior and physical setting (p. 119). Many LGBT patients have had negative coming out experiences or family reactions due to religious

beliefs, therefore, one might be wary of decorating the waiting room with religious symbols such as crosses. This initial observation may cause the patient to feel uncomfortable and less likely to disclose their sexuality or gender identity for fear of a negative reaction. Other waiting room suggestions include posting a written policy declaring equal treatment of all patients regardless of sexual orientation as well as providing educational materials specific to LGBT health issues (Bonvicini & Perlin, 2003, p. 120). Potter (2002), a self-identified lesbian physician, concurs by saying I try to communicate who I am nonverbally, by displaying pictures of my family and having gay-friendly posters and health literature in my office (p. 342). Communication and Disclosure Although a patients LGBT status may not always be necessary to specific health care provided, their satisfaction with the care provided could be directly related to their ability to be open about their sexual or gender identity. In research conducted more than 30 years ago Dardick and Grady found that those who revealed their sexual identity and who perceived their health professionals were supportive of this identity were much more satisfied with their health professionals (1980, p. 117). Granting this research is quite dated and responses in regards to self-identification may change, the correlation between open communication and patient satisfaction is likely to remain the same.

IMPROVING THE LGBT PATIENT EXPERIENCE Language Another factor in improving the patients experience in direct connection with communication is the use of appropriate language during interaction with the LGBT client. As

discussed before the assumption of heterosexuality can lead any of the health practice staff to use incorrect language in regards to the patient. A common mistake caused by this assumption is the referral to ones significant other, such as assuming that a female patient must have a partner that is of the opposite sex and referring to them as such. Makadon (2011) suggests when having initial conversations with a patient it is best to use gender-neutral terms and pronouns when referring to partners until you know which to use (p. 221). This same use of gender-neutral pronouns is suggested for the patients themselves, also if you make a mistake you can apologize and proceed to use the correct term now that you know it (Makadon, 2011, p. 221). He also suggests you mirror the patients language (Makadon, 2011, p. 222), which just means to use the same language to refer to the patient as they use to refer to themselves. Emily Dickinson once said, I know nothing in the world that has as much power as a word. This is most apparent in the fact that the accurate use of language in a patient interaction can make largest impact on how they view their experience with a health care professional. Improving the Lesbian Patients Experience Now that there has been an exploration of general issues that affect all members of the LGBT community, lets take a more specific look at the communities that are of special interest as well as the highest amount of personal knowledge and insight. Ten years of my life were spent self-identifying as a lesbian, as well as having a masculine physical presentation.

IMPROVING THE LGBT PATIENT EXPERIENCE Therefore, much of the information found in the research can be supported by personal experience. Birth Control and Reproductive Services Are you sexually active? Yes At least that was easy. Next question: What type of

birth control do you use? You can see it coming. Answering none means that you will have to explain why a sexually active, single woman would not use some form of birth control (Fields & Scout, 2001, p. 182) This story is the experience of many lesbians when visiting a health care provider for the first time. As discussed in the first section of this paper, this uncomfortable conversation is the result of heterosexual assumption that the entire LGBT population experiences but this particular issue specifically impacts the lesbian population. In a study done in Norway by Bjorkman and Malterud (2009), Some participants had been given medical information aimed at heterosexual activities; others had received prescriptions for contraceptives or had had pregnancy tests taken (p. 240). Although this particular study was done in Norway, it is believed to still be pertinent as there is a great deal of research that supports similar actions by health care professionals in the United States due to the same perceived heterosexual identity. Both of the reports above could have been avoided by the providers taking simple and cost-free initiatives towards a more positive experience for their lesbian patients. A simple alteration of the intake form to be more specific in regards to what kind of sexual activity or with what sex one is having intercourse with would help to diminish the number of accounts such as these. Another alternative to avoiding these scenarios is for the health care providers to seek out additional sensitivity trainings on how to accurately obtain sexual history and build a therapeutic relationship with these particular patients, Mravcak (2006) states that Building trust with

IMPROVING THE LGBT PATIENT EXPERIENCE lesbians and bisexual patients is paramount to overcoming the barriers to quality care (p. 280).

Although this option places the burden on the physician to complete the additional education, the administrative staff is also vital in determining said education is necessary. Beyond intake documentation, accurately representing all demographic information, including the LGBT patient, is an essential piece of the puzzle to creating the positive lesbian patient experience. Reproductive services are frequently required when a lesbian couple decides to start a family can be directly related to the fact that contraception methods are not of a concern. As acceptance of the LGBT community has evolved, more and more lesbian couples are deciding to have children. Even if a health care physician is not a provider of reproductive services, they may still improve their relationship with the lesbian patient. Mravcak (2006) suggests, Physicians should refer lesbian and bisexual women who wish to become pregnant to a health care professional who performs donor insemination (p. 283). From an administrative lens, one should facilitate the referral process by researching fertility doctors in the area that are also seeking to fulfill the specific health needs of the lesbian patient and is does not discriminate on the basis of sexual orientation as well. While this not only fosters a positive relationship between the practice and the patient, the practice could benefit fiscally as well. Just as you are able to refer patients for reproductive services, the fertility practice can also reciprocate this referral process and send patients to your facility for the specialty you supply. Fields and Scout (2001) support the idea of a positive patient assessment of the practice leading to fiscal rewards in their statement below: The benefits for health care providers in providing culturally competent care include increased use of their services, imporved prevention and early intervention, better communication and rapport, more accurate diagnoses, improved adherence and

IMPROVING THE LGBT PATIENT EXPERIENCE compliance, improved health and treatment outcomes, greater consumer satisfaction, increased patient retention, and more word-of-mouth referalls. (p. 186) Health Screening and Preventative Care Obtaining a full sexual history. The first step in determining the appropriate course of action in screening and preventative care is ensuring that all of the necessary facts have been collected. While many health care practice providers upon learning of a lesbian patients sexual identification may feel it is unnecessary to ask any further questions, this is not necessarily true. The article As Many Lesbians Have Had Sex with Men, Taking a Full Sexual History Is Important (2000) declares, Roughly three-quarters of lesbians who responded to a magazine survey have had sexual intercourse with men, and nearly two-thirds have had unprotected

heterosexual intercourse (p. 97). Essentially every piece of research used for the writing of this paper, in regards to lesbian health care, explicitly states obtaining a thorough sexual history for the lesbian identified patient is essential to the provision of appropriate screenings and preventative care. Pap Smears. Within the health care community there is an incorrect belief that lesbians are at low risk for cervical dysplasia and need less frequent Papanicolaou (Pap) smears than heterosexual women (Mravcak, 2006, p. 283). This can be linked directly back to the fact that a full sexual history is not obtained upon initial consultation with the patient. Health care providers make the assumption lesbian have not been or are not currently sexually active with members of the opposite sex because an accurate account of their sexual activity has not been obtained upon the declaration of the sexual identity. It is important for both staff and physicians

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to be well aware of the difference in definition of this these particular terms in regards to lesbian patients. In turn there is also a lack of education in the lesbian community around the necessity of these exams regardless of your sexual history. Diamant & Schuster assert, When health care providers make their recommendations for the frequency of screening tests for individual patients, it is important for them to recognize that risk factors for cervical dysplasia among lesbians may not be very different from those of heterosexual women (pp. 145-146). While personal experience is not usually recommended, there is definitely a disparity of available research on this topic and it is of necessity to properly convey this point. Having been a member of the lesbian community for 10 years and having not had sexual experiences with men I was unaware of the necessity for pap smear exams regardless of this fact. My masculine appearance also led health care providers to make the assumption of my lesbian identity and lack of heterosexual activity and therefore did not seek further information as to my sexual history or make recommendations that a pap smear be completed. While a broad assumption cannot be made due to my singular experience, this has also been the experience of many people within the lesbian community (especially if of a masculine appearance) that I have spoken with about this topic. A similar story appears in Addressing the Needs of Lesbian Patients in which this was the case for a lesbian who recently had her first Pap smear at age 42 (Fields & Scout, 2001, p. 183). In order to improve the current status of awareness among a practices lesbian patients, the practice should look to make available information specific to this demographic in terms of the health care providers as well as in the form of pamphlets and other publications. Through the provision of such publications the practice not only informs the

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patient of their specific health care needs but also helps to enhance the lesbian patients level of comfort by showing acceptance and inclusivity of the LGBT community. Improving the Transgender Patients Experience Despite the critical importance of assessing patient satisfaction with transgender care, virtually no research has focused on this (Bockting, Robinson, Benner, & Scheltema, 2004, p. 279). In completing this paper it was found to be true that research completed in regards to the transgender patients experiences an satisfaction with the health care system are almost nonexistent. This lack of research is a prime indicator of the lack on education at the provider level as well which would then lead one to believe there is much room for improving the transgender patients experience with health care. Primary Care While there are several concerns particular to the transgender, there is one theme from the initial examination of the LGBT community as a whole that has an overwhelming impact on the transgender patients opinion of the health care provided. The proper use of language when speaking to transgender patients can for some be the sole determining factor in their evaluation of the health care provided to them. When treating the transgender patient it is culturally appropriate to refer to individuals as their self-identified gender, regardless of their appearance or level of transition (Maguen, Shipherd, & Harris, 2005, p. 479). Practice staff should use the preferred pronoun as well as a patients preferred name when addressing a client. When in doubt is okay to ask a patients preference. Samel and Evezaritsky (2008) assert, Pertinent questions are best asked in a frank and simple manner (p. 649).

IMPROVING THE LGBT PATIENT EXPERIENCE It has been found that not only is this of particular interest to you as a business owner who wishes to generate repeat business and positive referrals, but as a health care practice it

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should be known that their actions could potentially affect that patients decision to access health care again in general. Lombardi (2001) states, lack of sensitivity on the part of health care providers who do not respect the expressed gender identity of transgender persons can adversely influence whether these individuals access and stay in treatment (p. 870). For this reason, a practice should provide sensitivity training as well as impose clear guidelines for health care providers, medical office staff and emergency personnel on providing sensitive, quality care to transgender individuals (Hussey, 2006, p. 157). Gynecological exams in the FTM (Female-to-Male)community. The need for sex specific (biological sex at birth) health care does not change with ones gender identity (Hussey, 2006, p. 157). This of course can change if one chooses to undergo sexual re-assignment surgery. But, the FTM community poses a unique need in the health care community due to the fact that a majority of the population chooses not to participate in any type of genital reconstruction or removal of female internal sex organs. The reason being a lack of adequate technology for the former and various barriers to access of health care for the latter. Therefore, gynecological exams are essential to the care of the FTM patient participate in hormone therapy due to increased risk for development of endometrial hyperplasia, and subsequent endometrial carcinoma (Hussey, 2006, p. 130) as well as ovarian cancer. The challenge is these exams can lead to an extremely high level of vulnerability and anxiety to this particular demographic. Specifically, patients found the waiting room seems to cause an intense level of anxiety when waiting to be seen for their gynecological appointments. In one particular study a respondent state that his strong reaction to the waiting room experience caused him from

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obtaining gynecological health care (Hussey, 2006). A possible solution to enhance the patients experience would be to simply be aware of the anxiety these visits can cause by asking questions about any perceived lack of comfort. Once the issue has been identified, simply making the practice professionals aware and escorting the patient quickly to an exam room to wait privately would vastly reduce the amount of anxiety experience during these appointments. In many instances the smallest gestures will make the largest impact on the patients perceived experience with health care professionals. Conclusions and Looking to the Future
The LGBT community is one of the least researched minorities in the health care field which leads to several disparities and invisibility in regards their patient experience. Though several particular issues were addressed in this paper, the theme that resonates throughout as far as improving the experience of the LGBT patient is that of training and education. Although specifically referencing the treatment of the transgender patient, Hussey (2006) recommends the following: Training that that specifically addresses all aspects of working with transgender people in a health care setting is recommended: (1) at the provider level (including doctors, nurses, physician assistants, and nurse practitioners); (2) at the frontline staff level (including the office staff and receptionists who are often the first to encounter a patient in an office setting); and (3) at the emergency and crisis intervention level (including, emergency medical technicians (EMTs), paramedics, police, and firefighters who may deal with transgender people in emergency situations). (p. 156) Although this list may seem extensive, these professionals are equipped and trained to be sensitive to the health care needs of with all other sects of the minority population, and should be as

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equally prepared to deal with the LGBT patient. The LGBT minority population may not be the only

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minority that is not identifiable by any physical characteristic but with the growing acceptance in todays society these health care professionals are likely to interact with an out member of this community. Lastly, in order to put the provide the proper education for these health care professionals, the medical community must also begin to look deeper into the issues affecting the LGBT community and allocate the appropriate resources to accommodate such research.

IMPROVING THE LGBT PATIENT EXPERIENCE References

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As Many Lesbians Have Had Sex with Men, Taking a Full Sexual History Is Important. (2000). Family Planning Perspectives, 32(2), 97-98. Bjorkman, M., & Malterud, K. (2009). Lesbian women's experiences with health care: A qualitative study. Scandinavian Journal of Primary Care, 27, 238-243. Bockting, W., Robinson, B., Benner, A., & Scheltema, K. (2004). Patient Satisfaction with Transgender Health Services. Journal of Sex & Marital Therapy, 30, 277-294. Boehmer, U. (2002). Twenty Years of Public Health Research: Inclusion of Lesbian, Gay, Bisexual, and Transgender Populations. American Journal of Public Health, 92(7), 11251130. Bonvicini, K., & Perlin, M. J. (2003). The same but different: clinician-patient communication with gay and lesbian patients. Patient Education and Counseling, 51, 115-122. Dardick, L., & Grady, K. E. (1980). Openness Between Gay Persons and Health Professionals. Annals of Internal Medicine, 93(1), 115-119. Diamant, A. L., Schuster, M. A., & Lever, J. (2000). Receipt of Preventative Health Care Services by Lesbians. American Journal of Preventative Medicine, 19(3), 141-148. Fields, C. B., & Scout (2001). Addressing the Needs of Lesbian Patients. Journal of Sex Education and Therapy, 26(3), 182-188. Hussey, W. (2006). Slivers of the Journey: The Use of Photovoice and Storytelling to Examine Female to Male Transsexuals' Experience of Health Care Access. Journal of Homosexuality, 51(1), 129-158. Lombardi, E. (2001). American Journal of Public Health. Enhancing Transgender Health Care, 91(6), 869-872.

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Makadon, H. J. (2011). Ending LGBT invisibility in health care: The first step in ensuring equitable care. Cleveland Clinic Journal of Medicine, 78(4), 220-224. Marguen, S., Shipherd, J. C., & Harris, H. N. (2005). Providing Culturally Sensitive Care for Transgender Patients. Cognitive and Behavioral Practice, 12, 479-490. McWayne, J. (2010). LESBIAN, GAY, BISEXUAL, AND TRANSGENDER HEALTH DISPARITIES, AND PRESIDENT OBAMA'S COMMITMENT FOR CHANGE IN HEALTH CARE. Race, Gender & Class, 17(3-4), 272-287. Mravcak, S. A. (2006). Primary Care for Lesbians and Bisexual Women. American Family Physician, 74(2), 279-286. Potter, J. E. (2002). Do Ask, Do Tell. Annals of Internal Medicine, 137(5), 341-343. Samuel, L., & Evezaritsky (2008). Communicating Effectively with Transgender Patients. American Family Physician, 78(5), 648-650.