Like all other groups that have been historically marginalized, those who identify as LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning, and others) often have a complex history and relationship with medicine. “In health care, just as in most parts of our society, there has been stigma around gender identity and sexual orientation,” said Kevin Kline, MD, the director of LGBTQ+ Health in Family Medicine and Community Health and an assistant professor of Family Medicine and Community Health in the Perelman School of Medicine at the University of Pennsylvania. “Many people are afraid of being judged by their clinicians or care team, and that can lead them to withhold information during appointments or not visiting a doctor at all in order to protect themselves.”
In fact, roughly 25 percent of transgender people delayed medical care that they knew was important for them out of fear that they’d experience discrimination, bias, and even physical assault, according to a 2015 survey of American trans people. And it’s easy to see the basis for that fear; in another survey from the Center for American Progress, 29 percent of trans people said their provider used abusive language or harsh language while treating them in the previous year. This discrimination extends to lesbian, gay, bisexual, and queer people, too, with 7 percent in the survey saying that their provider refused to acknowledge their family (a same-sex partner or a child), and an appalling 7 percent said that they received unwanted physical contact from a provider.
In order to provide equitable health care despite this history of fear and a discrimination, Penn Medicine has been focused on not only getting LGBTQ+ patients in the door to receive the important health care they need and deserve, but also on creating an environment where they feel safe, listened to, and willing to come back. Kline and those involved in the LGBTQ Health Program at Penn Medicine have been continuing work to ensure patients have access to respectful, compassionate, and equitable health care.
“Members of the LGBTQ+ community experience higher rates of many serious health conditions, like certain cancers, alcohol use disorders, depression and suicide. If we don’t make our clinics more welcoming for these patients, these disparities are not going to get better,” said Ayiti-Carmel Maharaj-Best, MD, an assistant professor of Clinical Family Medicine and a clinician in the LGBTQ Health Program.
The First Appointment
The first primary care appointment for a patient who identify as LGBTQ is exactly like any appointment for any patient — clinicians are focused on treating them holistically and on listening to the concerns that brought them in for care. However, as some may have delayed care over the years, there can be many issues or topics a patient might want to address.
“There are times when a patient who is queer comes for a first appointment and there are multiple aspects of their health that we should and can help them with,” said Kline. That might mean that a patient is coming in for an appointment to receive care related to their sexual health or to start gender-affirming care, but they may have a disease like diabetes, for example, that needs to be managed.
“We identify the most critical concerns and preventive health needs for all of our patients. Then we make a plan together of what can and should be addressed during the first appointment,” he said. “This shared agenda setting allows us to address both the most vital medical needs and cover the patient’s most important concerns, which becomes especially important if those don’t align. As a clinician, you’re often doing a little triage, but acknowledging your patients’ main concerns and the reasons that brought them in is equally as important as addressing my goals for a first appointment.”
Compassionate and Coordinated Primary Care
One thing Kline watches out for with LGBTQ patients are potential issues and conditions that may be more common with those who identify as LGBTQ+. For example, while there has been an increase in mental health concerns across the country, depression affects LGBTQ folks at higher rates than those who are straight and cisgender. LGBTQ people may also struggle with anxiety, heavy drinking, tobacco use, and drug use.
Within Family Medicine, clinicians like Kline assume a primary-care role and can coordinate specialized care within one visit. “We have a pretty complete view of our patients, and that allows us to tag in the right people to help manage conditions, treat new ones, or discuss other needs a patient might have, such as planning for gender-affirming surgeries,” said Kline. “We always strive to holistically take care of our patients. For example, a patient might come in requesting a referral to a gynecologist to discuss contraception, but we can have that discussion and provide their contraception during that visit with us.”
Family Medicine clinicians often care for people within multiple generations of one family — from couples and their kids, parents, and entire families. That understanding of family and couple dynamics creates a shorthand when caring for patients from the same family and can lead to better follow-through on care plans and better dialogue between patients and their clinician, Kline explains.
Kline and other Family Medicine providers can also provide obstetric care, for LGBTQ people starting or building a family. And when they can’t provide direct care themselves on certain issues, they connect patients to the deep bench of experts across the system for care like gender-affirming surgeries.
Doing the Little Things
“A lot of small actions can really make LGBTQ+ patients feel welcome in a medical setting,” said Kline. For example, when Kline sees patients, he wears a rainbow clip and pronoun clip which becomes a signal, letting them know they are in a supportive and inclusive space. And in the exam room, clinicians should not assume sexual orientation, said Kline.
“I ask patients what the gender or genders of their sexual partners are and how they define their sexual orientation,” said Kline. Simply asking that can create a space where patients know that you aren’t making assumptions and want to care for them holistically, he said.
Communication is key outside of the exam room as well, Kline explains. At Penn, patients’ electronic medical records list people’s preferred names and gender identity. Clinicians and staff are instructed on how to avoid mis-gendering people and how to use more non-gendered language.
“Taking care of this population has made me focus on how I talk to all patients and to focus more on showing respect through the language I use,” Kline said.
Beyond efforts to manage communication and care, there are education efforts, research initiatives, and more across Penn — all to continue building a safe, friendly, equitable environment. Recently, Penn Medicine’s hospitals were honored by the Human Rights Campaign Foundation, the educational arm of the nation’s largest LGBTQ+ civil rights organization, for its dedication and commitment to LGBTQ+ inclusion. The designation is an important part of continued efforts towards promoting an LGBTQ-inclusive climate.
On the Horizon
Kline and Maharaj-Best are excited about the future of LGBTQ+ care at Penn, but access to LGBTQ-competent care remains a challenge in Philadelphia, so in addition to providing primary care, the clinicians of the LGBTQ Health program at Penn Family Care work to make sure more primary care doctors are being trained.
“Patients should not have to search as hard as they do to find a provider who will make them feel comfortable to be themselves,” said Maharaj-Best. Resident physicians and medical students work alongside Kline, Maharaj-Best and their colleague Laura Kurash, MD, an assistant professor of Clinical Family Medicine and Community Health and the assistant medical director of Penn Family Care, to learn best practices in LGBTQ+ care.
“LGBTQ+ health is often overlooked in medical school education, leaving patients to educate their providers on how to take care of them,” said Maharaj-Best. “Our goal is that every trainee that comes through our clinic leaves knowing at least the basics of LGBTQ+ health, and able to create an affirming environment.” The skills trainees practice to care for LGBTQ+ patients make them better doctors for all their patients. “Whether it’s how to do a trauma-informed physical exam, or how to talk about sexual health, or just how you make a patient feel like their experience matters, all our patients benefit from the skills trainees learn in the LGBTQ+ clinic.”