Culturally Competent Care for GLBT People: Recommendations for Health Care Providers

A health care provider's job is to care for the health of her or his patients. This necessarily requires that the provider understand important details about the patient's behaviors, and that the patient invests in the provider with a high degree of trust.

In order to gain trust, you will need to create an atmosphere of openness and affirmation with all patients. There are many different components to creating an environment welcoming to GLBT patients, including outreach, office space, intake forms, confidentiality policies, staff training, and the patient interview. Small changes you make in these areas can have a big effect on the comfort felt by your GLBT patients, and this will translate into a more satisfying patient-provider relationship and better health outcomes.

Sometimes providers are unaware of the degree of discrimination a GLBT person may have experienced in the health care setting, and of his or her resulting discomfort in your office. Sometimes this bias may be very obvious and flagrant. More often, however, the discrimination is felt in many small and seemingly subtle ways that add up to the GLBT patient feeling invisible and unsafe. For example, providers commonly ask women what form of birth control they use while performing a gynecological exam. Not only does this assume heterosexuality, it forces the lesbian patient to come out to their provider at an extremely vulnerable moment.

These webpages provide simple and specific recommendations for making your practice more welcoming to your GLBT patients. Remember that cultural competence is a learnable skill. It requires ongoing practice and commitment. Expect to make "mistakes" in good faith, and be willing to grow in your understanding.

Unfortunately, gay, lesbian, bisexual and transgendered people have reasonable fears of discrimination when seeking health care:

Approximately 5 to 10% of your patient population may be lesbian, gay and bisexual and approximately 1 to 10% may be transgendered (not all will be transsexual, though). If these numbers sound high to you, it may be that you are not asking the right questions, or that patients are not comfortable disclosing. Begin with self-evaluation and reflection. What expectations and assumptions do you bring to the patient encounter? What values, biases and beliefs?

This is where creating a welcoming environment begins. Few providers target GLBT people with marketing and outreach, and GLBT people are likely to respond very favorably to advertisements in local GLBT service directories and publications. This is a direct indication that you are interested in welcoming GLBT patients into your practice.

Patient interview

Remember that any person who walks into your office could self-identify as gay, lesbian, or bisexual and/or have a history of relationships with members of the same sex. Similarly, they may have been born the other sex than they appear. If a patient has left blanks on the intake form, this may be an indication that they felt uncomfortable being open in writing. You have another, better chance to create trust with the GLBT patient during the initial interview.

Ensure that questions you ask are open-ended and apply to all patients.
It is important to take a complete sexual history in a non-judgmental manner. Revisit the sexual history each time you see the patient as practices and partners may change (this is true, of course, for heterosexual/non-transgender patients, too). It is important when discussing sexuality to focus on behavior and not just sexual orientation or identity, as not all people with homosexual behaviors identify as such.
If a patient seems offended by something you've said, you may simply apologize and offer a brief explanation about why information is necessary to provide the best care possible. Ask what terminology the patient prefers.
Seek out colleagues who have experience in gay, lesbian, bisexual, and transgender healthcare (many more providers are experienced with GLB health than with transgender health). You may use these colleagues for advice and for referrals.
Explain how the patient's confidentiality will be protected, and who will have access to the information. Give the patient the option of refusing to answer a question. If the patient's confidentiality cannot be protected, it may be to the patient's disadvantage to provide specific information if it is recorded in the medical chart.
If a teenager or young person does disclose their lesbian, gay, bisexual, or transgendered identity to you, you must treat this information with great privacy and respect. You may be the first person he or she has told. As sexual minority young people are at increased risk for both suicide and abuse, pay special attention to the mental health of this patient. Ask about the patient's access to support. Isolation from peers and rejection by family are very real risk factors for some sexual minority youth.
Ask GLBT patients about a personal history of hate crimes/violence. Victims of violence are at increased risk of post-traumatic stress disorder.
If you are a pediatrician seeing a child with same-sex parents, include both in discussions about the child's health care even if both do not have legal custody. Health care is compromised when any primary caregiver is excluded.

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Transgender healthcare

Transgendered people are especially likely to have experienced misunderstanding and bias in a healthcare setting. Most health care providers, like most people in general, do not know any transgendered people nor do they understand the motivations behind transgender identification.

You have an excellent opportunity to create a safe and non-judgmental environment for your transgendered patients, and it will be greatly appreciated. Recognize your personal feelings and biases about transgendered individuals' motivations or mental status. Express your primary interest and concern in your transgendered patient's general well being or specific complaint, as you would any other patient.

Remember that gender identity (e.g., male, female, and transgendered) is distinct from sexual orientation. Some transgendered people identify as transgendered, some identify as male or female, and others identify as both transgendered and male or female. How a person identifies their gender may also change over time.
Educate yourself about basic transgender healthcare issues, including hormone doses and their effects and available surgeries.
Be aware of uncomfortable feelings that transgendered patients may feel about their bodies or life histories and the particularly difficult experiences they may have had in the healthcare environment. Transgendered patients may be particularly sensitive about disrobing for examinations.
Avoid making assumptions about a patients' sexual orientation, relationships or parental status based on a particular gender identity or expression.
Recognize that not all natal sexual organs may have been surgically removed in transsexual individuals, and that there may be consequent screening exams which need to be performed. For example, it would be common to conduct prostate exams for the post-operative MTF and breast exams and cervical exams for the post-operative FTM. Respectfully ask the patient which surgeries, if any, he or she has undergone.
Transgendered individuals receiving hormone therapy should be monitored carefully by knowledgeable providers.

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Avoiding assumptions about GLBT patients

Below are some of the most common incorrect assumptions about gay, lesbian, bisexual, and transgendered people. You shouldn't feel surprised or embarrassed if some of these thoughts have occurred to you; that is true for most people. Remember that cultural competence is a learnable skill requiring ongoing practice and commitment, and that small changes will make a big difference to your GLBT patients.

Avoid the assumption that your patients are heterosexual just because they haven't told you otherwise. It may take time for a GLBT patient to trust you.
Lesbian, gay, bisexual and transgender people often have children. Make no assumption that a patient with children is heterosexual.
If a teenager tells you he or she may be gay, lesbian, or bisexual, be open and supportive. Try to avoid the assumption that he or she is going through a phase or is too young to make such a declaration. Teenagers are often aware of their sexual and romantic attractions. Some may indeed be unsure what their orientations are yet, but to assume they cannot know at this age will foreclose their being candid with you.
Equally, children usually know their gender identity at a very young age. If a child or young person expresses to you that he or she feels like a boy even though he or she is biologically female, or vice versa, be respectful of this information and supportive of the child. You have been trusted with very personal information, don't assume that it is false or that she or he needs to be talked out of it.
All women need regular Pap tests, including lesbians. There is evidence that women who have only female sex partners contract HPV at significant rates. Many women who identify as lesbian have male sex partners or have had male sex partners in the past.
Transgender men (female to male transsexuals) need Pap tests, unless they have had a complete hysterectomy. Do not assume that a transgender man has had a hysterectomy; many have not. Be especially sensitive when performing a gynecological examination on a transgender man. This is likely to be an extremely uncomfortable experience for him, both physically and emotionally. It is critical that you continue to use the male pronoun ("he") when performing this procedure.
Transgender men (female to male transsexuals) need regular breast exams, as all breast tissue has generally not been removed even after chest reconstruction. As stated above, this may be an uncomfortable experience for him, and it is critical that you continue to use the male pronoun ("he") when performing this procedure.
Transgender women (male to female transsexuals) need prostate exams. This may be uncomfortable, and it is critical that you continue to use the female pronoun ("she") when performing this procedure.
Remember that sexually active gay or bisexual men may need STD screening from the pharynx and rectum as well as genitals, as per their behavior.
However, avoid the assumption that a gay man's health issues revolve around sexuality, sexually transmitted diseases, or HIV/AIDS. Consider all possible diagnoses for a set of symptoms as you would with any other patient.
Avoid the assumption that lesbians are not at risk for sexually transmitted diseases. Many STDs have been found to be readily transmissible between women (trichomoniasis, HPV) and lesbians may have sexual contact with men.
It is important to screen for domestic violence among GLBT persons as well as heterosexuals.

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Related websites

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