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Making patients feel welcome and cared for - regardless of where they are, who they are and how they are - is the essential meaning of “healthcare.” But as physicians, we sometimes focus too little attention on “care” because we are so busy addressing pressing health conditions.

Approximately 4.5 percent of Americans identify as either lesbian, gay, transgender or bisexual, according to a 2018 Gallup poll. As the number of individuals identifying as LGBTQ+ increases, physicians need to revisit their communication and care strategies.

Historically, LGBTQ+ individuals have faced unique barriers to healthcare.

They still do.

Startlingly, a recent survey found that among lesbian, gay, bisexual and queer respondents who visited a healthcare provider in the prior year, 8 percent said a healthcare provider refused to see them because of their actual or perceived sexual orientation. In addition, 6 percent said a healthcare provider refused to provide care for the same reason.

The numbers were even higher for transgender patients: 29 percent said a healthcare provider refused to see them because of their actual or perceived gender identity, while 12 percent said they were refused care.

This is unacceptable and is antithetical to the practice of patient-centered medicine.

Healthcare providers and staff should ensure they create a non-judgmental, welcoming and inclusive environment for their patients. Here are three ways to advance LGBTQ+ care and improve sexual health:

Establish the right foundation for appropriate care.

Not everyone who identifies as LGBTQ+ is going to disclose their identify to their healthcare providers. Therefore, healthcare providers should use inclusive language and non-stereotyped communication to create an open space, conduct a thorough yet sensitive interview and deliver care in a way that allows patients to feel comfortable.

The care team can begin patient encounters by asking three routine questions of all new patients - and noting their preferences in the electronic health record:

• What is your current gender?

• What sex were you assigned at birth?

• What pronouns do you prefer?

These questions will lay the groundwork to talk about patients’ sexual health.

In addition, healthcare providers need to be prepared for questions that have heightened sensitivity for LGBTQ+ patients. One area in particular is fertility services. The Ethics Committees of the American Society for Reproductive Medicine and the American College of Obstetricians and Gynecologists (ACOG) have affirmed the right of single or coupled gay and lesbian persons to have access to fertility services.

For patients who are biologically female, this opens the discussion about gynecologic and reproductive health issues along with fertility goals in the manner that feels most comfortable to them.

Make sure the first encounter is safe.

Providers can help recognize individuals needs and acknowledge their experiences.

Pediatricians, OB-GYNs and primary care physicians are the often the first healthcare providers to speak with an adolescent struggling with gender dysphoria or distress caused by the incongruence between one’s expressed or experienced (affirmed) gender and the gender assigned at birth. Making sure that first encounter is safe can be key to fostering continued engagement with the healthcare system and good healthcare outcomes. It’s also an opportunity to recommend medical and mental health resources or refer to specialists.

The National LGBT Health Education Center offers a toolkit to help facilitate conversations about LGBTQ sexual health in primary care. ACOG also has clinical guidance for lesbian and bisexual women, transgender individuals and transgender adolescents.

Studies have shown that LGBTQ+ persons report higher rates of and more severe instances sexual violence than heterosexual women. Because of these disparities, ACOG and other experts encourage clinicians to be sensitive to issues regarding confidentiality, sexual history and intimate partner violence. Physicians should also be attuned to signs of depression, anxiety or self-harming behaviors and prepared to counsel patients appropriately.

Ensure unbiased primary and sexual healthcare.

Medical care for LGBTQ+ individuals has historically been delivered through a cis-normative and hetero-normative framework. As a result of disparities, stigma and prior negative experiences, research has found LGBTQ+ persons often underutilize healthcare, present later in disease process than heterosexual individuals, and have fewer encounters for preventative healthcare. 

But there is reason for optimism.

At a 2018 forum on LGBTQ+ health sponsored by the Harvard T.H. Chan School of Public Health, participants noted that physicians have “a learning attitude” and genuinely endeavor to provide better care for patients when they “become aware that there are differences in care needs and that ignoring them can do damage.”

Primary care is the most critical entry point to providing that unbiased, comprehensive preventive care and access to specialty care, including reproductive care. LGBTQ+ patients who are welcomed and cared for will not only experience better health but also safety and well-being.

Jane van Dis, MD, FACOG, is medical director for business development for Ob Hospitalist Group, the nation’s largest provider of obstetrician hospitalist services.