Health Advocacy for LGBTQ Patients
The world is a different place now than it was in 1983, when San Francisco General Hospital created the first units in the world dedicated to those battling AIDS. It’s a different place than it was in 1987, when homosexuality was listed as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, and it’s even a different place than in 2010, when same-sex spouses were kept from their partners in hospitals (see “You Define Family” for how to prevent this). Society has evolved, and it’s past time the medical community caught up. Healthcare systems tend to cling to heteronormative and gendered frameworks, which comes at the expense of excluding patients.
Because of lacking competency in practice, women who have sex with women receive misleading information about their risk for cervical cancer or how often they should have Pap smears. Bisexual patients receive inconsistent and confounding information about STI transmission and contraceptive management. Transgender patients are forced to go out of their way for hormone therapy because their primary care clinic isn’t up to date on basic practices, and on many intake forms they are excluded completely, having to chose between “male” and “female.”
To sidestep this problem, it’s key to have a provider with whom you feel comfortable. Talking about sex and gender up front can be a good litmus test for your overall rapport and fit. Next, the ideas below may help shape important conversations:
You do not need an explicit label for or definition of your sexuality when talking to a provider. You don’t have to tell them the details of your sexual evolution.
Recommendations for Pap smear frequency are the same for all women, regardless of the sex of their partners. The test screens for cervical cancer, which can be passed through HPV—which all individuals can potentially carry.
Men who have sex with men should discuss HIV and HPV screening with their provider. Have these discussions up front and tailor prevention.
STIs do not discriminate based on sexual orientation or gender identity. Risk comes down to the individuals engaging, their past history, and their health status, among other factors. Regardless of your sexual or gender identity, navigate safe sex and ask questions about your partner’s status.
The LGBTQ population as a whole is at higher risk for certain chronic illnesses, likely because of historic marginalization of and prejudice against them in the healthcare system and society at large. These external, imposed stressors can impact mental and physical health. Your provider’s office should be a safe space to discuss these issues. (If it’s not, find a new provider.)
My friend and research colleague Margo Presley is a Family Nurse Practitioner at the Multnomah County Health Department, in Portland, Oregon, where she works with some of the city’s most underserved populations, including refugees and transgender youth. She’s a model practitioner, incredibly thorough researcher, and an advocate for LGBTQ health. Below are some of her thoughts and recommendations for patients regarding this complex and often mishandled topic:
This one is a no-brainer, but don’t go to any old PCP in your neighborhood if you are a sex or gender minority. Instead, go to a local LGBTQ resource and ask for recommendations, from agencies, friends, Facebook groups, etc.
If you can, talk to or e-mail with the provider or RN (someone from the clinic) before the appointment to try and find out about first appointments and what they entail so you can set your expectations accordingly.
If you have a support person you can bring to appointments (see here on choosing an advocate), bring one! This can be a friend, family, or anyone you trust.
Providers are not objective beings without life experiences of privilege and oppression themselves. Chances are there is something that led them to do the work of serving LGBTQ patients, and it’s perfectly okay to ask them how they got into it and what kind of ongoing training they seek out.
Co-set a flexible agenda with the provider. First visits are often about your past medical history, and if you have other goals for the visit make them known and try to negotiate what you can and can’t accomplish in that visit. Remember, the saving grace of primary care is that it’s incremental and ongoing. One can return as many times as it takes to address one’s health goals.
Many health professionals are well-meaning but are steeped in the same heterosexist and cisgenderist culture everyone else exists in. Sadly, prepare yourself for being put into a category of cis or straight and how you might address that.
Questions about sexuality and gender identity should come up at the visit; it’s basic information asked of everyone. The LGBTQ community has higher rates of STIs so even though it’s uncomfortable/awkward for some, you want this to be brought up at your visit. It’s a way for your provider to know you and know how to provide you with good care.
Know that you can refuse any exam. It may change the course of treatment, but if you’re not comfortable with something, it’s likely better to refuse it until you’re ready rather than have a traumatizing experience and inauthentically consent to something. Even if you consent to an exam, you can stop it at any point. The provider should explain what they’ll do and why before any exam.
You can agree on language to use for the body together, and ask providers to use that language throughout your time, just like they should use your correct name and pronoun.
Especially for trans patients, health maintenance and routine screening (cancer and otherwise) are important and occur less often. This may be in part because providers are less comfortable talking about one’s anatomy and hormone history. A provider should be asking about what anatomy one has in a respectful way, couched in an explanation, so they know what to look for. Same with how long someone has been on hormone therapy, and if they went for prolonged periods without exposure to any hormones.
Regarding top surgeries, it’s good to know if you have any breast tissue remaining (many people do for cosmetic reasons). Breast/chest cancer screening is still important, albeit done more commonly by ultrasound than mammogram.
The University of California, San Francisco (UCSF) has a great explanation on health maintenance and routine cancer and other screenings that are of extra importance for elder trans patients.
Regardless of sexual activity and sexual partners, the recommendation is to get a cervical cancer screening starting at age twenty-one and every three years until age thirty when one has “co-testing” of both cell changes (cytology) and HPV. If both are negative, it’s every five years until age sixty-five, even if a cis woman has never had any kind of sex with a cis man.