MetroDoctors Guest Post: Deborah A. Thorp, MD
Creating a welcoming practice for the LGBTQIA+ community
Deb Thorp, MD has been in practice at Park Nicollet for over 30 years as an OB/GYN. She has been providing gender affirming care since shortly after starting in practice, and is currently the Medical Director of Gender Services at Park Nicollet/HealthPartners.
Did you know that, according to Rainbow Health Initiative’s 2021 Voices of Health Survey, 13% of LGBTQIA+ respondents in Minnesota were NOT out to their clinical care team? That 57% have had to teach their clinicians about the care they need? And that 23% didn’t get care in the past year because they feared being disrespected or mistreated?
It’s not that we, as clinicians, want that to be the case. We WANT our patients to feel welcomed in our clinics. We WANT our patients to feel that their care is competent and informed. It can be a lot to remember everything we need to know to have everyone feel cared for. I get it. So I’m going to take you through some of what we have done and some of what we wish we could do to make all of our patients feel welcome.
Examine our biases
Before we do anything else, I would suggest this one not-so-simple step: look at our own internal biases. We all have biases. It’s human. It’s just a matter of knowing what the biases are and being honest with how that might impact our patients’ experiences in our clinics. So many people in the LGBTQIA+ community do not seek care because they do not trust that they will be respected. We are much more likely to respect our patients in a way that they believe if we are aware of our biases and how we might come across to our patients. It’s something we should all do, both clinicians and support staff alike.
Before the clinic
At HealthPartners, we started by thinking about our patients’ first exposure to the clinic, which is often the practice’s website or electronic medical record (EMR) portal. For most of us, we have no control over this – it’s up to large EMR companies or our marketing departments. However, advocating for inclusivity by asking to display a progress flag or making a statement in our online bios about being inclusive is important.
When a patient calls the clinic, make sure staff are trained to avoid assumptions. For example, do not assume the patient on the other end of the phone is cisgender (i.e., their gender identity is consistent with their sex assigned at birth) or heterosexual. This will go a long way in making people feel comfortable. It’s also important to ask about the patient’s preferred name and pronouns during their intake and registration. Even if it seems awkward at first, it’s a meaningful gesture for patients who may feel uncertain about coming in.
At the clinic
Once in the clinic, one way to demonstrate inclusivity is by displaying pictures in waiting rooms and exam rooms that depict different cultures, such as gay or lesbian couples, progress flags or photos that are inclusive of any aspects of the LGBTQIA+ community. At the Gender Services Clinic, we put rainbows over the windows in the doors, and we have a progress flag hanging in the hallway.
Another way to help is by encouraging staff to include their pronouns on their ID badges. That opens the door to people who use different pronouns than what might be assumed from their appearance or on their legal documents. In the clinic, the rooming personnel should confirm what the front desk has ascertained in a non-judgmental way in terms of names and pronouns used. When introducing themselves to patients, they can say something like “I see you prefer the name ‘XXX.’ My name is ‘YYY’ and I use ‘ZZZ’ pronouns.” That helps the patient open up about their own pronouns if they wish.
Open-ended questions
Our patient history intake forms in both OB/GYN and Gender Services Clinic have open-ended questions about gender identity and sexual orientation rather than check boxes. There are endless gender identities and sexual orientations, so this allows patients the freedom and safety to enter what is most appropriate for them. Many of the larger EMR software programs now allow a wide range of gender identities.
In the EMR, many have a Sexual Orientation and Gender Identity (SOGI) component to identifying information. The goal would be to have all primary care clinics fill this out with the patient’s assistance and regularly update it, much as care teams regularly update other parts of the medical record. In Epic, this results in gender identity showing up with an “i” next to the preferred name, indicating the sex assigned at birth is not the patient’s gender identity. This simple identifier can help clinicians and support staff know to ask clinically appropriate questions depending on the appointment scenario. For example, while there is no need to discuss gender identity in evaluating an acute injury in the ER, it can be helpful when evaluating a thromboembolic event.
Legal considerations
There are times when the patient’s legal name needs to be used, or at least listed on a document. However, we proactively share with our patients that they may see their “dead name” on documents for legal reasons, which lets them know we understand this may be triggering for them. I have only had a couple patients who are unhappy with that.
Whenever possible, it’s important to include the patient’s preferred name and pronouns even when listing their legal name. For example, in a patient letter, we use their preferred name in the salutation, but list their legal name on the bottom to fulfill legal requirements. Surgical consent forms have the legal name listed with the medical record number, but the patient can list their preferred name in the blank space for the handwritten name, as well as sign it with either or both names. We have also removed the legal sex from name bands and all labels as it is not needed for two-factor identity authentication.
These are but a few of the numerous ways to help our LGBTQIA+ patients feel safe and welcome in our practices. By creating a welcoming, trusting environment, we can truly help them overcome some of the health disparities that they experience. But that’s an article for a different day!