Have You Done an Assessment of Your Practice to Ensure There are No Implicit Biases That May Affect Your Care or Treatment Decisions?
A goal of CAP’s Risk Management and Patient Safety team is to provide education to our members that will improve medical care for all patients. Addressing healthcare disparity and implicit bias now tops the list of necessary education. This article will help you, our members, understand the LGBTQIA+ patient, offers risk strategies for better care, and provide additional resources to learn more.
Despite the best efforts of most members of the medical community, disparities in healthcare delivery and outcomes for members of the LGBTQIA+ community, due to discriminatory practices, is still an issue. Fortunately, in the past decade, the Affordable Care Act (ACA), along with several important court rulings, provided protections to members of the LGBTQIA+ community by prohibiting discrimination in healthcare based on gender identity or orientation. Despite the progress made, there is still much to learn and understand in order to improve how we care for members of this vulnerable population. Below are some things to consider, along with risk reduction tips:
LGBTQ+ Terms and Definitions
Many of us are familiar with the LBGT initialism that came into popular use in the 1990s; however, to be more inclusive of all members of the gay and transgender community, it has now evolved to LGBTQIA+, but many who are not a part of this community are left wondering, what does this mean? LGBTQIA+ stands for lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and gender minorities. By becoming familiar with and trying to understand some of the terms used by the LBGTQIA+ community, this not only demonstrates to your patients that you have taken an interest in learning, but will also enable you to better understand what some of your patients’ individual needs may be. Here is a sample of some recognized terms:
Sexual Orientation - how a person describes his or her emotional, romantic, or sexual attraction to others. i.e. lesbian, gay, bisexual, etc.
Gender Identity - an individual’s concept of his or her maleness, femaleness, a combo of both, or neither.
Transgender - a person whose gender identity differs from the sex assigned biologically at birth. For example, a trans-woman is one who was born a biological male, but now identifies a female.
Non-Binary - refers to an individual that does not fit into another LGBT classification.
More terms and their definitions can be found here: https://www.lgbthealtheducation.org/publication/lgbtqia-glossary-of-terms-for-health-care-teams/
As you become familiar with the terms, keep in mind that their use may vary across LGBTQIA+ sub-communities, so it is best practice to defer to the terms your patient prefers.
Considerations for the LGBTQ Patient/Things to Consider/Risk Strategies
Names: Patients who identify as non-binary may have two names — their legal name and a chosen name that they selected. It is best practice to obtain both and use the chosen name when addressing your patient.
Pronouns: Pronouns used in EHR auto-generated letters (EOBs, follow-ups, reminders, etc.) are populated with sex-assigned at birth as noted in the medical record, so the problem is that transgender and non-binary patients will have the wrong pronoun in their letters. The solution is to incorporate gender-neutral pronouns. Terms such as “they,” “them,” and “theirs” when used as singular pronouns are now considered to be grammatically correct by most major dictionaries and, in fact, have already been adopted by some corporations and major U.S. newspapers.
Radiological Testing and Transgender Males: Transgender males who have not undergone gender confirmation surgery (GCS) may still have female reproductive organs, so it is appropriate to screen for pregnancy and to explain why it is necessary to ask.
Gender Identity Care: Primary care providers need to be prepared to refer their patients who are seeking to start hormone therapy for gender confirmation. The referral could be to an endocrinologist or a reproductive endocrinologist; however, it is never okay to refuse to assist a patient based on the provider’s feelings about gender confirmation.
Surgery Concern for Transgender Women: Transgender women taking estrogen may not be aware that it is a thrombogenic; however, pre-operatively, this needs to be addressed. In most cases, the surgeon will want the patient to temporarily discontinue taking it, but it is very unlikely the patient would be willing. In this case, the best approach is to discuss the risks with the patient and if they decline to stop it, then document the informed consent discussion and have them sign an informed refusal form.
Surgery Concern for Transgender Males: Female airways are smaller than their male counterparts, so when selecting an endotracheal tube for a transgender male, the tube selected should be the appropriate size for a biological woman.
Transgender Women: Pre-Exposure Prophylaxis (PrEP) should be offered to all biological male (i.e., transgender women) patients who are at risk for exposure to HIV.
Disease Screening: When screening for conditions (endometriosis, autoimmune diseases, etc.) or cancers (cervical, ovarian, prostate, etc.) that are limited to, or more prevalent with, one gender, remember to screen with consideration to the patient’s gender assigned at birth.
In healthcare, we continually strive to do better for our patients and by being open to discussing sensitive topics and asking direct questions about sexual preference and identity, the provider can gain a better understanding of the patient’s needs. This not only enables them to provide better, safer care, but reassures the patient that that he or she is understood and accepted, which in turn helps improve patient compliance and satisfaction.
For more information about Implicit Biases visit here: https://www.lgbtqiahealtheducation.org/wp-content/uploads/2018/10/Implicit-Bias-Guide-2018_Final.pdf
Implicit bias self-assessment quiz:
Information and resources from the AMA:
Cynthia Mayhan is a CAP Senior Risk Manager and Patient Safety Specialist. Questions or comments related to this article should be directed to cmayhan@CAPphysicians.com.