Patients who identify themselves within the broad category of LGBTQ (lesbian, gay, bisexual, transgender, and queer or questioning) are an increasingly visible population. Research has consistently shown that LGBTQ-identified individuals suffer higher rates of depression, suicide, anxiety, smoking, substance abuse, and sexually transmitted infections (STIs) than the general population (Gay and Lesbian Medical Association: Healthy People 2010. Apr 2011, bit.ly/yzytUH).
For instance, a recent large-scale study of teens found that 21.5% of LGB teens were likely to have attempted suicide in the past year, compared to 4.2% of heterosexual teens (Hatzenbuehler ML, Pediatrics 2011;127(5):896–903). Unfortunately, not many providers are experienced with treating this community, so these statistics may stem from disenfranchisement and stigma, rather than any pathology inherently associated with LGBTQ identity. In this article I will provide you tips for how to create an environment in which these patients will feel welcome.
Although we tend to treat sexuality and gender as though they fall into discrete categories (eg, straight versus gay), they are more realistically understood as continua. Here are some frequently used terms and concepts related to gender and sexuality.
Gender Identity: An individual’s self-conception of being male, female, or anything in between. Many of today’s youth conceptualize gender in non-binary terms.
Sexual Orientation: An enduring pattern of attraction (sexual, romantic, and emotional) to a specific gender or genders.
Queer: An umbrella term used to describe non-normative sexual orientations and gender identities. Once considered highly pejorative, “queer” has become a more acceptable term among younger generations.
Transgender: Individuals who do not identify with the gender they were assigned at birth. This may include transgender people and all gender nonconforming identities. [See “A Primer on Transgender Care” in this issue for more information.] ‘Transgender’ should always be used as an adjective (“a transgender individual”) and not a noun (“a transgender”), and “transgendered” is not a preferred term.
Cisgender/cis: A person who identifies with the gender he or she was assigned at birth.
Genderqueer (also known as “non-binary”): A term used by some individuals who do not define themselves as either male or female, but rather inbetween or outside of this continuum altogether (some examples include bigender, genderfluid, or genderless).
Passing: This is used among gender and sexual minorities to refer to being perceived as having a mainstream identity (eg, a gay man passing as straight, a transgender woman passing as female).
Outing: Sharing a person’s gender identity or sexual orientation without permission.
The term homosexual is considered offensive to many LGBTQ individuals and is best avoided.
As is true for patients who suffer any form of stigma, it is best to listen to and reflect your patients’ choice of language when they are describing their gender identity, sexual orientation, and relationships.
Welcoming LGBTQ Patients
Since there is so much social stigma associated with minority sexual identities, you can help such patients open up by adding some welcoming touches to your office. Research shows that LGBTQ-identified patients and their families are likely to scan waiting areas for indications of whether they are welcome in your practice (Gay and Lesbian Medical Association: Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients, http://bit.ly/zDAmjd). Are there any explicit indications that they are welcomed in this space? If not, consider adding a couple simple markers: an LGBTQ-themed magazine, a brochure relevant to LGBTQ individuals, or a small rainbow flag. Some periodicals to consider include The Advocate, Out, and Curve; options for flags and stickers can be found on www.amazon.com.
Restrooms can create challenges for some patients who are changing genders. They may struggle with using restrooms when given the typical option of “men’s” or “women’s” rooms (Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the LGBT Community. Oct 2011, http://bit.ly/vTAChJ). Sometimes they may even be harassed by others for using the “wrong” restroom. This can be avoided by offering a gender-neutral restroom in your building—it’s often a simple matter of creating a new sign.
Look over any intake forms that you ask your patients to complete, and consider switching language such as “marital status” and “spouse” to gender-neutral terms such as “relationship status” and “partner.” Also, if you have a question asking for your patient’s gender, consider making it a fill-in-the-blank.
Evaluating LGBTQ Patients
First and foremost, you can’t always tell by a patient’s appearance the gender with which they identify. If you’re unsure of the correct gender pronoun, clarify with a question such as, “How would you like to be addressed?” or, “What name would you like to be called?” Similarly, keep questions regarding relationship history gender-neutral: if a female patient notes that she is in a committed relationship, ask about her “partner” rather than her “boyfriend.” Keep in mind that sexuality and gender can be fluid and change over time: a man currently partnered with a woman may have had boyfriends in the past, and a man may identify as heterosexual but engage in sex with other men.
Discussing sexual issues can be tricky, but speaking openly with patients will allow them to feel they can be frank with you. Depending on your intuition about a patient’s comfort level in discussing sex, you may find that a straightforward question is appropriate, such as, “How do you characterize your sexual orientation?” or “Can you tell me about your sexual history?”
In other cases, it’s best to broach the topic more obliquely. For example, you can start with a standard social and developmental history, and lead into the topic of sexuality with a question like “Could you tell me about your history, if any, with intimate relationships?”
A frequent assumption among some professionals is that it is always preferable to be “out”—that is, open about one’s gender or sexual minority status. To the contrary, many individuals rightly feel uncomfortable or unsafe being out in certain settings or phases of life, and some may choose never to come out publicly at all. Pushing patients to be out before they are ready can backfire and harm the therapeutic relationship. Similarly, not everyone who is transgender will feel the need for hormonal or surgical intervention. Finally, it is sometimes assumed that a person who is bisexual will have trouble committing in relationships, or that a person in a heterosexual marriage will not identify as bisexual. In fact, bisexual individuals can, and do, make lifelong commitments to their partners.
Depression and anxiety are prevalent in the LGBTQ population, so it is important to screen carefully for depression and current life stressors, as well as suicide risk factors. It is also helpful to explore support systems, since strong social support networks are correlated with positive mental health outcomes as well as decreased risk for STIs (Gay and Lesbian Medical Association, http://bit.ly/ zDAmjd). Finally, always screen for intimate partner violence, a serious health concern in both opposite-sex and same-sex relationships.
It’s always helpful to do a quick check-in with yourself regarding your motivation for asking a given question. If a question is not germane to treatment, or it carries the expectation that patients educate you about their identities, think twice about asking. Some examples of questions that generally tend to be appropriate include, “How was your coming out experience?” “Are you currently taking hormones?” and “Can you tell me about your transition experience?” Questions that are generally irrelevant or inappropriate include, “How do you know you’re gay?” “Are you still really a man right now?” and “What’s your real name?” Finally, explaining why you’re asking a particular question (eg, to assess for STI risk or risk of hormone exposure) can help avoid the perception of intrusion.
In sum, LGBTQ individuals are a growing and diverse population, and those with mental health needs are actively seeking psychiatric care that is both clinically and culturally competent. Attending to your office environment, language, and your own assumptions can go a long way toward helping LGBTQ patients to feel more welcome in your care.