Creating a Welcoming Space
Caring for your patients identifying as sexual and gender minorities
By Stuart Foxman
When it comes to patients identifying as sexual and gender minorities (SGM), what does a welcoming clinical environment look like? It could be one that:
- Features displays of openness, e.g. positive space or pride stickers, and all-gender washrooms.
- Allows for self-disclosure, e.g. patients are asked what name and pronoun they prefer to use, and have the opportunity to state who they are and disclose their gender and sexual orientation.
- Avoids assumptions, where clinicians appreciate that each patient is unique, and make efforts to know the differences between sex, gender identity, gender expression and sexual attraction.
- Uses open-ended questions about sex, like “How would you describe your sexual orientation?” As opposed to closed-ended questions, like “Are you sexually active with men, women or both?”
Recently, the University of Toronto’s Faculty of Medicine developed an infographic to sensitize its medical learners to the needs of the SGM community. Many of these patients self identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ).
Although the information relates specifically to serving the SGM community, in many ways the advice comes down to fundamental principles of patient-centred care, says Dr. James Owen.
“These are building blocks to creating inclusive and safe care environments, and showing respect for your patients,” says Dr. Owen, the LGBTQ2S Health Education Theme Lead at the University of Toronto MD Program.
Much of the material in the infographic concerns communication and terminology. Patients from many minority communities self identify with terms you may be unfamiliar with or have context specific meaning. Language evolves over time. ”You should be open to new terms and feel comfortable asking for their meaning,” says Dr. Owen.
For instance, the infographic includes definitions of the acronym LGBTTQQIP2SAA (often abbreviated as LGBTQ+). “When in doubt, follow the patient’s lead. That matters. So does understanding the concepts of sex, gender and sexuality — intertwined yet distinct,” he says.
Sex refers to physical aspects of our body, including genitals, hormones, etc. Gender identity relates to your internal experience of gender, and gender expression to the way you publicly present that identity (including dress and behaviour). And sexual attraction is your desire or interest.
There’s often a need for physician education in these areas. “Historically, we weren’t taught these concepts in medical school,” says Dr. Owen, who’s also a staff physician at the St Michael’s Hospital Department of Family and Community Medicine.
Consider too that sexual preferences, attractions and gender aren’t always static for everyone. An individual’s attraction and gender can be fluid and can evolve over time. This should not in any way invalidate someone’s identity or attraction in the past or present. “Fluidity does not indicate that an individual is confused,” states the infographic.
Assumptions or comments such as “this is just a phase” that someone will “grow out of” (around patients of any age, including children) aren’t appropriate. What is important is respecting the individual and their unique lived experiences, rather than judging and stereotyping.
What happens if your patient reacts negatively to the language you use?
“Have the comfort and rapport to say ‘I may have used the wrong words; how can I have said that better?’ It’s important to have some degree of humility,” says Dr. Owen.
1. Open Ended Questions are Inclusive
Close-ended questions often involve assumptions and can make patients feel that their identity and experiences are not recognized or valued.
Examples of open-ended questions are “How would you describe your sexual orientation?” or “with whom are you sexually active?” instead of “Are you sexually active with women, men or both?”
Another open-ended question would be “Can you please describe your gender?” instead of “Are you male or female?”
2. Do not underestimate the weight of your words
Ask questions that are medically relevant and avoid questions out of curiosity. Asking questions about hormones and gender surgeries to the trans population with no medical relevance can be stigmatizing.
3. Soften your approach by explaining the purpose of your questions
For example: “To better understand your risks of sexual transmitted infections, I need to take a sexual history. Some of these questions are personal. Is that ok?”
The University of Toronto infographic reminds practitioners not to underestimate the weight of their words: “Ask questions that are medically relevant and avoid questions out of curiosity.”
More tips: get to know your patients, appreciate that some may be sensitive about their bodies, and soften your approach by explaining the purpose of your questions. That’s advisable with any patient. Remember, respecting someone’s right to define themselves means respecting their ways of understanding the world.
Beyond interactions with patients, SGM competencies should extend to colleagues and learners. As Dr. Owen notes, some members of the SGM community have reported negative experiences with their health care. Doctors may think they’re providing proper care, he says. But patients might perceive stigma, insensitivity or outright discrimination. That can affect their care, or lead them to avoid or delay seeking care.
To learn much more about the issues, Dr. Owen recommends these resources:
- The 519’s Glossary of Terms
- Rainbow Health Ontario There’s all sorts of material for service providers, on everything from chronic diseases, to body image, to reproduction, to cultural competencies.
- From Rainbow Health, you can link to one of the Ministry of Health and Long-Term Care’s Health Equity Impact Assessment Tools (HEIA). These aim to help reduce avoidable health disparities between population groups. The HEIA includes a template and workbook, and is complemented by population-specific supplements such one for LGBTQ+ populations
- “Transgender People in Ontario: Statistics from the Trans PULSE Project to Inform Human Rights Policy”
- “Vanessa Goes to the Doctor” — a video on an inclusive health care centre
- CMHA information, including some for health care providers, on mental health and the LGBTQ+ community
- Canadian Professional Association for Trans Health
Here are another few useful resources from the Ontario Human Rights Commission (OHRC):