Over the past 20 years, there has been a noticeable increase in the presence of LGBTQ+ individuals in the workplace both as patients and colleagues.
Numerous surveys have consistently revealed a significant rise in the numbers of people who identify as LGBTQ+. Most notably, daily anonymous phone surveys inquiring about sexual orientation and gender identity in the United States population were conducted by Gallup between 2012–2018. These surveys demonstrated a steady increase in the rate of Americans identifying as lesbian, gay, bisexual or transgender from 3.5% to 4.5%. A follow-up study in 2022 demonstrated the rate across the entire U.S. population has increased further to 7.1%.1
This extrapolates to approximately 18.6 million LGBTQ+ Americans. While the percentages may seem small, in the aggregate, the numbers are significant. Further, this only accounts for sexual orientation through the dimension of identity and does not capture the aspects of sexual orientation as expressed by attraction, behavior and relationships. There are likely many more people not identifying as LGBTQ+ who do not follow typical heteronormative models.
The presence of sexual and gender minorities (SGMs) in the medical workforce is largely unknown. However, data collected by the American Association of Medical Colleges (AAMC) Medical School Graduation Questionnaire does provide some important insights. Since 2016, the AAMC annual anonymous survey of graduating medical students has made an inquiry regarding sexual orientation and gender identity. Over this span, the rate of students identifying as transgender has increased from 0.3% to 1.1%. The rate of students identifying as lesbian or gay, asexual, pansexual, queer, or other has increased from 3.1% to 6.1%. The rate of students identifying as bisexual has increased from 2.1% to 5.1%.2 The 2021 survey of Year-2 medical students showed higher rates in each of these categories (transgender 1.3%; LGAPQ 8.6%; bisexual 6.5%). There is no data regarding the presence, workplace experience or contributions of LGBTQ+ radiologists in the U.S. workforce.
These numbers lead me to wonder if our specialty and practices are prepared for this cultural shift.
In one survey, 20% of transgender patients report being refused medical care, and over 50% report having to educate the healthcare providers regarding their care.3 In a 2019 article in the American Journal of Roentgenology, 71% of transgender patients undergoing imaging procedures experienced at least one negative imaging encounter involving physical and/or psychological trauma. As an innovative, cutting-edge specialty, we are well-suited for addressing this issue, starting with our own practices.
Creating an inclusive environment won’t happen organically. It must be crafted with intention based on the needs of each unique community we serve. It calls for a nuanced approach in our role as minimally invasive surgeons engaged in direct patient care and as leaders in shaping the policies and practices of our institutions. Although this seems like a daunting topic to address, there are specific steps that physicians can take to create a welcoming practice.
Step 1: Understand disparities
As with any group, it’s crucial that providers understand the historic disparities, lived realities and risk factors associated with that patient population. There are multiple structural and historical factors that have impacted the healthcare of the LGBTQ+ community with demonstrable disparities in breast, cervical and colorectal screening rates. This in turn leads to later-stage diagnoses and poorer outcomes.
On average, LGBTQ+ patients come from backgrounds where adverse childhood experiences (ACEs), such as emotional abuse, physical abuse, bullying, homophobia and transphobia, occur at much higher levels than their cis-gendered heterosexual counterparts.4 While these experiences occur in childhood, they often lead to problems in adult life reflected in health, overall wellbeing, educational attainment and economic potential. These problems may be significantly compounded by other social determinants of health such as economics, education, healthcare access, built environment and community. Further, LGBTQ+ individuals are more likely to be underinsured and to not have a primary care provider, and biases—both institutional and interpersonal—may make them more reluctant to seek medical care at all.5
LGBTQ+ individuals and racial minorities have higher incidents of poverty than the overall population, and insecure housing also impacts this at-risk population.5,6 It’s estimated that LGBTQ+ people constitute 20-40% of the overall homeless population, which is significantly higher than their representation in the overall population. 29% of LGBTQ+ youth (ages 18–25) experience homelessness—more than double that of the overall population—forcing them to participate in survival tactics that implicitly impact health and overall wellbeing.6
Step 2: Adjust patient interactions
Practitioners by their very nature want to help patients and don’t want to engage in offensive behaviors. However, ignoring the full humanity of our patients to avoid potentially uncomfortable territory isn’t the best approach. In a 2017 study, providers indicated they believed 80% of their patients would not be open to disclosing their sexual orientation, while 90% of patients in the same pool said that they would. That’s not just a narrow gap in misunderstanding; it’s a broad chasm that demands we reconsider the choices we’ve made engaging with our patients.
Pronouns
The pronouns people use for themselves have expanded over the past 15 years. Though this dynamic may be especially fraught for those who are unfamiliar, using the appropriate pronouns conveys respect, while applying the incorrect pronouns can have significant consequences. Professional psychological and psychiatric organizations have demonstrated that not using inclusive language for LGBTQ+ individuals increases anxiety, depression and suicidal ideations for those affected.8
When working with patients, use and encourage the usage of names and pronouns of their choice. Prioritizing anatomy and assigned birth sex over the patient’s expressed wishes can create an experience that is hostile, dehumanizing and anxiety provoking.
When there is uncertainty in pronouns, consider offering your pronouns when you introduce yourself, then ask your patient how they want to be addressed and which pronouns they prefer.
If you make an error, promptly offer a brief and sincere apology—but don’t overdo it. Excessive apologies can be awkward for the recipient, and they may feel pressured to comfort you, which is not their responsibility. Follow up by thanking them for their patience and then introduce yourself using your preferred pronouns if you haven’t already.
Default to gender-neutral and stated preference
We may not be able to understand the experience of each of our patients, but we do have the choice and responsibility to be respectful in our interactions. Consider using gender neutral pronouns (they/them/theirs) rather than guessing and causing a needless misstep.
For example, try not to presume that a married patient is partnered to someone of the opposite sex. Instead, they may be with someone from across the gender spectrum. In such instances, use “spouse” rather than “husband” or “wife.”
Consider their care network
Many LGBTQ+ patients are estranged from their birth families and utilize chosen family and others who are unrelated as their main support system in times of crisis. Ensure these essential care providers are welcomed into appropriate spaces during visits.
Step 3: Assess systems, policies and practices
As leaders, we need to craft policies that are nuanced in their approach and gender-neutral in language when appropriate. Consider whether the verbiage or practices hew towards cis-gender, heteronormative standards that may exclude a significant amount of the population we serve. Perhaps create a workgroup from various areas of your organization to develop ideas and transfer them into actionable strategies. Welcoming policy changes could be as simple as having staff include their pronouns on ID badges, regardless of gender identity, to signal that your institution possesses an awareness and sensitivity to such matters and wants to get it right. Including pronouns in institutional email signatures is another way to signal this—and has already become common practice in many companies and facilities.
After policies have been implemented, make certain the institution evaluates outcomes. Even policies that are utterly neutral in their language and approach may unintentionally lead to disparate outcomes. Expect that policy revisions will be required over time.
Institute safety policies
Safety and high-quality outcomes are bedrock principles of IR, and part of that is mitigating the risks of radiation in early-stage pregnancies. Regardless of a person’s gender expression, if a patient has the functional anatomy to conceive, pregnancy may be possible. It may be awkward to inquire if a male-presenting patient may be pregnant. However, if there is any doubt regarding a patient’s reproductive status for procedures requiring radiation, an inquiry must be made. Develop a departmental process and strategy to inquire about the possibility of pregnancy rooted in safety and respect. For instance, politely engage the patient by inquiring, “For your safety and wellbeing I have to ask, is there any chance that you’re pregnant today?”
Update paperwork
In signage, brochures, discharge instructions and forms, utilize gender-neutral language when practical. Steer away from needlessly gendered language for cancer screening and focus on the body parts that need to be screened.
Intake forms are an excellent place to focus attention. Consider updating forms that provide options for patients to choose to designate their gender identity, birth sex, sexual orientation, chosen name and preferred pronouns. The One Colorado and Callen-Lorde forms9,10 offer examples of how to implement an inclusive approach.
Include and educate staff
Organizations won’t be impactful if they focus all their energies in crafting policies. Involving employees from across the organization to devise solutions and assess their impact is the best way to build a broad coalition. An enduring leadership commitment focused on implementation and dedicated to change over time is what will win.
Consider including antidiscrimination language that directly includes LGBTQ+ individuals in standard contracts between the institution and employees as well as contractors. Additionally, rather than waiting for a harmful incident to happen, proactively provide specific education to staff regarding the nuances of interacting with and assisting LGBTQ+ patients and colleagues.
Step 4: Consider public image
Many patients will assess a healthcare institution by their website and advertising. These outward-facing displays are often the best way for patients to determine whether they will be welcomed and whether the institution can fit their needs.
Thus, crafting a platform that displays a variety of patients’ families is essential. Specifically including sexual orientation and gender identity in the nondiscrimination statement is another important signifier of an inclusive space. Ensure the website search box has content for “LGBT,” “gay,” “lesbian” and “transgender” inquiry, and consider using a small rainbow flag icon throughout the year or during Pride Month in June.
Finally, try to use gender-neutral language when appropriate. Promoting breast or cervical cancer screening sites may be accepted more broadly if branded under Gynecologic or Breast Cancer Treatment Center rather than “Women’s Cancer Center.”
Step 5: Consider your physical environment
Through design, the built physical environment of a healthcare space is another opportunity to ensure patients feel welcomed. For instance, consider displaying the Patients’ Bill of Rights11 and using LGBTQ+ imagery in brochures and institutional art.
When possible, gender-neutral bathrooms can reduce stress for everyone. Best practices for signage offer a variety of ways to demonstrate sensitivity in this universal human matter.
Step 6: Seek outside resources
If your organization is starting to reach out to the LGBTQ+ community, don’t go it alone or with a well-intended but inexperienced internal group. Get input from those with deep expertise in this domain. There are several high-quality resources developed by institutions that specialize in LGBTQ+ healthcare, such as The Fenway Institute.12 Originated in Boston’s Back Bay neighborhood in 1971, The Fenway Institute started as a one-day-a-week drop-in center staffed by medical students and has evolved to become a worldwide leader in evidence-based care for LGBTQ+ patients. In 2009, they opened a 10-story, 100,000-square foot facility—at the time, the largest building ever constructed by an organization with a specific mission to serve the LGBTQ+ community. Their National LGBTQIA+ Health Education Center facilitates education for healthcare organizations and providers to advance health equity, eliminate disparities, optimize access and improve healthcare quality for all sexual and gender minorities.
The National LGBTQ Cancer Network13 is a nonprofit organization that aims to improve the lives of LGBTQ+ patients living with cancer. Their website provides an immense wealth of information including a resource library and provider database, and they offer an online cancer peer support group three times a week. They provide education to the LGBTQ+ community regarding cancer risks as well as the importance of screening and early detection. Further, they provide training to healthcare providers and institutions so they may deliver more culturally competent care in a safe and welcoming environment.
They also offer a powerful, free CME course, “Welcoming Spaces: Treating Your LGBTQ+ Patient,” that offers education regarding LGBTQ+ healthcare disparities and how practitioners and organizations can act to dismantle their effects.
Local LGBTQ+ organizations can also help you customize efforts to meet the specific needs and concerns of the community you serve, as they vary by locality. Also consider forming a community advisory board regarding local LGBTQ+ health needs.
Conclusion
As IRs, collaboration is our superpower. Be open to proactively reaching out to healthcare practices and community entities who specialize in serving LGBTQ+ populations. Be a player in developing pathways to care for populations who may not easily have access to advanced medical specialties.
References
1. Jones J. LGBT identification in U.S. ticks up to 7.1%. Gallup, Feb. 17, 2022. news.gallup.com/poll/389792/lgbt-identification-ticks-up.aspx.
2. aamc.org/data-reports/students-residents/report/graduation-questionnaire-gq.
4. New report reveals rampant discrimination against transgender people by health providers, high HIV rates and widespread lack of access to necessary care. National LGBTQ Alliance. thetaskforce.org/new-report-reveals-rampant-discrimination-against-transgender-people-by-health-providers-high-hiv-rates-and-widespread-lack-of-access-to-necessary-care-2.
5. Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health care disparities among lesbian, gay, bisexual, and transgender youth: a literature review. Cureus. 2017 Apr 20;9(4):e1184. doi: 10.7759/cureus.1184. PMID: 28638747; PMCID: PMC5478215.
6. Carroll L. LGBT adults less likely to have jobs, health insurance. Reuters Health. July 26, 2018. reuters.com/article/us-health-lgbt-employment-insurance/lgbt-adults-in-u-s-less-likely-to-have-jobs-health-insurance-idUSKBN1KG36V.
7. Morris A. The Forsaken: A Rising Number of Homeless Gay Teens Are Being Cast Out by Religious Families. Rolling Stone. Sept. 3, 2014. rollingstone.com/culture/culture-news/the-forsaken-a-rising-number-of-homeless-gay-teens-are-being-cast-out-by-religious-families-46746/.
8. Glossary of terms. Human Rights Campaign. hrc.org/resources/glossary-of-terms.
9. Russell ST, Pollitt AM, Li G, Grossman AH. Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. J Adolesc Health. 2018 Oct;63(4):503–505. doi: 10.1016/j.jadohealth.2018.02.003. Epub 2018 Mar 30. PMID: 29609917; PMCID: PMC6165713.
10. Cabrera M, Cheevers C. Intake form best practices for LGBTQ patients. One Colorado. one-colorado.org/wp-content/uploads/2019/06/Intake-Questions-Best-Practices.pdf.
11. Patient forms. Callen-Lorde. callen-lorde.org/patient-forms.
12. Patient bill of rights. Dept. of Health and Human Services, National Institutes of Health. clinicalcenter.nih.gov/participate/patientinfo/legal/bill_of_rights.html.
13. The Fenway Institute. fenwayhealth.org/the-fenway-institute.
14. National LGBT Cancer Network. cancer-network.org.
