Working with LGBT Youths: A Community Partner’s Perspective

Evan–whose name has been changed here to protect his privacy–is a teenage transgender man who was assigned female sex at birth. In order to begin hormone therapy during his senior year of high school, Evan’s doctor told him that a pregnancy test would have to be conducted. Evan resisted, saying it wasn’t possible that he was pregnant. His doctor replied, “Since your body is really female, we have to do this before we can begin hormones.”

This response did not honor Evan’s experience of his gender and could have been deeply damaging, though it is unlikely the doctor intended any harm by the remark. Another one of Evan’s doctors expressed the need for a pregnancy test in a different way. “I have two kinds of patients: those who can get pregnant and those who can’t. Since you can get pregnant, we need to do this test before beginning hormones.” Evan had no problem with this approach, as it showed that the doctor was sensitive to his concerns and respected him.

The unhappy reality of outcomes among LGBT youths

Unfortunately, dealing with this kind of misunderstanding is not uncommon for LGBT people; in many cases, LGBT people have even worse interactions with members of the health care system than what Evan experienced. 56 percent of lesbian, gay, or bisexual people and 70 percent of transgender or gender nonconforming people have experienced at least one of the following: “being refused needed care; health care professionals refusing to touch them or using excessive precautions; health care professionals using harsh or abusive language; being blamed for their health status; or health care professionals being physically rough or abusive.”¹Lambda Legal. When health care isn’t caring: Lambda Legal’s survey on discrimination against LGBT people and people living with HIV [Internet]. New York (NY): Lambda Legal; 2010 [cited 2019 Feb 27]. Available from: https://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf. Non-urban areas, where it may be difficult to find doctors and staff who are affirming of LGBT identities, can be especially problematic for these patients.

Difficulty getting appropriate medical care exacerbates the other challenges faced by LGBT people of all ages but is especially hard on young people. Research done by the Family Acceptance Project found that family rejection is the primary cause of LGBT youth homelessness. It’s estimated that around 7 percent of youths in the United States are LGBT, while up to 40 percent of youths experiencing homelessness are LGBT.²Choi SK, Wilson BDM, Shelton J, Gates G. Serving our youth 2015: the needs and experiences of lesbian, gay, bisexual, transgender, and questioning youth experiencing homelessness [Internet]. Los Angeles: The Williams Institute with True Colors Fund; 2015 June [cited 2019 Feb 27]. 22 p. Available at: http://truecolorsunited.org/wp-content/uploads/2015/05/Serving-Our-Youth-June-2015.pdf. Homelessness increases the risk these young people will experience exploitation or violence. Family rejection also makes suicide among LGBT youths eight times more likely, increases the likelihood of drug use and unsafe sex three-fold, and makes depression six times more likely than among non-LGBT youths.³Substance Abuse and Mental Health Services Administration. A practitioner’s guide: helping families to support their LGBT children; HHS Publication No. PEP14-LGBTKIDS [Internet]. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014 [cited 2019 Feb 27]. 15 p. Available at: https://familyproject.sfsu.edu/sites/ default/files/FamilySupportForLGBTChildrenGuidance.pdf Be sure to bear in mind the way that intersecting identities may also impact your patients. The Center for American Progress found that due to fears of discrimination, LGBT people of color are twice as likely to avoid the doctor’s office than LGBT white people. People with disabilities tend to do the same.

Recommendations for providers working with LGBT young people

The first step to closing these health disparities is to ensure that provider offices are places where all patients feel safe and comfortable seeking treatment. Make sure that all staff are culturally competent when it comes to LGBT issues and people. In the state of Ohio, Lighthouse Youth & Family Services offers free training for youth-serving organizations through the Safe and Supported youth program. Many organizations across the country such as the National LGBT Health Education Center, the National LGBT Cancer Network, and the Substance Abuse and Mental Health Services Administration also offer training in issues of LGBT health. Beyond making sure staff are culturally competent, medical care providers can communicate that their offices are safe, trustworthy healing environments by employing some simple recommendations:

1. Have single-occupancy or all-gender restrooms available for all patients.
2. Hang art or symbols that communicate the office’s openness to LGBT people.
3. Instead of giving only “Male” and “Female” as options on forms, have a place where patients can write in their gender as they understand it.
4. Ask for preferred names and pronouns on intake forms.

A patient’s gender identity and sexual orientation are important for providers to know in order to offer adequate care. Yet many providers are uncomfortable asking for this information, even in a confidential setting. A study published in JAMA Internal Medicine demonstrates why this fear is unfounded. While almost 80 percent of providers think that LGBT patients don’t want to disclose their sexual orientation or gender identity, almost 90 percent of these patients would be willing to share this information with their doctor.⁴Haider AH, Schneider EB, Kodadek LM, Adler RR, Ranjit A, Torain M, et al. Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity : The EQUALITY Study. JAMA Intern Med. 2017;177(6):819-28. Epub 2017/04/25. doi: 10.1001/jamainternmed.2017.0906. PubMed PMID: 28437523; PubMed Central PMCID: PMCPMC5818827. That said, it’s important not to make assumptions based on a patient’s sexual orientation or gender identity. Within some communities, particularly those of color, there are men who identify as straight who are sexually active with other men. Likewise, if someone identifies as a lesbian, that does not necessarily mean that there is no need for contraceptive care.

Research also shows that it’s critical to use the preferred names and pronouns of transgender patients. A 2018 study found a marked decrease in both suicide and depression rates among transgender youths when those around them used their preferred name and pronouns.⁵Russell 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;63(4):503-5. Epub 2018/04/04. doi: 10.1016/j.jadohealth.2018.02.003. PubMed PMID: 29609917; PubMed Central PMCID: PMCPMC6165713. Making sure that staff are aware of this is important–not only because it is courteous, but because it is a matter of safety and survival for these patients.

A patient’s gender identity and sexual orientation are important for providers to know in order to offer adequate care.

Though a patient’s chosen name might not be their legal name on forms, ascertaining this information can be simple. Say to a patient, “I’m Dr. Smith. What do you like to be called?” If the name they give doesn’t appear in your records, ask, “Could your chart be under another name?” or, “What name is on your insurance?” If you do make a mistake on a patient’s name or pronoun, simply apologize and move on: “I’m sorry I used the wrong pronoun. I didn’t mean to disrespect you.” This shows the patient that you are concerned about their treatment and care about them as a person while not awkwardly belaboring the point. Many transgender patients also have particular ways that they like to talk about their bodies; follow their lead when referring to body parts and organs. [Editor’s note: see our guide to gender pronouns for more information on discussing and using pronouns with patients.]

Finally, since family rejection is the core factor in many negative health outcomes for young LGBT people, it is important to know about resources for parents who may be struggling with their child’s identity. In the greater Cincinnati area, Lighthouse Youth & Family Services’ Faith in Families program–offered in partnership with LOVEboldly–is a model for helping parents and caregivers process their feelings about their child’s sexual orientation or gender identity. The program is respectful of the diversity of religious and personal beliefs regarding LGBT matters, and all questions are welcome. The session includes education on behaviors to avoid and others that could be helpful to LGBT children. Nationally, PFLAG offers support to parents and has local chapters throughout the United States. The Strong Family Alliance is a good online support network that offers information and further resources. The National LGBT Health Education Center, GLMA: Health Professionals Advancing LGBTQ Equality, and the section on LGBT Health and Wellness of the American Academy of Pediatrics offer other good resources for providers to explore.

Health care professionals are in a unique position to help families remain intact and help LGBT people get needed support and care. Whatever one’s personal beliefs about issues of LGBT identities, we can work together to help ensure that youths like Evan have access to quality, compassionate health care and remain together with their families.