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Advice for clinicians on addressing gender- and sex-related issues

2633907150_6303146d75_zFor great patient care, a doctor needs to understand the patient's life and the patient needs to feel comfortable sharing. This can be especially challenging when it comes to the LGBT community, which was part of the impetus for a talk on the Stanford Medicine campus last week. The event focused on challenges faced by sexual and gender minorities (SGM) in medicine, not just as patients, but as physicians and medical students as well.

Matthew Mansh, a fourth-year Stanford medical student; Gabriel Garcia, PhD, professor of medicine and associate dean of medical school admissions at Stanford; and Mitchell Lunn, a research fellow at UCSF and a graduate of Stanford's medical school, are all part of Stanford's LGBT Medical Education Research Group. After hearing the three speak, I walked away with a greater understanding of how important and challenging it is for doctors to have intimate conversations with their patients.

Of the three, Lunn's talk was the most oriented towards helping practitioners be more sensitive about  He began by laying out some terminology (terms are moving away from assuming two genders - bisexual is falling out of favor, for example), but emphasized that even the most sophisticated labeling won't tell you which organs patients have or which sex acts they're doing. Providers have to ask and be comfortable with the terms they should use to ask, Lunn said.

Coming from an anthropology background, I know how hard it can be to not make assumptions. But Lunn emphasized that it's crucial for clinicians to try: Patients overwhelmingly answer when asked about things in their lives, and they subsequently receive better care, such as screenings for HIV and hepatitis. Among the barriers to providers asking about sex and gender practice/expression are fears of being intrusive, cultural differences, ignorance regarding the clinical relevance of such questions, patient's lack of genital complaints, and uncertainty of how to ask. Most of these can be combated with provider education; as for how to ask, Lunn says it doesn't matter as long as the doctor's questioning makes no assumptions and is the same for everyone.

Intake forms could ask preferred pronouns, for example. Stigmatizing language like "atypical practices" and questions like "Are you married?" should be avoided. Questions about sex and gender practices can be grouped with those about drug use, wearing a seat belt, and going to the dentist - the goal is to normalize these conversations; people don't want to be targeted or singled out. In every intake visit, Lunn says to his patient: "I talk to my patients about gender identity - do you know what I mean by that?" Crack the door like this and most who are gender nonconforming will go through it, he assures.

Garcia joked that it requires more intimacy to ask questions about sex behaviors than to engage in them! He said the best information about how to talk about these issues came not from any academic text, but from the literature of the Sisters of Perpetual Indulgence.

Lunn also encouraged providers to acknowledge when they make mistakes. If they have offended a patient, they should apologize and ask why. They may be the first to ever ask these questions of this person. He says to his patients, "My job is to take care of you as an entire human being - that's why I ask."

Better assessment of SGM patients will be crucial in addressing health disparities; this population is linked with higher risk of smoking, HIV infection, homelessness, and suicide, said Lunn, although more data collection needs to be done. (LGBT demographics are not yet included in the census, for example.)

Mansh, Garcia, and Lunn have collaborated on two recent publications in Academic Medicine on SGM experiences in medicine: "From Patients to Providers: Changing the Culture in Medicine Toward Sexual and Gender Minorities" and "Sexual and Gender Minority Identity Disclosure During Undergraduate Medical Education: 'In the Closet' in Medical School."

Previously: Stanford study shows many LGBT med students stay in the closet, Study shows funding for LGBT health research lacking, offers solutions, A call for more training on LGBT health issues, Medical schools neglect LGBT issues and Advances being made for LGBT med students
Photo by David Yu

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