LGBT CARE: Asking the Sexual-Orientation Question

Daniel Blumkin, MD

When dealing with lesbian, gay, bisexual and transgender (LGBT) patients, the easiest route for physicians is to avoid that initial question about sexual orientation and proceed with the patient’s care while ignoring this important piece of information. For many doctors, asking such a personal question feels invasive.

In my experience, the sexual-orientation question is best treated as part of a complete social history. If your pattern is to ask about smoking, alcohol and recreational drug consumption, simply continue to ask if the patient is sexually active, and if he or she has sex with men, women, or both. When these questions become part of your script, they will flow like all your history questions and will not feel any more awkward than any other question.

Why ask the sexual-orientation question? There are many reasons. LGBT patients are at increased risk for developing certain cancers and of having sexually transmitted diseases. The CDC recommends that LGBT patients be screened for STDs every year; some may even request more frequent testing. When offering testing, it is important to discuss sexual behavior and counsel about risky sexual practices. In addition, LGBT patients should be immunized for hepatitis A and B.

LGBT patients are also more likely than straight patients to drink alcohol, smoke tobacco, use drugs and attempt suicide. Of even more importance, more than 25% of LGBT patients in a recent survey reported postponing medical care for sickness or injury due to concerns about discrimination.[1] Postponing care is possibly the highest health risk for LGBT patients. As compassionate care providers, we need to do what we can to make them feel comfortable in our offices.

Probably no more than 3% of my patients are LGBT. Many of them are over 50 years old, and there was no documentation in their charts that they were LGBT when I first met them. Surprisingly, the sexual-orientation question in my routine social history put them at ease, probably because that was no longer a hidden piece of information. They became more conversational, more willing to share a story that didn’t have to be censored or use gender-neutral pronouns.

Knowing an LGBT patient’s current family status is helpful as well. They may be in a family setting with children at home, information that could be important when evaluating an infectious illness, rash or other diagnostic issue. Lesbians who have never been pregnant are at higher risk for breast cancer and should be screened regularly. Male-to-female transgendered patients will have an intact prostate, and they should be offered the same information as male patients about screening for prostate cancer.

I am listed in the Gay Lesbian Medical Association directory of LGBT-friendly physicians and have received emails from patients as far away as the South Bay asking for help because they feel uncomfortable with their current physician. One such patient had a question about pain with unprotected anal sex. I responded by attempting to use a vocabulary that reflected the words he used, to avoid putting him off. I offered to communicate with him via email when appropriate, since it is unlikely he is going to travel to San Rafael for care.

As a family physician, I often try to let patients know that the “family” in family physician is defined by them, not by me or by society. I attempt to be as inclusive as possible. Last year in the course of a social history, a new patient told me he was gay. I saw that he was wearing a wedding band and asked if he was married. He beamed and answered yes. Two questions later I inquired who lived at home with him, and he told me that he lived with his partner. I answered, “Don’t you mean your husband?” I asked that question for a few reasons, but one was to state clearly that I recognized his relationship and valued it. I trust he will never hesitate to delay care or withhold information from me out of fear of being judged or discriminated against.

The care of transgendered patients requires even more delicacy in finding a balance between obtaining information and protecting privacy. When I was still a resident in New York City, I attended a grand rounds that featured transgendered speakers, and I have never forgotten their indignation when they reported having a genital examination for a upper respiratory infection when they presented in the emergency room. They said this was not uncommon. Apparently many physicians are curious to see whether transgendered patients are pre- or postoperative. The question might be pertinent at a complete physical, but only the question. The exam is only pertinent if there is an issue in that area.

With computerized health records, many transgendered patients do not have correct gender assignments in their chart. Most records are also used for billing, and the gender must be consistent with the gender the insurer has on file. Making the first entry on the problem list “Transgender M to F, preoperative” prevents a lot of confusion and discussion.

Transgendered patients are more likely than the general population to have experienced violence at home or from discrimination. By recognizing this risk, looking for signs and asking specific questions, we physicians can help provide these patients with the medical and social interventions they need.

I once heard a moving personal account of the difficulties LGBT people face in our culture. Being LGBT was compared to being deaf. A deaf child may be born to hearing parents. In most instances, those parents will immediately seek support and help for their child. Their child will be identified by educators and given as many opportunities as possible, including various support networks.

Not so for the LGBT child. That child will usually be born into a family of heterosexual adults. The child will recognize, some at a very early age, that there is a difference that he or she is feeling inside that is difficult to express. As the child becomes older, he or she realizes that this difference is not welcomed by many people in our society. The support available to other children and teens is often not there for the young LGBT person.

Providing a safe, welcoming environment for the LGBT community in our offices is a small step we can take to offer some support. Whether the person is a brave, self-assured 18-year-old or a troubled 55-year-old finally coming to terms with their true identity, we can offer them help by being open and nonjudgmental.

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Dr. Blumkin is a family physician at Kaiser San Rafael.

Email: daniel.m.blumkin@kp.org

References

1. Grant JM, et al, “National Transgender Discrimination Survey Report on Health and Health Care,” National Center for Transgender Equality, transequality.org (2010).