Establishing trust with LGBTQIA+ patients


For patients who are part of the LGBTQIA+ community, a medical visit can be unexpectedly stressful. LGBTQIA+ people have to keep track of who they’re out to and how out they are, especially if they fit more than one letter of the acronym; some people might know they’re gay, fewer people might know they’re transgender, while some people probably don’t know anything about their private life at all.

Why does this matter to you? Maybe you’re their pulmonologist, or oncologist, or hepatologist. Your role in their care is related to something specific. You’re not their psychiatrist or social worker; you’re not their primary care physician. However, your interactions with patients can still matter much more than you realize.

As a physician, you are imbued with a certain level of social importance. You are expected to be an expert, at least in your field, although patients will often talk to you as though you are an expert in every medical topic that has ever existed. Over time, you may come to take that respect for granted. It’s part of your life, more background noise than anything else. After all, you know you don’t know everything. You know your limitations, and that likely keeps you humble.

And if you forget how much weight patients place on your expertise, you may not realize how big an impact your opinions on non-medical issues can have on your patients.

Patients who come to see you pay attention to how you ask them questions. If you ask, “Who do you live with?” rather than “Do you live with your wife?” it gives the patient a chance to say, “I live with my partner” or “I live with my husband.” It gives them a space to feel more comfortable coming out to you. If you ask, “Are you dating?” rather than “Do you have a boyfriend?”, they can tell you, “Actually, dating isn’t really my thing,” or “I’m seeing a girl.”

The question “Do you sleep with men, women, or both?” was a step forward for care providers when we started asking that. It gave patients more freedom to be honest with providers, but the conversation has changed over the years, and now that question tells patients something very specific about where you’re coming from: it suggests that you assume they’re having sex, and that you think “men” and “women” are the only options for gender. For asexual patients who don’t want to have sex and find their lives complete without it, that can be a signal they shouldn’t come out to you. For patients who are trans or seeing a trans partner, it can suggest that you think that knowing their gender tells you about their genitals and what sexual health and safety counseling is applicable.

Building a therapeutic relationship doesn’t need to be complicated. It can be as simple as giving your patients a chance to tell you what their life is like. We already put in the time and effort to ask many of these questions; asking about sexual orientation doesn’t necessarily have to be a separate, awkward question.

Asking patients in a slightly different way can yield better information for you. If you’re a gynecologist and your patient is a cisgender woman who mentions her wife, for example, you may think you don’t need to talk about birth control — but asking the patient, “Did you want to discuss contraception?” can open up surprising conversations about the patient, her wife, and what kind of things they hope for or fear. A lesbian patient may be seeing a cisgender woman or a transgender woman; they might be hoping to get pregnant, or she might be afraid of sexual assault and want an IUD for insurance.

When patients do disclose their sexual orientation and/or gender identity to you, that’s a big compliment. It’s a mark of trust. It means you’ve started building the foundations of a positive, healthy therapeutic relationship. When patients can be honest with you, they can give you better, more complete information, and you can do the best possible job of helping them live healthy, fulfilling lives. Even something as simple as “Who will be able to help you when you’re recovering from this surgery?” can be a meaningful and important moment for patients who may never have been able to come out to a physician before.

Respect your patients, and let that respect inform what questions you ask them and how. It makes for better medicine.

Kristin Puhl is a medical student and can be reached on Twitter @kristinpuhl.

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