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Providing Inclusive Care for Sexual and Gender Minority Patients
Visibility of gender diverse people is increasing across all domains of life, with a consonant blossoming of medical literature dedicated to the health and well-being of this population in recent years. Current estimates suggest that approximately 4.5% of the United States population identify as part of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities.1 Additionally, up to 0.6% of the adult population, or 1.4 million people,2 and 0.7% of those aged 13 to 17, or 150,000 teenagers, identify as transgender.3 However, these estimates are likely underestimated, as traditional data collection tools often fail to capture the breadth of the fluidity of gender identity. Dermatology, like many other medical specialties, has an opportunity to become more inclusive of these patient populations.
“Dermatologists must be equipped to provide an excellent standard of care for transgender and gender diverse (TGD) people just as they would any other population,” said Klint Peebles, MD. “As the TGD community continues to grow not only in number but also in visibility and awareness, the need for access to quality care will only increase and become an important part of our practices.”
Dr Peebles is a board-certified dermatologist with Kaiser Permanente, Mid-Atlantic Permanente Medical Group in Washington, DC, and suburban Maryland. Dr Peebles is a well-known expert in sexual and gender minority (SGM) health and gender-affirming dermatology. In addition to clinical practice, Dr Peebles currently serves as co-chair of the American Academy of Dermatology’s (AAD) Expert Resource Group on LGBTQ/SGM Health and a member of the LGBTQ Health Specialty Section Council of the American Medical Association.
Following a presentation at the AAD Virtual Meeting Experience on SGM/LGBTQ health policy, Dr Peebles shared insights into recent research; efforts across medicine, legislation, and culture; and tips on how to provide medically appropriate and culturally sensitive care.
Understanding Cultural, Medical, and Legislative Shifts
Over the last decade, organized medicine and other professional organizations have consistently echoed calls to action to ensure that appropriate attention is given to the health and well-being of the gender minority community and to mitigate the structural barriers and discrimination that underlie the disparities facing this population. In 2016, the National Institutes of Health formally designated SGM people as a health disparity population for research purposes,4 and the most recent iteration of the federal Healthy People initiative continues its emphasis on SGM people by emphasizing population-level data collection and specifically addressing the needs of LGBTQ adolescents.5
At a legislative level, several states have collectively introduced more than 35 bills that would limit medical care for TGD individuals.6 The Arkansas state legislative body, in particular, overrode its governor’s veto to enact into law a bill that bans gender-affirming treatments for TGD minors.7 Even further, in some of these states, the proposed legislation would enact criminal penalties for medical professionals who provide care to transgender youth despite organized medicine resoundingly affirming the need for unobstructed access to gender-affirming care and recognizing that such care is medically necessary. Research has revealed that TGD youth attempt suicide at alarming rates,8 and evidence in the literature support that gender-affirming hormone therapy can reduce symptoms of anxiety and depression, lower perceived and social distress, enhance safety, and improve overall quality of life and self-esteem.9 In a recent statement, the American Medical Association asserted that these legislative efforts represent a “dangerous governmental intrusion into the practice of medicine and will be detrimental to the health of transgender children across the country.”10 The statement goes on to highlight how these bills disregard clinical, evidence-based guidelines for the care of TGD people and were not developed with involvement from experienced medical professionals. Dr Peebles related this impact to dermatology.
“Like the rest of the medical profession, dermatology will be significantly impacted by these discriminatory measures. Depending on the specific language of each state’s law and the precedents they establish, dermatologists may be unable to perform important gender-affirming procedures, such as pre- and perioperative hair removal, minimally invasive facial and body modification/contouring, or possibly scar revision, among others. Further, medical interventions such as the treatment of acne and hair loss in the setting of gender-affirming therapy could be scrutinized and considered to be in violation of some of the proposed laws.”
In May 2021, the federal government announced that the Office for Civil Rights will continue to interpret and enforce Section 1557 of the Affordable Care Act, the law’s nondiscrimination provision that effectively extends Title IX’s prohibitions on sex discrimination to health care, as including discrimination on the basis of sexual orientation and gender identity.11 This action mirrors prior executive guidance from the Obama administration and comes on the heels of the landmark Supreme Court decision of June 2020 in Bostock v Clayton County, Georgia, which found that SGM individuals cannot be discriminated against in the workplace on the basis of sex under Title VII.12 This precedent—that sexual orientation and gender identity are inherently bound up in the term sex—has profound implications for SGM equality across the legislative and judicial spectrum and allows for judicial challenges to many of the discriminatory measures being proposed at the state level. The penultimate provision for SGM equality would be congressional legislation defining sexual orientation and gender identity among the prohibited categories of discrimination, thereby prohibiting such discrimination across all facets of society. Such a provision is part of the language of the Equality Act, which passed the US House in February 2021 and is currently awaiting a vote in the Senate.13
Dr Peebles stressed that this is something health care providers should take an active role in outside of the examination room. “While the role of physicians in political activism may be controversial to some, this is an instance in which the vocal advocacy of the physician community is essential for the health and well-being of our patients. It is critical to recognize that our medical care does not exist in a vacuum. Our patients face numerous obstacles related to social determinants of health and factors that impact their access to care and ability to be compliant with medical recommendations that extend well beyond the exam room,” Dr Peebles said.
“Along with advocacy and knowing the details of what’s going on in your state, it is important to express empathy to your patients and let them know that you stand in solidarity with them during these challenging times. Let your patients know that you see what is happening and that you understand how deeply stigmatizing and disappointing it must be to see these policy measures being supported, passed, or enacted. Reassure them that the medical community is on their side and that physicians along with organized medicine as a whole will always be their champion and advocate.”
Tips for Improving Care for SGM Patients
“While dermatology of course plays an important role in gender-affirming health, it is first necessary to develop basic skills of structural competency and cultural humility when caring for gender minority individuals,” said Dr Peebles. There are a number of ways to practice more inclusive care for LGBTQ-SGM patients.
Make no assumptions. Arguably the most important tip, Dr Peebles explained, is to make no assumptions when seeing patients. Identities change and evolve over time, and an individual’s identity at one time point may not be how they identify at another time. This is where open-ended questions can be critical, and the simplest way of knowing what terms to use to describe a patient and their lived experiences is to echo the terms the patient chooses to use.
Use gender-inclusive language. Another important principle is to use inclusive and gender neutral language when appropriate. For instance, when discussing pregnancy risk in the context of isotretinoin or other teratogens, the dermatologist might say people who can become pregnant instead of women who can become pregnant. Similarly, instead of male pattern hair loss when discussing androgenetic alopecia in the setting of hair loss secondary to masculinizing hormone therapy, providers can say androgenetic hair loss or pattern hair loss.
“In my own practice, I tend to use terms such as people who produce sperm instead of men/male in the appropriate context,” added Dr Peebles. Gender inclusive descriptive terms can help validate and affirm TGD individuals who do not feel supported by the prevailing societal cisnormative paradigms and who may feel that their needs are insufficiently met in care models that rely exclusively on the traditional binary approach to gender.
Collect a gender-inclusive sexual history. Dr Peebles recommended taking advantage of opportunities to collect a gender-inclusive sexual history and use inclusive sexual health language. This can be incredibly important in the care of transmasculine individuals when discussing contraception, as comprehensively detailed by Krempasky et al.14
Approach care with professionalism. While TGD patients certainly have unique needs and experiences that inform their care, the dermatologist should not assume that every chief complaint or health concern is tied to these unique needs.
“Just because someone may identify as transgender does not mean that they are coming to your office with a concern that is solely linked to their gender identity,” said Dr Peebles. “In general, we should have a good reason for asking the questions that we ask during any encounter with a patient.” Providers should take the time to explain to patients why the information being asked for is important to care as well as avoid asking questions solely to satisfy personal curiosity.
“For instance,” explained Dr Peebles, “knowledge of sexual behaviors can aid in the assessment of risk factors for certain conditions and assist with counseling on risk reduction strategies while information about gender identity and transition helps to ensure ongoing validation of that identity and to help guide dermatologic support during affirmation.”
Intentionally integrate SGM health into education and training. The The Association of American Medical Colleges recommends including SGM health-related content into undergraduate medical education.15 However, there are no SGM-related requirements by the Accreditation Council for Graduate Medical Education (ACGME). Studies have shown that medical students receive only an average of 5 hours of SGM health-related content in medical school curricula,16 despite knowing this training is insufficient.17 A recent survey found that nearly half of US dermatology residency programs currently have zero hours dedicated to SGM content even though an overwhelming majority of program directors recognized that it is important for trainees to receive this education.18
“Dermatology residents must be prepared to care for diverse populations, and knowledge of how to manage cutaneous effects of hormone therapy and familiarity with minimally invasive gender-affirming procedures is a key step in the systematic mitigation of health disparities for TGD people,” said Dr Peebles. Dr Peebles added that program directors should work to infuse SGM content into didactic curricula, incorporate these concepts into existing ACGME core competencies and dermatology milestones, recruit diverse faculty expertise in SGM health and dermatology, and blend routine exposure to intersectional SGM populations in the clinical environment whenever possible. Finally, institutional environments should be created that are welcoming and affirming of not only SGM patients but SGM trainees as well.
Dr Peebles suggested dermatologists and trainees review the soon-to-be-launched (approximately Fall 2021) SGM-focused module in the AAD Basic Dermatology Curriculum as a complement to the rapidly evolving literature dedicated to dermatologic SGM education in addition to the other learning opportunities in this area periodically offered by the AAD and American Society for Dermatologic Surgery, among others.
Promote and champion TGD providers in dermatology. “There is also emerging—and expected—data that TGD people are underrepresented in the dermatology workforce, which must change if dermatologists are to mirror the patients we serve,” said Dr Peebles. Creating a culture of inclusion is not only important for patients but the workforce and trainees as well.
Programs should try to explicitly demonstrate structural and institutional support for TGD residents and students with clear information on the health care and gender-affirming services available within the program. Further, visible signs of support should be consistent throughout training. “Workplace and institutional culture is certainly about more than curricula and is equally reflected in clinic spaces, online and virtual environments, faculty and staff attitudes, institutional commitment and vision, affirming policies, and the like,” said Dr Peebles.
Practice with humility. This goes back to avoiding assumptions and being aware of the role dermatologists and other health professionals can play in a patient’s well-being. “We must understand why patients are coming to us and recognize that there is significant humility that goes into learning about a person and their authentic self. This is in addition to understanding the experiences they have and where they come from in relation to the care that we can provide. Sometimes that means that we have to take their gender identity or sexual orientation into account, and sometimes it doesn’t.”
Words of Advice
As society moves toward a more accepting and inclusive embrace of TGD people, dermatologists can practice with intersectionality in mind. Dr Peebles offered hope for the future of SGM care.
“As we celebrate another Pride month [in June], my hope is that the dermatology community will continue to acknowledge its role in affirming and validating the dignity and worth of every human being and that we continue to recognize the many ways in which we can and should contribute to gender-affirming care as a specialty,” said Dr Peebles.
“At the end of the day, there’s nothing magical about this work. If we simply listen to our patients and commit to understanding their perspective, they will tell us everything we need to know. Whether an expert or a novice when it comes to providing care for this population, just asking important questions provides overwhelming validation, setting the stage for a healthy, productive, and rewarding patient-physician
relationship. As with all patient encounters, we as physicians will undoubtedly learn and grow from these interactions, and ultimately I think that’s all we can ask for.”
References
1. Suen LW, Lunn MR, Katuzny K, et al. What sexual and gender minority people want researchers to know about sexual orientation and gender identity questions: a qualitative study. Arch Sex Behav. 2020;49(7):2301-2318. doi:10.1007/s10508-020-01810-y
2. Flores AR, Herman JL, Gates GJ, Brown TNT. How many adults identify as transgender in the United States? The Williams Institute. June 2016. Accessed May 27, 2021. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/
3. Blad E. How many transgender children are there? EducationWeek. March 7, 2017. Accessed May 27, 2021. https://www.edweek.org/leadership/how-many-transgender-children-are-there/2017/03
4. Pérez-Stable EJ. Sexual and gender minorities formally designated as a health disparity population for research purposes. National Institutes of Health. October 6, 2016. Accessed May 27, 2021. https://www.nimhd.nih.gov/about/directors-corner/messages/message_10-06-16.html
5. Overview and objectives. Healthy People 2030. Accessed May 27, 2021. https://health.gov/healthypeople/objectives-and-data/browse-objectives/lgbt
6. Schneiberg E. These are the states attempting to pass anti-trans health care bills. Human Rights Campaign. February 12, 2021. Updated May 18, 2021. Accessed May 27, 2021. https://www.hrc.org/news/these-are-the-states-attempting-to-pass-anti-trans-health-care-bills
7. Romo V. Arkansas Gov. Asa Hutchinson On Transgender Health Care Bill: ‘Step Way Too Far’. NPR. April 6, 2021. Accessed May 27, 2021. https://www.npr.org/2021/04/06/984884294/arkansas-gov-asa-hutchinson-on-transgender-health-care-bill-step-way-too-far
8. Toomey RB, Syvertsen AK, Shramko M. Transgender adolescent suicide behavior. Pediatrics. 2018;142(4):e20174218. doi:10.1542/peds.2017-4218
9. Nguyen HB, Chavez AM, Lipner E, et al. Gender-affirming hormone use in transgender individuals: impact on behavioral health and cognition. Curr Psychiatry Rep. 2018;20(12):110. doi:10.1007/s11920-018-0973-0
10. Madara JL. AMA to states: stop interfering in health care of transgender children. Press release. American Medical Association. April 26, 2021. Accessed May 27, 2021. https://www.ama-assn.org/press-center/press-releases/ama-states-stop-interfering-health-care-transgender-children
11. Shear MD, Sanger-Katz M. Biden administration restores rights for transgender patients. The New York Times. Updated May 13, 2021. Accessed May 27, 2021.
https://www.nytimes.com/2021/05/10/us/politics/biden-transgender-patient-protections.html
12. Bostock v Clayton County, Georgia, 590 US ___ (2020). Accessed May 27, 2021. https://www.supremecourt.gov/opinions/19pdf/17-1618_hfci.pdf
13. Equality Act, HR 5, 117th Congress (2021). Accessed May 27, 2021. https://www.congress.gov/bill/117th-congress/house-bill/5
14. Krempasky C, Harris M, Abern L, Grimstad F. Contraception across the transmasculine spectrum. Am J Obstet Gynecol. 2020;222(2):134-143. doi:10.1016/j.ajog.2019.07.043
15. Hollenbach AG, Eckstrand KL, Dreger A, eds. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Nonconforming, or Born with DSD. Association of American Medical Colleges; 2014. Accessed May 27, 2021. https://store.aamc.org/downloadable/download/sample/sample_id/129/
16. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender–related content in undergraduate medical education. JAMA. 2011;306(9):971-977. doi:10.1001/jama.2011.1255
17. Zelin NS, Hastings C, Beulieu-Jones Br, et al. Sexual and gender minority health in medical curricula in new England: a pilot study of medical student comfort, competence and perception of curricula. Med Ed Online. 2018;23(1):1461513. doi:10.1080/10872981.2018.1461513
18. Jia JL, Nord KM, Sarin KY, Linos E, Bailey EE. Sexual and gender minority curricula within US dermatology residency programs. JAMA Dermatol. 2020;156(5):593-594. doi:10.1001/jamadermatol.2020.0113
