October 27, 2021

LGBTQ+ History Month provides ample opportunity to celebrate the many strides queer folks have made, and to continue honoring those triumphs. It wasn’t until 1982 that the City of Philadelphia amended the Fair Practices Act¹, the city’s anti-discrimination policy, to include LGBTQ+ folks. Although the queer community has made vast progress over the years, queer health disparities continue to persist. For example, in a national survey, about 50% of respondents reported having to teach their own medical providers about queer health². In another survey, one out of three respondents has had at least one negative experience related to being transgender, such as being verbally harassed or refused treatment because of their gender identity³. LGBTQ+ youth are 120% more likely to experience homelessness, which directly relates to health disparities they face later down the line⁴. Health care professionals are given the privilege and responsibility of upholding equity in practice, and this includes advocating for the safety and inclusion of LGBTQ+ patients.

Sara Ali, a third-year medical student at Drexel University College of Medicine, and Nina Solis, a graduate student in Drexel’s Master’s in Nursing Education program shared with me their stories of implementing advocacy into their medical practice:

During Sara’s first clinical rotation, she had no idea what the etiquette of a third-year medical student was supposed to be. As a result, she often chose to be more conservative with her behavior, especially with the attending physicians precepting her. Pediatrics was a field she potentially saw herself in, and naturally she wanted to make a good impression. During a physical exam appointment with an adolescent, medical students are required to perform the Home & Environment, Education & Employment, Activities, Drugs, Sexuality, and Suicide/Depression (HEADSS) assessment. If the adolescent is accompanied by a parent, they are kindly asked to leave so the assessment may be conducted in private. Both students and providers conduct the assessment in private to not only honor the patient-physician relationship, but also to provide a feeling of safety for the adolescent. After developing rapport with a particular patient, Sara and her attending physician began the HEADSS assessment with her.

The patient was a quiet, shy, 17-year-old who was about to start college. During the “Sexuality” part of the assessment, Sara asked her what her sexual orientation was as a way to initiate a “safe sex” talk. Initially hesitant, the patient eventually disclosed to Sara that she was bisexual. The patient had been working with the attending physician since she was born, so the provider was delighted that she felt comfortable enough to share this. After Sara finished giving the appropriate guidance to her, the attending had mentioned to the patient that whenever she was ready to come out, her family would accept her and love her. The attending even “guaranteed” it. Sara’s mind instantly flashed back to the many youth she personally knew who were displaced to the street after coming out to their families. She felt internal conflict arise but did not want to seem confrontational to her preceptor and risk leaving a poor impression. However, Sara also didn’t want her attending to continue “guaranteeing” such an outcome to unassuming youth. She knew she wouldn’t be able to forgive herself if she didn’t speak up. After all, it is a privilege to have such vulnerable conversations with youth; we owe it to them to guide them well.

After the visit concluded, Sara gently asked her preceptor if she had made this same guarantee to all her LGBTQ+ adolescent patients. The attending looked at Sara curiously for a few minutes, and finally replied that if she knew the patient and their families well, she did. Gathering her courage, Sara mentioned the homeless LGBTQ+ youth she knew and how their families in fact did not accept them. Their conversation led to an enlightening discourse on communication, and how even though the attending’s intent was to reassure the patient, she also had an obligation to discuss possible outcomes. After their conversation, Sara’s preceptor changed the way she spoke to LGBTQ+ adolescents, such that she assured warmth and love, but not without the possibility of turbulence. Anticipatory guidance is not just for parents, but also for growing adolescents.

Sara has been devoted to advocating for LGBTQ+ folks since her first year as a medical student. She started QueerHealthNarratives.com, which serves as a forum to help amplify the voices of queer patients. QueerHealthNarratives.com is featured in the medical school’s Sex & Gender curriculum and serves as a resource for medical students to learn what it is like being a queer patient, and what quality health care looks like for queer patients. This type of care is not just applicable in one-on-one office visits; it can be implemented in acute care hospital settings as well. You can follow them on Instagram as well, @QueerHealthNarratives.

While she was in nursing school, Nina was the co-president of an organization called SNUGS (Student Nurses Understanding Gender and Sexuality). She and her peers worked to change curriculum within the nursing school and to create a more welcoming space for queer and trans students. After graduating and starting her job as a hematology-oncology RN, she was curious to see how she could weave her passion for LGBTQ+ education into practice. Eventually she learned that one-on-one conversations and group engagement were possible even in a professional setting. However, she did experience a few difficulties along the way.

Since beginning her career as an RN, Nina has had the chance to work with patients from a variety of backgrounds. For the most part, her hospital system takes a welcoming approach to care for LGBTQ+ patients. However, she’s seen and heard individual staff members make disrespectful, transphobic remarks during her time working on an inpatient unit. Nina has taken the time to pull staff aside if she hears them comment on a trans patient’s situation and tells them directly that it’s unacceptable. Most of the time, the core issue is a lack of education on trans health care or even unawareness of a trans person’s life experience.

Nina had an experience a few years ago in which she signed up to be the “primary” nurse for one of her trans patients. As this patient’s primary nurse, Nina was able to guarantee that each time she worked on the floor, she would have him included in her patient assignment until the day he was discharged. This not only ensured a continuity of care for his oncology treatment, but also enabled him to have space to heal, -as he deserved to, in a nonjudgmental, respectful environment.

During the time that she was his primary nurse, she educated individual staff members on the effect of their language and directly addressed unnecessary health information in his daily handoff report. At the end of the day, the patient was not there for gender-affirming care, or any issues relating to his gender. He was a cancer patient who was on the floor for chemotherapy. Any other information about his identity was irrelevant to his care, unless he brought up a concern himself. Nina’s dedication to creating an inclusive environment for her primary patient allowed for greater visibility and knowledge of trans-inclusive health care on her floor. On his last day in the hospital, her patient gave her a card that said, “Each way you cared for me fulfilled your promise to ensure top-notch services on my road to wellness… You are the best advocate so many patients can have, especially those of our community, and I admire your commitment to making a patient’s stay the best it can be.”

Nina’s experience educating staff on her floor and providing competent, respectful care to her primary patient promoted a shift in floor culture and allowed her patient to feel safe and cared for during his hospital stay. Similarly, the courage Sara mustered to educate her preceptor paid off. Not only was the attending thankful for and impressed by their conversation, but Sara also knew that quality health care was now being given to all LGBTQ+ youth entering her office.

Health care providers can and should be held to a standard of providing holistic, equitable care to all of their patients regardless of their sexual orientation or gender identity. Just as all providers are expected to provide quality care to their patients, we should also feel empowered to educate our peers, our administration and ourselves. Speaking up when we feel internal conflict – even if it may risk turbulence – is how we begin to hold ourselves and others accountable. During LGBTQ+ History Month and year-round, healthcare providers should feel encouraged to evaluate, adapt and change their practice for the better.

References:
1: Nickels, T. Gay and Lesbian Philadelphia. Arcadia, 2002.
2: Grant, Jaime M., Lisa A. Mottet, Justin Tanis, Jack Harrison, Jody L. Herman, and Mara Keisling. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
3: James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). Executive Summary of the Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality
4: “Our Issue: LGBTQ Homeless Youth.” True Colors United, 26 Aug. 2021, https://truecolorsunited.org/our-issue/

 
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