Creating a practice that's open to GLBT patients

When Joseph Freund, MD, was applying to join a group practice, he warned his interviewer that as an openly gay physician, he has a lot of gay, lesbian, bisexual and transgender (GLBT) patients.

“This will be great,” said the physician interviewing him, “because we don't have any gay patients in our practice now.”

The physician was most definitely wrong, according to Dr. Freund, who practices family medicine in Des Moines, Iowa. “We had some very obviously gay people in his practice. He was a wonderful doctor, but that filter can grab us and influence the care we give people,” he told attendees at the annual meeting of the American Academy of Family Physicians, held in Philadelphia in October.

Many physicians also assume that their practices can be welcoming to GLBT patients without any specific attention to the issue. “People tell me, ‘I treat all my patients with respect. Why should it make a difference if they are gay, lesbian, bisexual, transgender?’” said Dr. Freund.

But good GLBT medical care requires attention to the particular risks facing these patients. It may also require some extra attention to deal with the effects of past and current discrimination. “In many, many places, people's safety, their job, or their family could be at risk if they came out,” Dr. Freund said.

Such discrimination is an issue even in medicine: 40% of people in one survey said they would not see a gay or lesbian physician, Dr. Freund reported. Despite that statistic, he's found plenty of demand for his services. “For a few years now, I've been the official gay doctor of Iowa,” he joked.

Based on that “official” experience, he offered some tips to conference attendees on making a physician practice welcoming to patients of all sexual orientations.

The effort starts in the waiting room. “We can provide some visual cues,” said Dr. Freund. “If you have a nondiscrimination policy, is it posted? And do you include gender identity and sexual orientation?” The American Cancer Society makes brochures about GLBT topics, and having some copies around can provide reassurance to patients that a practice is welcoming to them.

The practice's new-patient paperwork is also important. The traditional setup of one questionnaire or section with a set of questions for women and another for men doesn't work well for transgender patients, Dr. Freund noted. “Avoid male- or female-only questions,” he said. “A lot of trans people have parts you wouldn't normally ask about.”

More open-ended questions are preferable, for example, letting patients fill in their preferred pronoun and allowing them to report different sexes for legal and insurance purposes. Offering more choices in questions about sexual orientation and relationship status can provide patients a way to describe themselves and give physicians useful information.

“I'm seeing more people than I ever would have guessed identifying as bisexual, pansexual or polyamorous,” Dr. Freund said. “In the marital status, don't forget to put long-term relationship [as a choice].”

But once you get information about the patient's sexual orientation and relationship status, be sure to avoid any unfounded assumptions based on it. “Don't assume marriage means monogamy. Don't assume gay means never monogamous,” said Dr. Freund. “We've got to ask.”

Willingness to ask direct questions about sexual activity and listen to and discuss patients' answers openly is important, he said. “Patients are really good at picking up when we're not comfortable talking about something,” he said. “You need to talk about butts and hemorrhoids and toys and dildos and vibrators without blushing or stopping.” It's important not to be nosy, though, he clarified—never ask anything that doesn't relate to medical care.

Obviously, patients' responses will determine their need for sexually transmitted infection (STI) testing and safe sex counseling. Men who have sex with men have higher than average risk for syphilis, gonorrhea, chlamydia and HIV, and the CDC recommends screening annually for these diseases. Tests for gonorrhea and chlamydia should be conducted in multiple sites of the body, Dr. Freund advised. “If you only do urines, you miss a lot,” he said.

Sex between women is much less likely to transmit infection, but it happens. “It's a myth that lesbians don't need Pap smears,” said Dr. Freund. In particular, if one woman in a couple has bacterial vaginosis, her partner is likely to, too.

But the specialized needs of GLBT patients extend beyond their sexual health, Dr. Freund said. They may have greater need of mental health care. “You're going to see much more depression, anxiety, panic,” he said. Transgender patients are particularly at risk, with a 32% risk of suicide over their lifetimes, he noted.

“Men who have sex with men have increased risk of eating disorders,” said Dr. Freund, while women who have sex with women are somewhat more likely than average to be overweight.

GLBT patients may also be more likely to engage in substance abuse, from smoking and overuse of alcohol to illegal drugs. A sexually transmitted infection can provide an opportunity to raise this subject. “When people come in for an STI check, I ask, ‘What raised the concern?’” It's almost always related to substance abuse, usually alcohol, said Dr. Freund.

In addition to the risks posed by higher smoking rates, some other cancers are a more common threat. Men who have sex with men have an increased risk of anal cancer, so they should be screened with anal cytology and receive the human papillomavirus vaccine when appropriate.

Women who have sex with women have increased risk of breast, cervical and ovarian cancer due to a number of factors, including presumably less childbearing, use of contraceptives, and visits to gynecologists, Dr. Freund said.

Violence and discrimination can also have a negative impact on GLBT health. Some patients may have not seen physicians often, either because of lack of access or concern about the potential repercussions. “People may not use their insurance because they're afraid they might be outed,” said Dr. Freund.

The continued existence of discrimination is a reason for physicians to be cautious in referring GLBT patients to specialists. Make sure the physician receiving the referral will be accepting. “One little mistake can keep people away,” said Dr. Freund.

While you're feeling out others' views on the subject, it's important to note how your own staff will treat GLBT patients. “Do beliefs get in the way? Moral beliefs are sometimes a big roadblock,” said Dr. Freund.

If you and your staff are welcoming to GLBT patients, they can make up a significant part of your practice. Transgender patients especially are in great need of primary care, said Dr. Freund. Both the obstacles to care and health risks faced by gay, lesbian and bisexual patients are magnified for them.

A family doctor or internist can provide not only routine care and screening, but even assistance with the transgender transition, if a patient wants it. A therapist should be involved, but medical therapy consists of testosterone for female-to-males and estrogens and anti-androgens for male-to-females. These uses are off label but are not difficult to master, according to Dr. Freund.

“You can do it right now with the training and experience you have,” said Dr. Freund. “If you don't do it, who will?”