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The pivotal moment in Dr. David Jaspan’s decision to create an LGBT-friendly practice was when a first-year resident physician told him a lesbian woman had presented with advanced-stage cervical cancer to their Philadelphia-based community ob.gyn. clinic.
“She had health insurance. She lived within walking distance of the clinic,” recalled Dr. Jaspan, chairman of the Einstein Medical Center in Philadelphia.
The patient had been avoiding preventive care, including routine Pap smears, because she feared being judged for her sexuality, he said. “She had access to care, but was afraid to use it. That’s ridiculous. We had to do something.”
In a 2010 survey of nearly 5,000 LGBT (lesbian, gay, bisexual, transgender) individuals nationwide conducted by the LGBT advocacy group Lambda Legal, more than half of the nearly 400 transgender individuals, and nearly 10% of the entire gay, lesbian, and bisexual population surveyed said they believed they would be refused care if they sought it.
An analysis of the literature published in the last 5 years, conducted by Dr. Gloria Bachmann, professor and interim chair of obstetrics and gynecology at the Robert Wood Johnson Medical School in Newark, N.J., and her colleagues, showed that in the ob.gyn. setting, 2% of transgender respondents in one survey reported being physically attacked in a patient waiting area, while nearly 20% of respondents reported being denied care altogether.
Aside from these real or perceived fears of harm or denial, another barrier to care for the LGBT community appears to be a lack of education in the medical training establishment.
A survey published earlier this year in the American Journal of Public Health, and conducted by researchers from the University of California at Los Angeles, showed that of the half of all 138 U.S. academic medical faculty practices currently accredited by the Liaison Committee on Medical Education that responded to the survey, only 10% have standard procedures for connecting patients to LGBT-competent physicians.
The medical community at large seems to be more proactive about inclusion. In 2014, the Human Rights Campaign Foundation designated more than 400 community health care facilities across the country as leaders in LGBT health care equality, more than double the number they designated in 2013.
“I think that things are better than they used to be,” said Dr. Rachel Levine, Pennsylvania’s first transgender physician general.
Dr. Levine was appointed to her post earlier this year by Gov. Tom Wolf (D). “I can’t see someone being refused care because they are LGBT.” Besides, she added, “it’s not ethical.”
While not everyone will practice LGBT medicine, Dr. Levine said, “all medical personnel should have training in, and at least be aware of, the broad outlines of LGBT health issues.” She pointed to a growing number of organizations, such as the Institute of Medicine and the American Medical Association, that also offer guidelines for treating the LGBT population.
Achieving culturally competent care
For Dr. Jaspan, the will and desire to provide care was strong, even though he wasn’t entirely sure how to go about it. “I wondered, What if a man walked into our clinic? But it was clear to me, it doesn’t matter. What matters is that he chose to access care.”
Delivering what is largely referred to by LGBT health experts as “culturally competent care” comes down to two factors: gender neutrality and honesty, according to Dr. Bachmann.
“Unconscious biases find their way into personal and professional interactions, but defining all clinical encounters as gender equal works to eliminate that bias in clinical-patient interactions,” she said.
Gender neutrality helps to establish trust with a transgender patient and makes it easier to get a full history, including details about the surgical and management strategies for the patient’s transition, the difficulties the patient might be having, and how to get the assistance that patient might need, Dr. Bachmann said.
That leads to the second essential element of culturally competent care: honesty.
“[Physicians] don’t have to know everything,” Dr. Bachmann said. “Opening the lines of communication is probably the most important, and acknowledging that you might not have the most in-depth knowledge to meet the [LGBT patient’s] needs, but you do want to take the best care of them, and that you might need their assistance for that.”
Clear communication also helps maintain accurate electronic health records, particularly in the case of transgender patients, said Dr. Levine, who before assuming her role as Pennsylvania’s top physician, was the vice chair for clinical affairs for the department of pediatrics and chief of the division of adolescent medicine and eating disorders at the Penn State Hershey Children’s Hospital at the Penn State Hershey Medical Center.
“In the privacy of the examination room, ask the patient what name they would like to be called, what pronoun they would like you to use, and in the context of the visit, you use those,” Dr. Levine said.
But because both HIPPA and insurers require a person’s legal name and gender, it is important their EHRs reflect that information, while the dictation makes the patient’s preferences clear.
‘A very important lesson’
But sometimes, as Dr. Jaspan discovered, a notation is simply not enough.
Once Dr. Jaspan’s clinic officially announced it was LGBT friendly, the first patient from that community to enroll was a bearded transgender man who’d had his breasts removed, but still had a uterus and ovaries and so was in need of a pelvic ultrasound.
Dr. Jaspan wrote the script for the radiologist, but Dr. Michele Style, the resident who had first urged him to reach out to the LGBT community, pointed out the peril of not thinking through how the patient would be received at the radiology clinic. She told him that unless they gave fair warning, the radiology tech would call out the patient’s legal name, which would indicate a woman would respond, but instead, it would be a man who would reply.
“Rather than have the tech say, ‘Oh sorry, I have the wrong person,’ and create embarrassment for the patient, we needed a different plan,” he said.
Instead, Dr. Jaspan’s office contacted the radiology staff before the appointment, and they were “overwhelmingly happy to help,” he said. The patient was greeted by a staff member of the radiology clinic who was also part of the LGBT community and was escorted to the exam room without being called by name.
“It was a very important lesson,” Dr. Jaspan said.
Rainbow power
When word got out about plans to open the Pride Clinic at Einstein Medical Center in Philadelphia, Dr. Jaspan started receiving calls from people across the country offering to collaborate, or to give financial assistance.
“It was unbelievable,” Dr. Jaspan said. One important ally was the LGBT brown bag lunch group who met regularly at Einstein and whose members were happy to serve as a focus group for the project. “They also trained our staff on how to answer the phones so LGBT people would immediately feel at ease,” he said.
But what surprised Dr. Jaspan the most was the power of the rainbow. Although he expected the clinic would need some type of overhaul, the focus group assured him that simply by displaying a sticker of a rainbow – long the international symbol of the LGBT community – at the clinic’s entrance, as well as placing rainbow flags on the reception desk and the door of every examination room, LGBT individuals would know they were welcome.
“I thought it was so phenomenal there was that much power in a symbol,” Dr. Jaspan said. “I just couldn’t believe that would make that much difference, but it does.”
From start to finish, including applying for the designation as an LGBT health equality leader by the Human Rights Campaign Foundation and training his staff in how to take information from patients using language that makes no assumptions about their sexual identity or preferences, the process of officially opening his doors to Philadelphia’s LGBT community took a year. “But I was aggressive with it,” Dr. Jaspan added.
Since opening, the clinic has enrolled about 10 LGBT patients on its patient panel, all of whom have access to a network of physicians, including cardiologists, pediatricians, endocrinologists, psychiatrists, and the gynecologic oncologists who now care for the lesbian patient who first presented with advanced-stage cervical cancer.
“I learn something new every day, every single day,” said Dr. Jaspan. “Just because we’ve opened doesn’t mean we’re doing it right, but a [college-aged LGBT patient] we saw the other day said she’d spread the word because she thought we had done everything right.”
Checklist for transgender patient exams
The main barriers to getting basic health care in the lesbian, gay, bisexual, and transgender community are “anticipated, perceived, and actual insensitivity, or rejection,” said Walter O. Bockting, Ph.D., codirector of the LGBT Health Initiative and professor of medical psychology at the New York State Psychiatric Institute and the Columbia University School of Nursing.
Underlying that, he said, is the lack of training in LGBT health concerns for health care professionals, given this cohort’s “marginalization.”
Dr. Bockting shared his advice for providing the best possible primary care for transgender patients.
Mental health
Screen for depression and anxiety, create a network of mental health professionals with expertise in transgender-related concerns, and help patients with resilience-building strategies, Dr. Bockting advised.
Transgender women have a higher relative risk for depression and anxiety, he said. This is often a result of “social stigma attached to their nonconformity,” and rejection of their claimed sexual identity by family members, especially if they are a parent. Additionally, “simply having to deal with being transgender, the process of finding a comfortable gender role and expression, and parts of the coming out process may be stressful, contributing to feelings of vulnerability, and symptoms of depression and anxiety.”
Preventive care
Continue to perform pelvic exams and Pap smears in transgender men with a cervix and uterus, screen transgender men for uterine and breast cancers, and screen transgender women for prostate cancers, Dr. Bockting advised.
In addition to the medical interventions necessary to affirm gender identities, one’s sex at birth, and one’s sexual orientation, taking a complete medical history that includes what surgeries the patient has had to date, and what the subsequent management strategies have been, is essential to knowing which preventive care is most appropriate for the individual patient, he said.
“What being transgender means, and is, varies from person to person,” Dr. Bockting said. “Developing an understanding of what it means for a particular patient is key.”
Educate yourself
Own your limitations, but also seek to learn by enlisting colleagues with more expertise, Dr. Bockting advised.
If you have been treating anatomical women your entire career, being called upon to treat a transgender woman with prostate concerns can be daunting, he said. But understanding your limitations is good, according to Dr. Bockting, though even better is to “do your homework, and talk to colleagues and other experts about how to provide the best possible care.”
“It’s okay to admit you do not know it all,” he said. “That is often referred to as having ‘cultural humility.’ ”
Resources for providing LGBT care
For more information about creating an LGBT-friendly clinic, the following organizations can offer tips, support, and expertise:
This is one of the nation’s oldest LGBT-focused clinics, and the largest U.S. LGBT health research center, with locations throughout Boston.
617-927-6400
Initially opened in 1979 to serve San Francisco’s lesbian community, it now offers care and resources to the entire LGBT community.
415-565-7667
Also opened in 1979 to serve the LGBT community, it is one of the first AIDS-service organizations in the United States.
215-563-0652
World Professional Association for Transgender Health
Formerly the Harry Benjamin International Gender Dysphoria Association, in Minneapolis, WPATH promotes evidence-based care, education, research, advocacy, public policy, and respect in transgender health.
This LGBT advocacy group based in Washington, D.C., issues an annual report on leaders in LGBT health care delivery, and offers resources to help meet their criteria.
On Twitter @whitneymcknight
The pivotal moment in Dr. David Jaspan’s decision to create an LGBT-friendly practice was when a first-year resident physician told him a lesbian woman had presented with advanced-stage cervical cancer to their Philadelphia-based community ob.gyn. clinic.
“She had health insurance. She lived within walking distance of the clinic,” recalled Dr. Jaspan, chairman of the Einstein Medical Center in Philadelphia.
The patient had been avoiding preventive care, including routine Pap smears, because she feared being judged for her sexuality, he said. “She had access to care, but was afraid to use it. That’s ridiculous. We had to do something.”
In a 2010 survey of nearly 5,000 LGBT (lesbian, gay, bisexual, transgender) individuals nationwide conducted by the LGBT advocacy group Lambda Legal, more than half of the nearly 400 transgender individuals, and nearly 10% of the entire gay, lesbian, and bisexual population surveyed said they believed they would be refused care if they sought it.
An analysis of the literature published in the last 5 years, conducted by Dr. Gloria Bachmann, professor and interim chair of obstetrics and gynecology at the Robert Wood Johnson Medical School in Newark, N.J., and her colleagues, showed that in the ob.gyn. setting, 2% of transgender respondents in one survey reported being physically attacked in a patient waiting area, while nearly 20% of respondents reported being denied care altogether.
Aside from these real or perceived fears of harm or denial, another barrier to care for the LGBT community appears to be a lack of education in the medical training establishment.
A survey published earlier this year in the American Journal of Public Health, and conducted by researchers from the University of California at Los Angeles, showed that of the half of all 138 U.S. academic medical faculty practices currently accredited by the Liaison Committee on Medical Education that responded to the survey, only 10% have standard procedures for connecting patients to LGBT-competent physicians.
The medical community at large seems to be more proactive about inclusion. In 2014, the Human Rights Campaign Foundation designated more than 400 community health care facilities across the country as leaders in LGBT health care equality, more than double the number they designated in 2013.
“I think that things are better than they used to be,” said Dr. Rachel Levine, Pennsylvania’s first transgender physician general.
Dr. Levine was appointed to her post earlier this year by Gov. Tom Wolf (D). “I can’t see someone being refused care because they are LGBT.” Besides, she added, “it’s not ethical.”
While not everyone will practice LGBT medicine, Dr. Levine said, “all medical personnel should have training in, and at least be aware of, the broad outlines of LGBT health issues.” She pointed to a growing number of organizations, such as the Institute of Medicine and the American Medical Association, that also offer guidelines for treating the LGBT population.
Achieving culturally competent care
For Dr. Jaspan, the will and desire to provide care was strong, even though he wasn’t entirely sure how to go about it. “I wondered, What if a man walked into our clinic? But it was clear to me, it doesn’t matter. What matters is that he chose to access care.”
Delivering what is largely referred to by LGBT health experts as “culturally competent care” comes down to two factors: gender neutrality and honesty, according to Dr. Bachmann.
“Unconscious biases find their way into personal and professional interactions, but defining all clinical encounters as gender equal works to eliminate that bias in clinical-patient interactions,” she said.
Gender neutrality helps to establish trust with a transgender patient and makes it easier to get a full history, including details about the surgical and management strategies for the patient’s transition, the difficulties the patient might be having, and how to get the assistance that patient might need, Dr. Bachmann said.
That leads to the second essential element of culturally competent care: honesty.
“[Physicians] don’t have to know everything,” Dr. Bachmann said. “Opening the lines of communication is probably the most important, and acknowledging that you might not have the most in-depth knowledge to meet the [LGBT patient’s] needs, but you do want to take the best care of them, and that you might need their assistance for that.”
Clear communication also helps maintain accurate electronic health records, particularly in the case of transgender patients, said Dr. Levine, who before assuming her role as Pennsylvania’s top physician, was the vice chair for clinical affairs for the department of pediatrics and chief of the division of adolescent medicine and eating disorders at the Penn State Hershey Children’s Hospital at the Penn State Hershey Medical Center.
“In the privacy of the examination room, ask the patient what name they would like to be called, what pronoun they would like you to use, and in the context of the visit, you use those,” Dr. Levine said.
But because both HIPPA and insurers require a person’s legal name and gender, it is important their EHRs reflect that information, while the dictation makes the patient’s preferences clear.
‘A very important lesson’
But sometimes, as Dr. Jaspan discovered, a notation is simply not enough.
Once Dr. Jaspan’s clinic officially announced it was LGBT friendly, the first patient from that community to enroll was a bearded transgender man who’d had his breasts removed, but still had a uterus and ovaries and so was in need of a pelvic ultrasound.
Dr. Jaspan wrote the script for the radiologist, but Dr. Michele Style, the resident who had first urged him to reach out to the LGBT community, pointed out the peril of not thinking through how the patient would be received at the radiology clinic. She told him that unless they gave fair warning, the radiology tech would call out the patient’s legal name, which would indicate a woman would respond, but instead, it would be a man who would reply.
“Rather than have the tech say, ‘Oh sorry, I have the wrong person,’ and create embarrassment for the patient, we needed a different plan,” he said.
Instead, Dr. Jaspan’s office contacted the radiology staff before the appointment, and they were “overwhelmingly happy to help,” he said. The patient was greeted by a staff member of the radiology clinic who was also part of the LGBT community and was escorted to the exam room without being called by name.
“It was a very important lesson,” Dr. Jaspan said.
Rainbow power
When word got out about plans to open the Pride Clinic at Einstein Medical Center in Philadelphia, Dr. Jaspan started receiving calls from people across the country offering to collaborate, or to give financial assistance.
“It was unbelievable,” Dr. Jaspan said. One important ally was the LGBT brown bag lunch group who met regularly at Einstein and whose members were happy to serve as a focus group for the project. “They also trained our staff on how to answer the phones so LGBT people would immediately feel at ease,” he said.
But what surprised Dr. Jaspan the most was the power of the rainbow. Although he expected the clinic would need some type of overhaul, the focus group assured him that simply by displaying a sticker of a rainbow – long the international symbol of the LGBT community – at the clinic’s entrance, as well as placing rainbow flags on the reception desk and the door of every examination room, LGBT individuals would know they were welcome.
“I thought it was so phenomenal there was that much power in a symbol,” Dr. Jaspan said. “I just couldn’t believe that would make that much difference, but it does.”
From start to finish, including applying for the designation as an LGBT health equality leader by the Human Rights Campaign Foundation and training his staff in how to take information from patients using language that makes no assumptions about their sexual identity or preferences, the process of officially opening his doors to Philadelphia’s LGBT community took a year. “But I was aggressive with it,” Dr. Jaspan added.
Since opening, the clinic has enrolled about 10 LGBT patients on its patient panel, all of whom have access to a network of physicians, including cardiologists, pediatricians, endocrinologists, psychiatrists, and the gynecologic oncologists who now care for the lesbian patient who first presented with advanced-stage cervical cancer.
“I learn something new every day, every single day,” said Dr. Jaspan. “Just because we’ve opened doesn’t mean we’re doing it right, but a [college-aged LGBT patient] we saw the other day said she’d spread the word because she thought we had done everything right.”
Checklist for transgender patient exams
The main barriers to getting basic health care in the lesbian, gay, bisexual, and transgender community are “anticipated, perceived, and actual insensitivity, or rejection,” said Walter O. Bockting, Ph.D., codirector of the LGBT Health Initiative and professor of medical psychology at the New York State Psychiatric Institute and the Columbia University School of Nursing.
Underlying that, he said, is the lack of training in LGBT health concerns for health care professionals, given this cohort’s “marginalization.”
Dr. Bockting shared his advice for providing the best possible primary care for transgender patients.
Mental health
Screen for depression and anxiety, create a network of mental health professionals with expertise in transgender-related concerns, and help patients with resilience-building strategies, Dr. Bockting advised.
Transgender women have a higher relative risk for depression and anxiety, he said. This is often a result of “social stigma attached to their nonconformity,” and rejection of their claimed sexual identity by family members, especially if they are a parent. Additionally, “simply having to deal with being transgender, the process of finding a comfortable gender role and expression, and parts of the coming out process may be stressful, contributing to feelings of vulnerability, and symptoms of depression and anxiety.”
Preventive care
Continue to perform pelvic exams and Pap smears in transgender men with a cervix and uterus, screen transgender men for uterine and breast cancers, and screen transgender women for prostate cancers, Dr. Bockting advised.
In addition to the medical interventions necessary to affirm gender identities, one’s sex at birth, and one’s sexual orientation, taking a complete medical history that includes what surgeries the patient has had to date, and what the subsequent management strategies have been, is essential to knowing which preventive care is most appropriate for the individual patient, he said.
“What being transgender means, and is, varies from person to person,” Dr. Bockting said. “Developing an understanding of what it means for a particular patient is key.”
Educate yourself
Own your limitations, but also seek to learn by enlisting colleagues with more expertise, Dr. Bockting advised.
If you have been treating anatomical women your entire career, being called upon to treat a transgender woman with prostate concerns can be daunting, he said. But understanding your limitations is good, according to Dr. Bockting, though even better is to “do your homework, and talk to colleagues and other experts about how to provide the best possible care.”
“It’s okay to admit you do not know it all,” he said. “That is often referred to as having ‘cultural humility.’ ”
Resources for providing LGBT care
For more information about creating an LGBT-friendly clinic, the following organizations can offer tips, support, and expertise:
This is one of the nation’s oldest LGBT-focused clinics, and the largest U.S. LGBT health research center, with locations throughout Boston.
617-927-6400
Initially opened in 1979 to serve San Francisco’s lesbian community, it now offers care and resources to the entire LGBT community.
415-565-7667
Also opened in 1979 to serve the LGBT community, it is one of the first AIDS-service organizations in the United States.
215-563-0652
World Professional Association for Transgender Health
Formerly the Harry Benjamin International Gender Dysphoria Association, in Minneapolis, WPATH promotes evidence-based care, education, research, advocacy, public policy, and respect in transgender health.
This LGBT advocacy group based in Washington, D.C., issues an annual report on leaders in LGBT health care delivery, and offers resources to help meet their criteria.
On Twitter @whitneymcknight
The pivotal moment in Dr. David Jaspan’s decision to create an LGBT-friendly practice was when a first-year resident physician told him a lesbian woman had presented with advanced-stage cervical cancer to their Philadelphia-based community ob.gyn. clinic.
“She had health insurance. She lived within walking distance of the clinic,” recalled Dr. Jaspan, chairman of the Einstein Medical Center in Philadelphia.
The patient had been avoiding preventive care, including routine Pap smears, because she feared being judged for her sexuality, he said. “She had access to care, but was afraid to use it. That’s ridiculous. We had to do something.”
In a 2010 survey of nearly 5,000 LGBT (lesbian, gay, bisexual, transgender) individuals nationwide conducted by the LGBT advocacy group Lambda Legal, more than half of the nearly 400 transgender individuals, and nearly 10% of the entire gay, lesbian, and bisexual population surveyed said they believed they would be refused care if they sought it.
An analysis of the literature published in the last 5 years, conducted by Dr. Gloria Bachmann, professor and interim chair of obstetrics and gynecology at the Robert Wood Johnson Medical School in Newark, N.J., and her colleagues, showed that in the ob.gyn. setting, 2% of transgender respondents in one survey reported being physically attacked in a patient waiting area, while nearly 20% of respondents reported being denied care altogether.
Aside from these real or perceived fears of harm or denial, another barrier to care for the LGBT community appears to be a lack of education in the medical training establishment.
A survey published earlier this year in the American Journal of Public Health, and conducted by researchers from the University of California at Los Angeles, showed that of the half of all 138 U.S. academic medical faculty practices currently accredited by the Liaison Committee on Medical Education that responded to the survey, only 10% have standard procedures for connecting patients to LGBT-competent physicians.
The medical community at large seems to be more proactive about inclusion. In 2014, the Human Rights Campaign Foundation designated more than 400 community health care facilities across the country as leaders in LGBT health care equality, more than double the number they designated in 2013.
“I think that things are better than they used to be,” said Dr. Rachel Levine, Pennsylvania’s first transgender physician general.
Dr. Levine was appointed to her post earlier this year by Gov. Tom Wolf (D). “I can’t see someone being refused care because they are LGBT.” Besides, she added, “it’s not ethical.”
While not everyone will practice LGBT medicine, Dr. Levine said, “all medical personnel should have training in, and at least be aware of, the broad outlines of LGBT health issues.” She pointed to a growing number of organizations, such as the Institute of Medicine and the American Medical Association, that also offer guidelines for treating the LGBT population.
Achieving culturally competent care
For Dr. Jaspan, the will and desire to provide care was strong, even though he wasn’t entirely sure how to go about it. “I wondered, What if a man walked into our clinic? But it was clear to me, it doesn’t matter. What matters is that he chose to access care.”
Delivering what is largely referred to by LGBT health experts as “culturally competent care” comes down to two factors: gender neutrality and honesty, according to Dr. Bachmann.
“Unconscious biases find their way into personal and professional interactions, but defining all clinical encounters as gender equal works to eliminate that bias in clinical-patient interactions,” she said.
Gender neutrality helps to establish trust with a transgender patient and makes it easier to get a full history, including details about the surgical and management strategies for the patient’s transition, the difficulties the patient might be having, and how to get the assistance that patient might need, Dr. Bachmann said.
That leads to the second essential element of culturally competent care: honesty.
“[Physicians] don’t have to know everything,” Dr. Bachmann said. “Opening the lines of communication is probably the most important, and acknowledging that you might not have the most in-depth knowledge to meet the [LGBT patient’s] needs, but you do want to take the best care of them, and that you might need their assistance for that.”
Clear communication also helps maintain accurate electronic health records, particularly in the case of transgender patients, said Dr. Levine, who before assuming her role as Pennsylvania’s top physician, was the vice chair for clinical affairs for the department of pediatrics and chief of the division of adolescent medicine and eating disorders at the Penn State Hershey Children’s Hospital at the Penn State Hershey Medical Center.
“In the privacy of the examination room, ask the patient what name they would like to be called, what pronoun they would like you to use, and in the context of the visit, you use those,” Dr. Levine said.
But because both HIPPA and insurers require a person’s legal name and gender, it is important their EHRs reflect that information, while the dictation makes the patient’s preferences clear.
‘A very important lesson’
But sometimes, as Dr. Jaspan discovered, a notation is simply not enough.
Once Dr. Jaspan’s clinic officially announced it was LGBT friendly, the first patient from that community to enroll was a bearded transgender man who’d had his breasts removed, but still had a uterus and ovaries and so was in need of a pelvic ultrasound.
Dr. Jaspan wrote the script for the radiologist, but Dr. Michele Style, the resident who had first urged him to reach out to the LGBT community, pointed out the peril of not thinking through how the patient would be received at the radiology clinic. She told him that unless they gave fair warning, the radiology tech would call out the patient’s legal name, which would indicate a woman would respond, but instead, it would be a man who would reply.
“Rather than have the tech say, ‘Oh sorry, I have the wrong person,’ and create embarrassment for the patient, we needed a different plan,” he said.
Instead, Dr. Jaspan’s office contacted the radiology staff before the appointment, and they were “overwhelmingly happy to help,” he said. The patient was greeted by a staff member of the radiology clinic who was also part of the LGBT community and was escorted to the exam room without being called by name.
“It was a very important lesson,” Dr. Jaspan said.
Rainbow power
When word got out about plans to open the Pride Clinic at Einstein Medical Center in Philadelphia, Dr. Jaspan started receiving calls from people across the country offering to collaborate, or to give financial assistance.
“It was unbelievable,” Dr. Jaspan said. One important ally was the LGBT brown bag lunch group who met regularly at Einstein and whose members were happy to serve as a focus group for the project. “They also trained our staff on how to answer the phones so LGBT people would immediately feel at ease,” he said.
But what surprised Dr. Jaspan the most was the power of the rainbow. Although he expected the clinic would need some type of overhaul, the focus group assured him that simply by displaying a sticker of a rainbow – long the international symbol of the LGBT community – at the clinic’s entrance, as well as placing rainbow flags on the reception desk and the door of every examination room, LGBT individuals would know they were welcome.
“I thought it was so phenomenal there was that much power in a symbol,” Dr. Jaspan said. “I just couldn’t believe that would make that much difference, but it does.”
From start to finish, including applying for the designation as an LGBT health equality leader by the Human Rights Campaign Foundation and training his staff in how to take information from patients using language that makes no assumptions about their sexual identity or preferences, the process of officially opening his doors to Philadelphia’s LGBT community took a year. “But I was aggressive with it,” Dr. Jaspan added.
Since opening, the clinic has enrolled about 10 LGBT patients on its patient panel, all of whom have access to a network of physicians, including cardiologists, pediatricians, endocrinologists, psychiatrists, and the gynecologic oncologists who now care for the lesbian patient who first presented with advanced-stage cervical cancer.
“I learn something new every day, every single day,” said Dr. Jaspan. “Just because we’ve opened doesn’t mean we’re doing it right, but a [college-aged LGBT patient] we saw the other day said she’d spread the word because she thought we had done everything right.”
Checklist for transgender patient exams
The main barriers to getting basic health care in the lesbian, gay, bisexual, and transgender community are “anticipated, perceived, and actual insensitivity, or rejection,” said Walter O. Bockting, Ph.D., codirector of the LGBT Health Initiative and professor of medical psychology at the New York State Psychiatric Institute and the Columbia University School of Nursing.
Underlying that, he said, is the lack of training in LGBT health concerns for health care professionals, given this cohort’s “marginalization.”
Dr. Bockting shared his advice for providing the best possible primary care for transgender patients.
Mental health
Screen for depression and anxiety, create a network of mental health professionals with expertise in transgender-related concerns, and help patients with resilience-building strategies, Dr. Bockting advised.
Transgender women have a higher relative risk for depression and anxiety, he said. This is often a result of “social stigma attached to their nonconformity,” and rejection of their claimed sexual identity by family members, especially if they are a parent. Additionally, “simply having to deal with being transgender, the process of finding a comfortable gender role and expression, and parts of the coming out process may be stressful, contributing to feelings of vulnerability, and symptoms of depression and anxiety.”
Preventive care
Continue to perform pelvic exams and Pap smears in transgender men with a cervix and uterus, screen transgender men for uterine and breast cancers, and screen transgender women for prostate cancers, Dr. Bockting advised.
In addition to the medical interventions necessary to affirm gender identities, one’s sex at birth, and one’s sexual orientation, taking a complete medical history that includes what surgeries the patient has had to date, and what the subsequent management strategies have been, is essential to knowing which preventive care is most appropriate for the individual patient, he said.
“What being transgender means, and is, varies from person to person,” Dr. Bockting said. “Developing an understanding of what it means for a particular patient is key.”
Educate yourself
Own your limitations, but also seek to learn by enlisting colleagues with more expertise, Dr. Bockting advised.
If you have been treating anatomical women your entire career, being called upon to treat a transgender woman with prostate concerns can be daunting, he said. But understanding your limitations is good, according to Dr. Bockting, though even better is to “do your homework, and talk to colleagues and other experts about how to provide the best possible care.”
“It’s okay to admit you do not know it all,” he said. “That is often referred to as having ‘cultural humility.’ ”
Resources for providing LGBT care
For more information about creating an LGBT-friendly clinic, the following organizations can offer tips, support, and expertise:
This is one of the nation’s oldest LGBT-focused clinics, and the largest U.S. LGBT health research center, with locations throughout Boston.
617-927-6400
Initially opened in 1979 to serve San Francisco’s lesbian community, it now offers care and resources to the entire LGBT community.
415-565-7667
Also opened in 1979 to serve the LGBT community, it is one of the first AIDS-service organizations in the United States.
215-563-0652
World Professional Association for Transgender Health
Formerly the Harry Benjamin International Gender Dysphoria Association, in Minneapolis, WPATH promotes evidence-based care, education, research, advocacy, public policy, and respect in transgender health.
This LGBT advocacy group based in Washington, D.C., issues an annual report on leaders in LGBT health care delivery, and offers resources to help meet their criteria.
On Twitter @whitneymcknight
