Opening the ob/gyn door for sexual and gender minority patients

©Andrii_Zastrozhnov/shutterstock.com

Figure 1

Figure 2

Examples of questions

In 2011, the American College of Obstetricians and Gynecologists (ACOG) published Committee Opinion # 512, “Health care for transgender individuals”¹ and in 2012 it published Committee Opinion #525, “Health care for lesbians and bisexual women.”² Years later, however, many 

ob/gyns are still grappling with how to fit into their clinical practices caring for sexual and gender minority (SGM) people, which include but are not limited to lesbian, gay, bisexual, transgender, and queer and questioning (LGBTQ) people. 

According to a 2017 Gallup poll, the LGBTQ population represents at least 4.5% of the adult population (~11 million Americans). The percentage is higher among millennials at 7.3%,³ and increasing as a recent study found 27% of California youth are gender non-conforming.⁴Therefore, it is imperative that we learn how to integrate care for SGM people into our practices. However, many studies show that doctors receive little training on LGBTQ health care^5,6 and many ob/gyns lack critical knowledge about caring for LGBTQ people.⁷ We hope to support you by filling in gaps to meet this critical need. 

Why focus on SGM people?

Due to long-standing discrimination and stigma, SGM people have health disparities and are less likely to get the health care they need. Numerous studies have shown that: SGM people are less likely to obtain needed preventative care; present later for treatment; face discrimination, stigma, neglect, and poor treatment in doctors’ offices; and have to teach their doctors how to take care of them. This is true throughout health care, including sexual and reproductive health care.^8-11  

What do ob/gyns need to know to better care for SGM patients? 

First, who we are talking about? The term SGM is increasingly used including by the National Institutes of Health, replacing LGBTQ as a bigger, more inclusive umbrella term. SGM includes everyone who is not cisgender (i.e., their gender identity aligns with sex assigned at birth) and straight. Many people who might have been traditionally overlooked or excluded by “LGBTQ” fit under the SGM umbrella, including people who are asexual, pansexual, agender, genderqueer, gender non-binary, and two-spirit, to name an unexhaustive few. 

The second fundamental piece is to appreciate that sexual orientation, gender identity (often abbreviated together as “SOGI”), and sex assigned at birth are different components of people’s lives and need to be considered separately. 

Sexual identify, sexual behavior, and attraction. Sexual orientation comprises three different domains of every person’s experience: identity, sexual behavior, and romantic and/or emotional attraction. These three domains have distinct health correlates which research has shown may not all line up.¹² One study noted that 25% of adult lesbian-identified women were having sex with (assumed cisgender) men,¹³ highlighting the difference between sexual orientation and sexual behavior and having obvious implications around pregnancy planning and contraception, among other considerations. Whereas sexual behaviors inform sexually transmitted infection (STI) risk screening or whether to proceed with a colpocleisis for prolapse, considerations of sexual identity help clinicians understand social support networks, durable power of attorney/partner benefits, and legal documents needed before birth. Attraction also may be particularly relevant to discussions of sexual arousal dysfunction. 

Gender identity. In contrast, gender identity is one’s internal sense of their gender and their sense of being a woman, man, or another gender, including non-binary gender identities. Although often tied to gender expression-how people present themselves with language, dress, hair, make-up, voice, or mannerism etc.-gender identity and gender expression are still distinct characteristics. You cannot know someone’s gender identity without asking them. However uncomfortable asking may seem, it is critical to understanding who people are and how they would like to be referred to. (See more on asking about gender identity below).

Sex. Another distinct category is someone’s sex, more specifically sex assigned at birth, which is a constellation of one’s physical anatomic, metabolic, and chromosomal make-up. Knowing an individual’s sex assigned at birth is critical to understanding the organs they were born with: informing preventative care management like relevant cancer screenings and other anatomically relevant pathological risks. Sex assigned at birth is also important in appreciating and supporting reproductive and family planning goals, and how to assist someone with desired gender-affirming medical or surgical procedures.¹⁴ A note of caution: Sex assigned at birth is often assessed by examination of external genitalia. Experience of people with differences in sex development (formerly called disorders of sex development) such as androgen insensitivity syndrome (AIS) and for people who have had gender-affirming genital surgery (such as vaginoplasty) teach us that external genitalia may not correspond with internal organs or reproductive capacity.    

Putting it together. Having discussed the difference between sexual orientation, gender identity, and sex assigned at birth, it is important to understand how these domains are both distinct and overlapping features of our patients’ experiences. These components are also coupled with other aspects of experience and identity such as someone’s age, race/ethnicity, education, socioeconomic status, religion, region, family structure, etc.  In thinking about how all of these components interact, we start to appreciate the importance of one’s gender and sexual orientation in their health as part of the layers of complexity and beauty of SGM people’s lives. 

So how to get started in patient care? 

Dr. Obedin-Maliver has coined two different simple frameworks to educate other providers about caring for SGM patients: “The 3 principles” (Figure 1) and “The 4 doors” (Figure 2).  Let us start by looking at “The 3 principles”:  

Principle 1: SGM people are different from cisgender/straight people.

It is important to note that SGM disproportionately experience health disparities and resiliencies that manifest in different risk factors and health outcomes. An example is that cisgender lesbian women and transgender men are less likely to be up-to-date on Pap smears¹⁵ and for transgender men, Pap smear insufficiency is higher than for cisgender women.¹⁶ Cancer rates may also be higher, but because cancer registries do not collect such information, we are limited in our understandings.^10,17 Depression, anxiety, substance use, cardio-metabolic risk factor differences, self-reported health and well-being, obesity, diabetes, and asthma rates are all different between SGM and non-SGM people.^9,11,12  Why is this? Well, according to the minority stress theory,¹⁸  living and moving in the world as a SGM person in a socio-cultural landscape that is designed for cisgender and straight people can be tough. This results in poor health.¹⁹ From infancy on, gender is assumed to be consistent with one’s sex assigned at birth and it is assumed that people of one sex will be attracted to those of the other (another) sex. You can see the heteronormative and cisnormative push everywhere once you start to look: consider baby onesies in the “boy’s” section stating “lady killer” or the gendered norms that say a young girl is a “tom boy” if she likes to be outside or play sports. Clearly this extends into adulthood with popular and very gendered magazines that focus on specific gender roles, including opposite-gender dating, romantic novels, wedding magazines, pregnancy and parenting books. 

Findings and experiences of the SGM population who “break” societal assumptions might surprise you. We authored a study about the experiences of transgender men who experienced pregnancy after transitioning.²⁰ In this initial study and follow-up interviews,²¹ we found that despite typical notions of womanhood and manhood, transgender men desired pregnancy. Though some had gender dysphoria in relation to having what is generally considered the sole purview of women, some saw pregnancy as a clear and unconflicted path to fatherhood. Here we have a glimpse into the lived reality of SGM people that is so often in conflict with normative expectations, services, and resources. 

Principle 2: SGM people are the same as cisgender/ straight people. 

Despite different experiences of moving through the world, fundamental medical principles, biology, and anatomy still apply to SGM people. Therefore, if someone has an organ, cancer screening should continue: the “if you have it, screen it” mantra applies. All the services that an ob/gyn and other reproductive and sexual health expert provides will be needed and should be made accessible to SGM people. These include but are not limited to: routine preventative gynecological care; treatment for pelvic, vulvar, and vaginal pathology, infertility treatment; full-spectrum family planning (including contraception, abortion, preconception, perinatal, postpartum care); breast/chest feeding support; cancer screening and treatment; and infectious disease screening and treatment. Each of these may need to be modified to be appropriate patient-centered care, but all of these services will be needed at some point by SGM people and should be framed to be comfortable and welcoming for people of any gender and sexual orientation. 

Principle 3: SGM people are unique and different from one another. 

It would be laughable to assume that if you have seen one woman give birth or undergo a hysterectomy that you have seen them all. Similarly, SGM people are unique from one another. What one bisexual cisgender woman wants for support around sexual dysfunction may be very different than what another bisexual cisgender woman wants. To carry it further, because one transgender man wants a hysterectomy and bilateral salpingo-oophorectomy as part of his gender affirmation does not mean that all transgender men desire this, as has been shown by the United States Transgender Survey of over 27,000 participants.²² Work with your patients, be aware of some trends and considerations that can inform conversations, but don’t be proscriptive. Being SGM is one aspect of people’s lives, but it is not determinative, nor monolithic. As mentioned above, other aspects of people’s lives and identities, such as race, ethnicity, education, class, geography, native and preferred languages, partnership, religion, family structure, employment etc. are also critical to consider as they interact with care decisions, resources, and needed services. 

Now using basic principles, the concept of the “4 Doors” helps clinicians think about how to create an accessible and safe clinical practice for SGM people (Figure 2). 

Door 1: What happens when you get in the door?

Good patient care starts before a patient ever sees a health care provider. In a vulnerable time of getting health care, being respectfully treated and feeling welcome goes a long way to helping establish a good clinical rapport that can lead to a healing interaction. Some examples of this are ensuring that your registration process and front desk staff respectfully ask and consistently use people’s correct pronouns and can gracefully document that there may be a difference between someone’s current gender identity and sex assigned at birth, between someone’s affirmed gender and legal gender marker on identification, or that the primary insurance holder of a pregnant woman may be a patient’s lesbian partner. Having a physical environment that affirms the personhood of all patients is also important. This means signage that reflects that people of different genders need obstetric and gynecological care services, magazines that show different types of parents and partnership, and posters that show different families. And this also means having bathrooms that are for people of any gender.²³

Door 2: What happens behind closed doors (i.e., between you and the patient)?

Interactions with clinicians are central to care experiences. Much has been written about the importance of patient-centered care and that starts with knowing patients. As discussed previously, learning how to ask about people’s lives, including their sexual orientation, gender identity, and sex assigned at birth in sensitive ways will enhance a therapeutic rapport. We recommend incorporating the questions in Box 1 into your daily clinical practice with every patient. 

There are many ways to incorporate these questions into your practice setting. Some ob/gyns may prefer to ask for this information on a pre-visit questionnaire whereas others may exclusively ask the questions in the clinical interview. However you approach it, do ask! These questions should not be shied away from and are critical to supporting accurate evidence-based medical care. In a study of four clinics with over 300 people of all identities, most people wanted to be asked about their sexual orientation and gender identity and very few failed to answer the question.²⁴ 

Door 3:What happens between doors?

Often patients will need to be referred to other providers. Other providers may not have implemented the steps you have, or hopefully will soon, to support SGM people in your practice. But our patients view people we refer them to as extensions of our relationship with them. If they have a bad experience with another provider, it may not only undermine therapeutic goals, but your relationship. Therefore, calling ahead, noting (with permission) SGM status to the referring provider and following up with your patients about their experiences can go a long way. 

Door 4:What happens to get people into the door (i.e., thinking about SGM people as a sought-out population to serve and get expertise in)? 

For many providers, supporting SGM people may not be only a necessary component of providing excellent care to a broad swath of population, but also a way to grow your practice. We advocate for thinking about engaging with the SGM population as sought-out recipients of the care you provide. While ensuring your environment is supportive once people arrive is critical, thinking about how to bring more SGM people into your clinical space and making it a destination of choice can open up a new population to your practice and expand available services for a medically underserved community. Concrete steps include having SGM people and relationship/family patterns in signage and advertisements, focusing advertisements on experiences unique to SGM people, such as providing gender-affirming hormones for transgender men, reciprocal in vitro fertilization or “co-maternity services” for sexual minority women, and post-vaginoplasty care services for transgender women. 

Next steps

Some resources to delve deeper into concrete steps you can take to shape SGM-supportive care environments are available from The Fenway Institute²⁵ and the Diversity and Inclusion Initiative and associated monograph from the Association for American Medical Colleges.²⁶ Multiple organizations exist to help advocate for the care of SGM minorities and many put out information resources and directories for SGM patients and their providers, including GLMA: Health Professionals Advancing LGBTQ Equality, Project HEALTH’s Transline e-consultation service for questions about advancing transgender health, the Human Rights Campaign (HRC), and the World Professional Organization for Transgender Health (WPATH) . An additional quick online video training with avatars from the University of California, San Francisco (UCSF) can help take you through how to assess gender identity and sex assigned at birth.²⁷

Providing care that is open, accepting, supportive, and when needed, tailored to the SGM community is the bold action that is needed now to help eliminate critical health disparities. By increasing your awareness, expanding your knowledge base, and tweaking your already existing scope of practice, you can help make a big difference.

Disclosures:

Dr. Light reports no potential conflicts of interest with regard to this article.
Dr. Obedin-Maliver is a consultant for Ibis Reproductive Health.

References:

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• ACOG Committee on Health Care for Underserved Women. ACOG Committee Opinion No. 525: health care for lesbians and bisexual women. Obstet Gynecol. 119.5 (2012): 1077.

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• Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120-1127.

• Hoffkling A, Obedin-Maliver J, Sevelius J. From erasure to opportunity: a qualitative study of the experience of transgender men around pregnancy and recommendations for providers. BMC Preg Childbirth. 2017;17(Suppl 2):332.

• James SE, Herman J. The Report of the 2015 US Transgender Survey: Executive Summary. National Center for Transgender Equality, 2017.

• Ramadan SS. Creating a Welcoming Clinical Environment for LGBT Patients. (2016). Family Medicine Clerkship Student Projects. University of Vermont. Available at: https://scholarworks.uvm.edu/fmclerk/163 Accessed December 6, 2018.

• Cahill S, Singal R, Grasso C, et al. Do ask, do tell: high levels of acceptability by patients of routine collection of sexual orientation and gender identity data in four diverse American community health centers. PLoS One. 2014;9(9):e107104.

• Makadon HJ, Potter J, Goldhammer H. The Fenway guide to lesbian, gay, bisexual, and transgender health. ACP Press, 2008.

• Curricular, AAMC Implementing. Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Nonconforming, or Born with DSD: A Resource for Medical Educators. First. Association of American Medical Colleges (2014). 

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