To excel with LGBTQ+ patient care, avoid harmful assumptions

Physicians, especially those who recently finished their residency training, are learning about making practices more welcoming and affirming for LGBTQ+ patients. But what they are learning is still not a routine part of medical practice.

“There’s still quite a bit of homophobia—even in the medical world,” said Kaiyti Duffy, MD, MPH, the chief medical officer for the Los Angeles LGBT Center, which has 800 people on staff and gets about 50,000 monthly patient visits.

“Even with our most well-meaning physicians, that’s still the case,” said Dr. Duffy, a family physician. “For people who really do want to better serve this population, there is still some discomfort. It’s about fear. It’s about confusion and not having the confidence with our language and not wanting to offend patients sitting in front of you.”

Dr. Duffy spoke during “Creating a Safe and Welcoming Environment for LGBTQ+ Patients” (Apple Podcasts | Spotify), an episode of the AMA STEPS Forward®podcast.

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Even as a queer-identifying woman who has been out since 18, Dr. Duffy noted that she also was not immune to making false assumptions about patients she sees. As a federally qualified health center, the LGBT Center is often assigned patients enrolled in Medi-Cal, the California Medicaid program, even though they have no relation to the LGBTQ+ community and sometimes feel awkward receiving care there.

This included a divorced, “very masculine-presenting” patient with a complex medical history. Despite spending considerable time with this patient, Dr. Duffy acknowledged that she never asked the patient about gender or sexual identity out of fear of giving offense. Only later did Dr. Duffy learn that the patient had made an appointment to start hormone therapy.

“I still get emotional because of the courage it took that patient to come and present how they were presenting and to interact with me and having this hope that I would be different than at other places,” Dr. Duffy said.

“I fell into that trap of—this is somebody who looks very straight, who looks like they’ve been forced into the clinic, and I don’t want to make them uncomfortable by asking the questions I usually would ask,” Dr. Duffy added. “So I didn’t. I put them in a box and shame on me.”

The experience has given Dr. Duffy empathy for other physicians who struggle to be more welcoming to LGBTQ+ patients.

“I understand the challenges that the general primary care physician or specialist feels when they don’t know the percentage of the people in front of them who might be grappling with these issues,” she said.

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Dr. Duffy recommended creating scripted questions and practicing them until they “roll off the tongue,” and then asking them of every patient. She begins by telling the patient her name and the pronouns she uses, and then asking patients their preferred pronouns.

“It can be jarring for people,” Dr. Duffy said.

She also prepares patients for further, intimate questions by saying she will ask some questions that are very personal in nature—but they are ones that everyone is asked, so they shouldn’t be offended or think that assumptions are being made based on appearance.

Creating an affirming and welcoming practice, however, starts well before patients enter the exam room. Waiting-room signs proclaiming, “This is an affirming place for people of all genders and sexualities” help set the tone, as do patient-education materials that picture this diversity.

“Unfortunately, a lot of places stop with the signs,” Dr. Duffy said. “If a place has a sign, but the front desk person proceeds to misgender someone, that sign hasn’t done anything.” Intake forms can also go beyond asking whether patients are male or female and should be “inclusive of multitudes of genders and sexualities.”

Regarding pronouns, Dr. Duffy said this requires practice and patience.

“When somebody has never tried to use a pronoun other than ‘he’ or ‘she,’ you stumble because it’s not how we were trained grammatically,” she said. When that happens, Dr. Duffy recommended apologizing, moving on and promising to do better next time.

Learn more with the AMA about creating an LGBTQ+-friendly practice, and explore relevant AMA Ed Hub™ modules.