How to take a Gender and Sexuality Conscious Medical History

Presented by Jules Zeng, Adriana Moses, Zack Orban, Julia Tompkins, and Dr. Camilla Larsen

Original slides by Taylor Drew

Stritch PRIDE x FMIG x SOG

NOTE

• We will start broadly and then become more focused in our discussion
• There will be time to practice these skills with your peers throughout
• Please feel free to ask ANY questions – this is a judgement-free space
• If you are confused by any terms, please let us know – we do not want to presume knowledge
• Info presented today was compiled by medical students using reputable resources and physician feedback

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Why is it important?

• To be a better and more holistic provider of medical care
• To make your queer patients comfortable
• To support marginalized patients in healthcare, prevent their traumatization from the healthcare system, and support them in their individual and community healthcare needs
• You don’t have to be a specialist to provide care to LGBTQ+ patients! Anyone can use these skills in their practice
• We lack the data on LGBTQ+ health needs because most providers are afraid/unwilling to even ask. There is also a misconception that if providers ask, patients will be unwilling to disclose

Concepts to Understand

• Definitions and labels fall short. How the patient identifies helps us in assessing them but sometimes the information we gather is more important than the label we assign
• Language matters, and what might be innocuous to you can be damaging to LGBTQ+ patients and their psyche
• Mirror the patient’s language! If they call a part of their anatomy by something, show your patient respect by reflecting those terms back to them. It can help ease dysphoria they may have regarding their gender identity vs gender presentation
• The more you practice being comfortable with terms, the more comfortable your patients will be! Practice truly makes perfect!

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Pronouns

• Asking a patient their pronouns can be one of the first ways you as a provider can build rapport with queer patients
• It can be a sticky question, especially when asking patients who are not particularly open minded, but any patient should be asked this question in order to ensure you address them properly
• Decreases assumptions
• Decreases stigma and NORMALIZES THE PRACTICE!
• Invites further conversation and breaks the ice around gender
• Ask it at the top of the interview, asking name, DOB and pronouns
• Ex. “Can you please confirm your name and DOB for me? *Answers* And I use x/y/z pronouns, what pronouns would you like me to use when discussing your case with the care team?”
• If you forget at the beginning, don’t be afraid to bring it up at any other time. “I forgot to ask…”
• Pronoun badges on your ID can also help signal your support for these patients (Stritch PRIDE is in the process of getting these!)

PRACTICE!

Practice asking each other’s pronouns

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Question: What were/are your apprehensions around asking pronouns? How might you handle patients that give a close minded response?

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Sample Practice Case

• What stands out to you?
• Practice how you would begin this patient interaction, taking turns being the physician and patient.
• Practice introducing the patient as if you were giving an oral presentation to a colleague

Physician: You are a resident working in family practice outpatient clinic today. The next patient on your schedule is a 22 year old here for their annual wellness visit. You see in the chart that at their last visit the patient was using he/they pronouns and had expressed that they had been thinking a lot about their gender identity recently. The name on the chart is Isaiah. You want to be supportive, but are wondering if bringing up the patient’s gender identity will make them uncomfortable, or if it’s relevant to their medical care today.

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Patient: You are a 22 year old, recent post grad who is seeing your doctor today for your annual wellness visit. In the past year you have started identifying as non-binary and your pronouns are they/them/xe/xem. You have started going by Isa. You are comfortable with your gender identity and hoping to discuss gender affirming care options with your provider today. However this is your first visit to the doctor as openly non-binary and you are unsure how to initiate a conversation or if your doctor will understand your identity.

�Sexual History

• The more comfortable you are discussing it the more comfortable the patient will be
• Some people preface the sexual history, others don’t. Go with what feels most natural to you
• Do not cast judgement based on number of partners or relationship status of individuals. Monogamy is not for everyone!
• Remember to screen for intimate partner violence! Anyone of any gender can experience IPV, but the LGBTQ+ community is at an elevated risk

�Best Practice Terminology

• When discussing sexual partners:
• “Do you have sex with men, women or both?”
• “What are the genders of your sexual partners?”

Can someone tell me why this language distinction is important?�

When discussing safer sex:

• “How frequently do you and your partner(s) use condoms/contraceptives?”

✔ “How frequently do you and your partner(s) use protective sexual barriers?”

Can someone tell me why this language distinction is important?

Sexual Hx Review

Sexual activity – “Are you currently sexually active (or in a sexual relationship?” or “Have you been sexually active in the year?”

�If NO, ask “Have you ever been sexually active”

�If NO, “Are you in any romantic relationships?”

Sexual behavior – “What are the genders of your partners?” (“Tell me about your partners”). How many partners in…last 6 months, last year?”

Gender Identity -Is there anything you would like me to know about your gender identity so that I may best care for you?

Contraception – “Are you currently using anything for contraception (or to prevent pregnancy)?” if no, “Are you hoping to conceive (have a child, get pregnant)?”

Sexually Transmitted Infection (STI) History – “What do you use to protect against STIs?” ”Have you ever had a sexually transmitted infection?” or “Have you ever been tested for STI’s” or “Would you like to be tested for sexually transmitted infections today?”

Open-ended - What concerns regarding your sexual health do you have today?

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PRACTICE!

Practice asking each other the sexual history

(Scenarios A, B, C)

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Question: What are your apprehensions around the sexual history?

The Sexual History – For Life!

• Sexual history is not always relevant, only ask when it is pertinent
• When it is relevant, ask patients what parts/anatomy they use during sex. Do not ask them what positions the go into or how they have sex, it’s way too personal, adds to stigma and is not relevant at all to your practice and treatment
• Ask TGNC patients what parts of their anatomy they have and the terms they call them by. Mirror these terms throughout the rest of your visit, especially during physical exams!
• Some physicians will tell you to use clinical anatomy, but that is not only dysphoric to some patients but also
• Discuss sexual pleasure just as much as the risks when it comes to queer sexual history. Historically queer people have the risks of sexual encounters overemphasized relative to their joy and satisfaction. Also, it’s a good way to screen for sexual dysfunction and pain!

The Sexual History – For Life!

• Gender identity does not always match sexual identity, remember this in screening questions
• Ex. TGNC patients can get pregnant/get others pregnant despite being in a MLM or WLW relationship
• Ex. Not all women menstruate and not all who menstruate are women
• Ex. Women’s health vs reproductive health
• Remember context!
• We want to be inclusive, but we don’t want to be invasive or have the patient wondering why you’re asking something
• Others in the room? Maybe ask them to leave before the history if the patient is comfortable/if they want a chaperone (usually just for physical)

“Anything else?”

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Made a mistake?

• We are all destined to make mistakes, that’s why medicine is a practice and not a perfect art
• Show, don’t just say your apology
• Use it as a learning opportunity, do the work to educate yourself and do not expect patients to educate you on the topic, that’s not their job!

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Other things to consider when working with LGBTQIA+ patients

Family History: Genetic history vs chosen family

Housing

• Particularly LGBT+ youth

Medical trauma

For TGNC folks – determining appropriate preventative screenings, gender neutral terms

• e.g. chestfeeding vs breastfeeding

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Every physician, no matter their specialty, will work with LGBTQIA+ patients!

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Illinois Patient Resource

Working with Queer Patients in a Catholic Healthcare System

Dr. Larsen- Family Medicine

Questions?

No such thing as a stupid question in this space!

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