Skip to main content

Fostering an Inclusive Health Care Environment

Fostering an Inclusive Health Care Environment

Kenneth A. Katz, MD, MSc, MSCE, discusses caring for LGBTQ patients and how dermatologists can create a more inclusive environment with The Dermatologist

Dr Kenneth Katz

Kenneth A. Katz, MD, MSc, MSCE, is a board-certified dermatologist practicing at Kaiser Permanente in San Francisco, California, where he is also chief of Outpatient Pharmacy and Therapeutics. 

Dr Katz graduated from Harvard Medical School, completed an internship in internal medicine at Brigham and Women’s/Faulkner Hospital in Boston, and completed a residency in dermatology at New York University and the University of Pennsylvania. He received an MSc in medical statistics from the London School of Hygiene and Tropical Medicine and an MSCE in epidemiology from the University of Pennsylvania. 

He is co-chair of the American Academy of Dermatology’s (AAD) Expert Resource Group on Lesbian, Gay, Bisexual, and Transgender/Sexual and Gender Minority Health, and is a member of the AAD’s Dermatology World Editorial Advisory Workgroup. He is a volunteer attending in dermatology at San Francisco General Hospital. 

In addition, Dr Katz serves on the editorial board of JAMA Dermatology and on the FDA Dermatologic and Ophthalmic Drugs Advisory Committee. Prior to joining Kaiser Permanente in 2012, he worked in public health, including in positions at the FDA, the Centers for Disease Control and Prevention (CDC), and the county of San Diego.

Q. What are some of the health-related care and risks for Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) patients?

A. LGBTQ people in the United States face substantial health disparities.1 Those disparities2 relate to many aspects of health, including higher rates of attempted suicide and homelessness among LGBTQ youth, higher rates of tobacco, alcohol, and other substance use among LGBTQ persons, higher rates of obesity among lesbian women, and lower rates of health insurance among transgender persons. Disparities also extend specifically to dermatologic health, including the following: 

  • Gay men and other men who have sex with men: Higher rates of HIV3 and other sexually transmitted diseases (STDs),4 including syphilis5; higher rates of Kaposi sarcoma6; outbreaks of invasive meningococcal disease7 and methicillin-resistant Staphylococcus aureus infections8; higher rates of skin cancer9 and indoor tanning10; and higher rates of mental health concerns among persons with acne.11
  • Lesbian women and women who have sex with women: Lower rates of HPV vaccination initiation12;  at risk for HIV and other STDs.13
  • Female-to-male/transgender men14: Adverse effects of testosterone therapy, including acne and androgenetic alopecia; keloids after gender-affirming surgery; skin infections and inflammatory disorders related to chest binding.
  • Male-to-female/transgender women14: Higher rates of HIV and other STDs; adverse effects of estrogen therapy, including melasma; keloids after gender-affirming surgery.

Importantly, Healthy People 2020—which is the federal government’s public health agenda—recognizes and attempts to mitigate LGBT health disparities. It attributes the disparities in part to societal stigma, discrimination, and denial of civil and human rights, as well as a shortage of health care providers who are knowledgeable and culturally competent in LGBT health.2 

Additionally, because of the health disparities that LGBTQ persons face, recommendations regarding HIV/STD screening,15 sexual-health related vaccinations,16 and HIV pre-exposure prophylaxis (PrEP)17 and post-exposure prophylaxis (nPEP)18 from the CDC and other public health organizations are different for some LGBTQ persons than for non-LGBTQ persons. 

Q. What are some of the challenges for caring for LGBTQ patients?

A. Caring for LGBTQ patients, just like caring for other patients, requires dermatologists to provide medically and culturally competent care. And it is worth keeping in mind that LGBTQ people’s view of us as medical providers is often colored by prior negative experiences in health care settings. A 2017 survey19 of LGBTQ Americans, for example, found that 16% said they had experienced discrimination when going to a doctor or health clinic because of their LGBTQ status. In another survey,20 from 2015, one-third of transgender persons reported a negative experience related to transgender status in the past year alone. Furthermore, the Trump administration’s efforts to allow health care providers to opt out of providing care on the basis of moral or religious objections has raised concerns about anti-LGBTQ discrimination in health care settings.21

With that context, we should try to create a positive care experience for LGBTQ patients from the outset. From a medical competency perspective, that means being aware of LGBTQ health disparities and, hence, the importance in some cases of ascertaining whether a patient is LGBTQ. It also means understanding LGBTQ-specific public health recommendations regarding HIV/STD screening, sexual-health related vaccinations, and HIV pre-and post-exposure prophylaxis so that those services can be provided, or appropriate referrals made. 

From a cultural competency perspective, it means creating an office (and virtual) environment, including reception interactions, language, intake forms, and bathroom accessibility, that is welcoming to LGBTQ persons; knowing how to elicit and document history related to sexual orientation, sexual behavior, and gender identity, when appropriate; and treating patients and patients’ spouses, partners, or other companions in a respectful, nonjudgmental manner, without making assumptions. 

It is important to remember that language matters. Sometimes patients might use terms related to sexual orientation, sexual behavior, or gender identity with which a physician might not be familiar.  Asking for clarification in a respectful way is appropriate. Sometimes we physicians might inadvertently use words in ways that LGBTQ persons might not appreciate. Apologizing and asking the patient for help in choosing the right words is a good approach if that happens. 

When it comes to conversations around sexual orientation and gender identity, it is often we physicians—not patients themselves—who are uncomfortable. In a 2017 study,22 for example, nearly 80% of emergency department physicians thought that patients would be offended by or would refuse requests to provide sexual orientation or gender identity information. But only about 10% of patients surveyed said they would be offended or would refuse to provide that information. Other studies have reported similarly high levels of acceptance among LGBTQ patients about being asked about sexual orientation23 or gender identity.24

There are some instances when our efforts to provide culturally and medically competent care are simply stymied by factors outside our control. One case is that of iPLEDGE, the FDA-mandated Risk Evaluation and Mitigation Strategy (REMS) for isotretinoin. Like other REMS programs, iPLEDGE requires classification of transgender men (who can develop severe acne while taking testosterone) as females. That makes for a nearly unavoidably awkward doctor-patient interaction,25 and in some cases is enough for some transgender men to decide not to access a medicine that could really help.26 Dermatologists,27 the AAD,28 the American Medical Association,29 and transgender health advocates have for more than 2 years been pushing FDA to change iPLEDGE and other REMS program to classify people on the basis of pregnancy potential, irrespective of sex or gender. From discussions with FDA officials, it is clear they want to do the right thing. But we are still waiting. 

Finally, it is worth remembering that LGBTQ status is often only one aspect of a person’s identity, which is also typically informed by countless other aspects of that person’s background. Medical and cultural competence around those other characteristics is also critical. 

Article continues on page 2

{{pagebreak}}

Q. What improvements would you like to see in medicine and the AAD curriculum for LGBTQ patients?

A. The AAD, with the Society of Pediatric Dermatology (SPD), has created an outstanding online curriculum to teach medical students and other trainees the basics about dermatologic conditions. And certainly, that sort of medical knowledge is essential to being an excellent dermatologist. But dermatologists do not treat basal cell carcinomas or psoriasis or acne; we treat people who have those conditions. 

To help improve dermatologists’ ability to care for patients, the curriculum should incorporate aspects of care that relate to cultural competence, including culturally competent care for LGBTQ persons. That’s in line with guidelines30 from the Association of American Medical Colleges, published in 2014, that recommend integration of cultural competency objectives throughout the medical school curriculum. To their credit, and reflecting their mission and values, both AAD and SPD have indicated their desire to revise the curriculum to better address competencies in caring for LGBTQ patients. 

Q. How can dermatologists better equip themselves to treat LGBTQ patients while waiting for updates to the AAD and other curriculums? 

A. Fortunately, there are other resources available for dermatologists. Those include dermatology-specific reviews31 articles14 on LGBTQ health, a 2017 Dermatology World cover story (entitled “Do Ask, Do Treat”32) on caring for LGBT patients, sessions on LGBTQ health at the AAD annual and summer meetings, and the first-ever symposium on LGBTQ health at a World Congress of Dermatology planned for Milan in 2019. 

And more is to come: A 2-part CME article on LGBTQ health in dermatology is in press at Journal of the American Academy of Dermatology, chapters on LGBTQ health will appear in the next editions of some standard dermatology textbooks, an upcoming “Dialogues in Dermatology” will cover LGBTQ health, a Dermatology World article will discuss transgender health concerns, and “Hands On” sessions at future AAD meetings will focus on LGBTQ patients. 

Additionally, the AAD now has an Expert Resource Group (ERG) on LGBT/Sexual and Gender Minority Health. The ERG, which has an active Facebook page, is open to any dermatologist or trainee (regardless of sexual orientation, gender identity, or expertise in LGBTQ health) who is interested in learning more about LGBTQ health in dermatology. (Contact Kenneth.Katz@gmail.com for more information about the ERG.) 

The Gay and Lesbian Dermatology Association is another resource for dermatologists (For more information, visit http://www.glderm.org/). 

Finally, the National LGBT Health Education Center has a wide range of educational materials on caring for LGBTQ persons (For more information, visit www.lgbthealtheducation.org/).

figure 1

Figure 1. Poster displayed in the waiting area at Kaiser Permanente.

Q. What are your recommendations for dermatologists working with LGBTQ patients? 

A. As for many other patients, a successful care experience for LGBTQ patients often starts well before the dermatologist meets the patient. It begins with building a welcoming environment. I am proud to work at an organization, Kaiser Permanente, that does so by training staff and doctors on interacting with LGBTQ people in health care settings, prominently posting signage about the value we place on diversity and inclusion (mentioning sexual orientation and gender among many characteristics) (Figure 1) and providing access to gender-neutral restrooms. Our electronic health record allows us to document patients’ given and preferred names and pronouns, as well as sexual behavior and sexual orientation. (Examples of LGBTQ-friendly intake forms are available at https://www.lgbthealtheducation.org/wp-content/uploads/2018/03/Ready-Set-Go_2018.pdf.) Many of us, regardless of our own sexual orientation or gender identity, wear small rainbow stickers on our name badges to let our LGBTQ patients know we welcome them (Figure 2). 

Katz id badge

Figure 2. Rainbow flag sticker on Dr Katz’s identification badge.

In my practice, issues related to sexual orientation, sexual behavior, and gender identity typically come up often, in 1 of 2 ways. First, there might be a dermatologic issue for which sexual orientation or behavior is relevant. Syphilis, for example, is more common among men who have sex with men,5 so if I suspect syphilis it will help my clinical decision-making to ask about the gender(s) of my male patient’s sex partner(s). In this case, I will normalize the discussion by telling the patient that I ask all patients with a rash like his a few questions about their sexual history, because it helps with my care for them. I will ask if that is okay. If it is—and I cannot think of an occasion when it has not been–then I ask, in a matter-of-fact way, whether he is sexually active, and if so, whether he has sex with men, or women, or both. 

I then might ask some follow-up questions, if necessary, on time frames and anatomic sites of exposure. And then I will explain, again matter-of-factly, how the answers affect his care. Do they make syphilis more likely? Do they mean he should be screened for HIV or other STDs, or get additional vaccinations, or consider HIV prophylaxis?

The second way that these issues come up is during routine rapport-building with LGBTQ patients who, like most LGBTQ patients, are not seeing me for an LGBTQ-specific dermatologic condition. But I am always trying to get to know my patients better. It is good for both sides of the doctor-patient relationship. I will sometimes ask about relationships, family, or other elements of a patient’s background, and the ensuing conversation might include same-sex relationships or gender transitioning (or not). We might just stick to discussing where the best burrito in town can be had, or what the Golden State Warriors’ playoff prospects are. On the latter point, nearly all—LGBTQ or not—will be rooting for the home team.

Acknowledgment: Matthew D. Mansh, MD, for helpful comments in preparing this article.

References on page 3

{{pagebreak}}

References

1. About LGBT health. Centers for Disease Control and Prevention website. https://www.cdc.gov/lgbthealth/about.htm. Updated March 25, 2014. Accessed May 21, 2018.

2. Lesbian, gay, bisexual, and transgender health. Healthy People 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health. Updated May 15, 2018. Accessed May 21, 2018.

3. HIV among gay and bisexual men. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/group/msm/index.html. Updated February 17, 2018. Accessed May 21, 2018.

4. Gay, bisexual and other men who have sex with men (MSM). Centers for Disease Control and Prevention website. https://www.cdc.gov/std/life-stages-populations/msm.htm. Updated September 22, 2017. Accessed May 21, 2018.

5. Syphilis & MSM (men who have sex with men) - CDC fact sheet. Centers for Disease Control and Prevention website. https://www.cdc.gov/std/syphilis/stdfact-msm-syphilis.htm. Updated September 26, 2017. Accessed May 21, 2018.

6. Liu Z, Fang Q, Zuo J, Minhas V, Wood C, Zhang T. The world-wide incidence of Kaposi’s sarcoma in the HIV/AIDS era. HIV Med. 2018;19(5):355-364. 

7. Nanduri S, Foo C, Ngo V, et al. Outbreak of serogroup C meningococcal disease primarily affecting men who have sex with men — Southern California, 2016. MMWR Morb Mortal Wkly Rep. 2016;65(35):939-940. 

8. Centers for Disease Control and Prevention. Outbreaks of community-associated methicillin-resistant Staphylococcus aureus skin infections—Los Angeles County, California, 2002-2003. MMWR Morb Mortal Wkly Rep. 2003;52(05);88.

9. Mansh M, Katz KA, Linos E, Chren MM, Arron S. Association of skin cancer and indoor tanning in sexual minority men and women. JAMA Dermatol. 2015;151(12):1308-1316. 

10. Blashill AJ. Indoor tanning and skin cancer risk among diverse US youth: results from a national sample. JAMA Dermatol. 2017;153(3):344-345. 

11. Gao Y, Wei EK, Arron ST, Linos E, Margolis DJ, Mansh MD. Acne, sexual orientation, and mental health among young adults in the United States: A population-based, cross-sectional study. J Am Acad Dermatol. 2017;77(5):971-973. 

12. Agénor M, Peitzmeier S, Gordon AR, Haneuse S, Potter JE, Austin SB. Sexual orientation identity disparities in awareness and initiation of the human papillomavirus vaccine among US women and girls: a national survey. Ann Intern Med. 2015;163(2):99-106. 

13. Lesbian and bisexual women. Centers for Disease Control and Prevention website. https://www.cdc.gov/lgbthealth/women.htm. Updated March 15, 2017. Accessed May 21, 2018.

14. Ginsberg BA. Dermatologic care of the transgender patient. Int J Womens Dermatol. 2017;3(1):65-67. 

15. Centers for Disease Control and Prevention. 2015 sexually transmitted diseases treatment guidelines. https://www.cdc.gov/std/tg2015/specialpops.htm. Updated January 25, 2017. Accessed May 21, 2018.

16. Centers for Disease Control and Prevention. Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2018. https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. Accessed May 21, 2018.

17. US Public Health Service and Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States — 2014: A clinical practice guideline. https://www.cdc.gov/hiv/pdf/guidelines/PrEPguidelines2014.pdf. Published May 14, 2014. Accessed May 21, 2018.

18. US Public Health Service and Centers for Disease Control and Prevention. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV— United States, 2016. https://www.cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdf. Published May 6, 2016. Accessed May 21, 2018.

19. National Public Radio, Robert Wood Johnson Foundation, Harvard T.H. Chan School of Public Health. Discrimination in America: experiences and views of LGBTQ Americans.  https://www.npr.org/documents/2017/nov/npr-discrimination-lgbtq-final.pdf. Published November 2017. Accessed May 21, 2018.

20. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M, National Center for Transgender Equality. The report of the 2015 U.S. transgender survey. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf. Published December 2016. Accessed May 21, 2018.

21. Eilperin J, Cha AE. New HHS civil rights division to shield health workers with moral or religious objections. Washington Post. January 27, 2018. https://www.washingtonpost.com/national/health-science/trump-administration-creating-civil-rights-division-to-shield-health-workers-with-moral-or-religious-objections/2018/01/17/5663d1c0-fbe2-11e7-8f66-2df0b94bb98a_story.html?noredirect=on&utm_term=.4f3966c11ed8. Accessed May 21, 2018.

22. Maragh-Bass AC, Torain M, Adler R, et al. Risks, benefits, and importance of collecting sexual orientation and gender identity data in healthcare settings: a multi-method analysis of patient and provider perspectives. LGBT Health. 2017;4(2):141-152. 

23. Meckler GD, Elliott MN, Kanouse DE, Beals KP, Schuster MA. Nondisclosure of sexual orientation to a physician among a sample of gay, lesbian, and bisexual youth. Arch Pediatr Adolesc Med. 2006;160(12):1248-1254. 

24. Maragh-Bass AC, Torain M, Adler R, et al. Is it okay to ask: transgender patient perspectives on sexual orientation and gender identity collection in healthcare. Acad Emerg Med. 2017;24(6):655-667. 

25. Yeung H, Chen SC, Katz KA, Stoff BK. Prescribing isotretinoin in the United States for transgender individuals: ethical considerations. J Am Acad Dermatol. 2016;75(3):648-651. 

26. Turrion-Merino L, Urech-García-de-la-Vega M, Miguel-Gomez L, Harto-Castaño A, Jaen-Olasolo P. Severe acne in female-to-male transgender patients. JAMA Dermatol. 2015;151(11):1260-1261. 

27. Katz KA. Transgender patients, isotretinoin, and US Food and Drug Administration–mandated risk evaluation and mitigation strategies: a prescription for inclusion. JAMA Dermatol. 2016;152(5):513-514. 

28. American Academy of Dermatology. Position statement on isotretinoin. https://www.aad.org/Forms/Policies/Uploads/PS/PS-Isotretinoin.pdf. Published December 9, 2000. Updated February 19, 2018. Accessed May 21, 2018.

29. Miller RN.  AMA takes several actions supporting transgender patients [press release]. Chicago, IL: American Medical Association, June 12, 2017. https://wire.ama-assn.org/ama-news/ama-takes-several-actions-supporting-transgender-patients. Accessed May 21, 2018.

30. Hollenbach AD, Eckstrand KL, Dreger AD, AAMC Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development, Association of American Medical Colleges. Implementing curricular and institutional climate changes to improve health care for individuals who are LGBT, gender nonconforming, or born with DSD. 1st ed. Washington, DC: Association of American Medical Colleges, 2014. https://members.aamc.org/eweb/upload/LGBTDSD%20Publication.pdf. Accessed May 21, 2018.

31. Katz KA, Furnish TJ. Dermatology-related epidemiologic and clinical concerns of men who have sex with men, women who have sex with women, and transgender individuals. Arch Dermatol. 2005;141(10):1303-1310. 

32. Houghton V. Do ask, do treat. Dermatology World. 2017;27(11):31-35.

Back to Top