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.
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.
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