I recently cared for a middle-aged male named Robert with chest pain. He was admitted by the night team, and I saw him the next morning after much of his work-up was complete. His only cardiac risk factor was that his father had a heart attack at age 55. The patient’s workup included a normal echocardiogram, normal troponins, and a normal nuclear stress test.
So, what was causing Robert’s chest pain?
As part of his social history, I ask about sexual orientation and gender identity (SOGI). He shared with me that he was gay and that he was worried about HIV. He said that he was in a long-term monogamous relationship with another man and that they were always careful to use condoms, but they recently had a scare.
Minority stress may have been causing his chest pain.
Minority stress is stress that is unique to a minority community. Minority stressors can accumulate beyond what a person can manage. Reaching their breaking point, the individual seeks relief. For some, that relief comes as nurturing from a counselor or a friend. For others, maladaptive coping techniques may prevail, including smoking, alcohol use, anger, violence, or illicit substance use. These maladaptive responses to stress can lead patients to the hospital.
As a hospitalist, asking patients about SOGI has become a routine part of my new patient intake. My SOGI questions are simple: “Are you attracted to men, women, or both?” and “Is your gender the same now as when it was assigned at birth?” I fold these questions in with my other social history questions.
I know that the LGBTQ+ community endures disproportionate levels of social violence, sexual assault, HIV, anxiety, depression, alcoholism, anxiety, homelessness, bullying, domestic violence, unemployment, and financial insecurity. The list goes on. Many LGBTQ+ patients prefer to hide those problems behind a closed door for fear that their health care provider either doesn’t care or doesn’t know how to help. Asking SOGI questions opens that door. Opening the door is a way to connect with LGBTQ+ patients, take a look around, and offer a hand in whatever way possible. At the very least, my LGBTQ+ patients see me as an ally who cares about them and sees them for the survivors they are.
My patient was suffering from anxiety about HIV, and his chest pain was a physical manifestation of his anxiety. I offered to check the patient for HIV and also had a conversation with him about pre-exposure prophylaxis (or PrEP) that can help prevent an HIV infection. He was interested in a referral to a PrEP provider and expressed his appreciation for my caring enough to ask and to help. He was also glad to know his heart was OK.
The CDC’s Morbidity and Mortality Weekly Report (MMWR) 2019 tells us that only 18.1% of those with PrEP indications were prescribed PrEP. Until everyone is screened for HIV, we must discuss HIV risk factors with our patients. In 2017, there were 37,500 new HIV infections, and this number has been stable since 2013. PrEP is an effective (96% risk reduction) tool to stop the spread of HIV and to reduce the number of new infections. Robert’s chest pain was not going to hurt him, but HIV could.
Some LGBTQ+ patients are reluctant to come to the hospital because when they engage with the healthcare system in which they do not feel welcome. In November of 2017, the Robert Wood Johnson Foundation and Harvard T.H. Chan School of Public Health published Discrimination in America: Experiences and views of LGBTQ Americans. Authors outlined statistics related to the LGBTQ+ experience in America. Remarkably, 11% of LGBTQ+ patients report that providers use excessive precautions or even refuse to touch them. 25% of transgender patients reported being harassed in a doctor’s office, and 19% reported being denied medical care. Transgender individuals have had so many bad experiences in healthcare that 31% reported having no regular form of healthcare, and 24% reported avoiding healthcare altogether.
The Barriers of a Binary Healthcare System
Michelle is one of the patients that pushed our health system to adopt a SOGI program.
Michelle’s birth name was Michael and was male-assigned at birth. Michelle was in a supporting home and felt comfortable talking to her parents about how she felt. Even though the world thought she was a boy, she knew she was a girl. Later, she would learn that these feelings had a name, gender dysphoria, and that she was transgender. As she neared adolescence, she had to engage with the medical system, which required occasional trips to the lab for blood work and hormone levels.
This particular day was busy at the lab with many patients in the waiting room. Her medical facility did not have the ability to accommodate her pronouns (she, her, hers) or her preferred name (Michelle). When her mother spoke to the receptionist and asked that her daughter be referred to as Michelle, she was told that they could not do that because her legal name was Michael, and a name change would mess up the lab work and the billing. Michelle sat in the waiting room with her mother for a couple hours until finally she was called by the lab technician. In front of a crowded waiting room, “Michael?” was called. Michelle was presenting female and to respond to the name Michael meant she was going to have to “come out” in front of a room full of strangers, an experience that was not new to her. She looked at her mom, and her mom understood. That day, it was too much, and they decided to come back another time when the waiting room was less crowded.
Unfortunately, this is the reality for many transgender patients who are trying to engage with a binary (either male or female) healthcare system. In order to receive the life-changing and lifesaving healthcare they need, trans patients have to abdicate control over their own coming out process. Or worse, they have to endure confusion and sometimes hurtful comments about their gender identity. Our healthcare system is alienating some of society’s most vulnerable patients.
Transforming Barriers into Solutions
Motivated by people like Michelle, UPMC Pinnacle’s diversity and inclusion committee started meeting to try to find ways to help a historically binary healthcare system create space for nonbinary patients (patients whose gender identity, gender expression, or sexual orientation are something other than straight or cisgender). Making space for nonbinary patients in our electronic health record was an important step in creating a safer and more affirming environment for the LGBTQ+ community.
As it turned out, not only was our SOGI project good for patients, it was good for staff. I have lost count of the number of colleagues who have shared with me that they are either a member of the LGBTQ+ community or an ally to the community. This project was also important for staff recruitment and retention. As many as 12% of people aged 18-34 years in the US identify as a gender other than cisgender. Given this reality, health systems need to take a serious look at their LGBTQ+ outreach. No health system can afford to alienate either 12% of their patients or 12% of a potential employee applicant pool.
Being gay or trans can be stressful. Hospitalists can use SOGI questions to open the door to discuss stressors unique to LGBTQ+ patients. Understanding minority stress helps us see the connection between social risks and the reasons our LGBTQ+ patients come to the hospital. Giving the right medical care at the right time is what hospitalists do. Making a positive difference in the lives of people like Robert and Michelle is what our work is all about.
Additional Resources
For further reading on the topic of LGBTQ issues in healthcare:
The GLMA Handbook on LGBT Health is a two-volume reference providing a comprehensive discussion of the topic. It is a must read for all health care providers.
The Fenway Institute is a web-based national provider of culturally competent, affirming, and nondiscriminatory LGBTQIA+ health education.
The Fenway Institute also has the Do Ask, Do Tell Toolkit for collecting sexual orientation and gender identity information in a clinical setting.
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