Block by block: Building on our knowledge to better care for LGBTQIA+ patients

Abstract

Background Emergency physicians need to recognize the diversity of identities held by sexual and gender minorities, as well as the health implications and inequities experienced by these communities. Identities such as lesbian, gay, bisexual, transgender, queer, questioning, intersex, asexual, aromantic, and many others fall under the LGBTQIA+ acronym. This wide spectrum is seldom discussed in emergency medicine but nonetheless impacts both patient care and patient experience in acute and critical care settings. Aims This commentary aims to provide a brief but nonexhaustive review of LGBTQIA+ identities and supply a critical framework for applying this understanding to patient encounters in the emergency department, as well as describe the challenges and educational aims at the level of medical school, residency, and postresidency. Materials and Methods The commonly used and widely accepted definitions of LGBTQIA+ terms are described, as well as implications for patient care and emergency physician education. The authors of this writing group represent the Society for Academic Emergency Medicine, LGBTQ Task Force of the Academy of Diversity Inclusion in Medicine. Results LGB terms are addressed, with LGBTQIA+ adding “intersex,” “asexual,” and “+,” to include other gender identities and sexual orientations which are not already included. This paper also addresses the terms “transition,” “nonbinary,” “polyamorous.” “two‐spirit,” “queer,” and others. These acronyms and terms continually expand and evolve in the pursuit of inclusivity. Additionally, with some health issues potentially related to medications, hormones, surgery, or to internal or external genitalia, important EM physician tools include gathering an “organ inventory,” asking about sexual history, and conducting a physical exam. Discussion Most persons have congruent biological sex, gender identity, and attraction to the “opposite” gender. However, humans can have every imaginable variation and configuration of chromosomes, genitalia, gender identities, sexual attractions, and sexual behaviors. Terms and definitions are constantly changing and adapting; they may also vary by local culture. Obtaining relevant medical history, conducting an “organ inventory,” asking about sexual history in a nonjudgmental way, and conducting a physical exam when warranted can all be important in delivering best possible medical care. Although there has been increased focus on education at the medical school, residency, and faculty level on LGBTQIA+ patient care in the ED, much work remains to be done. Conclusion Emergency physicians should feel confident in providing a model of care that affirms the sexual and gender identities of all the patient populations we serve. Optimal patient‐centric care requires a deeper understanding of the patient’s biology, gender identity, and sexual behavior encapsulated into the ever‐growing acronym LGBTQIA+.

Emergency care considerations for transgender and gender diverse youth: a review to improve health trajectories

“…Asking open ended questions is important to prevent passing judgement and providers should leave room for patients to express their own concerns. As always, chaperones should be utilized for all genital exams and patients should be told prior to examination why more-sensitive exams are necessary to the patient's medical management [25,28].…”

“…Although there is increasing curricula at the undergraduate medical education level, it is still inadequate with up to 25% of EM residents expressing discomfort taking histories from lesbian/gay/bisexual patients and >40% noting challenges in history taking from transgender patients [16]. Education needs to extend to all levels, especially more experienced faculty, who, given their seniority, may have a greater knowledge gap and higher level of discomfort [16,28].…”

“…Once in a confidential provider-patient encounter, optimal care for TGD youth requires focused, relevant history taking and physical examination [28]. Providers should only ask questions relevant to the patient's chief complaint and explain why certain questioning is medically relevant (e.g., sexual history as risk factors for sexually transmitted infections) [24].…”

“…• Federal and private insurers should cover interventions as prescribed by a physician as well as appropriate medical screenings that are recommended for all body tissues that a person may have. [28]Combined statement: AAFP, AAP, ACOG, ACP, AOA, APAApril 2021• Oppose any laws and regulations that discriminate against transgender and gender-diverse individuals or interfere in the confidential relationship between a patient and their physician. • Strongly oppose to any legislation or regulation that would interfere with the provision of evidence-based patient care for any patient, affirming our commitment to patient safety…For gender-diverse individuals, including children and adolescents, this means access to gender-affirming care.• Strongly oppose any effort to criminalize or penalize physicians for providing necessary care for their patients.…”

Urinary symptoms after genital gender-affirming penile construction, urethral lengthening and vaginectomy

“…Clinicians should include an "organ inventory" or "anatomy inventory" and prior relevant surgical procedures in the electronic health record; this entails documenting a patient's current anatomy, uncoupled from their gender identity, assigned sex, or pronouns (i.e., documentation of whether a patient has testes, prostate, vagina, cervix, uterus or ovaries, among other organs). Use of organ inventories allows providers to remain updated regarding risk factors and diagnoses related to anatomy, facilitates relevant screening exams and diagnostic testing, and can facilitate taking a thorough sexual history (12)(13)(14).…”