As the patient census has become increasingly diverse, it has become more challenging for EDs to provide quality care in emergency situations. Studies show that marginalized populations face greater social inequalities and healthcare disparities, placing them at higher risk for diseases and death. One patient group that is not immune to these disparities is the lesbian, gay, bisexual, and transgender (LGBT) community. Approximately 9 million people in the United States identify themselves as LGBT.
“It’s important for emergency physicians to better understand the disparities and health risks that LGBT patients face in order to communicate more effectively with these individuals,” says Sara Jalali, MD. “An inherent challenge with treating this patient population is that sexual orientation and gender identity are not always evident. In many cases, patients hide this information from their healthcare providers for fear of discrimination. Compounding the issue is that there are few universal standards that are specifically applicable to LGBT health education. Healthcare providers are often poorly prepared to care for this at-risk population, which in turn can result in distrust and avoidance in seeking prompt medical care.”
In Annals of Emergency Medicine, Dr. Jalali and Lauren M. Sauer, MS, had an article published that outlined strategies for improving care for LGBT patients in the ED. It discusses legal issues, healthcare considerations, and current educational practices pertaining to the LGBT community. The article also provides several tips for improving the care of LGBT patients (Table) and communicating more effectively with the LGBT community as a whole as well as transgender patients.
From a legal standpoint, the laws pertaining to LGBT healthcare rights are complex and vary from state to state. Some facilities are incorporating LGBT-inclusive non-discriminatory policies, but many EDs still do not have explicit regulations in place. “To optimize care for LGBT patients, emergency providers should be informed about their state’s laws and hospital policies,” says Dr. Jalali. Clinicians should also learn about national laws and regulations so that patients are not deprived of support from their loved ones.
Social stigma, discrimination, homophobia, and transphobia are some of the factors that the LGBT may experience that can negatively affect their quality of life, influence their access health insurance, and impact their health behavioral choices. “There are specific healthcare risks that LGBT patients face,” says Dr. Jalali. While some progress has been made thanks to the Affordable Care Act (ACA), many states deny coverage for transgender patients seeking services related to sex changes. In addition, the ACA does not change biases among healthcare providers or ensure the quality of care.
An important factor to consider is that the LGBT community may have a heightened awareness of discriminatory behaviors from healthcare providers, even when intentions are positive. Small things like poor eye contact, infrequent follow-up care, or awkward body language may be interpreted as healthcare provider discomfort or discrimination. Some patients may avoid the ED because of these instances. “ED providers can’t make assumptions about the LGBT community,” adds Dr. Jalali. “Increased knowledge of healthcare barriers and evaluation of self-biases can help emergency providers positively change the care and outcomes of LGBT patients.”
Many medical schools are behind the curve with regard to incorporating LGBT healthcare education into standard medical curricula. “Some schools teach students to ask sensitive social history questions, but many do not teach them the differences between behavior and sexual identity,” Dr. Jalali says. “In many places, there is no educational standard for teaching students how to incorporate sexual history with other aspects of patient evaluations, such as sensitivity during physical examinations.”
The Association of American Medical Colleges has published a comprehensive guide to address the needs of LGBT education in the healthcare system. Available for free at offers.aamc.org/lgbt-dsd-health, this tool educates clinicians about the health needs of LGBT people, offers guidance for integrating this material into a curriculum, and assesses learner competency to determine effectiveness of change. As more institutions adopt these changes, new physicians entering residencies will be better prepared to treat LGBT patients.
The Accreditation Council for Graduate Medical Education does not currently include LGBT-related education in the emergency medicine curriculum, but residencies can benefit from having access to LGBT healthcare educational resources. The material can be presented as lectures on LGBT health in the ED or tied into various emergency medicine–related topics. Emergency medicine programs could also consider inviting expert speakers for additional education and develop methods for evaluating the effect of this education. Legislation is also supporting the notion of including sexual orientation and gender into electronic health records in order to reduce invisibility of the LGBT community.
“We need to enhance our advocacy efforts and enact effective educational curricular reform,” says Dr. Jalali. “Only then will emergency providers have the appropriate skills and empathy to help LGBT patients whenever they seek medical care.”
Readings & Resources (click to view)
Jalali S, Sauer LM. Improving care for lesbian, gay, bisexual, and transgender patients in the emergency department. Ann Emerg Med. 2015;66:417-423. Available at: http://www.annemergmed.com/article/S0196-0644(15)00092-X/fulltext.
Moll J, Krieger P, Moreno-Walton L, et al. The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: what do we know? Acad Emerg Med. 2014;21:608-611.
Kosenko K, Rintamaki L, Raney S, et al. Transgender patient perceptions of stigma in health care contexts. Med Care. 2013;51:819-822.
Kelley L, Chou CL, Dibble SL, et al. A critical intervention in lesbian, gay, bisexual, and transgender health: knowledge and attitude outcomes among second-year medical students. Teach Learn Med. 2008;20:248-253.