I recently wrote about changes in the way medical students are taught about LGBT health issues. In the piece, I mentioned that new regulations will soon require doctors to ask patients about their gender identity and sexual orientation, an observation that generated a wide range of comments, many of which were quite hostile to the notion of physicians discussing gender and sexuality. Should physicians really broach these topics during routine visits?
Simply put, sexual practices and gender identity should be viewed similarly to other categories that we now consider to be a necessary part of patients’ medical histories—for example, their past medical and surgical history, travel history, or family history of cancer. As many recent studies have demonstrated, patients in the LGBT community represent a population with certain inherently higher risks; therefore, a careful understanding of patients’ gender and sexuality can help tailor medical care to their individual risk factors.
If physicians think that LGBT patients are a rarity in their clinics, they are mistaken. In a survey of more than 7,000 adolescents published in the journal Pediatrics, 9.3 percent of sexually active teens reported having a same-sex partner; however, 38.9 percent of them self-identified as heterosexual/straight. A similar finding was seen in the adult population: A survey of more than 4,000 men revealed that 72.8 percent of men who have sex with men identified as being straight. This raises an important point: If the goal of the medical interview is to assess and address risk, then questions must be both specific and directed toward particular sexual practices, not simple categories.
There are many considerations that are not unique, but are nevertheless particularly relevant, to the LGBT community. According to data published by the Centers for Disease Control and Prevention, 29.2 percent of gay high-school students experienced dating violence in the prior year (versus 13.8 percent of the heterosexual students in the same districts). Meanwhile, the National Longitudinal Study of Adolescent Health demonstrated that lesbian, gay, and bisexual youths in Grades 7 to 12 were twice as likely as straight youth to attempt suicide. That is not to say that questions about sexual violence and self-harm should be limited to LGBT patients—these discussions are likely to be standard topics for many pediatricians.
However, for certain LGBT teens who may already feel misunderstood and marginalized, the physician’s office can represent a safe space to engage in a conversation about sexuality and identity. Being able to have this conversation openly and consistently can thus not only appropriately shape the visit and guide patients toward necessary resources but also function to build rapport. In fact, students do wish for these conversations to happen: A study of more than 2,000 high-school students revealed that 80-90 percent of them would find it helpful to discuss sexual matters with their physician. However, physicians rarely broached the topic, as only 15 percent were asked about their sexual history and just 8 percent were asked about their sexual orientation.
At the same time, a 2014 study published in the Annals of Behavioral Medicine revealed that lesbian, gay, and bisexual young adults (age 12-22) were less likely to take part in physical activity and were 46-76 percent less likely to participate in team sports, raising concerns for associated complications like obesity, diabetes, and cardiovascular complications later in life. This concern was echoed in a 2010 study in the American Journal of Public Health, which revealed that lesbian, gay, and bisexual adults were more that twice as likely to have cardiovascular disease as straight adults. To put this in perspective, a person's risk of cardiovascular disease roughly doubles in the presence of a family history of it. Though these studies and risk factors should not be treated equivalently, it is important to recognize that asking patients about their sexual orientation can be as important for a cardiologist as noting their family history of heart disease. The issue is further complicated by a well-documented increased prevalence of smoking—the California LGBT Tobacco Use Survey demonstrated that people in the LGBT community were 50-200 percent more likely to smoke than the general population. The complications associated with smoking go without saying.
Perhaps the greatest risk that the LGBT community faces, one that is too often left out of the conversation in a physician’s office, is HIV. Here are some simple facts: According to the CDC, in 2010, 63 percent of new HIV infections affected men who have sex with men; yet only 49 percent of gay and bisexual men age 18-24 were aware that they had been infected with the virus. At the same time, 24 percent of gay and bisexual men report never using condoms. Most striking is the fact that despite these statistics, 56 percent of gay and bisexual men say that a doctor has never recommended that they be tested for HIV. In the same study, almost half of gay and bisexual men reported never discussing their sexual practices with their physician.
Patients who are transitioning can be particularly affected by poor physician communication. A December 2015 study of 314 trans women in San Francisco published in LGBT Health revealed that 49.1 percent reported using hormone replacement therapy that wasn’t prescribed by a clinician, raising concerns for potentially deadly complications such as liver damage, heart disease, and clot formation. At the same time, a September 2015 study in Lancet Oncology noted the decreased ability of transgender people to receive cancer care, with some evidence suggesting that “transgender people have a disproportionate cancer burden.” Making the issue more difficult is the lack of cervical and breast cancer screening seen in trans men and of prostate cancer screening in trans women. Indeed, physicians need to be both aware and vigilant of the often-complex nature of continued cancer screening in transgender patients.
If that list seems long, the roster of LGBT-related health risks is actually much more extensive. Here is one more: The average primary care visit is roughly 20 minutes. That’s not enough time to ask every patient about every issue. So, in an environment where time is always limited, questions that help assess risk factors also help physicians to tailor their questions, interventions, and counseling, ensuring that patients receive the best possible care.
Ultimately, though, the root cause of the communication breakdown goes beyond time constraints. Often, it can be traced back to physicians’ basic discomfort discussing sex-related topics with patients in general, and with LGBT patients in particular. Whether from lack of education, lack of comfort, or lack of time, these important topics simply fall by the wayside.
Aspects of a patient’s history like sexual practices, gender-related surgery, identification, or plans for self-treatment, are all part of the larger picture of the patient’s life and health. Doctors cannot chose to ignore these practices any more than they can choose to ignore what medications their patients are currently taking. If the goal of medicine is to treat the entire person, physicians must begin by taking a complete history.