WASHINGTON -- Taking a good sexual health history of an LGBT patient can be made easier by being neutral and using the most current terminology, specialists said here Friday at the .
Of course, the biggest issue is just making sure you ask about sexual history in the first place, said , director of Women's Health at the Fenway Institute, in Boston. "If you think for a moment about whether a clinician has ever asked you about your history of sexual health, your sexual orientation, or your gender identity, you will start to have a sense of how we don't do this as well as we might."
She reminded the audience that sexual orientation and gender identity are not the same. Sexual orientation has three parts: attraction/desire (which sex or sexes you are attracted to); identity (do you identify yourself as straight, gay, bisexual, or something else); and behavior (do you have sex with men, women, or both). Gender identity, on the other hand, refers to which gender the patient identifies with -- male, female, both, or neither. There is also gender expression -- how people present themselves outwardly in terms of gender.
"Increasingly, gender identity is on a spectrum," Potter said.
Discussions around issues of sexuality are not easy for some providers; they may feel comfortable discussing, say, medications for HIV but not other issues, Potter said. A found that while 84% of HIV care providers discussed adherence to antiretroviral therapy with their patients who were taking it, only 16% discussed condom use, while 14% said they discussed HIV transmission and/or risk reduction.
In its 1997 report, "," the Institute of Medicine (now the National Academy of Medicine) noted, "Ironically, it may require greater intimacy to discuss sex than to engage in it," Potter pointed out.
, co-chair of the Fenway Institute and a professor of medicine at Harvard, noted that there were many tools available to clinicians and patients about the importance of discussing this topic, including the materials available from the Fenway Institute.
"As internists, the first thing is thinking about the whole patient, so not only focusing on gender identity but thinking of it in a larger context and integrating it, making it more routine," he said, noting that the federal government is enhancing that process by requiring this data in various kinds of reports. "The Uniform Data System for Community Health Centers, for example, at the end of 2016, will be requiring obtaining this data from our patients," he added.
That being said, there is no one correct way to collect the information, Mayer continued. "It could be obtained at registration, or it could be obtained by the clinician. And increasingly, with new technology, we have other opportunities to collect this data, such as secure patient portals where the patient can provide that information in addition to other behavioral health information."
At the Fenway Institute, patients are asked on an intake form whether they think of themselves as:
- "Lesbian, gay, or homosexual"
- "Straight or heterosexual"
- "Bisexual"
- "Something else"
- "Don't know"
"This is one question that we think is a helpful one that seems least judgmental," he said. "Each community may need to do some testing of what are the cultural norms."
The Center for Excellence in Transgender Health at the University of California San Francisco asks patients about their current gender identity as well as what sex was assigned to them at birth, he noted.
If the data are being collected during an interview, there are several important questions to ask, Mayer said. For example, what pronoun does the person prefer to be addressed by?
Another point for physicians to remember is that you cannot assume someone's gender or sexual orientation based on how they look or sound, so it's best to have your staff use gender-neutral terminology -- instead of the front desk person asking, "How may I help you, sir?" just have the person say, "How may I help you?" rather than putting a pronoun on the end.
Physicians also should avoid outdated terms such as "transvestite," "transgendered," "homosexual," "sexual preference," and "lifestyle choice," and replace those with "transgender," "gay," "lesbian," "bisexual," "LGBT," or "sexual orientation" as appropriate, Mayer said.
Similarly, although the word "queer" was once thought to be an insult, some people now proudly use the term to indicate they're not heterosexual. "Genderqueer" or "gender fluid" are now also being used by some younger people to describe their gender identity and expression as both male and female, or neither male nor female.
"Certainly, terminologies continue to change," Mayer added. "What we're discussing today in May 2016 may not be relevant a year or two from now -- [though] the basic principles of respect for autonomy and listening and trying to maintain open-ended conversation are important."
Disclosures
Mayer disclosed relevant relationships with Gilead Sciences and ViiV.