Improving LGBTQ Sensitivity in Eyecare for Improved Patient Outcomes

The LGBTQ community is one that faces unique challenges when it comes to healthcare. This group can be subject to discrimination and stigmatization that is unwarranted and unfair. Because of such challenges, patients may be apprehensive to share their information about themselves publicly, even to their doctors.

Optometrists, and all healthcare providers, should be as culturally sensitive and accepting as possible to not only improve patient comfort but patient outcomes. Becoming familiar with the common terminology, promoting a setting of acceptance, and modifying the way you gather information can make a difference in the quality of eyecare for LGBTQ patients.

Inequality in LGBTQ healthcare

Research completed by The Joint Commission and Institute of Medicine highlights inequality in healthcare for the LGBTQ community. These organizations found that LGBTQ patients, especially transgender patients, may avoid seeking routine and preventative care.¹ To facilitate positive change in this area, The Joint Commission created an extensive field guide for providers to improve cultural competence and patient-centered care for the LGBTQ community.

Roughly 50% of transgender adults and 30% of LGB patients reported having delayed or avoided medical treatment. This was compared to 20% of heterosexual adults. If a patient had a previous experience with a provider who was not supportive or sensitive, they were more likely to wait until a condition became severe or life-threatening to obtain care in the future.¹

Patients in this population are also at higher risk of conditions like anxiety, depression, stress, eating disorders, substance abuse and homelessness.¹ Improving the practice of routine and preventative care in this group could go a long way in addressing healthcare issues remediating the inequity.²

Let’s define some common LGBTQ terms

First and foremost, optometrists should gain familiarity with the terminology used in the LGBTQ community to better be able to understand, connect, and discuss with patients. The list below is non-exhaustive but includes the most generally accepted definitions for the most often used terms, adapted from Medical Provider’s Guide to LGBT Terminology (www.pride in practice.org)³

LGBTQ Glossary of Terms

LGBTQ- Lesbian, gay, bisexual, trans (gender or sexual), queer
Agender- Lack of gender identity (may identify as gender neutral)
Asexual- Lack of sexual attraction to others
Bisexual- Attraction to two genders
Cisgender- Consistency in one’s birth sex and gender
Gay- Attraction of men to other men (or can mean a person to others of the same gender)
Gender Identity- Internal sense of a person’s gender (can be different from sex assigned at birth and gender expression)
Gender Dysphoria- Distress or discomfort caused by discordance between a person’s sex assigned at birth and their gender identity
Gender Expression- Outward manifestation of a person’s gender (this can include clothing, voice and mannerisms, behavior, hairstyle, makeup etc.)
Genderfluid- Having a gender that changes
Heterosexual- An attraction to people of a different gender
Homosexual- An attraction to people of the same gender
Intersex- Spectrum of disorders in which one’s genitals, chromosomes, hormones or other factors do not all align with the same sex
Lesbian- Attraction of women to women
Non-binary- Not exclusively male or female gender identity
Pronouns- Terms used to refer to a person in lieu of their name (she/her, he/him, they/them)
Queer- Inclusive term referring to other sexual orientations other than heterosexual
Sex at Birth- Male or female, assigned based on reproductive organs, hormones and chromosomes
Sexual orientation- Sexual attraction to one or more genders
Straight- Attraction of a person of one binary to the other (often synonym for heterosexual)

Six steps to create an LGBTQ-inclusive environment

1) Updating your intake or history form is a great place to start. When asking for gender, consider adding birth sex and gender identification a two separate questions. If you have selections include transgender and “other” as options; alternatively, you may want to leave the questions open ended and simply allow the patient to fill in with their own appropriate response.

2) Pronouns can also be obtained quite easily through the intake forms. You may also want to ask for a legal name and preferred name on the intake form. Confirm with the patient whether it’s okay to note their responses in the medical record. Providers should try to follow the patient’s lead when it comes to their preferences.

3) When inquiring about any sexual history or relationships use open ended questions so the patient can respond in their own words. If you need to ask a specific question related to lifestyle or sexual orientation, make sure you explain why the information is medically necessary. Establishing a trusting relationship is key since there may also be patients who are members of the LGBTQ community who do not make their gender or sexual orientation public. If this is suspected to be the case, providers should remind patients that all medical record information is confidential.²

4) Making your office LGBTQ-friendly also lets patients know it is a safe place without judgment. Having unisex restrooms can make patients feel more comfortable since this can be a point of stress or anxiety.

5) Staff members should receive training on cultural sensitivity and should know where to find the preferred identification and pronoun information.

6) Displaying symbols or posters supportive of the LGBTQ community or wearing rainbow pins or stickers are all easy ideas that can go a long way to make patients feel comfortable and accepted.² Embracing LGBTQ pride month this June is a great opportunity to start!

From personal experience: case study

A 36-year-old male, new patient presented to my office with complaints of slightly blurry vision and mild headaches on and off for a few months. The headaches were dull and seemed to be “behind the eyes or forehead.” The patient was not sure if they were related to near work or reading or any other associated factors.

The patient reported unremarkable medical and ocular history as well as family medical and ocular history. Best corrected visual acuity was 20/25 in the right eye and left eye. Pupil reaction was normal, extraocular motilities were normal and confrontation visual fields were normal.

On dilated fundus exam, apparent bilateral disc edema was present in this seemingly healthy 36-year-old male patient. I told the patient what I was seeing and probed for any more medical information that may be relevant (like a history of hypertension, diabetes etc). The patient denied any further history and seemed like an accurate historian.

I ran through differentials in my head but knew that this could possibly be a hypertensive emergency (and I had no blood pressure cuff available at this optical location) or papilledema, warranting an emergency referral. I made my recommendation to the patient to go to the emergency room, wrote down my findings for the patient to bring and made a referral to a local neuro-ophthalmologist for follow up.

I called the patient to follow up the next day who, I was happy to hear, reported back that there were no emergency findings (no hypertensive emergency, no tumor, or mass) and he had a scheduled follow up with the neuro-ophthalmologist in a few days. I received the referral report back from the neuro-ophthalmologist a few days later which read “A 36-year-old female with IIH status-post bariatric surgery presents for follow-up” and was very confused.

As it turns out, this patient was born a female and was a transgender male. The patient identified and expressed as male and, therefore, circled male on the office’s medical intake form. The patient had also been embarrassed about the weight loss surgery because being overweight had led to depression. The patient did not think it could be related to the eyes, therefore did not mention it to me. When the patient presented to the emergency department after hearing this could be very serious, he then shared the full medical history.

Had I known the birth sex of this patient and history of obesity, that along with the symptoms and signs would have led me to a primary differential diagnosis of classic idiopathic intracranial hypertension (IIH).

Though ultimately my recommendations would have been the same, since it was a new patient and emergency causes need to be ruled out, I spent a great deal of time thinking about how I went wrong. The additional information would have helped me develop differentials more clearly and I needed to figure out how I could prevent this from happening again.

In conclusion

It is our responsibility to obtain the relevant information needed to treat our patients successfully and effectively. If barriers exist in communication or pertinent information is overlooked, we cannot perform our due diligence. So, ask yourself, “How do I create an environment that facilitates openness and honesty without fear of judgment for the sake of my ability to properly treat and diagnose?”

I challenge each of you to consider the ideas presented in this article and integrate them into the way you practice. Optometry is a field where we are fortunate to have the opportunity to help patients and improve their lives.

When patients receive care in a judgment-free environment, it fosters the honest disclosure of health and lifestyle information. Setting the stage for cultural sensitivity establishes the best possible patient-doctor relationships and allows us to better serve the LGBTQ community. Let’s all make sure we are providing our care in a way that is complete, authentic, inclusive, and sensitive to all individuals.

References

1.Levitt N, Klingenstein K, Reiss E. “Enhancing Your Clinical Skills in Caring for LGBTQ

Patients.” Hospital for Special Surgery, Retrieved June 1, 2022, from https://www.hss.edu/conditions_enhancing-clinical-skills-LGBTQ-care-hospital-setting.asp

Creating an LGBTQ-friendly practice. Retrieved June 1, 2022, from https://www.ama-assn.org/delivering-care/population-care/creating-lgbtq-friendly-practice

2.Bass B, Nagy H. Cultural Competence in the Care of LGBTQ Patients. [Updated 2021 Oct 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563176

3.Medical Provider Guide to LGBT terminology pride in practice. Retrieved June 1, 2022, from https://www.prideinpractice.org/wp-content/uploads/2019/05/Medical-Provider-Guide-to-LGBT-Terminology-Pride-in-Practice.pdf