Why LGBTQIA+ Competence and Humility Are So Important in Health Care

Physicians Committee: Help us and our followers understand the unique considerations medical professionals should keep in mind when treating their LGBTQ+ patients and why it's important to educate medical professionals on LGBTQIA+ specific care.

Dr. Dissen: Very often when topics such as LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and Others) competence is brought into a health care discussion, a common response I receive is, “Oh, I treat everyone the same, so it doesn’t matter what their sexuality or their gender identity are, as I will treat them the same as anybody else.” And while this is often rooted in a desire to be supportive and compassionate, it really is important to realize that all medical and/or health care professionals really do need to know that the LGBTQIA+ community does have unique health needs and considerations that must be taken into account in order to provide quality care. 

First, we need to recognize that many LGBTQIA+ are profoundly distrustful and suspicious of the health care system, and for rather good reasons. When the first Diagnostic and Statistical Manual (DSM) was published in 1952, there was an official diagnosis for “homosexuality” which was viewed as a “a sociopathic personality disturbance” alongside pedophilia and sexual assault. It would take 35 years before the DSM would no longer same-sex attraction as a psychiatric or medical disorder, or a form of sexual deviation. And it wouldn’t be until 1990 before the World Health Organization would stop classifying homosexuality as a mental disorder. During the time period during which the DSM did classify homosexuality and same-sex attraction as a disorder, the medical community committed horrific abuse towards LGBTQIA+ people including chemical castration, aversion therapy, and forms of shock treatment.

There has also been a harmful history of medicine viewing any deviation from the standard gender binary as pathologic as well. In 1980, in the third publication of the DSM, we first saw the presence of a diagnosis of “transsexualism,” and in 1990, the World Health Organization created an ICD diagnosis code for “transsexualism.” And as of 2018, with the most recent version of the ICD to date, there is still the view that being transgender, gender nonbinary, or gender expansive is a physical and/or mental health condition instead of a valid means of self-development and expression of identity.

And for those people who are born intersex, medical discrimination and a denial of bodily autonomy continues. In 2013, the international pilot study “Human Rights Between the Sexes” was conducted, where it was found that intersex people experience discrimination worldwide due to the prejudices and biases of medical practitioners. In a direct quote from the study, “Intersex individuals are considered individuals with a ‘disorder’ in all areas in which Western medicine prevails. They are more or less obviously treated as sock or ‘abnormal’, depending on the respective society.” The ways in which these discriminatory practices are found in medicine and health care are numerous. Some of the more egregious examples include involuntary genital surgeries during infancy and throughout childhood, and the use of coercion and shame-based tactics in convincing patients and/or their parents into taking hormonal treatments. The results of these and similar medical abuses include lifelong physical and psychological problems.

As a result, many LGBTQIA+ people are very distrustful of the health care system for fear of being discriminated against, treated poorly, denied access to care, or not be cared for in a respectful and empowering way. The consequences of this are numerous and are part of the reason why many LGBTQIA+ people have higher rates of heart disease, food insecurity, housing insecurity, diabetes, stroke, certain forms of cancer, body dysmorphia, and eating disorders. In addition, many LGBTQIA+ people experience discrimination in the workplace, which can mean higher rates of unemployment, which can also then mean lack of access to health insurance in order to then access and gain entry into the medical system. 

Lastly, for people who are transgender, gender nonbinary, gender expansive, or intersex, there can be unique physical health needs and considerations pertaining to how certain medical interventions such as surgery, hormone therapies, and puberty blockers can impact nutrition needs, overall calorie needs, changes in baseline laboratory values, and potential changes in risks for certain chronic health conditions. In order to provide quality care, health care professionals and medical providers need to not only create an environment that allows their LGBTQIA+ patients and community members to know that this is a safe and supportive place to receive respectful care, but also that the care team has the competence and knowledge needed to provide care and assess for potential disease markers and risks.

Physicians Committee: At the Physicians Committee, we value continuing education for physicians. How can our physician members access resources and training for LGBTQIA+ patient care?

Dr. Dissen: One of my favorite organizations is GLMA. First founded in 1981 as the American Association of Physicians for Human Rights, GLMA (or more formally, GLMA: Health Professionals Advancing LGBTQ+ Equality) is the oldest and largest health care association in the world that is focused on the health and well-being of LGBTQIA+ people. They are an amazing resource of research, education, training, and best practices in working with LGBTQIA+ people and communities, and they also allow practitioners to add themselves to a directory so that LGBTQIA+ patients looking for competent and respectful providers can more easily find practitioners near them. You can find more about their incredible work at GLMA.org/.

In addition, I highly recommend the National LGBTQIA+ Health Education Center. They are another incredible organization that provides programming, educational trainings, resources, and supportive consultations to health care practitioners and care organizations in order to provide more culturally competent and evidence-based care to LGBTQIA+ people. This is an excellent place to not only gain more education and training, but also become more involved in advocacy if that is something a care provider is interested in exploring. They can be found at LGBTQIAHealthEducation.org/.

Lastly, I would also encourage practitioners to learn more about the work of SAGE: Advocacy & Services for LGBTQ+ Elders. Older adults who are part of the LGTBQIA+ community often experience particularly high levels of discrimination, bias, prejudice, and suffer from a lack of health care provider understanding and training. If your work in any way involves the care and well-being of older adults, please learn more about their work and check out their resources at SAGEUSA.org/.

Physicians Committee: Another thing we value here at the Physicians Committee is research. We conduct human-relevant research studies, and we'd love to hear more about your research and your team's work to shed light on this space.

Dr. Dissen: Thank you so much! I am very proud of the research that my teams and I have been doing to advocate for the health of LGBTQIA+ people! Most recently, one of the wonderful teams that I work with published “Orthorexia nervosa in gay men – the result of a Spanish-Polish eating disorders study” in BMC Public Health. In this study, we were looking at factors that were predictors of orthorexia nervosa and body satisfaction in gay men living in Spain and Poland. What we found was that lower body mass index and the use of sexual hookup apps like Grindr were the most important predictors of orthorexia nervosa in the study population. And interestingly, those gay men who used pre-exposure prophylaxis (PrEP) medications on a daily basis also were found to have a significantly lower risk of developing orthorexia nervosa compared to those who only used PrEP medications occasionally, and those with a higher BMI were also found to have a lower risk of orthorexia nervosa. 

In the past year, I also had the wonderful opportunity to publish an article in Cutting Edge Nutrition and Diabetes Care – Diabetes Dietetics Practice Group discussing the importance of equitable care for LGBTQIA+ patients with a specific focus on how discrimination, bias, and lack of provider competence can increase several important risk factors for type 2 diabetes, and how provider competence and training is needed in order to better screen for and manage diabetes in the LGBTQIA+ population. 

Lastly, I have the amazing joy of leading a research team with two incredible colleagues of mine that specifically focuses on the food and nutrition considerations and needs of LGBTQIA+ people. We recently completed two studies, one of which is currently under peer review with a journal, and the other we are currently in the process of writing up the manuscript for to submit for peer review. Without sharing too much before the peer review process has been completed for either study, I will share some key details. The first looked at the LGBTQIA+ competence and professional behaviors of nutrition professionals and dietitians. And while their attitudes were quite positive, the translation of those attitudes towards professional skills, behaviors, and practice was quite low, and showed how many nutrition and dietetic professionals do not know how to match their skills to the unique needs and identities of LGBTQIA+ people. The second study was specifically looking at experiences of transgender and gender nonbinary people, with a particular emphasis on their relationships with food, nutrition, and the kind of nutrition care they have received during their times navigating the healthcare system as a transgender and/or gender nonbinary person. Some preliminary results show that their care teams have spent little to no time talking about the role of food and nutrition on their physical health, and there has been particularly very little time spent on how food and nutrition needs might change as a result of medical interventions like hormone therapy and surgeries. We are excited to share both of these studies with the health care field after (fingers crossed!) they may it through the peer review process.

Physicians Committee: What are a few key takeaways someone who might be learning about these topics for the first time can take with them today?

Dr. Dissen: The most important takeaway I could hope for is this: Please recognize that many LGBTQIA+ people have been wounded and harmed by the health care system in the form of bias, prejudice, discrimination, and lack of provider competence and knowledge. As a result, they may be very hesitant to share key information about themselves, their health histories, or their needs for fear of further discrimination, or may outright avoid engaging with the health care system all together. To remedy this, consider how you can make your work, your engagements, and your professional environment universally supportive and inclusive. Ask yourself the following questions:

• Adapt and evolve. How can your intake forms be updated to be more inclusive? Do you allow spaces for people to indicate their sex assigned at birth? Their current gender identity? Their pronouns?
• Look at your patient education literature and materials. Do they only feature people in heterosexual relationships? Do they only feature cisgender people? How can they be updated to show a more diverse range of human experience and expression?
• Practice cultural humility. Be honest and reflective with yourself about what you know, what you don’t know, and what you are uncomfortable with learning more about. Take a training, talk with LGBTQIA+ identifying people, and build your knowledge base while also allowing people to share the richness of their stories and experiences without interruption.
• Get yourself out into the community! If you want to be an ally and an advocate for LGTBQIA+ people, don’t wait for them to come to you. Table and march at Pride parades, speak at Pride centers, go to LGBTQIA+ events and ask people about their experiences with the health care system and what it is they wish they had provided for them.
• Recruit and retain LGBTQIA+ providers. You need to have professionals and providers on your staff that are part of the community. Patients and community members want and need to see themselves represented in health care spaces. The more that LGBTQIA+ providers and professionals can be actively sought out and brought onto the team, the more that their knowledge, experience, and insights can be heard.

Physicians Committee: What are some ways our members who are not medical professionals can help ensure LGBTQIA+ patients receive appropriate and inclusive care?

Dr. Dissen: What a wonderful and important question! First and foremost, listen to people’s stories. Ask friends, family members, community members, and others in your life (perhaps even yourself) who are part of the LGBTQIA+ community what their experiences have been in navigating the health care system. Listen, hold space, and see what has been wonderful and what has been problematic. By doing so, you can learn more about exactly what they need. 

Next, go to appointments as an advocate and supportive friend when someone you know needs to see a member of the health care team. Come with them, make sure providers are using the correct pronouns, speak on their behalf if something biased occurs so that you can take on the effort of correcting that wrong as opposed to that struggle always falling upon the one who had to experience the blow in the first place. The best way I have ever heard allyship described is this: An ally is someone who stands in front of you when rocks are being thrown. So be an ally, get into the thick of it, and show the LGBTQIA+ people in your life that you are there to make sure they are healthy, supported, and cared for whenever they are engaging with the health care system.

Anthony Dissen, EdD, MPH, MA, RDN, CPH, is a registered dietitian nutritionist, health educator, and public health researcher. He is currently a tenured assistant professor of health science in the School of Health Sciences at Stockton University where his scholarly work focuses on the intersections between queer and gender-nonbinary communities and the health care system, particularly in the area of cultural competence, body liberation, and nutrition considerations of queer people.