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Creating a Safe and Welcoming Environment for LGBTQ+ Patients

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Speaker: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward program is open access and free to all at stepsforward.org.

Marie Brown, MD: Well, welcome to the AMA STEPS Forward podcast. I'm Dr Marie Brown, an internist here in Chicago, and I am joined today by Dr Kaiyti Duffy, the chief medical officer at the LA LGBT Center. Welcome Dr Duffy. And thanks so much for taking the time out of your incredibly busy day.

Dr Kaiyti Duffy: Of course. Thank you for having me. I love talking about this kind of thing.

Dr Marie Brown: Well, we really appreciate it. So could we start by having you tell us a little about yourself and the center?

Dr Kaiyti Duffy: Sure. So, I'm fairly new to the LA LGBT Center. I'm from Chicago originally. And I started here in January of 2020. So right before the pandemic. I was the inaugural medical director for Audre Lorde program. And our Audre Lorde program is dedicated to those folks who have identified as a woman or a girl at any point on their journey. In the LGBT health world this is a population that often hasn't gotten the focus of other groups, particularly with the HIV crisis. So, I was hired to build that program and then with the pandemic, our focus shifted and our CMO retired. And so now I've stepped into that role, but I'm a family medicine doctor by training. I've worked my whole career pretty much in LGBT health. So, this is my professional home, and this is the population that's closest to my heart.

Dr Marie Brown: Wonderful. And I should say that when I introduce myself that I use the pronouns, she/hers.

Dr Kaiyti Duffy: Thank you, yeah.

Dr Marie Brown: Which we all, hopefully at the end of this podcast, we will all begin to do.

Dr Kaiyti Duffy: Yes.

Dr Marie Brown: If we're not doing it already. So, let's get started. Why do we really need to have this conversation amongst our colleagues, our physician colleagues and our teams, and our nurses? Is the current or the past experience of many of our patients in the LGBT community that different? Do they have different insurance? Is there different socioeconomic challenges? And have they experienced health care differently? What's the research out there?

Dr Kaiyti Duffy: Yeah, so I think we are definitely making strides as a medical community, but there's still quite a bit of work to do. Before I came to this job, I was the medical director at the Broadway Youth Center in Chicago, which is a drop-in center for LGBT youth experiencing homelessness. And we had a clinic embedded. And I got into the habit of asking the young people questions about their experiences with the medical community up until that point. And part of it was an informal exercise just to see, were there any points that a doctor, a caring doctor or health care team, could have intervened? Were there any missed opportunities for these young people that could prevent them from sitting in front of me? And without exception, I'd ask, when was the first time somebody asked you about your sexual orientation or about your gender identity? And they would say here, during my encounters here.

So, many of these young people had been in the foster system, had definitely been to routine pediatrician visits. And no one ever asked them the question. And that always struck with me that even though training is moving, we're now training medical students and residents about the importance, both clinically and socially of taking a full sexual history and asking about questions of identity. It's still not making it into practice. And so, for LGBT folk who are trying to access care, there's the fear that either their presentation is going to be met with condemnation, disgust, or at best, ignorance, so that people—they'll be ignored, this part of their identity. And even in, I think, our most well-meaning providers, that's still the case. So, I think the younger people who are just emerging from training, will tell you, yes, we got a lecture on transgender people. We got a lecture on the sexual history, but we're missing that connection to practice.

And I think if we're going to break down why, I think there are those folks who really will never, no matter how much training or how much we talk to them about it, this will never be a part of their practice for whatever reason. There's still quite a bit of homophobia even in the medical world. So this isn't really for them, because we don't want people accessing care from somebody who really is not willing to consider these aspects. But for those people who really do want to better serve this population, I think are still having some discomfort, and it's about fear. It's about confusion and not having the confidence with language, and not wanting to offend patients sitting in front of them. I have my own story that I fall back on because it helps me empathize with providers who are new to this population.

And if you'll humor me, I can tell you my own story, but I'm a queer identified woman. I've been out since I was 18. And I went to medical school and did family medicine pretty much for the sole purpose of caring for LGBT people because of my own experiences, coming of age, my own fears about disclosing to a doctor, and the shame that brought with it. So, I did a track in residency that was HIV focused. I started practicing with hormones, providing hormones and gender-affirming care in residency. My first job out of residency was Howard Brown, which is also an FQHC, like my clinic currently, that's dedicated to LGBT people, but like all FQHCs, we're also assigned people through Medi-Cal or Medicaid. So some people who have no relationship with the LGBT community come to get care with us. And sometimes interactions with those folks can be a little bit awkward.

They'll look around and look at the posters and say, oh, I see what's going on here. I see what this clinic is. And I had one patient during my first couple weeks there who was assigned to us through Medi-Cal. The person was very masculine presenting, was wearing a religious necklace, and had a very complex history of diabetes, uncontrolled, and CHF. And I spent a lot of time on their medical history. I got their med rec done. I delved into social history. They were getting divorced. They identified as heterosexual, hadn't started dating yet, but it was a long visit, and I felt I got to know this patient. They did disclose some depression symptoms. I did a PHQ-9. It showed that they were experiencing some mental health challenges. So, as I left after saying my goodbyes, I tapped the behavioral health consultant to come into the room and just explore a little bit more about these mental health issues.

Behavioral health consultant was in there for almost an hour. And so, she came out and eventually found me and she sat next to me, and she put her hand on my shoulder and she said, so this patient made the appointment today to start hormones. And I still cry every time I think about it. I still get emotional because the courage that it took that patient to come and present as they were presenting and to interact with me and had this hope that I would be different than other places. And I fell into that trap of this is somebody who looks very straight, who looks like they'd been forced into the clinic here. And I don't want to make them uncomfortable by asking the questions that I usually would. And so I didn't, I put them into a box, and shame on me. And that's something I think about often because I'm somebody who was really trained in this. And I expected most people who walked in the door to be responsive to those questions.

And so, I understand how the challenge that the general primary care provider or specialist feels when they don't know what percentage of the people in front of them might be grappling with these issues. And so, I think in starting these conversations, hopefully it piques some interest, and it starts creating habits in our scripts that start utilizing and incorporating language that is more expansive and affirming, and it just becomes part of how we practice, so that we don't differ depending on our assumptions of the person sitting in front of us.

Dr Marie Brown: And I will share—thanks for sharing that because we all are fearful that we're going to say the wrong thing and offend, or embarrassed that we didn't do the right thing. I will say that one of my brothers is gay. He died of AIDS years ago and lived with me, and yet I just took the AMA module on LGBT, and I failed. Now I got 60% and I was like, darn, here I am thinking I'm a little bit more sensitive. I'm a little bit more aware. And we have developed, as I shared with you earlier, a toolkit on concrete steps for small practices to address equity. And part of that, what we're talking about today, is the LGBT community.

So, what are the dos and don'ts? So, for a physician who wants to do the right thing, doesn't have biases, but is unaware and unfamiliar and has not had much experience, and certainly not any training or fellowship in the specific needs of this community. What are some of the dos and don'ts that somebody in our audience might be listening to who has a general practice? I was an internist. So, I saw the hypertension and the diabetes. It was not exclusively for this community. So, some of the dos and don'ts and how do we create a safe and welcoming environment for all of our patients?

Dr Kaiyti Duffy: Yeah. So, I think the first tangible thing to do, particularly for providers who've been practicing for a while is look at our scripts, look at the questions that we ask in a history, that we ask, that we know just roll off our tongue. And then look for areas that might seem that there could be opportunities to expand. So, for instance, somebody will—a female presenting person might be asked, what are you doing to prevent pregnancy? And that statement is loaded with assumptions. And so, picking that apart is very worth it in the end, even if that person is heterosexual identifying, it becomes part of the script so that it doesn't change with the person. So, I'll ask, are you currently sexually active with someone who produces sperm? That's a question that now I ask everybody. And I'll preface when I'm starting a history with, there's questions that are very personal in nature and I do ask everybody, so please don't be offended or think that I'm making any assumptions about you.

When I walk into the room, and again, because this is a big thing at our clinic, but I would definitely recommend other providers consider this. I say, my name is Dr Kaiyti Duffy, I use she/her pronouns. What pronouns do you use? And that can be jarring for people. They'll say, I'm a woman, or I'm a man, look at me, and I'll say, well, this is something that I do ask everybody so that it rolls off the tongue. And for patients, even who've never considered this. It is a moment also for me of quiet activism of saying, there are people who are gender expansive within this clinic. And so, me asking about that, hopefully, insights in you the knowledge that not everybody corresponds with the binary. And they might, or they might not, but the more normal we make it, these discussions with patients, hopefully, the more accepting they are themselves and the safer that our patients feel when it comes out of my mouth and they're able to answer affirmatively.

Dr Marie Brown: And I liked what you said that you practiced it until it rolled off your tongue easily. And I remember doing that as a medical student, being concerned about asking something that I would blush over, and you just practice—practice saying it. And I think that's very helpful. I also read in, and we'll talk about resources at the end, the Gay and Lesbian Medical Association has some very concrete steps, including name tags, that underneath the name tag, you could put the pronouns so that if most of your patients are not representative from the LGBT community, you're at least making a statement. So along those lines, in the waiting room, what could someone who wants to be more welcoming do?

Dr Kaiyti Duffy: Well, I think signs—signs stating that this is an affirming place for people of all genders and all sexualities. But unfortunately, I think a lot of places stop with the sign. So, if a place has a sign and then the front desk person proceeds to misgender someone who is checking in, that sign hasn't done anything. So, you want to be sure that we're not just using symbols, but signage is a good thing. I think taking a look at forms, intake forms to ensure that they're not binary, they're not just asking about male and female. They're not just asking about assumptions of heteronormativity, that they are inclusive of multitudes of gender and sexualities. And I think that does strike people when they're filling those out. And then training. So, training staff in values clarification, and looking inside themselves and looking at their own biases and how can they prevent those from being a part of the interaction with patients?

I think that's key. That's very important. And it has to be the physician at the practice, and the care teams have to make that commitment that this is something that this whole practice is willing to do and interested in doing. Pronouns are something that it takes a little bit of time, it's a muscle. And so, we have a lot of patients who go by they/them. And someone who identifies as they/them, initially when somebody has never, ever tried to use a pronoun other than he or she, you stumble, and you sometimes make mistakes. And for some people, they/them feels awkward because it's not how we were trained grammatically, but it's something that becomes easier with practice, with that muscle memory.

And we also have to, as we're learning, and as our practice are becoming more affirming, we also have to be honest when we've made a mistake, when we have used an incorrect pronoun or made an assumption and apologize, move on, and then say, you're going to do better next time. But that's really important, I think, why a lot of us don't start asking these questions and don't start down this process because of that fear that you know you're going to mess up.

Dr Marie Brown: And I think those are really good points. And I think it reminds me of asking the patient, how do you want to be addressed? And then being consistent. So, I think asking the pronouns and being humble, I think. Because we don't know, and we don't know what we don't know.

Dr Kaiyti Duffy: And that can be done way in advance of even that first encounter. It can be done with the intake forms. It can also be on the banner in the EHR. Every EHR is different, but we've been enabled it so that we see the preferred name. We have to have the legal name, but we see the preferred name and parentheses. You can see pronouns—preferred pronouns in those parentheses as well. So, there's ways that you can help your staff so that they can see that information right away. And sometimes these things change for a person—their preferred name or their pronouns. So, it's still appropriate for the physician and the provider to have the conversation. But as much as the practices systems can support this, you stand a better chance of succeeding.

Dr Marie Brown: And patient education materials, or even magazines that might be in the waiting room, same-sex patient education, where clearly the partners of the same sex. I would imagine that would quietly convey a more inclusive experience for somebody new to the practice.

Dr Kaiyti Duffy: Sure. And education posters about cervical cancer screening that don't just include people who are female-presenting. So, language to suggest that not only women have cervixes or things like that, that you don't often see, but does send a message about your office's approach to different populations.

Dr Marie Brown: And then you—just to be sure that we are all using inclusive forms, which you mentioned. So, getting away from wife, husband, and using the phrase a partner and leaving an opportunity for other when female, male, other. Any other things like that. And where might we find some of those resources so that we are informed correctly about the way we can use our forms to be more welcoming.

Dr Kaiyti Duffy: Right. And it's a challenge because as clinicians, we do need to know the gender assigned at birth, the sex assigned at birth. We do need to know that. That's clinically very important. So, we need spaces to be able to establish that. And then also establish how this person identifies. So having forms that have a section on both of those things. So, allowing people to describe themselves in the way that they feel most appropriate, but yeah, so giving more options for gender and some department of motor vehicles are even moving in this direction where you can either say you're non-binary or you can give another answer for that. Also, with people who might be male-identified and menstruate. So you want forms—I know that sometimes there's intake forms for females, for males, you want to be sure that your forms open up to the possibility of people having experiences that aren't necessarily in line what you assume to be about a gender.

Dr Marie Brown: And I guess that also refers back to gender-neutral restrooms.

Dr Kaiyti Duffy: And sometimes that's an area where we get different kinds of feedback that some people want to have gendered, some people want gender neutral. I think that whatever you decide, you want to be sure that people feel safe using the bathroom of the gender where they identify. And having a gender-neutral option, even if you do have the other two, can provide that opportunity. So, for people who are using a wheelchair that often will have, there could be a separate bathroom in some offices. So, have that also be the gender neutral.

Dr Marie Brown: Right. And we've used a lot of terms just in our few minutes that we've been speaking. Where would someone who doesn't know what they don't know, a physician who wants to be more inclusive, go to really get a primer on some of the vocabulary that we should all be using now?

Dr Kaiyti Duffy: So, there's definitely resources, GLMA has quite a few resources on this. I think that's something maybe the AMA, we should do. We should have that overview of language and terms that we use, because it is, for many people, it's very surprising that a trans man might identify as heterosexual or might identify as straight, and that those things don't go in line with each other. So sexual orientation and gender identity can be totally distinct. And so, these are concepts that are clinically important and that need to be broken down for folks. I know there are toolkits out there, but I know internally we do quite a bit of training with folks on all the modules with LGBT health. And it's definitely something I think that the mainstream medical organization should be able to offer to them.

Dr Marie Brown: And I took the AMA LGBT medical Med Ed module, and it was helpful. And you would get some understanding of and learn more about the proper vocabulary and become more familiar with it. And you mentioned GLMA, which is the Gay Lesbian Medical Association, which I found very easy to read and very helpful for thinking how to make my practice much more welcoming. And apparently, they mentioned that you can sign up in your local community so that someone can go online to find a practice.

Dr Kaiyti Duffy: That's right. Yeah. So, they identify practices that patients can refer to, to know that they are affirming and that it's a safe place to seek care. I think though, that as physicians, I think we're perfectionists, and we want to be the best that we can be, but I don't think somebody has to have mastered all of these modules before trying to broaden their focus at their office. I think just even having a little bit of information, and the best intention, and the honesty is the absolute first step. Someone wanted to become a specialist to really carve out for this population then they can advance, but most providers can do small steps to make their offices and their own clinical care more LGBT friendly.

Dr Marie Brown: We are seeing things change, and we really need to provide that primary care. So sometimes what I read, is it so that many people in this community don't get regular preventive services, is that—

Dr Kaiyti Duffy: That's for sure correct. The LGBT population, we have our fair share of disproportionate health outcomes. I think predominantly that stems from often the trauma that people still carry with them from the time that they were coming out or living in secret, and what that process was coming out can cause a lot of damage that we carry with us as adults. And so, we can have a lot of complex psychosocial attributes that go along with our physical health. Also, the delay in presenting for care because of the reasons that we talked about—this fear of having to disclose how is the physician going to respond? And if you need screenings that don't align with how we assume a person's gender should be. So, like trans-masculine folks who need cervical cancer screening, that's a population that is very likely going to not be screened because of the pain, the trauma of having to go through that disclosure, and then the speculum exam itself. So, you'll find that there are disparities in health outcomes based on that.

I would say most gay people, queer people, can give you a synopsis of a time where a health care professional really offended them. And that's unfortunate. That's very unfortunate. And that's why it's so important to have these places of safety.

Dr Marie Brown: Well, that's why we appreciate you taking the time, but that also adds to—we, physicians, can educate ourselves and hopefully the audience taking time listening to this will become a bit more aware, but what about our staff? We have medical assistance. They come from all walks of life. They may have negative feelings about this community. How do you train or engage your staff?

Dr Kaiyti Duffy: Yeah, since we are the LGBT Center, this is something that we are very unapologetic about, that if somebody comes to work here, they need to be affirming, and they need to use affirming language, and they need to confront whatever biases they might have up to this point. So, we have very intensive trainings during their first week of employment, where they'll have discussions with folks who are trans-identified, and they'll have a lecture or a presentation on all the vast different presentations of gender identity and sexual orientation. And so, I think with us, we're unique in that sense, but I think with practices that are serious about wanting to move towards being more inclusive and more affirming, this is something that should be a part of the onboarding process. So, looking at how patient-facing staff might have to engage with their own internal biases. And that's not just about sexual orientation, it can definitely include larger topics, but I would encourage practices to incorporate that kind of discussion in their onboarding and having a module or having at least a dedicated section on this issue.

Dr Marie Brown: Hopefully the audience has learned a few ideas, and we can refer them to a couple of resources at GLMA, the Gay Lesbian Medical Association, has a very nice primer that's open access as is the EdHub at the AMA. Any other last suggestions or anything else you'd like the audience to take away?

Dr Kaiyti Duffy: Well, one area that I think is incredibly important when a primary care provider is seeing folks with cervix and uteri, is developing a practice of trauma-informed pelvic care because there are folks who are lesbian identified, who might never have had penetrative sex. There are lots of people in our community who've had a strong history of sexual trauma. And I think this type of practice, of trauma-informed pelvic care, goes beyond LGBT folks, but I think is intrinsic to the care of our population. So understanding that this kind of exam for us is clinical, and we've done it lots and lots and lots of times, but that's not the case for many people. And medical trauma is real. And there are many people who can tell you stories of how it felt to have a speculum exam and how traumatic it felt. And it felt like assault. And so, part of what I am trying to do at our practice, but also talk about on a larger front is how to undo that, how to stop medical trauma from happening within our clinics.

You can tell a patient, walk a patient through what a speculum exam is, and their brains understand, but their bodies sometimes don't. And so, for providers and physicians to connect with that and understand that this interaction can have lasting effects. And so that being trauma-informed particularly about those sensitive exams is really key to having a safe practice.

Dr Marie Brown: And I think that making sure that the patient knows they have the control. That at any point you want me to stop, we'll stop.

Dr Kaiyti Duffy: And I've had patients who've cried, who've gotten tearful when I've said that to them—that this exam is uncomfortable, but it shouldn't be painful. If it's painful, you tell me, and you have bodily autonomy during this whole process. If at any point you want to stop, then we stop. And I think using those words is incredibly important, not just thinking, oh, my demeanor sends that message. I'm being kind, I'm speaking softly, but you need to say those words to somebody who's in a very vulnerable position sitting in front of you. And I think that could make the difference between, are they going to delay this next screening, or are they going to come because they have this memory of having a safe encounter. And I'd also say, we talked about this before about specialists.

Dr Marie Brown: Yes.

Dr Kaiyti Duffy: So, we send a lot of our patients to get assessments from a specialist, for whatever reason, lots of things going on with patients. And I can't tell you how many times our patients have had negative experiences, and we're not specialists. So, I can't provide that care to this patient. So, it leaves us feeling fairly desperate that we're sending our patients out into this world, and we can't ensure that they're going to be treated with respect, that their gender sexuality isn't going to be called into question.

And that's an area that I think needs quite a bit of work with specialist society. So, learning more about populations and how maybe hormones might or might not interact or affect a certain condition. Because we get back a lot of consult notes that say the person needs to go off hormones, and that's it. And it's just untrue, number one, and it doesn't help us with the workup at all. So, we're happy to partner with specialist groups or individual specialists in the community to talk with how these issues may or may not impact their overall health, but it is the responsibility of the specialist as well. And so, I want to underscore that, because I do think that primary care providers express this interest and learning about these things, and they know that this is part of their care—full sexual history of full social history. But in the specialist world, I don't think is common.

Dr Marie Brown: And I was just thinking, I started signing my emails with and adding the pronouns. And a friend of mine who I hadn't spoken to in quite a while in another state, we were emailing, and he said to me, I just don't get those pronouns. And so, the House of Medicine, our own peers, we need to do a better job. We may not be able to change the world around us, but having a difficult conversation with our colleagues who we're referring our patients to, so that they feel as welcome as, hopefully, our patients feel under our care. And I want to thank you for your time and I want to thank the listeners for their time.

Dr Kaiyti Duffy: Thank you.

Dr Marie Brown: Thank you, Dr Duffy.

Speaker: Thank you for listening to this episode from the AMA STEPS Forward podcast series. AMA STEPS Forward program is open access and free to all at stepsforward.org. STEPS Forward can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward podcast series, stepsforward.org.

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