Improving Healthcare for the LGBTQ+ Community

Dr. Graham McMahon talks with Dr. Ricardo Correa about how clinicians and educators can build a more inclusive and compassionate healthcare environment for LGBTQ + patients and their families.

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Melody 00:02
Hello, and welcome to Coffee with Graham, a podcast discussion brought to you by the Accreditation Council for Continuing Medical Education. My name is Melody Cohn, and I'll be your host as we discuss important topics brewing in continuing education with ACCME's president and CEO, Dr. Graham McMahon. Grab yourself a cup of coffee or tea and join us for the discussion.

Melody 00:37
In June 2021, we both celebrated Pride month and observed the 40th anniversary of the beginning of the AIDS epidemic. As we move forward into the fall, we reflect on the advances in LGBTQ equality and AIDs treatments, as well as the ongoing challenges faced by the LGBTQ community. Specifically, those challenges in healthcare and the issues and disparities LGBTQ people continue to face. How can clinicians and educators build an inclusive and compassionate healthcare environment that provides high quality care for LGBTQ patients and their families? Today, we are delighted to welcome our guest, Dr. Ricardo Correa, Director of Diversity for Graduate Medical Education and Program Director Endocrinology, Diabetes, and Metabolism fellowship, University of Arizona, College of Medicine, Phoenix, and staff clinician and researcher at Phoenix VAMC. He also serves on the board of GLMA Health Professionals Advancing LGBTQ Equality, previously known as the Gay and Lesbian Medical Association. Thank you for joining us today, Ricardo.

Ricardo 01:56
Thank you so much for the invitation. It's a real honor to be here sharing this experience and definitely to be here with Graham as a mentor for me for many years. So it's a real pleasure to be here.

Melody 02:09
So turning to Graham, you have written very openly about your experiences as a gay clinician, patient, father, and a husband, and how that's affected your perspective on healthcare. What has that experience taught you about how we can build a more compassionate and inclusive healthcare system?

Graham 02:31
Thanks Melody, and great to join you and Ricardo for this conversation that's so important for me, for my community. And I think the message I'd really like to communicate to educators out there is that we have an opportunity to help our colleagues avoid assumptions about the patients that we're seeing. There's a much greater diversity in the behaviors and the identity of their patients than they may realize, and if they make assumptions that are heteronormative, that's not sensitive to the diversity of their patients, and they're not going to be able therefore to access those patients' real stories or the truths of their lives. They're not going to be able to connect with them. And the patients are not going to be able to feel like they can connect with the provider, and obviously that's a barrier and a problem that we shouldn't have to navigate or tolerate.

Graham 03:19
I'm used to, for example, being in the pediatrician's office and have a pediatrician ask me where my wife is or how my wife is, for example, or the nurse. I'm used to having patients make assumptions about me,

Graham 03:31
and when I encounter somebody who doesn't know me, I kind of steel myself for that opportunity or that challenge, that somebody's going to ask me something where I have to correct them or correct an assumption, and it shouldn't have to be that way. So I think the key thing that I'd like people to understand is not to make assumptions about the people that they're seeing and recognize the diversity of the community that they're taking care of. When LGBT people are everywhere. Well, we're just a normal part of the landscape. It shouldn't generate a surprise or a reaction. It would suggest to me that I'm not going to get the same level of care than someone else, and that's not appropriate or acceptable. I think my experience has taught me that there's a lot of ingrained attitudes out there to what my needs might be and assumptions are made about me and my family that I'd like my clinicians to be more aware of. If the clinician has questions, bring them on, but don't make assumptions because that would suggest to me I'm not going to get the care I need. And that's true for not just me, but for patients and people like me.

Melody 04:37
So there's a common misperception that because of all of the advances made in the LGBTQ community, Pride Month being widely celebrated in the US, same sex marriage being made legal across the country, seeing more LGBTQ characters reflected in movies and on TV, that we're in some kind of post-equality era. Some people think, well, what else is there to do? Ricardo, do you hear comments like this? Like, “move on, what's the big deal?” In your experience, what are the key healthcare issues affecting the LGBTQ community today?

Ricardo 05:18
Going back to that question, what else is there to do? There is a lot of things to do. There is just a starting point and I want to comment on some things that I don't know if people have been realizing, but one of them is many states has been passing some legislations in the last months about banning the use of hormone reaffirming therapy in younger population, in the adolescent. This affect great the transgender community. Plus the second thing that is, there's still a lot of fear from the people to declare if they are part of the LGBT community or not. Even when they go to the physician. This is very important for physicians to know, not because we want to judge anyone, but there are certain things that we need to take into account in the history and physical. The other thing we know that the LGBTQ community has more prevalence of suicide because of not supporting from the community, not supporting from their own family and not supporting even from the healthcare system.

Melody 06:39
Graham, any additional thoughts or issues that you would like to point out?

Graham 06:44
Thanks, Melody. We're definitely not in that post-pride era, and there are so many issues to address, like Ricardo said. There is so much evidence of widespread health disparities all across the country and around the world. A continuing issue remains, unfortunately, just violence, especially against trans people, but also against so many members of the LGBTQIA community. The second issue is self-harm, suicidality, just like Ricardo mentioned, those rates are still outrageously and frustratingly high. And in many cases, those are avoidable issues of self harm and even suicide because they're related to the way in which we treat each other as people. If family members just reject their spouses, their children a little bit less, then those patients, those people will survive. And that doesn't take a lot of give, to be a little more accepting, accommodating. You don't have to start marching in Pride parades to be less rejecting of a family member or a loved one.

Graham 07:52
But there are other issues that we face in our community. Access to care, in general, is much poorer. LGBTQIA people are less insured, underinsured, they access care less frequently. They don't participate in screening for preventable health conditions or even maintaining and managing their own sexual health. And as people get older, the systems of care for older LGBT people is also missing in many cases. You try finding an accommodating nursing facility for an older couple that needs nursing care who may be gay or lesbian for example, that's very hard. Those systems just aren't present in many parts of the country or the world. Topically relevant for me, of course, is another issue of diversity and inequity, which is the ability just to donate blood or bone marrow. I'm O negative and a universal donor, and I've twice been a bone marrow match and have been declined because I'm gay. And even though I'm healthy, in a monogamous relationship, at very low risk, I'm unable to be a blood donor. Those are essentially limiting access for donations from people like me into the system and suggests that I am different because of who I'm married to or who I love rather than my health status, and that's not appropriate.

Melody 09:23
Thank you for sharing. So clearly there's a ton of work still to do. Ricardo, what skills do clinicians and teams need in order to address these issues and provide better care for the LGBTQ community?

Ricardo 09:39
Yes. So I think that this is the key education for clinicians and for the next generation, because that's where I see that things will change. I think that in diversity, equity, and inclusion, every time that we do something, we will see really the change in the next generation because we're starting the process right now, but it will come, but education is key. One of it is try to teach all the students in the healthcare area, what are the correct way of approaching an LGBTQ person, how to understand what are the correct pronouns, what are the correct things to ask, and not just focus on the medical part, but there is an important component that is a psychosocial part that is very important. And I focus a lot on my fellows on whenever a transgender come to the clinic, as I mentioned, the medical part is five minutes, but ask about what is the social support, this risk of suicide, what are the other things that are happening?

Ricardo 10:54
So make them understand that there's more than just the person and the physiology of the person. There is the other component that can put that at risk. So education, not just only for the endocrinologist, but education for everybody on this. Something that, speaking with Graham, we were talking about this, is that trans care is not only for endocrinologist. Yes, we can be the leader of the team and manage a lot of the hormone reaffirming therapy. But this is a team that include multiple other healthcare workers that include primary care providers that can also support a lot of this. So at the VA, there is this kind of education. We still have some reluctancy of some of the providers or the clinicians, but we are trying to create a community where wherever that trans person go, feel comfortable in going. And it's not just one specialty that is responsible because at the end, this is a multidisciplinary approach.

Ricardo 12:02
The education-develop more and more education. So people do not reject patients because they don't feel comfortable. Sometimes you see even endocrinologist that says, I don't see trans patients. For me, that's absurd, outrageous that you don't see one kind of patient. It's like, if I'm a rejecting that diabetic patient, I don't see patient with diabetes. If you're a physician and you have the oath, then you have to serve any kind of patients. And in those patients, the LGBTQ community is included. I think that in order to address these kind of things, the first things to do is start educating the next generations so we don't need to talk about this 50 years from now.

Melody 12:49
Graham, your thoughts?

Graham 12:51
In terms of what clinicians should actually do, I think there's two steps here. The first is not to reject your patient like Ricardo said, and the second is to try and both encourage and accept them, and then probably the third is, if you can't provide the care that the person needs, refer them. And these three things are true, regardless of whether somebody is coming out, whether they're asking for support, if they're questioning or they need trans care. For example, first of all, don't reject. Number two, try and give them encouragement and acceptance. They're often on a journey and they need support. And third, if you can't provide the care, find somebody who can and refer them and follow up to make sure that that referral was completed.

Melody 13:49
It certainly requires a compassionate approach to care. Thanks Graham. The members of the LGBTQ and other marginalized communities can be sensitive to behaviors and attitudes that indicate bias. This question is for Ricardo: what are a few simple ways that clinicians can build trust and provide a safe space for LGBTQ+ patients and their families, so that a patient's first impression when visiting the website or going to the office is one of welcome, and feeling respected, and recognized, and safe.

Ricardo 14:26
The first thing is definitely, if we talk about your practice, is going again to education. Train the people that are in the front of your clinical practice, the people that receive others, medical assistant, administrative, whatever is the people that is in the front. So to one, be very open, non-discriminatory, and use neutral pronouns. Do not start asking things that are, or assuming, as Graham mentioned a few moments ago, assuming things like wife or husband, or why you are coming with two dads or two moms. Be very neutral and just try to stick to the more appropriate things to ask during that. That is the main thing, because when you enter and from the beginning, the environment is stressful, the rest of the encounter, even if the clinician is the best clinician of all, you already have a bad experience. Then for the clinicians, definitely is the same thing, it's trying to get the sense of being a human being. I think that that's the summary of everything, is being a human being and being empathetic with your patient, doesn't matter what your patient has or preference is.

Melody 15:53
Graham, in an article you talk about how even casual comments from front staff can create anxiety for patients and send the message that they won't be treated with care and with empathy. Can you give a few examples and describe how clinicians can raise awareness with their staff and teams?

Graham 16:14
Yeah, you're right, Melody. There's been a lot of examples in my personal life and experience. We're a two dad, family, a mixed race family, an LGBT family that has children, and we're very used to getting confronted with a variety of experience and attitudes where people find my family unusual. They may not be receptive to it, they may find it surprising. But the thing that bothers me the most is when somebody puts my children in a position where they have to defend or articulate the construction of their family to someone in a professional capacity, like a healthcare provider. You would expect better of a doctor or a nurse or somebody who's trained than to ask a child to justify or explain their family construction. That's not appropriate and you shouldn't put a barrier like that in front of a child who's trying to access basic,

Graham 17:07
For example, pediatric care. It'd be easy to look at each of these things I'm reporting to you and say, they're super trivial, they're minor, well, what's he complaining about? But the problem is that they just accumulate. All of these trivial little things, just accumulate. And it makes you feel like you're having to steel yourself as you go into an encounter with an unfamiliar person or make you feel like you're less than or different than the rest of the people in the environment. And that's just not fair. It's not what delivers positive and affirming healthcare for everybody.

Melody 17:45
So it sounds like clinicians have a bit of reflecting to do on their level of self-awareness possibly. And Ricardo, how do you think that they could best go about doing that?

Ricardo 17:57
Definitely. I think that something that is important is when, when you say that "I don't have a problem with homophobia," you have a problem. It's the same thing to say, "I don't have a problem with racism." You have a problem. So it's very important to understand that all of us, to certain point, we have bias. But the bias is not the problem. What we need to do is overcome our own bias and understand our own bias so we can be better person. So that's the key. There are certain ways that we can do this. There are certain tests that we can take as a clinician. I think the most famous test is the Harvard test for bias that you can test and see what are your own bias because all of us comes with bias. Nobody can say, "oh, I have no bias in everything."

Melody 18:58
Thank you for pointing out that there are so many resources available. It's just a matter of going and finding those for yourself. Graham, you've talked about how accredited continuing medical education not only build skills and changes behaviors, but also helps to evolve attitudes and change perspectives. What are some ways that educators can address these issues?

Graham 19:23
I think it's really important for educators to realize what you just said, Melody, which is that education can be used to bring people together and help them evolve their understanding of, and their insight in, and their acceptance of, diversity in all of its forms. And part of our role as educators is to facilitate exactly those types of interactions. There's a couple of specific things that we as educators can do to achieve that purpose and address those gaps. I've certainly found role-playing exercises, for example, really useful. You can imagine if you're a straight woman being asked to play the role of a gay male, or you're a straight male asked to play the role of a trans person. Once you subsume that role or embark on trying to play that role, you start to feel what it might be like, and that by itself can create the empathy that changes attitudes.

Graham 20:18
Those types of experiences are part of our role as educators to try and drive that experience. The second thing I'd say is that you shouldn't necessarily have to cover LGBT issues as a standalone topic. It's the kind of thing that you should incorporate into your routine approach to education. So if you're talking about heart failure, make the patient in the case happen to be an older lesbian woman, and her wife is the one who's expressing concern about their experience, and just that inclusion of a normal LGBT family in the construction of a case is irrelevant for the medical issues of the case, but important for the inclusion of diversity in the cases that are being discussed in a group. The other approach educators can use is to actually ask LGBT people to share their experience in that public forum or in their online activity. Much better to hear directly from the lived experience of LGBT people than to talk about them in the third person. That can be pretty compelling, it can be interesting, it can share the real life of people with this lived experience.

Melody 21:37
Thank you so much, Graham. So Ricardo, thank you so much again for being with us today and joining us for the discussion. Do you have any final thoughts or any final recommendations that you would like to share with our audience?

Ricardo 21:52
I think that in this process of being in a world that is more inclusive, in a world that is changing and is more diverse, I think that we should create and educate ourselves in multiple areas. And as clinicians we should be aware of all the things from now on, change our practice to an appropriate practice for the community, and we should be advocating or a better system that allows everybody to receive good healthcare and to receive healthcare in their own appropriate way. So my last recommendation is if you don't know something, try to find the answer and treat your patients as you treat your family.

Melody 22:45
Thank you so much. It seems like to achieve better inclusivity and healthcare, it requires those who are already included to make a space for those who aren't yet, and that education is the first step to creating that space. Ricardo, it's been a pleasure to have you. Thank you again to you and Graham for sharing your insights and shedding light on an important topic.

Melody 23:12
And thanks to you, our audience for joining us. If you have enjoyed this podcast or found it to be helpful, please subscribe to Coffee with Graham. We are available across a variety of platforms, Apple Music, Spotify, Buzzsprout, et cetera. And if you're able to leave us a review, we would love to hear your feedback. If you have any questions about today's podcast, or if there are any topics you'd like us to cover, you can feel free to write us at info@ACCME.org. Thank you for listening and as always, learn well.