Affirmative History Taking
The LGBT Health Education Center, in collaboration with the Health Resources and Services Administration, developed a resource for creating an inclusive environment for LGBTQ patients. Their guidelines for inclusive health history taking and health history forms are summarized below.
When asking about relationships, instead of mentioning “wife/husband” or “mother/father,” use terms that are inclusive of LGBTQ families, such as “partners” and “parents.” It is also helpful to include a blank space for the patient to specify the relationship in their own words.
In asking about family history of disease, use the biological term “blood relative” instead of gendered terms like “mother/father” to allow the inclusion of people who are adopted in addition to LGBTQ families. If a history of disease is present, provide a blank space for the patient to specify which relative.
Ensure any diagrams asked to specify the location of pain on the body do not have a gendered human outline. Use boxes or quadrants of the body instead. See the image below for an example.
The information above can be found at the following web address: https://www.lgbthealtheducation.org/wp-content/uploads/2017/08/Forms-and-Policy-Brief.pdf.
Affirmative Sexual Health History Taking
The Centers for Disease Control (CDC) and others recommend the six “P’s” when conducting a sexual health history. The discussion should focus on:
Partners: Number and genders.
Practices: What is going where.
Protection from STDs: Appropriate risk reduction counseling.
History of STDs: May include more specific reduction counseling.
Prevention of pregnancy: Is a pregnancy possible and/or desired?
Pleasure or pain: Are sexual practices uncomfortable or painful? Are they enjoyable?
The PDF “Guide to Taking A Sexual Health History,” which includes example dialogue and more details on the topic, is available from the CDC on this website: https://www.cdc.gov/std/treatment/SexualHistory.pdf.
The LGBT Health Education Center, in collaboration with the Health Resources and Services Administration, developed a resource about creating an inclusive environment for LGBTQ patients. Their guidelines for inclusive sexual health history taking and health history forms are summarized below.
Questions about sexual history should not assume heterosexuality and, as a result, not every sexually active person will require contraception. However, do not assume monogamy either, and therefore it is best to inquire about each current sexual partner(s).
Sexual health discussions should also allow the patient room to discuss broader issues, such as past or present intimate partner violence and reproduction concerns or options.
Eliminate “female only” or “male only” sections of the health history form or discussion. All questions should be offered to all patients with an option to check “Not applicable.” This approach is consistent with the guideline to “screen for the organ” rather than to screen for organs based on designated or perceived gender.
The information above is from the LGBT Health Education Program and can be found at the following web address: https://www.lgbthealtheducation.org/wp-content/uploads/2017/08/Forms-and-Policy-Brief.pdf.
When discussing birth control options and the possibility of pregnancy with your patients, this resource from reproductive access is beneficial. It includes transgender and gender-diverse people and uses gender-inclusive language. https://www.reproductiveaccess.org/wp-content/uploads/2018/06/bc-across-gender-spectrum.pdf.
Physical Exams
Physical exams can bring up past trauma for any patient, and that reality is especially relevant for transgender and gender-diverse people. In general, physical exams should be delayed until sufficient trust and rapport have been established with the patient. Here are some suggestions for inclusive and affirming behaviors when conducting a physical exam:
Physical exams should focus on the parts of the body and not the gender identity or sexual orientation of the patient.
Mirror language that the patient uses to describe their body. For example, a transgender man might use the word “chest” instead of “breasts” to refer to their body. By using that language, the patient feels affirmed in their understanding of their body.
When asking patients to undress, avoid gendered words for clothing such as “panties,” “blouse,” or “bra.” Healthcare providers can say, “Please undress from the waist up,” rather than name body parts when preparing to complete a breast exam.
A full explanation of how the physical exam will happen can put the patient at ease and remove uncertainty about what will happen.
Explain to the patient why it is medically important for the healthcare provider to examine their uncovered body to avoid situations where the patient thinks that the provider is doing something unnecessary because of their desire to see the patient’s body.
The following guidelines from the Center of Excellence for Transgender Care at the University of California, San Francisco include greater detail than the information provided above: https://transcare.ucsf.edu/guidelines/physical-examination.
Caring for Transgender and Gender-Diverse Patients
In the areas of health specific to transgender and gender-diverse patients, the seminal resource is The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) for the Health of Transsexual, Transgender and Gender Nonconforming People, Version 7 (2012). The SOC document is available for free download in many languages on the WPATH website: https://www.wpath.org/publications/soc. Chapter topics include:
Mental Health
Hormone Therapy
Reproductive Health
Children and Adolescents with Gender Dysphoria
Epidemiologic Concerns
Surgery
There are detailed hormone protocols for administration both before and after puberty, recommendations of how to discuss effects on reproductive health, as well as a chapter outlining the differences between gender nonconformity and the medical diagnosis of gender dysphoria.
Another great resource is the University of California’s (UCSF) Center of Excellence for Transgender Care website, which offers short explanations to common questions providers may encounter when caring for
transgender and gender-diverse patients, including initiating hormone therapy. It also provides informative overviews of both masculinizing and feminizing hormone therapies. https://transcare.ucsf.edu/guidelines