I recently wrote a thread on Twitter to celebrate the LGBTQ+ affirming health care our family received from our midwife last spring when my partner gave birth to our baby.* My partner is non-binary (their gender doesn’t fall neatly within the binary of male/female) and our family is made up of queer folks. We were lucky to receive inclusive, affirming care during the process of bringing our child into the world. I say “lucky” because as a longtime LGBTQ+ health advocate I know this isn’t the norm for many people in the LGBTQ+ community. I think this is one of the reasons why my tweets have been liked and shared by thousands of people - at last count, the thread has been liked over 9,400 times and retweeted almost 2,700 times. Many people made comments about crying happy tears as they read our story and expressed hope that they’ll receive similarly affirming care in the future. Our experience gave them a glimpse that another world is possible, that it’s possible to receive health care in a way that makes space for you and that honours your identity in all its beauty and complexity. In fact, you deserve this kind of care. Everyone does!

If you don’t know what it feels like to be scared to see a health care provider or go to the hospital because you’re afraid they might discriminate against or even harm you, you might not understand why my tweets made people cry. The tl;dr version is this: as an extensive body of research** and the lived experiences of countless people prove, many LGBTQ+ people face stigma and discrimination when accessing health care. It can be so bad that some people avoid accessing health care altogether. A recent US survey found that 8% of all LGBTQ+ people had avoided or postponed needed medical care and 7% had avoided or postponed preventative screenings because of disrespect or discrimination from health care providers. Transgender people in this survey were much more likely to postpone or avoid seeking care - 22% reported avoiding medical care and 19% reported avoiding preventative screening. This is consistent with findings of a Canadian study in which over 20% of trans people said they’d avoiding going to the emergency department because they were afraid of gender-based discrimination. It’s also consistent with findings of the European Union LGBT survey, in which 10% of lesbian, gay and bisexual respondents and 20% of transgender respondents who’d accessed health care reported experiencing discrimination over the past 12 months.

The effects of stigma and discrimination are worse for LGBTQ+ people who are Black, Indigenous or people of colour (BIPOC), transgender, non-binary and gender diverse - especially transgender women and transfeminine people - as well as bisexual people, people who are disabled, living in poverty, experiencing homelessness, using drugs or doing sex work. In saying this, I want to emphasize that LGBTQ+ folks are not inherently less healthy than other people - it’s the stigma, discrimination and oppression we experience as gender and sexual minorities that makes us sick. (Want to know more about this? Great! I edited a whole book about it.)

There are many people working hard to change this both within and outside the health system. To these folks, I say: I see you, and I am deeply grateful for your work. The LGBTQ+ community has a long history of resilience and creativity in developing community-driven solutions to ensure we get the health care we need. That resilience and creativity is present today as people work to transform the delivery of health care so it’s more inclusive and affirming. And that’s good news, because we have some catching up to do. Research has shown that, on average, medical students in the US and Canada receive about five hours of teaching on LGBTQ+ content across the entire curriculum, and schools rated the quality of their content as “fair.” (I would love for us to work our way up to a rating of “excellent!”) This is changing in medicine and other health professions thanks to many people’s hard work and advocacy, but we’re not there yet.

Working towards systemic change can sometimes feel overwhelming, because it’s big and complex and progress isn’t linear. I try to keep this in mind as I do my part of the work to make health care more affirming and accessible to LGBTQ+ people, and I also look for small things we can do right now to move us closer to where we want to be. To the health care providers reading this, what small actions can you take today in service of supporting LGBTQ+ people to feel healthy and thriving? Since many providers receive little to no training on LGBTQ+ health in school or through your continuing education, I understand that it might feel daunting to figure out where to begin. Your jobs are busy and demanding - many of you make life or death decisions every day. Maybe you feel like you never have enough time for your patients or clients, never mind having extra time and resources to learn and try new ways of caring for them. It might feel intimidating (and maybe a little exhausting) to figure out how to care for LGBTQ+ people. How will you learn all this new terminology? What if you make a mistake? I get it. It’s scary to screw up, especially in the context of a culture where providers may be scrutinized and held professionally accountable for the care you offer.

But here’s the thing: LGBTQ+ people need you to learn and we need you to try, because too many of us aren’t receiving the care we deserve - and some of us aren’t receiving any care at all. This is reflected in the health disparities that disproportionately affect our community. And if you’ve read this far, I’m guessing that maybe you’re someone who feels called toward social accountability in health care - that is, to move from knowing about health disparities to doing something about them. In this spirit, I’m going to offer some suggestions for small actions you can take today, inspired by my family’s experience with our midwife and that I think are applicable across a range of contexts. In offering these suggestions, I want to emphasize that they’re coming from my perspective as a patient and an LGBTQ+ health advocate, not as a health care provider.

1. Ask open-ended questions and use language that reflects how your patient or client describes themself and their family/relationship structure: Instead of making assumptions about language (what pronouns people use, what words they use to describe specific body parts, etc.) or family/relationship structure, ask open-ended questions. For example, “What pronouns do you use?,” “What words do you use for the body parts we’re here to talk about today?,” and “Who are the important people in your life?” Our midwife did this during our first visit, which helped build trust and rapport between us and our health care provider. If you’re looking for tips on how to talk about gender pronouns with patients, Pride in Practice has a helpful guide that’s written specifically for health care providers. You can also signal that you’re open to these conversations by including your own gender pronouns on your nametag or ID.

   Listen to your patient or client’s answers to these questions and document this information in their chart and in your notes. Where possible, make your forms and other documentation practices and systems more open-ended and inclusive of diverse identities. Practice consistently using the right language in your interactions with your patient or client. This helps build trust, because it shows your patient or client that you’re paying attention to what they say. Make an effort to ensure that other members of the health care team also have access to this information and model using the correct name, pronouns, etc. for your patient or client even when they’re not there. I emphasize this because I know that conversations with patients sometimes look different than conversations about them, and respect for people’s identities needs to be woven into every aspect of their care.

2. Ask for consent before touching or examining your patient or client: Consent sometimes gets treated as a “one-and-done” sort of transaction where we ask for it once at the beginning of an encounter and assume that it covers every interaction that follows. Instead, approach the process of asking for consent as an ongoing conversation with your patient or client. This doesn’t need to add a lot of extra time or complexity to your interactions - it can be as simple as checking in before touching, moving or otherwise interacting with your patient or client’s body, listening to what they say and, if they say no or not right now, figuring out an alternative strategy that allows you to do what’s clinically necessary while respecting your patient’s boundaries. This will look different depending on how emergent or acute the situation is, and the extent to which you’re able to communicate with your patient, but it’s essential in fostering a feeling of safety and trust.

   This is important for all patients and it’s integral to trauma-informed care, something that’s of particular significance for LGBTQ+ people. At a population level, the LGBTQ+ community experiences higher rates of violence and trauma. These experiences can be both triggered and exacerbated by the health care system. (If you’re interested in learning more about this topic, check out the chapter on trauma and resilience in the LGBTQ+ community in this report from the American Association of Medical Colleges.) By practicing good consent skills, you can minimize the likelihood of triggering a trauma response in the person you’re caring for and help your patient or client feel seen and safe. Treat consent like a trauma-informed conversation, not a cursory transaction. There are lots of great online resources for learning about consent, and I think that the health care community could learn a lot from sex educators who’ve spent a lot of time breaking down how we can ask for and receive consent.

3. Advocate for your patient or client with other health care providers and hospital or clinic staff: When my partner was in labour, our midwife took responsibility for advocating for my partner and our family with other health care providers and hospital staff. Before a new member of the healthcare team like an anesthesiologist or a nurse came into our hospital room for the first time, our midwife had a quick conversation with them to get them up to speed on important personal details like my non-binary partner’s pronouns and our queer family structure. That small intervention made a big difference in enabling us to focus on our baby’s birth and not on having to explain ourselves each time a we met a new member of the health care team. It also helped ensure that the other care providers on our team had all of the information they needed to safely care for my partner and our family.

   LGBTQ+ people often do the work of teaching other people - health care providers, co-workers, family members, etc. - about our lives and identities, and many of us are accustomed to bracing ourselves against subtle and not-so-subtle forms of discrimination that can come up in those interpersonal interactions. When a health care provider takes on some of that work by acting as our advocate with other members of the health care team, it’s a form of solidarity, particularly in the context of a hierarchical medical system where patients’ voices aren’t always respected or heard. That doesn’t mean LGBTQ+ folks shouldn’t be able to share our stories or advocate for ourselves; by advocating for us you create space for us to choose whether or not to do the work of teaching others about ourselves.

Think of these actions as opportunities to support LGBTQ+ people to survive and thrive. Which of these three actions will you commit to practicing today, and how might it shift your interactions with the LGBTQ+ patients and clients you care for? Remember that it takes time and practice to learn a new skill – mastery doesn’t happen overnight. And learning can sometimes feel uncomfortable, especially if we’re stretching out of our usual comfort zone or if we’re accustomed to being positioned as the expert in the room.

The learning process usually involves making mistakes – that’s normal and isn’t a reason to give up or sink into shame. When you make a mistake, offer a genuine apology and move on. Want to build your apology muscles? Here’s a patient safety-informed take on it, here’s a video on how to apologize after getting called out and, if you’re up for a deep dive, here’s a whole book about apologies. You might also want to check out this roundup of tips on receiving critical feedback - it’s written for activists but I think that the advice is useful in many contexts.

As you put these suggestions into practice, you might find it helpful to think about and talk to other providers about them in terms of patient safety: gender- and sexual identity-based discrimination (whether as a result of implicit or explicit bias) in health care is a form of preventable harm. More importantly, it’s a way to show your LGBTQ+ patients and clients that you’re committed to their health and wellbeing and ultimately, to delivering health care in a way that actively seeks to shift entrenched patterns of stigma and discrimination. It’s socially accountable healthcare, and it’s good medicine!

Another world is possible. Let’s build it together.

Notes:

*Our family lives in British Columbia, Canada, where midwifery is a regulated health profession provided by registered midwives with hospital privileges.

**For example, see the Lambda Legal Report When Health Care Isn’t Caring, the European Union LGBT survey, recent survey data from the Center for American Progress, the results of the Canadian trans youth health survey, and research on trans people’s experiences with family doctors and in emergency departments.

Acknowledgements:

Thank you to Carly Boyce, Claire Bodkin, Janine Farrell and Rachel Rees for their feedback on an earlier draft of this piece.