Editor's note: This information in this article was further shared in an expanded poster presentation at the Alliance 2024 Annual Conference. "Recognizing and Mitigating Implicit Bias in Continuing Medical Education" received a best poster award at the conference. Congratulations to Alana Brody, MBA, CHCP; Michele Ingram; Poonam Kapadia; Emily Lewis; Susan Miller, Ph.D.; Nefertari Rigsby; and Ilon Rincon-Portas, MD. Click here to review the full poster.

A 2023 Gallup poll estimates 7.2% of Americans self-identify as LGBTQIA.¹ This translates to about 23 million individuals — up two-fold from the 2012 Gallup poll where 3.5% of respondents shared that they identified as such. As our society becomes more inclusive of gender diverse individuals, recognizing that a patient’s gender may be different than the socially constructed binary can help clinicians understand new terminology and the specific stressors encountered by patients in gender transition. In a 2019 study of oncologists at NCI-designated comprehensive cancer centers, 70% agreed or strongly agreed that they would be interested in education regarding the unique health needs of LGBTQIA individuals.²

According to the 2015 U.S. Transgender Survey, 24% of transgender patients have had to teach their providers about their health needs, causing them to feel frustrated, unsafe, anxious and/or burdened³. Likewise, health professionals have admitted their lack of training regarding LGBTQ + care⁴.

Ilon S. Rincon Portas, MD, executive director, Kaplan Medical Prep, suggests that a new language structure might help build trust within the clinicians’ practice. “This strategy goes beyond saying the incorrect name or using the wrong pronouns,” Dr. Rincon Portas says. “While a clinician may think they are being respectful, for example, calling people Mr. or Mrs., not everybody identifies with these titles.”

The basics begin with understanding the current lexicon for describing this group — most commonly referred to as LGBTQIA:

• Lesbian
• Gay
• Bisexual
• Transgender
• Queer/Questioning
• Intersex
• Allied/Asexual/Aromantic/Agender

Other terms that may be included are “2S = 2-spirited” and “P = Pansexual/ Polyamorous/Polysexual”. It is important to note that language continues to evolve, so clinicians need to pay attention to these changes and trends.

When HCPs refer to their patients with gender-neutral language, they continue to build trust, which goes a long way to helping patients to engage more fully with their providers. Figure 1 offers some suggestions for a more modern approach to language that is less gender specific.

Figure 1: Gender-inclusive Language Strategy

“It is OK to make mistakes,” Dr. Rincon Portas says. “Clinicians should feel comfortable to ask their patients how they want to be referred to and what their pronouns are.” 

HCPs should note their patients’ preferences in the chart so that they, or other staff, can easily refer to them in the future. This effort demonstrates for patients that the clinician cares about their patients’ well-being and emotional health and views them in a holistic way. It also goes a long way toward continuing to build patient trust.

A 2017 position statement offered by the American Society of Clinical Oncology (ASCO)⁵ proposed five strategies to reduce health disparities among Transgender and Gender Diverse (TGD) individuals:

• Patient education and support
• Workforce development and diversity
• Quality improvement strategies
• Policy solutions
• Research strategies

This aligns with the emphasis on ongoing cultural awareness education for clinicians in the Standards of Care for Transgender and Diverse People version 8 guidelines.⁶

It is essential that all medical office staff also exhibit cultural competence in speaking with this community of patients. Clinicians and their staff need to be aware of the appropriate pronouns to utilize. It is important that staff members have a working knowledge of the process and medications used in gender transition, thus reducing the possibility of hurtful or poorly informed questions being posed to the patient or their family.

Another consideration is the role of including gender identity information in the national registries. In order to improve the quality of evidence-based care, it is crucial that the traditional variables or data elements capture valuable gender and sexual identity demographics, for both clinical practice and research. One of the recommendations of the ASCO 2017⁵ position statement is to begin to capture this important patient information in cancer registry information and clinical trial enrollment. These changes will document cancer incidence, response to treatment, unique toxicities, and outcomes incorporating the gender and sexual orientation demographic.

Projects In Knowledge Powered By Kaplan is pleased to contribute to the conversation through a newly released educational series on Diversity, Equity and Inclusion Considerations which can be accessed via this link.

The series includes three (3) modules led by Dr. Portas.  All 3 sessions are CME/CE accredited.

• LGBTQIA Healthcare: A Practical Approach — General Knowledge
• LGBTQIA Healthcare: A Practical Approach — Caring for Lesbian, Gay, and Bisexual Folks
• LGBTQIA Healthcare: A Practical Approach — Trans and Gender Diverse-Specific Care

References:

1. US LGBT Identification Steady at 7.2%. Gallup. February 2023.  Accessed 10/2/23
2. Schabath, M B., et al. National Survey of Oncologists at National Cancer Institute-Designated Comprehensive Cancer centers: Attitudes, Knowledge, and Practice Behaviors About LGBTQ Patients with Cancer. J Clin Oncol. 2019 Mar 1; 37(7):547-558
3. Shetty G, Sanchez JA, Lancaster JM, Wilson LE, Quinn GP, Schabath MB. Oncology healthcare providers’ knowledge, attitudes, and practice behaviors regarding LGBT health. Patient Educ Couns. 2016 doi: 10.1016/j.pec.2016.05.004. 
4. Sutter ME, Bowman-Curci ML, Duarte Arevalo LF, Sutton SK, Quinn GP, Schabath MB. A survey of oncology advanced practice providers’ knowledge and attitudes towards sexual and gender minorities with cancer. J Clin Nurs. 2020 doi: 10.1111/jocn.15302. 
5. Griggs, J. et. Al. American Society of Clinical Oncology Position Statement: Strategies for Reducing Cancer Health Disparities Among Sexual and Gender Minority Population. Journal of Clinical Oncology. 2017.
6. Poteat T, Davis AM, Gonzalez A. Standards of Care for Transgender and Gender Diverse People. JAMA. 2023;329(21):1872-1874. doi:10.1001/jama.2023.8121

Ilon Rincon Portas, MD, is executive director for Kaplan Medical. Dr. Portas has been with Kaplan for over a decade. They lead content development and create new ways to better engage medical students and doctors all over the world in their learning journeys. Dr. Portas is an expert in education utilizing standardized patients, simulated cases, teaching and assessment. They also advise medical faculties in Latin America on ways to effectively use and integrate case simulation into their curriculums.