Guest editorial by Danielle Kalberer, OD, FAAO
Originally published for Eyes on Eyecare
The LGBTQ community is one that faces unique challenges when it comes to health care. This group can be subject to discrimination and stigmatization that is unwarranted and unfair. Because of such challenges, patients may be apprehensive to share their information about themselves publicly, even to their doctors.
INEQUALITY IN LGBTQ+ HEALTHCARE
Research completed by The Joint Commission and Institute of Medicine highlights inequality in health care for the LGBTQ community. These organizations found that LGBTQ patients, especially transgender patients, may avoid seeking routine and preventative care.1 The commission created an extensive field guide for providers to improve cultural competence and patient-centered care for the LGBTQ community.
Roughly 50% of transgender adults and 30% of LGB patients reported having delayed or avoided medical treatment, compared to 20% of heterosexual adults. If a patient had a previous experience with a provider who was not supportive or sensitive, they were more likely to wait until a condition became severe or life-threatening to obtain care in the future.1
Patients in this population are also at higher risk of conditions like anxiety, depression, stress, eating disorders, substance abuse and homelessness.1 Improving the practice of routine and preventative care in this group could go a long way in addressing health care issues remediating the inequity.2
DEFINING IMPORTANT TERMS
STEPS TO CREATING AN LGBTQ+ INCLUSIVE ENVIRONMENT
Update your intake or history form
Obtain pronouns easily through the intake forms
Use open-ended questions when inquiring about any sexual history or relationships
Make your office LGBTQ-friendly
Train staff
Show support
FROM PERSONAL EXPERIENCE: A CASE STUDY
A 36-year-old male, new patient presented to my office with complaints of slightly blurry vision and mild headaches on and off for a few months. The headaches were dull and seemed to be “behind the eyes or forehead.” The patient was not sure if they were related to near work or reading or any other associated factors.
The patient reported unremarkable medical and ocular history as well as family medical and ocular history. Best corrected visual acuity was 20/25 in the right eye and left eye. Pupil reaction was normal, extraocular motilities were normal and confrontation visual fields were normal.
On dilated fundus exam, apparent bilateral disc edema was present in this seemingly healthy 36-year-old male patient. I told the patient what I was seeing and probed for any more medical information that may be relevant (like a history of hypertension, diabetes etc). The patient denied any further history and seemed like an accurate historian.
I ran through differentials in my head, knowing that this could possibly be a hypertensive emergency (and I had no blood pressure cuff available at this optical location) or papilledema, warranting an emergency referral. I recommended that the patient go to the emergency room, wrote down my findings for the patient to bring and made a referral to a local neuro-ophthalmologist for follow up.
LESSONS FROM THE EXPERIENCE
In a follow-up call the next day, I was happy to hear that the patients reported that there were no emergency findings (no hypertensive emergency, no tumor, or mass) and he had a scheduled follow up with the neuro-ophthalmologist. The referral report back from the neuro-ophthalmologist read, “A 36-year-old female with IIH status-post bariatric surgery presents for follow-up” and was very confused.
As it turns out, this patient was born a female and was a transgender male, who identified and expressed as male and, therefore, circled male on the office’s medical intake form. The patient had also been embarrassed about the weight loss surgery because being overweight had led to depression. Not thinking it could be related to the eyes, the patient therefore did not mention it to me but did share the full medical history at the emergency department.
Had I known the birth sex of this patient and history of obesity, that along with the symptoms and signs would have led me to a primary differential diagnosis of classic idiopathic intracranial hypertension (IIH).
Though ultimately my recommendations would have been the same, since it was a new patient and emergency causes need to be ruled out, I spent a great deal of time thinking about how I went wrong. The additional information would have helped me develop differentials more clearly and I needed to figure out how I could prevent this from happening again.
START NOW
It is our responsibility to obtain the relevant information needed to treat our patients successfully and effectively. If barriers exist in communication or pertinent information is overlooked, we cannot perform our due diligence. So, ask yourself, “How do I create an environment that facilitates openness and honesty without fear of judgment for the sake of my ability to properly treat and diagnose?”
I challenge each of you to consider the ideas presented in this article and integrate them into the way you practice. Optometry is a field where we are fortunate to have the opportunity to help patients and improve their lives.
When patients receive care in a judgment-free environment, it fosters the honest disclosure of health and lifestyle information. Setting the stage for cultural sensitivity establishes the best possible patient-doctor relationships and allows us to better serve the LGBTQ community. Let’s all make sure we are providing our care in a way that is complete, authentic, inclusive, and sensitive to all individuals.
Patients.” Hospital for Special Surgery, Retrieved June 1, 2022.
Creating an LGBTQ-friendly practice. Retrieved June 1, 2022, from https://www.ama-assn.org/delivering-care/population-care/creating-lgbtq-friendly-practice
2.Bass B, Nagy H. Cultural Competence in the Care of LGBTQ Patients. [Updated 2021 Oct 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
3.Medical Provider Guide to LGBT terminology pride in practice. Retrieved June 1, 2022, from
Featured photo credit: Getty Images, LeoPatrizi
