Addressing Health Disparities in the LGBTQIA+ Community (eBook)

Chapter 3.
Accepting Care of LGBTQIA Patients: A Clinical Perspective

Michael A Greene, MD

Program Director, Creighton University Department of Family Medicine

In the longitudinal care of any patient, there are four principles and one attitude that are helpful in establishing the healing therapeutic provider-patient relationship that is foundational for primary care. These principles acted upon by an experienced clinician -well versed in navigating the sometimes turbulent waters of any committed human relationship, have the capacity to grow both the patient and provider in their respective self-actualization. Having a meaningful relationship with a primary care provider and the opportunities that arise from that can provide healing to person wounded by the inadvertent word or deliberate action. The attitude opens the space for the healing to occur as long as the patient feels safe and motivated to step into it. These four principles together and one attitude together act in synchrony to create a clinical culture that attracts persons seeking release and maintains persons seeking growth. While this culture is of universal benefit to all patients, LGBTQIA patients may especially benefit from the inherent inclusivity

The first principle is that the longitudinal care of the LGBTQIA person (indeed any person) takes time. In order to grow the relationship two people must spend some time together. In this time, they get to know each other, they find common interests and learn through trial and error preferences and dislikes. The healing of the provider-patient relationship often comes over time. The longer the time, the deeper the healing. On the first visit the patient presents with the broken wrist, which is cast. the next visit ends with a cast and some tears. the next visit brings xrays, and some revelations about unhappy relationships. fracture healing is followed by some veiled discussion of domestic violence. further visits culminate in a safe house and introspection. healing begins while health care maintenance is performed and after years, personal growth by both the patient and provider reveal the creation of support groups an blossoming of new relationships and safe spaces. The time of the provider-patient relationship is unique in its brevity. Often taking place in 15-minute intervals, this relationship is the Haiku of structured human relationships. Yet over time, those 15-minute intervals become years of shared experience and mutual reward. Keeping the principle in mind that a commitment to a long-term relationship occurring in fifteen-minute intervals over time is one way to bring health to a LGBTQIA person

The second principle is Trust. For the relationship to grow each party must have a reasonable belief that the other party is trustworthy. As is so often remarked trust must often be earned. of what does this trust consist of? what is trusted by the patient? what is trusted by the provider? To the patient, trust that the provider is beneficent, competent, committed. Beneficent here means that the provider has the patient’s best interest at heart as determined by the patient with guidance from the expertise of the provider. While the patient knows ze wants to run the half marathon the provider articulates the training pathway. Competent providers know their craft, study regularly, challenge old opinions with new information for the betterment of the patient and the leveling of the ego. The patient needs to trust the provider is committed to them. After much divulging, expunging, recounting, explaining, grappling and growing with the provider it is difficulty and frankly traumatic to start over. stability is one hallmark of a good primary care provider. For the provider, trust means willingness to move on the path to healing. Willingness is key concept but note that willingness to move on the path, and not actually movement, is sufficient for the provider to build a relationship on. what is conspicuously lacking as an essential requirement for providers to expect of patients in order to grow the provider-patient relationship is Honesty on the part of the patient. Honesty on the part of the provider is always demanded. Honesty is a tricky concept. While trust is building, information may be parceled out by the patient and not fully expounded upon and this is appropriate. The provider, for their part, must be always aware that this is happening and must not fall into the cognitive error of assuming information that has not been share or “read between the lines” of information that has been given out. Some disease states have denial as an essential feature of the illness through no fault of the patient. And in the case of addiction for example, lack of honesty is a gut-wrenching part of the illness and yet does not preclude a meaningful, healing relationship to develop. The patient cannot deliberately deceive the provider and still expect the same level of healing to occur as if the deception was not present, however. Denial, self-deceit is inhibitory to the growth of the patient but not necessarily the relationship.

The third principle is transparency. Transparency is as simple as telling the patient what you are going to do before you do it, and why. It is also revealing why you are asking or going to ask a series of questions in a way that the patient is able to understand why you need to know and how knowing will help the provider take better care of the patient. Most of all transparency is revealing and reassuring over and over that the intent and goal of the provider is to be helpful, beneficial and not to cause harm. Transparency in a relationship is essential in order to build rapport, prevent miscommunication and avoid anxiety. The provider should be transparent about their role as coach and advisor rather than one who will condemn or sit in judgment. In fact, judgement, with its resultant emotion of shame is rarely helpful to individual patient and self-judgment and shame are the cause of many health problems. The transparency about all actions or questions the provider has will help avoid any possible miscommunications. For example, rather than just asking about sexual partners, providers should instead announce the preamble “in order to make recommendations to you about your health its helpful for me to know . . .” Over time, as they get to know one another, less preamble is needed, and the conversation flows more naturally. The more specific the reason the more helpful for the patient to reduce anxiety. Questions should be asked in such a way as to not lead or appear judgmental. Simply asking questions of everyone has the effect of normalizing potentially embarrassing or shameful topics. In the interest of transparency, if what the provider wants to know is if the patient has had to engage in unwelcome sexual intercourse rather than asking “no one has ever forced you to have sex, right?” Ask instead “to the following questions answer always, sometimes, rarely, never. I have been forced to have sex when I did not want to”. The provider must at certain intervals, bring the relationship into the light as an object of infection to see what each of them has learned.

The fourth principle is that of trauma informed care. Trauma informed care is care of the individual with special attention the fact that many persons in our society have experienced trauma and the provider, as well as the entire health care team, is making special effort to not re-traumatize the patient. It is a way of conducting the entire health care experience from check in to visit to check out in a way that places the patient in the center and makes special care from the health care team to allow the patient to be safe, secure, cared for and respected. there are many aspects of trauma informed care, some of which have been discussed above.

Imbuing all of the foregoing, it is important the provider conduct themselves with an Attitude of curiosity. Curiosity allows the patient to be placed at center, as important and worthwhile. Curiosity and gentle wondering on the part of the provider fosters an atmosphere of value onto the patient. It acknowledges that every patient is unique, and every person has a backstory that lead them to where they are today. Even patients that the provider knows well should be approached with curiosity always allowing the patient to be the person that they are today and have the values that they have today rather than who they were yesterday. Being curious allows the provider to ask about goals and values over and over rather than assuming them in the case of long-standing patient. This non-judgement culture delights in patients being the person that they are and gives the space for them to express themselves as they are.

These are some of the important principles of the “care” of the LGBTQIA patient. The final piece to discuss is the “taking” part. In English speaking society the phrase “taking care” is often used, as in Taking care of someone. Taking care of any person requires a deliberate action on the part of the Provider, a reaching out to the other person to that which is handed over. For health care providers, Taking is an action that connotes an aggression or invasion. Perhaps a better phrase in English might be accepting care. The life is still that of the patient, the problems remain their own. What then is accepted? In actuality it is the relationship that is accepted. This relationship is a special kind of relationship. It is the healing of open honest and free conversation with a health care expert who is informed in the person of the patient as they stand in relation to their family, their culture, their society, their goals and their dreams.