Sexual orientation, gender identity training expected to improve LGBTQ+ care at Stanford Medicine

For LGBTQ+ people, being “out” is work. It requires them to reaffirm or explain their identity multiple times each day. Doing so while sick or attempting to access routine health care, perhaps from caregivers unfamiliar with caring for the LGBTQ+ community, is even more taxing. That struggle can erode the quality of care. Worse, many LGBTQ+ individuals will avoid engaging with the healthcare system due to these experiences.  

Stanford Medicine aims to change this dynamic, first by incorporating questions about patients’ sexual orientation, gender identity and the name the patient uses into routine intake procedures, then by training health care providers and staff to avoid assumptions of gender and sexuality when interacting with patients.

“We want to be affirming of each patient’s identity and be as inclusive as possible,” said Jaclyn Liu, community health program manager at Stanford Health Care. “This goes beyond just teaching staff how to ask these questions and to move away from gendered language. We want to normalize conversations around these issues, to make it a regular part of our thought process.”

Better data gathering

The initiative dovetails with the existing nationwide We Ask Because We Care campaign, a collaborative effort at Stanford Medicine that is led by Liu. The first phase of We Ask Because We Care focuses on collecting data about each patient’s race, ethnicity and preferred language. Expanding that effort to include information about sexual orientation and gender identity is designed to improve care for the LGBTQ+ community and create a foundation of reliable data that will enable Stanford Medicine to identify disparities or successes in treating this patient population. Aspects of the initiative — such as modifications to the electronic medical record system to include information about a patient’s gender identity and chosen name, ensuring names on wristbands and in-room televisions reflect the name they use, rather than legal names — will be rolled out during the coming months. Recently, Stanford Health Care’s MyHealth patient portal was changed to remove the visibility of assigned sex at birth from the patient’s information.

“Many LGBTQ+ patients no longer identify with the sex they were assigned at birth, so why should they have to be reminded every time they look at their patient chart?” asked Liu.

Collecting and acting on information about people’s sexual orientation and gender identities is more than just a feel-good project. Studies routinely find that LGBTQ+ people have poorer health outcomes than non-LGBTQ+ people.

“Health disparities exist for this community in almost every area,” said Bláz Bush, executive director of the LGBTQ+ Health Program, “from mental health to substance use to HIV and mpox infection — even body image and the likelihood of having an unhealthy relationship with food. Knowing this information is critical to addressing these problems.”

Negative experiences, even from well-intentioned interactions with health care providers, often drive patients away.

“There are many stories of patients who are cisgender woman and share they are sexually active who then face a barrage of insistence they take birth control,” Bush said. “What healthcare providers miss is asking about romantic and sexual attraction. They don’t learn that the patient identifies as lesbian and is not sexually active with someone they can become pregnant with. I’ve also heard of health care professionals arguing with patients, saying, ‘Your medical records say that you are a woman. If you say you are not, then you can’t be this person.’ What happens is that these people don’t come back, and they don’t get the care they need and deserve.”

Many experts encourage a shift to organ-based guidance to make decisions about appropriate care for LGBTQ+ people, rather than relying on outdated “male” and “female” binary classifications. A transgender man may still need routine mammography, for example, while a non-binary person with a cervix should have regular pap smears.

Training for all

Elements of the rollout will include training for a wide range of people who interact with patients, including those who work at the front desk or in the call center as well as nurses, physicians and other health care workers.

“Unfortunately, we know that misgendering and deadnaming happens,” said Liu, referring to the use of a name that someone no longer considers their own. “This is a terrible experience for patients.” A particular challenge, Liu noted, will be aligning the many entities at Stanford Medicine to ensure continuity among the clinics and the hospitals.

Today we could not tell you with confidence the population of our patients at Stanford Medicine who are LGBTQ+. We just don’t know. Until we have that data, we can’t look at outcomes in this population and recognize what we’re doing well, and we can’t address disparities that may exist.

The team is also considering how best to protect patients’ privacy while respecting their identities. A young person may use a different name and pronouns with their medical team than they do with their family, so medical communications — such as letters and emails — must be sensitive to the likely audience. 

“We are doing everything in our power to maintain patient choice and privacy,” Liu said.

Liu and Bush also recognize that the current, charged political climate may make some members of the LGBTQ+ community suspicious or reluctant to answer questions about their sexual orientation and gender identity.

“Studies have shown that, in general, people, particularly members of the LGBTQ+ community, appreciate being asked these questions,” said Bush, who is himself a member of the community. “We want to share this information so people can treat us better. But it is important to understand that answering these questions is always optional, and the answers can be changed at any time.”

“The more we can ask questions and engage with our patients, the better their experiences will be,” Bush added. “Today we could not tell you with confidence the population of our patients at Stanford Medicine who are LGBTQ+,” he said. “We just don’t know. Until we have that data, we can’t look at outcomes in this population and recognize what we’re doing well, and we can’t address disparities that may exist.”

Members of the Stanford Medicine community are eager to engage in the effort, Liu and Bush said. “At first some people had questions,” Liu said. “But once they understood how important this is, everyone got on board. It’s one of the few times people have been actively reaching out to me to ask what they can do to help. We are trying to move ahead as quickly and as thoughtfully as possible. People want this done, and they want it done yesterday.”