Taking an inclusive health history is a vital part of providing the highest-quality health care possible. A doctor who's knowledgeable about a patient's culture knows what questions to ask and how to ask them. Christopher Swales, MD, a family medicine doctor at Dignity Health Medical Foundation – Woodland and Davis, specializes in treating LGBTQ patients. He shared examples of how to take an inclusive history, and how this can establish respect and comfort in any doctor-patient setting.
1. Understand Their Unique Medical Needs
An important part of an inclusive medical history is understanding a patient's culture and the unique needs that come with it. Just like you would ask a female patient different questions than you would ask a male patient, you'll have to ask transgender, gay, and lesbian patients all different questions. For example, Dr. Swales said, it may be important to prescribe pre-exposure prophylaxis (PrEP) for gay men in order to reduce their risk of contracting HIV. But doctors who lack this particular cultural competency might not know which questions to ask to determine if PrEP is needed.
"Young gay men may say, 'I've had eight to 10 sexual partners this year,'" Dr. Swales said. "For that culture, that's not uncommon, and there are a lot of questions that should be asked after that. But it can be uncomfortable for doctors who are not cognizant of that culture, and they may not even know what the questions are."
And caring for transgender patients can require doctors to have an even more nuanced level of understanding. "Unique needs are magnified 10- to 100-fold for transgender folks," Dr. Swales added. He explained that transgender care is a lot more complicated. According to the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, created by the World Professional Association for Transgender Health, primary care physicians should work hand-in-hand with mental health professionals, endocrinologists (if needed), and other clinicians when treating transgender patients. If all doctors work as a team, they will be able to provide the best care possible.
2. Create a Sense of Comfort and Respect
Creating a sense of comfort is vital to keeping a patient around after the initial health history is collected, and simply being knowledgeable about a patient's unique needs and treating that patient with respect can go a long way. Unfortunately, this isn't always the reality.
"For transgender folks, a lot are not going to doctors because they're worried about how they're going to be treated," Dr. Swales said. "The perception is that primary care doctors don't know what they're doing, or they're going to treat LGBTQ people differently, or patients are going to feel embarrassed. ... For transgender folks, it can be difficult to find someone who's comfortable treating them, will treat them with respect, and really understand them."
Taking a health history can be a key step in establishing this respect, and it can start with using the right pronouns. This can make a patient more comfortable with you, which can result in a more candid discussion. "It's really not that difficult," Dr. Swales said. "You just call them by the name they want to be called, and use the gender or pronouns that they wish to be addressed by."
In other words, just ask what your patient prefers. "For LGBTQ patients, there's not a huge difference in care, but it's much more about how you approach it," Dr. Swales explained. "It's about treating them with respect and understanding."
3. Know How to Ask the Difficult Questions
When taking an inclusive health history, Dr. Swales suggests that you don't shy away from more difficult questions — but don't make them a big deal either. Just be matter-of-fact. "If you're worried when asking about sexual history, make it a standard question," he said. "No blinking, just go straight through it: 'Are you sexually active?' If yes, then ask: 'Men, women, or both?' The other person can see in your manner that you're asking a regular question and not trying to pry." According to a study in the journal JAMA Internal Medicine, it turns out that doctors often underestimate patients' willingness to be open about sexual orientation or gender identity.
For transgender patients, Dr. Swales said it can be a more challenging. But a respectful and professional approach that is not overly focused on body parts can make a patient feel at ease. "If I see someone new, I'll ask what they have and what they've had removed," he said. "That should be done in a mutually respectful manner."
Some physicians might feel inclined to invite interns or residents to observe an appointment with a transgender patient. But it's critical that you evaluate the potential negative impact this can have on the patient. Having an observer in the room can make the patient feel uncomfortable and less likely to be open with you. If you do wish to invite an observer, getting permission from your patient is an absolute requirement. According to the Transgender Law Center, "When patients are observed without first asking their permission, it can quickly feel like an invasion of privacy and create a barrier to respectful, competent health care."
It can also be helpful to ask questions related to mental history to assess if a patient might be depressed or anxious. Older transgender patients may be more likely to have a psychiatric illness because of everything they've gone through, according to the American Psychological Association. Dr. Swales explained that younger patients tend to be more open about their sexual orientation and willing to see doctors, but older patients are more hesitant. Keep these differences in mind.
4. Don't Be Afraid to Learn
The unique needs of the LGBTQ community illustrate why it's important to be educated about your patients' culture. If you don't understand enough to take a thorough history, you might consider referring a patient to another doctor in your clinic who better understands the unique cultural needs.
You can also study LGBTQ culture yourself. Talk to doctors who have a solid understanding of the cultural competencies. Seeking open and honest feedback on how you perform health histories can improve your patients' experience in your practice. You might even consider volunteering in that community outside of work. Dr. Swales volunteers in an LGBTQ pride event every year in his community.
By understanding your patients' culture, you can build trust and respect that makes it easier to ask difficult questions during an inclusive health history. This will help you know what health needs are unique to a particular community and allow you to better treat them. By showing respect and being educated, you can provide the highest-quality care possible.