A researcher created a new program for LGBTQ (lesbian, gay, bisexual, transgender, queer, and questioning) youth based on the idea that this population experiences more difficulty accessing reproductive healthcare, partly because of problems related to their choice of pronouns and names.

The program addresses which contraceptives and intrauterine devices (IUDs) transgender boys can use, and which are effective and do not interfere with their hormone treatment, says Ash Philliber, PhD, senior research associate with Philliber Research & Evaluation in Accord, NY.

The IN-clued: Inclusive Healthcare — Youth and Providers Empowered program was designed to reduce unintended pregnancies and sexually transmitted infections (STIs) among youths who identify as LGBTQ.1

“This program is two-part: Half is for youth, and half is for clinics,” Philliber says. “There was a strong desire from clinics and staff to be able to serve these youths and create more a more inclusive environment.”

The program teaches ways to ask youths which names and pronouns they use. For instance, Philliber uses “they,” “their,” and “them” as personal pronouns.

“That makes a big difference,” Philliber says. “Make sure brochures around the office reflect the whole spectrum of people, and not just heterosexual, cisgender couples. This makes a big difference when they go into the clinic and see something that looks like them.”

Reproductive health clinicians also should be clear and open about confidentiality and what patients can expect. Some youths may not have told their parents about their sexual and gender identities, so the clinic’s confidentiality and privacy guidelines should be posted publicly to show youths what to expect, they say.

With video/Zoom calls, clinicians should be aware of potential privacy issues when youths are speaking in the same room as a parent.

“One thing we’ve noticed is that, occasionally, doctors assume sexual orientation and sexual behavior are the same thing. If that were true, we wouldn’t have [unintended] pregnancy among lesbians, but it’s not true,” Philliber says.

Clinicians always should ask women who identify as lesbian about contraception just as they would ask any other patient.

“Ask, ‘Do you want to take condoms with you, just in case?’ Not assuming that they aren’t taking any kinds of risks,” they add. “Understand that there is a difference between sexual orientation and sexual behavior, and they’re not as closely linked as we think right now.”

Another incorrect assumption is that someone who is transgender also is lesbian, gay, or queer. “This may not be the case,” Philliber says. “You can’t make assumptions about sexual behavior based on gender.”

One way for physicians, nurses, and others working in reproductive health to view these issues is to think of how the world is constantly changing on so many levels, and they have to relearn how the world works.

“As kids, we’re told to put everything into a box and to characterize everything,” Philliber explains. “Now, we recognize that some things can’t be put in a box. Sexual orientation can’t be put in a box, and gender cannot be put in a box.”

Use Preferred Names, Pronouns

The little things can make a big difference in building trust with LGBTQ patients. This trust can encourage patients to seek contraceptive care. Before, they might have avoided care because of the discomfort they felt in a clinic that did not recognize who they believe they are.

“Just because five years ago I said, ‘My name is Ash,’ to my doctor, my doctor still needs to ask me what name I use today,” Philliber says. “Taking those little steps helps people feel more accepted and seen in that space. Being seen is a big thing.”

A lot of LGBTQ people wander around in spaces where they need to fit into gender-normative space. They need to make sure they can be seen as themselves in that space, because otherwise they will not get the care they actually need.

When clinicians attended the IN-clued program, some said they were uncomfortable with the discussion about pronouns and did not need to learn about it, Philliber notes.

“Within our own company, we had some staff, when we said, ‘You need to talk about pronouns,’ who said they weren’t comfortable with it, largely based on religious beliefs,” Philliber explains. “Instead of focusing on how they need to do this because it’s the right thing to do, it’s instead that they need to do this to do their jobs right. In order to serve youths and provide them with the healthcare they need, we need to make them seen so they’ll talk with us.”

If young people feel unheard or uncomfortable in a doctor’s office or clinic, they will be unable to ask for the care they came for, and clinicians are not doing their job. For instance, a youth who presents to a clinic to be screened for an STI might leave if the staff made the patient feel uncomfortable.

Make Youths Feel Seen, Heard

During the IN-clued clinic curriculum, the leaders heard anecdotes about youths who said they did not start a contraceptive they sought because the doctor did not listen when they asked for it, or the youths did not ask for it because they already were uncomfortable, Philliber says.

Examples of how LGBTQ youth may feel unheard and unseen include:

  • only two choices for gender on the clinic’s health history form;
  • the front office staff calling out the patient by a name the patient no longer uses;
  • the nurse using an assumed pronoun for the patient, instead of the correct pronoun.

“If I give a survey, and there are only two gender options on it, I feel unseen, and I won’t finish the rest of the survey,” Philliber explains. “For us to collect data, we have to make you feel seen in those forms.”

One important tactic in ensuring every patient is acknowledged and respected is to ask each person the same question about sexual activity, regardless of sexual identity.

“No matter what, treat everyone exactly the same,” Philliber says. “Don’t make assumptions based on whatever boxes you were taught to put people in.”

Practice Inclusivity

Another technique is to practice gender/sexual identity inclusivity. “We do practice within the clinic. Peer educators come in and train in the clinic, and they practice role-playing,” Philliber says. “They give feedback to doctors and staff and say, ‘This made me feel great,’ ‘This made me feel uncomfortable,’ and ‘I came in for this and left with this, so this is a problem.’”

Patients can use a resource called a Q card, which is a tiny card that can fit in someone’s wallet. People can write the names and pronouns they use and why they came to the doctor’s office and give it to the doctor or nurse.2

“A lot of clinics are using those cards at their front desk,” Philliber says. “You hand it to people when they come in, so they won’t have those missteps.”

When patients visit a clinic, the front staff are very important to how patients perceive their care. The staff set the tone and can make patients feel comfortable and understood by asking each person which name they want to use.

“It sets a better tone for the whole time. They are the ambassadors of the clinic, making sure people feel comfortable and safe there,” Philliber explains. “I can’t place too much value on these ideas; as someone who grew up not having this kind of care, I truly believe this kind of care is incredibly important.”

REFERENCES

  1. Philliber A. The IN-clued program: A randomized control trial of an effective sex education program for lesbian, gay, bisexual, transgender, queer, and questioning youths. J Adolesc Health 2021;S1054-139X(21)00195-6.
  2. Pacific Hospital Preservation & Development Authority. The Q Card: Empowering queer youth in healthcare. Feb. 20, 2015.