The chances are good that at least one patient you saw today could have been provided a better environment to foster your patient-physician relationship. A 2020 Gallup poll revealed that an estimated 5.6% of US adults identified as lesbian, gay, bisexual, and transgender (LGBT).1 Based on the estimated US population of 331.7 million individuals on December 3, 2020, this means that approximately 18.6 million identified as LGBT and could potentially require health care services.2 These numbers highlight the increasing need within the medical community to provide quality and accessible care to the LGBT community, and dermatologists have a role to play. They treat conditions that are apparent to the patient and others around them, attracting those that may not be motivated to see different physicians. They can not only help with skin diseases that affect all patients but also can train other physicians to screen for some dermatologic diseases that may have a higher prevalence within the LGBT community. Dermatologists have a unique opportunity to help patients better reflect themselves through both surgical and nonsurgical modalities.
Demographics and Definitions
To discuss this topic effectively, it is important to define LGBT terms (Table).3 As a disclaimer, language is fluid. Despite a word or term currently being used and accepted, it quickly can become obsolete. A clinician can always do research, follow the lead of the patient, and respectfully ask questions if there is ever confusion surrounding terminology. Patients do not expect every physician they encounter to be an expert in this subject. What is most important is that patients are approached with an open mind and humility with the goal of providing optimal care.
Although the federal government now uses the term sexual and gender minorities (SGM), the more specific terms lesbian, gay, bisexual, and transgender usually are preferred.3,4 Other letters are at times added to the acronym LGBT, including Q for questioning or queer, I for intersex, and A for asexual; all of these letters are under the larger SGM umbrella. Because LGBT is the most commonly used acronym in the daily vernacular, it will be the default for this article.
A term describing sexual orientation does not necessarily describe sexual practices. A woman who identifies as straight may have sex with both men and women, and a gay man may not have sex at all. To be more descriptive regarding sexual practices, one may use the terms men who have sex with men or women who have sex with women.3 Because of this nuance, it is important to elicit a sexual history when speaking to all patients in a forward nonjudgmental manner.
The term transgender is used to describe people whose gender identity differs from the sex they were assigned at birth. Two examples of transgender individuals would be transgender women who were assigned male at birth and transgender men who were assigned female at birth. The term transgender is used in opposition to the term cisgender, which is applied to a person whose gender and sex assigned at birth align.3 When a transgender patient presents to a physician, they may want to discuss methods of gender affirmation or transitioning. These terms encompass any action a person may take to align their body or gender expression with that of the gender they identify with. This could be in the form of gender-affirming hormone therapy (ie, estrogen or testosterone treatment) or gender-affirming surgery (ie, “top” and “bottom” surgeries, in which someone surgically treats their chest or genitals, respectively).3
Creating a Safe Space
The physician is responsible for providing a safe space for patients to disclose medically pertinent information. It is then the job of the dermatologist to be cognizant of health concerns that directly affect the LGBT population and to be prepared if one of these concerns should arise. A safe space consists of both the physical location in which the patient encounter will occur and the people that will be conducting and assisting in the patient encounter. Safe spaces provide a patient with reassurance that they will receive care in a judgement-free location. To create a safe space, both the physical and interpersonal aspects must be addressed to provide an environment that strengthens the patient-physician alliance.
Dermatology residents often spend more time with patients than their attending physicians, providing them the opportunity to foster robust relationships with those served. Although they may not be able to change the physical environment, residents can advocate for patients in their departments and show solidarity in subtle ways. One way to show support for the LGBT community is to publicly display a symbol of solidarity, which could be done by wearing a symbol of support on a white coat lapel. Although there are many designs and styles to choose from, one example is the American Medical Student Association pins that combine the caduceus (a common symbol for medicine) with a rainbow design.5 Whichever symbol is chosen, this small gesture allows patients to immediately know that their physician is an ally. Residents also can encourage their department to add a rainbow flag, a pink triangle, or another symbol somewhere prominent in the check-in area that conveys a message of support.6 Many institutions require residents to perform quality improvement projects. The resident can make a substantial difference in their patients’ experiences by revising their office’s intake forms as a quality improvement project, which can be done by including a section on assigned sex at birth separate from gender.7 When inquiring about gender, in addition to “male” and “female,” a space can be left for people that do not identify with the traditional binary. When asking about sexual orientation, inclusive language options can be provided with additional space for self-identification. Finally, residents can incorporate pronouns below their name in their email signature to normalize this disclosure of information.8 These small changes can have a substantial impact on the health care experience of SGM patients.