Caring for LGBTQIA+ Populations in the ED: A Quick Guide

According to recent statistics, an estimated 7.1% of the U.S. adult population identifies as lesbian, gay, bisexual, and/or transgender, including one in five adults born after 1997.¹

This is likely an underestimate, as federally mandated, nationally representative data on sexual orientation and gender identity are limited and do not capture the diversity of identities or experiences of individuals who are LGBTQIA+ (lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and more).²

A disproportionate number of LGBTQIA+ patients utilize the emergency department (ED), in part due to lower rates of insurance and primary care access.^3,4 While the ED is an important source of care for LGBTQIA+ patients regardless of the presenting issue and can even serve as a touchpoint into primary care, studies have shown that provider incompetence and discrimination contribute to ED avoidance and delays in receiving acute care, particularly among transgender and nonbinary patients.⁵

Utilizing appropriate language is an important step in building trust and rapport with LGBTQIA+ patients and in working to deliver competent, sensitive, and high-quality emergency care to a historically stigmatized community. The LGBTQIA+ acronym generally encompasses those who do not identify as cisgender and/or heterosexual and is not monolithic (i.e., an individual can hold multiple LGBTQIA+ identities, and these identities can change over time).^6,7

It is important to understand that sex — assigned at birth and based on a binary system — is distinct from gender, which is self-identified and expansive. Sex, gender, and sexual orientation should not be conflated. The language used to describe sexual orientation and gender identity is dynamic, rapidly evolving, and rooted in a deep history of oppression, activism, and reclamation. For example, the formerly derogatory term “queer” is now celebrated and embraced by many members of the LGBTQIA+ community. On the other hand, certain terms — including “transsexual,” “transvestite,” and “male-to-female”/”female-to-male” — are outdated and should not be used by providers to refer to transgender or nonbinary individuals unless preferred by patients.

Understanding basic terminology, health disparities, and ED-specific concerns relevant to LGBTQIA+ patients is a timely and urgent task, as LGBTQIA+ rights continue to be debated across the United States and proposed anti-transgender legislation threatens to restrict transgender health care.

Risk Factors/Clinical Outcomes
Several health and health-care disparities impact the LGBTQIA+ community. Rates of sexually transmitted infections, including HIV, are disproportionately high among men who have sex with men and transgender women.^8,9 LGBTQIA+ people have higher rates of mental health conditions, including substance use, mood disorders, and suicidal ideation: A 2022 national survey by The Trevor Project found that in the past year, 45% of LGBTQIA+ youth reported suicidal ideation, with one in five transgender and nonbinary youth attempting suicide.^10,11

Compared to the cisgender and heterosexual population, LGBTQIA+ people experience more negative outcomes related to the screening, prevention, and management of cardiovascular diseases and certain cancers.¹² Transgender women on gender-affirming hormone therapy have a greater risk of venous thromboemboli and ischemic strokes when compared to cisgender men and women.¹³ These disparities are all compounded by alarming rates of homophobic and transphobic violence, racism, classism, xenophobia, and homelessness, as well as the lack of accessible comprehensive health services for LGBTQIA+ patients.¹⁴

Bedside Awareness
ED providers can care for, and advocate for, LGBTQIA+ patients at the bedside by:

• Asking all patients for their name(s) and pronoun(s), informing the entire care team, and requesting that the care team use patient-reported identifiers. If you make a mistake, apologize, correct yourself, and move on.
• Correcting team members who misgender patients and speaking up if someone makes derogatory comments or jokes. In doing so, you are helping create an environment that does not tolerate patient discrimination, harassment, or mistreatment.
• Explaining the medical necessity of asking questions about genitals, gender-affirming care, and/or sexual history to patients. Do not ask these questions out of curiosity.
• Minimizing assumptions when taking a sexual history. Avoid using the binary approach of asking “men, women, or both?” Prioritize open-ended questions such as “How many sexual partners do you have?” or “What genders are your partners?”⁷
• Recognizing that gender-affirming therapies are often life-saving and not simply elective or cosmetic. For example, a patient on gender-affirming hormone therapy who is found to have a DVT should not immediately be counseled to stop hormones without further discussion.¹⁵

Key Actions
As ED providers, we can address these social/structural determinants of health by:

• Advocating for the inclusion of self-identified names and pronouns within the electronic health record (EHR) system that are clearly visible and accessible by the health-care team.⁷ Additionally, incorporating the use of an organ inventory within the EHR can help identify screening opportunities (e.g., pregnancy screening for a transgender man who has a uterus)⁷
• Standardizing sexual orientation and gender identity data collection at triage, preferably via written form rather than verbal disclosure¹⁶
• For pediatric patients, ensuring sexual orientation and gender identity data are collected confidentially and notes available to parents or guardians are marked as sensitive, to avoid inadvertently outing patients¹⁵
• Integrating public signage and structural changes to make LGBTQIA+ individuals feel comfortable and safe (e.g., gender-neutral restrooms, non-discrimination placards, gender-neutral language on forms)⁵
• Advocating for standardized training in LGBTQIA+ health for all members of the health-care team, and for formal inclusion of LGBTQIA+ health topics in medical school and residency curricula as well as continuing medical education for attending physicians^5,7

This article is part of an EMRA Social EM Committee initiative to disseminate information about social EM topics encountered in the emergency department. More information can be found in the EMRA MobilEM app’s Patient Conversation Toolkit, available for download via iTunes and Google Play.

References

1. Jones JM. LGBT identification in U.S. ticks up to 7.1%. Gallup.com. https://news.gallup.com/poll/389792/lgbt-identification-ticks-up.aspx. Published June 10, 2022. Accessed January 25, 2023.
2. National Science and Technology Council. Federal Evidence Agenda on LGBTQI+ Equity. The White House. https://www.whitehouse.gov/wp-content/uploads/2023/01/Federal-Evidence-Agenda-on-LGBTQI-Equity.pdf. Published January 2023. Accessed January 25, 2023.
3. Sánchez JP, Hailpern S, Lowe C, Calderon Y. Factors associated with emergency department utilization by Urban Lesbian, gay, and bisexual individuals. Journal of Community Health. 2007;32(2):149-156. doi:10.1007/s10900-006-9037-1
4. March C, Gonzales G. Frequent users of emergency departments in the United States by sexual orientation. Academic Emergency Medicine. 2021;29(1):112-114. doi:10.1111/acem.14363
5. Hsiang E, Ritchie AM, Lall MD, et al. Emergency care of LGBTQIA+ patients requires more than understanding the acronym. Academic Emergency Medicine Education and Training. 2022;6(S1). doi:10.1002/aet2.10750
6. Kruse MI, Bigham BL, Voloshin D, et al. Care of Sexual and Gender Minorities in the Emergency Department: A Scoping Review. Annals of Emergency Medicine. 2022; 79,196-212. doi.org/10.1016/j.annemergmed.2021.09.422
7. Driver L, Egan DJ, Hsiang E, et al. Block by block: Building on our knowledge to better care for LGBTQIA+ patients. Academic Emergency Medicine Education and Training. 2022; 6, s57-s63. doi.org/10.1002/aet2.10755
8. Sexually Transmitted Infections Treatment Guidelines, 2021: Men who have sex with men (MSM). Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/msm.htm. Published July 22, 2021. Accessed January 25, 2023.
9. Issue brief: HIV and Transgender Communities. Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/policies/data/transgender-issue-brief.html. Published April 22, 2022. Accessed January 25, 2023.
10. Rice CE, Vasilenko SA, Fish JN, et al. Sexual minority health disparities: an examination of age-related trends across adulthood in a national cross-sectional sample. Annals of Epidemiology. 2019; 31,20-25. doi.org/10.1016/j.annepidem.2019.01.001
11. The Trevor Project. 2022 National Survey on LGBTQ Youth Mental Health. TheTrevorProject.org. https://www.thetrevorproject.org/survey-2022/assets/static/trevor01_2022survey_final.pdf. Published December 2023. Accessed January 25, 2023.
12. Jalali S, Sauer JM. Improving Care for Lesbian, Gay, Bisexual, and Transgender Patients in the Emergency Department. Annals of Emergency Medicine. 2015; 4,417 - 423. doi.org/10.1016/j.annemergmed.2015.02.004
13. Getahun D, Nash R, Flanders WD, et al. Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study. Annals of Internal Medicine. 2018;169(4):205-213. doi:10.7326/M17-2785
14. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. National Center for Transgender Equality. https://transequality.org/issues/resources/national-transgender-discrimination-survey-full-report. Published February 12, 2015. Accessed January 25, 2023.
15. Janeway H, Coil CJ. Emergency care for transgender and gender-diverse children and adolescents. Pediatric Emergency Medicine Practice. 2020;17(9):1-20.
16. Haider A, Adler RR, Schneider E, et al. Assessment of Patient-Centered Approaches to Collect Sexual Orientation and Gender Identity Information in the Emergency Department: The EQUALITY Study. JAMA Network Open.2018;1(8):e186506. doi:10.1001/jamanetworkopen.2018.6506