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Queering OB-GYN Care

Doctors discuss how reproductive health care can be more affirming for LGBTQIA+ patients.
Xenia E.
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Xenia E.

Many people have a complicated relationship with their OB-GYN. Gynecology appointments are often a dreaded necessity. For queer people, that appointment is often fraught with fear of discrimination, cis-heteronormative assumptions from providers and past negative experiences that can delay a patient's readiness to reschedule.

A 2021 survey published in the Medical Science Educator found that of the 105 OB-GYN residents in Illinois training programs who responded, 50 percent felt unprepared to care for lesbian or bisexual patients, and 76 percent felt unprepared to care for transgender patients.

The study suggested that those doctors feeling well-equipped to provide care for lesbian or bisexual patients were associated with attending a university-based program, working in a hospital without religious affiliation and which year of their residence training they were currently in.

Receiving inadequate training for LGBTQIA+ affirming healthcare was part of the reason residents felt ill-equipped to care for them. Sixty-three percent of respondents stated their programs dedicate only one to five hours per year to lesbian/bisexual healthcare and transgender healthcare training. Ninety-two percent of respondents indicated they wanted more education on how to provide affirming healthcare.

While this study was small, it's no surprise that the American College of Obstetricians and Gynecologists (ACOG) notes that lesbian and bisexual women face barriers at the gynecologist regarding confidentiality, disclosure and discriminatory attitudes from providers. Sexual minorities, such as lesbians and bisexual women, are also more likely to delay care and less likely to have a dedicated place of care.

"Negative experiences at the doctor's office literally kill us," said Hannah Locke, M.D., F.A.C.O.G., an assistant professor of clinical obstetrics and gynecology for Indiana University. "LGBTQ people have higher rates of cervical cancer than the general population, and we know this is because they're getting screened less often."

Gendered health care is exclusionary

Gender-exclusive language is often pronounced as soon as you walk in the door to the OB-GYN—consider the term "well-woman exam."

"Think about how it feels to be a masculine-presenting AFAB [assigned female at birth] person—are you going to want to carry a baby if every OB-GYN office around you is called 'women's health center' and is painted pink?" Locke said. "Are you going to get your mammogram if you have to wear a pink robe while you wait—a thing that really happens?"

A 2012 national survey indicated only 27.7 percent of gynecologists who responded routinely asked about their patient's sexual identity. Asking this question before an exam could mitigate a range of potentially harmful cis-heteronormative assumptions that queer patients frequently face.

What does inclusive care entail?

Rixt Luikenaar, M.D., F.A.C.O.G., an OB-GYN at Rebirth OB/GYN in Salt Lake City, said inclusive care dictates the following:

  • Creating a set of inclusive staff
  • Using proper names and pronouns
  • Taking time to get to know a patient before any invasive procedures, such as blood draws, pelvic examinations or other screenings

Being an inclusive provider means taking an organ inventory history and being aware of the WPATH Standards of Care, Luikenaar said. An organ inventory is a series of open-ended questions that allow patients to comfortably share their body parts and the language they use to refer to them. Organ inventories should happen after a provider and patient have built rapport.

Providers shouldn't assume someone is in a heterosexual relationship, is sexually active (patients may be asexual or celibate) or does or does not need contraception, Luikenaar advised. Providers also shouldn't assume that someone does or doesn't want children.

Assuming monogamy and bi-erasure are two common mistakes by providers that can negatively impact sexual health for LGBTQIA+ individuals. Locke explained nonmonogamy and bi-erasure manifest as "not getting the chance to talk about contraception because they assume if you have a cis female partner, you never have sex with people that make sperm."

Safe sex and family planning

ACOG notes that lesbian and bisexual women face the barrier at the OB-GYN of a limited understanding of their health risks. This might lead to miscounseling on how they can have safer sex or misadvising them on how frequently they need Pap smears.

"An OB-GYN should be able to confidently counsel a patient on how to have safe and fulfilling sex no matter what body parts their partners have," Locke said. This involves being knowledgeable about queer sex.

"I talk to my patients about who their sexual circle includes so we can review risk factors for pregnancy, STIs, HIV," Locke continued. "We discuss PrEP if that's something they need. We review contraception if they're exposed to sperm.

"If you're not familiar with queer sex or not comfortable talking about it with your patients, it's going to be obvious and these conversations aren't going to go well," Locke added.

Locke recommends that residents read books by queer writers and watch movies that depict queer and trans experiences. "It's important to expose yourself to LGBTQ people if you're going to be taking care of them."

A negative experience at the OB-GYN also affects family planning for queer individuals. OB-GYNs are usually the first point of contact for fertility treatment or conversations about getting pregnant. Being queer-inclusive encompasses helping patients who are interested in pregnancy or starting a family with "affordable options on how to get pregnant, options for egg/semen donors and surrogacy, as well as discussing sexuality in an open-minded manner without presumptions and judgments," Luikenaar said.

Some patients have told Locke they've never been able to have conversations about family planning with their providers before coming to her. "All of the fertility conversations are geared to straight infertile couples, not queer folks," Locke said.

How to find an inclusive provider

Resources such as OutCare, WPATH and GLMA can help connect patients with inclusive providers. Out2Enroll helps LGBTQIA+ people find health insurance options that cover gender-affirming care. Local LGBTQIA+ centers can also aid in providing physician resources.

You can prescreen providers by asking about their training around LGBTQIA+ health, checking out the language on their website and speaking to staff, ensuring they aren't assuming pronouns or using gendered language.

An increase in LGBTQIA+ healthcare competency should be part of all residency programs. Providers can also do their own work by making sure they are sensitive, respectful, nonjudgmental, trauma-informed and affirming of queer identities. At its bare bones, "Queer-affirming OB-GYN care is having a physician that understands LGBTQ health," Locke concluded.