MSFC Update - April 2004

Supplementing Your Education: Providing Complete Reproductive Health Care to LGBTI Communities
By Elizabeth Ferrenz and Jenny Siegel

Examining our assumptions about the patients we work with each day is a key aspect of providing sensitive and complete reproductive health services. As pro-choice medical students, we need to take the initiative to acquire the knowledge and skills necessary to provide quality health care to a patient population with diverse sex and gender identities, sexual behaviors and romantic partnerships.

One group of individuals possessing a unique set of reproductive health needs is the lesbian, gay, bisexual, transgender, and intersex (LGBTI or queer) community. Continuing our own education about the issues facing LGBTI communities and bringing this awareness back to our campuses are ways of promoting comprehensive reproductive health care as a critical component of our medical education.

A comprehensive education including all aspects of reproductive health is paramount to ensuring that women receive the full range of reproductive health services. Such an education should encompass training in, among other things:

• sexual development and function
• family planning
• contraception
• infertility
• options counseling
• abortion provision

Further, this education should be culturally competent and address the diversity of patients that we will be serving in the future.

In this article, we aim to introduce some of the basic reproductive health challenges facing LGBTI communities and to suggest some ways in which you can incorporate education about these issues into the reproductive and sexual health programming at your campus.

Sexual History Taking
Sexual history taking exists as a core component of the clinical encounter, and openness and lack of judgment are central to discussions with every patient we meet, regardless of sexual or gender identity. One of the challenges we face with each patient involves finding sensitive and clinically complete ways to inquire about sexual behaviors and risk factors for STI transmission.

Identity is not equivalent to behavior; it remains important to inquire about activities like anal intercourse, oral sex, power/pain play, and use of sex toys without making assumptions about identity. Additionally, we must expand our knowledge bases about the risk of transmission of different STIs during a variety of sexual practices to provide adequate counseling to every patient.

Another important challenge involves determining the contraceptive needs of a variety of patients. Classically, many lesbians become frustrated when their sexual history consists primarily of questions surrounding their choice of birth control methods rather than fully exploring their safer sex and potential contraceptive needs.

Finally, reproductive health work with the transgender community carries its own set of responsibilities; it is important to find ways of inquiring about relationships and sexual practices that embrace and are inclusive of transgender patients and their partners (for example, using language in materials as well as in personal interactions that doesn’t assume only two genders — male and female).

Family Planning
Family planning (the decision about when and how to have and raise children) comes in a variety of forms including adoption, conception, surrogacy, in vitro fertilization, and artificial insemination.

Choosing the right option — based on personal preference, biological necessity, religious beliefs, and economic reality — provides a challenge for many people. Health care providers must be prepared to provide options counseling about this full array of family planning services to adequately answer questions presented by all patients.

Interactions with the Health Care System
Marginalized groups have in the past experienced, and still experience, negative and/or ineffective contact with the medical world.

One example centers around the experience of some persons with intersex conditions who have received medically unnecessary surgical procedures on their genitalia or unwelcome curiosity from health care providers. As these individuals prepare to begin families, they face a unique spectrum of reproductive health challenges including lack of awareness about reproductive capabilities, concerns about derogatory comments, and potential absence of fertility.

Another example involves the relationship of the gay and lesbian community with psychiatric medicine. Until the publication of the DSM-IV in 1980, homosexuality was listed as a mental illness and many psychiatrists refused to work with gay and lesbian patients for mental illness unless they were willing to view their sexual orientation as an additional illness to be treated. Practitioners of any medical specialty must be aware of this troubling history of pathologizing homosexuality and other sexual behaviors when seeing LGBTI patients who may harbor longstanding mistrust of the medical system.

Event Planning for Your Campus

Sexual History Taking
At our institution, we have had a series of successful lectures on sensitive and inclusive sexual history taking that have been widely appreciated by students striving to provide quality care to all our patients.

Artifical Insemination
Sponsoring a reproductive health talk about artificial insemination, for example, can bring together a variety of constituents at your school — students interested in reproductive technology and ob/gyn, populations like single women and LGBTI communities that are regularly served by the procedure, and, of course, students interested in comprehensive women’s health.

Ethics
A possibility for an educational event might include a panel with patients and providers to discuss the ways in which intersex conditions have impacted their reproductive lives. Holding an event such as this during your school’s reproductive biology course would be an excellent way to delve into the ethics and complexity of providing good reproductive health care.

Incorporating LGBTI-centered reproductive health information into your chapter’s activities is an important step toward expanding our efforts to provide comprehensive education about the full range of reproductive health options currently available to our patients. Further consideration of sexual history taking, family planning counseling, and interacting with the health care system is central to our ability to provide the best possible care to each individual encountered in the clinic.

Resources

• SEXUAL HISTORY TAKING —Association of Reproductive Health Professionals: http://www.arhp.org/healthcareproviders/cme/on-linecme/maturecmecp/sexualhistory.cfm?ID=44
• INTERSEX ISSUES —Intersex Society of North America: http://www.isna.org
• LGBTI MEDICAL TOPICS —Fenway Community Health: http://www.gayhealthchannel.com
• PATIENT AND PROVIDER INTERACTIONS AROUND LGBTI ISSUES —Health Care Without Shame: A Handbook for the Sexually Diverse and Their Caregivers by Charles Moser, PhD, MD

Elizabeth Ferrenz is a third-year medical student at Harvard Medical School, and an MSFC Board member. Jenny Siegel is a second-year medical student and School Coordinator at Harvard Medical School.