June 25, 2024
“It’s about patient-centered care. We’re trying to help all patients become the best version of themselves – and creating that relationship and just going on that journey together is so important.” – Dr. Krishna Jothikumar
Happy Pride Month! As part of our company-wide celebration, our Pride + Friends Employee Resource Group hosted a panel called “Provider Perspectives on LGBTQ+ Health Care.” This panel featured Dr. Krishna Jothikumar – board-certified family medicine physician – and Dr. Scott Nass – board-certified family medicine physician, HIV specialist and Regional Medical Director for Aledade.
The hour-long conversation touched on a range of topics and featured several staff-submitted questions. Here are a few powerful moments from the discussion:
Q: How do you ensure your practice is inclusive and welcoming to LGBTQ+ patients? And what steps do you take to ensure that LGBTQ+ patients feel heard and respected during their visits?
Dr. Nass: One simple thing my practice does is collect our patients’ pronouns right away, and we then display those pronouns on every patient chart, file, everything – wherever that patient’s name is, their pronouns are there also.
Something I want to stress is that there are some health care systems that are well-known for being inclusive and supportive of LGBTQ+ populations. But I think that we have to be careful, regardless of whether we are in those systems, to not take anything for granted. Not everyone in your system or organization may necessarily align with all of your mission. So individually, I think it’s super important to put yourself out there. I have a “he/him” badge on my white coat that I wear right next to a rainbow caduceus to signal to my patients that pronouns matter to me. Additionally, I’ve added myself to online LGBTQ+ directories…though, I will note that word-of-mouth has always been even more valuable. If somebody leaves your office feeling good about themselves, they’re going to talk about that experience. They’re going to tell people they feel like you heard them, you listened to them and that you care about what happens to them regardless of who they are. They’ll want to come back to have and continue conversations with you – and they’ll tell their friends and family about you.
But being in directories and pursuing public shows of support at community events are important, too. If there’s a drag queen story hour happening at your local library or there’s a pride event somewhere near you, reach out and see if you can buy pizza for it. If the pizza is sponsored by Dr. so-and-so at the local family medicine clinic…how great would that be for people to see that and go, “man, that was so cool of them”…and you’re gonna get new patients that way.
Q: As a provider, do you feel equipped to treat a trans person?
Dr. Jothikumar: That’s a great question because I think people often forget how much primary care physicians can actually do for gender-affirming care. It’s so straightforward. Now, there will be cases or some situations where a specialist will need to be involved – like referring out to an endocrinologist, for example. But most of the time, most situations are about gender-affirming care, and a primary care physician should easily be able to handle it (like providing HIV medicine). Obviously, it’ll take some practice…and finding mentors to learn about different cases and keeping up with the latest research…but there’s so much we can do on our own without involving specialists.
Dr. Nass: Absolutely. I love that about family medicine – and that’s what attracted me to it in the first place. It’s what I grew up with – a family medicine clinic back home – but I like to remind folks that we sort of default to doing gender-affirming care. We check a guy’s testosterone level when he’s worried about fatigue or not having as much muscle. We check a woman’s hormones post-menopause and prescribe estrogen pills or cream. We talk to teenagers about puberty. Those are all routine things, right? In many ways, it comes down to what someone’s gender goals are and helping them feel more like themselves – and that journey and that plan of care are different for everyone.
Dr. Jothikumar: Yes. And as a primary care physician, know your resources and who to go to for those cases that require specialists. I live in Palm Springs, which is very progressive. We have a decent amount of providers who do hormones…we have some speech therapists for voice feminization…there are some practices that specialize in surgical interventions. It’s important to be connected and meet new people in health care systems who you can refer patients out to when they’re needed. Our community has grown so much in the past decade, and it’s great to have colleagues who can and want to help.
Q: How do you address the unique health risks and needs of LGBTQ+ patients, and in particular, mental health concerns?
Dr. Nass: I think more and more clinics and health centers are trying to have co-located behavioral mental health, but there’s still such a shortage across the country. Focusing on how we, as primary care physicians, can be supportive is the most critical thing. It goes back to knowing who a person is at the most basic level – beyond what they put on their intake forms. What are they enjoying in life beyond what they do for work? Who do they surround themselves with? Is there a negative relationship with someone in their life, particularly with a family member or someone who raised them? Study after study, we see that when people aren’t able to express who they are, it has such a negative impact on their mental health.
Dr. Jothikumar: Exactly. And until you ask them these kinds of questions, you’ll never really know what’s going on. It’s horrible some of the stories you hear…and the environment some patients are living in where they can’t move forward (with their transition, as an example). You need to figure out what kind of resources they need and what you can do for them. Anxiety, depression…we can all experience that, regardless of gender or sexuality. As a physician, you need to always ask questions and see what you can do.
Dr. Nass: That’s right. We all want to live authentically and be who we are – it does wonders for our emotional health.
Q: How can people living with HIV navigate the stigma held by other medical professionals? And what can a primary care physician – or the patient’s main point of care – do to help support patients when dealing with this?
Dr. Nass: Yeah, HIV has such devastating origins, and we know how much it decimated the gay community. For a while, the government didn’t provide funding or even acknowledge that this was a condition that was taking too many lives…so the history is terrible. That said, I think a lot of the lingering stigma is that it’s a gay man’s disease or a disease for men who have had sex with men, and that’s not the case. When we focus on that, or define health issues like HIV that way, we create disparities for other folks who may be at risk or who have the condition but don’t fit in that category…and it’s not fair to them. Also, HIV is definitely a treatable chronic disease at this point. We have so many good medicines.
Other infections can sneak in through the backdoor, but if someone is undetectable, HIV is untransmittable. So, there’s a big campaign called “u=u” – undetectable equals untransmissible.
Dr. Jothikumar: The stigma may take a long time to overcome, and we may not accomplish overcoming it in our generation…but things are changing rapidly. Regardless of whether you are HIV positive, know that you have allies and people who can and will advocate for you – and your primary care physician can and should be one of those people.
Clinician Resources:
LGBTQ+ Healthcare Directory
Free listing for any provider who offers LGBTQ+-friendly health care
GLMA: Health Professionals Advancing LGBTQ+ Equality
Annual fall conference on LGBTQ+ health and ongoing educational opportunities
National LGBTQIA+ Health Education Center through the Fenway Institute
A wealth of on-demand content from basic to advanced
World Professional Association for Transgender Health (WPATH)
Annual fall conference on transgender health, live-streamed and in-person trainings in transgender health (certification available)