The words a hospitalist uses with a patient who identifies as LGBTQ are more than just semantics, according to ACP Member Keshav Khanijow, MD.
“Research has shown that using appropriate pronouns and terminology with transgender youth can be lifesaving. And I would posit that using appropriate pronouns and terminology for all LGBTQ people helps to build and foster trust with a medical provider, and that ultimately saves lives,” he said. “It's not the patient's job to teach us while they're battling illness. Rather, the onus is on us to learn it.”
Dr. Khanijow, a hospitalist and an instructor of medicine at Johns Hopkins University School of Medicine in Baltimore, taught attendees about modern LGBTQ terminology during a session at SHM Converge 2022, held in Nashville April 7 to 10.
For starters, it's key to understand all the words in the commonly used acronym. “While lesbian, gay, and bisexual may be familiar terms to us, the term queer may not be. It was actually a pejorative term in the 1980s, but in the 1990s, it was reclaimed by activists as a term of pride. … If someone doesn't feel like they fit within the silos of lesbian, gay, or bisexual, or the histories that come with them, they may identify as being queer,” he said.
The word homosexual has traveled the opposite trajectory. “It started off as a scientific term to describe people with same-sex attraction. But over time, it's kind of evolved into a term … of pathology,” said Dr. Khanijow. “I would not use that word” with patients.
Patients who identify with the T in LGBTQ may describe themselves as transmen or transwomen, but they also may prefer other terms. “They may just simply identify as transgender,” he said. “Their gender pronouns may be he/him, she/her, or gender-neutral—they/them.”
There's an easy way to find out which words to use for each patient. “Ask what their pronouns are, as well as how they identify,” said Dr. Khanijow. “Don't assume sexual orientation based on someone's partner. Remember, it may be a female who comes in with a female partner, but they may identify as bisexual or queer and not necessarily lesbian. So ask, don't assume.”
The next step in care for transgender patients is to record the information you've gleaned in a prominent place. “Once you know the identification, do use it in documents. This will avoid the patient having to come out over and over again to future providers,” he said.
How prominently to present information about sexual orientation is debatable, given the risk of bias. “Consider whether it's needed in their one-liner or not,” said Dr. Khanijow, offering an example: A 45-year-old male who identifies as queer, with past medical history of migraines, presents with headache.
“Why are we listing sexual orientation in the one-liner?” he asked. “Are we trying to highlight his increased risk of meningitis? Are we trying to highlight that he's dealing with coming-out issues, and there's stress around this that could be contributing to his headaches? Are we trying to highlight that he has a male partner visiting all the time, and we want to signify that it's not just a family member, but actually his partner?”
Those are all valid reasons to include sexual orientation from the start, but if you conclude that the information is no longer contributing to the patient's medical care, it's reasonable to take it out, Dr. Khanijow said.
He gave advice on describing transgender patients in the medical record, including that the terms male-to-female (MTF) and female-to-male (FTM) are falling out of use. “They ascribe to a gender binary, and now we're thinking about gender as more of a spectrum,” he said. The new preferred terms are assigned male at birth (AMAB) or assigned female at birth (AFAB).
Sex reassignment is another term that's no longer favored. “It's not about reassigning; it's about affirmation,” said Dr. Khanijow, offering another example one-liner. A patient who might have formerly been described as a “29-year-old transsexual MTF on sex reassignment hormones admitted for pyelonephritis” could now be described as a “29-year-old woman (transgender, AMAB, on gender-affirmation hormones) admitted for pyelonephritis.”
With so much rapidly changing terminology, even the most knowledgeable clinicians will slip up sometimes, Dr. Khanijow reassured attendees. “I make mistakes, and it's embarrassing, and I regret them. But it's good to have a framework to think about what to do when we're apologizing for the mistakes,” he said.
The first step is to thank the patient for correcting you. “Then correct yourself. Use the correct gender, and then apologize,” he said. Make it quick and simple. “Don't turn it into a long drawn-out apology, because then that forces the patient to apologize back to you,” Dr. Khanijow added.
Finally, as long as the patient isn't upset, get back to business. “Move on, because the medical care needs to continue,” he said.