In this MD Newsline exclusive interview with psychiatric nurse practitioner Dallas Ducar and pediatrician Dr. Andrew Cronyn, we discuss how to address anti-LGBTQ+ implicit bias in primary care. We also discuss how to rectify LGBTQ+ health disparities.
How can primary care physicians address implicit bias in their practice? How might their doing so improve healthcare for underserved communities?
Dr. Andrew Cronyn:
“I would say the other thing is hiring. For example, the unemployment rate for trans people is incredibly high, and a lot of those people are very qualified people who’ve accomplished huge things in their lives, and we’re wasting their talents. Having trans people in primary care offices—everywhere from the front desk, to nursing, to the provider who sees them, to an administrator who walks through the office—is really important.
With any implicit bias, it’s harder to hold on to your bias as tightly when you look people in the eyes, and you talk to them on a regular basis. And so, bringing more people into the system is really important. If everyone did that with all of their implicit biases, it would be transformational.
The other challenge that I have had as a cisgender, white man is admitting that I do have those biases and seeing them. We’re taught a lot in med school about what we’re good at. And we’ve been very good at a lot of things. We’re very smart people. We’re doing the best we can almost all the time.
We have to realize that this is an area that we probably weren’t taught about and we probably don’t know much about. But we’ve educated ourselves about the newest things in treating hypertension. We can educate ourselves in LGBTQ+ healthcare and incorporate it into our practice very well.
A lot of what we were taught turns out to be not as true as we thought it was, which is what science is. Science keeps learning new things. Now that we’re seeing our biases, we need to work on them. Who better than primary care providers to work on implicit bias in healthcare?”
“Harvard medical school has done a great job with baking in sexual and gender minority health throughout their curriculum, normalizing the fact that sexual and gender diversity is just a fact of human life. We’re seeing more and more people come out as trans, nonbinary, gay, lesbian, bi—lots of people on different sides of the Kinsey scale. And so, we’re recognizing the multiple layers that exist for any one person. In seeing the layers of who people are, that allows us to be a little less biased.”
How would you recommend primary care physicians support the LGBTQ+ community to rectify health disparities?
Dr. Andrew Cronyn:
“Number one, ask. It’s exactly what Dallas had said before. You don’t count if you’re not counted. So ask patients about their sexual orientation and their gender identity. The first time anybody ever asked me about my sexual orientation in the doctor’s office—and I’ve been out since I was 19—was when I was in my 40s, and it was someone I was friends with.
When you do large LGBTQ+ 101 trainings, and you ask, ‘other than at the OB’s office, has anyone ever asked you about sex? Has anyone ever asked you about your gender identity?’ It is so incredibly rare. It’s easier for us to talk about sexually transmitted diseases than it is to talk about sex. It’s easier for us to talk about pathologies of gender than it is to talk about gender and ask about identities. I think we still have that streak of the Puritans within us.
I think more and more we’re realizing that we do need to talk about sexual orientation and gender identity. And there’s a lot of times we can’t practice good medicine if we don’t know about our patient’s identity. With trans people, 100% because a lot of trans people will need a medical transition of some sort. We have to know about that.
In pediatrics, when you ask nonbinary kids about their gender identity, they look at you with this combination of absolute fear and absolute happiness that someone is going to see them. And suddenly, you’re finding out about all those things that they didn’t previously share with you. And now you get to know about them. So I think that is the number one thing: ask about sexual orientation and gender identity as part of your routine.”
“I love the idea of baking sexual orientation and gender identity into your assessment. I also encourage any clinician to think about the pathway of mutuality here. We’re not just helping the LGBTQ+ community. The LGBTQ+ community has a lot to teach healthcare.
I think where this work starts is to have every clinician sit and really think about their own sexual orientation and gender identity. ‘Who have I ever been attracted to? What do I think about my gender?’ And really think about it. You might find that you yourself are a little more queer than you might have thought. We all exist on these different spectrums.
And then I’d ask why there are fewer gender-diverse physicians than there are gender-diverse nurse practitioners and physician assistants? I think that’s because there are systemic barriers that exist in pursuing higher education. And sometimes, it can be easier to financially enter in as a nurse.
There are different pathways and different philosophies, but the point is when we talk about all the discrimination that is harming these communities, there just aren’t many educational settings where LGBTQ+ folks can authentically be themselves and navigate past those barriers.
So try to create mentor-mentee relationships with some of those folks. Think about how you might be able to support them in different ways. Maybe they can come in and learn a little bit about medicine through a mentorship program or start at some entry-level position. There are a lot of ways we can be inclusive and bring LGBTQ+ folks to the table.
And finally, what we’re doing here at Transhealth Northampton shouldn’t be revolutionary, but it is. We have enough time to talk to patients about who they are. We have enough time to ensure that our staff aren’t burnt out. We’re really trying to center affirming, holistic, comprehensive care. Some of what we do is about medical needs, and some of what we do is about community support—things that might often not be talked about in a provider’s office.
There’s a lot of beauty here that the LGBTQ+ community has created over many years. And there’s a lot that the LGBTQ+ community can teach healthcare.”
Responses have been condensed and lightly edited.