Equality care

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It’s time for current, future providers to understand LGBTQ health needs

By Dawn Goodlove

Whether she’s lecturing a class of University of Iowa medical students on the proper pronouns for patients, or telling family physicians the hormone medication regimen for transgender patients, Katie Imborek (’08 MD, ’11 R) is determined to flatten the learning curve for providers whose patients identify as lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ).

Almost three years ago, Imborek, clinical assistant professor of family medicine in the UI Carver College of Medicine, co-founded the LGBTQ Clinic at UI Hospitals and Clinics—Iowa River Landing with Nicole Nisly, MD, professor of internal medicine. The clinic has served more than 250 patients since opening; nearly 75 percent of patients identify as transgender or gender nonconforming, and 70 percent of all patients live in communities outside Johnson County, where the clinic is based.

“The people who drive hours to see us are the transgender people. They’ve gone to doctor, after doctor, after doctor and been told, ‘We don’t treat people like you,’’’ Imborek says.

“We were unsure of the number of transgender and gender-nonconforming patients living in Iowa and in need of health care, but as I’ve worked at the clinic and seen how many live in small-town Iowa, in all parts of Iowa, in places where our students are going to practice, I’ve been validated. I know this is important training,” she says.

With the Supreme Court legalizing same-sex marriage in all states, and media following the stories of transgender individuals such as Caitlyn Jenner, issues related to sexual orientation and gender identity are finding their way into doctor-patient conversations. The health care system, however, does not always welcome the discussion because of providers’ personal biases—often subconscious— as well as a lack of understanding of the health care needs of the LGBTQ community and discriminating laws and policies.

Last fall, the Association of American Medical Colleges released guidelines to help medical schools train future physicians to better care for patients who are LGBTQ, gender nonconforming, or born with differences of sex development. Even before the AAMC weighed in, UI colleges whose faculty support the LGBTQ Clinic were already working with future and current providers to diminish disparities.

“I don’t want there to be a need for an LGBTQ clinic. I want my patients in Marshalltown, for example, to be able to go to a doctor in Marshalltown and get great care,” Imborek says.

History of discrimination

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Physician Katie Imborek visits with UI Carver College of Medicine student Theang Ho at the LGBTQ Clinic.

A year before they opened the LGBTQ Clinic, Nisly and Imborek attended a UI event where transgender individuals described visits with doctors who didn’t know whether to call them by their birth name or preferred name, tried to send them to specialty clinics unnecessarily, or declined to schedule appointments with them at all.

“I felt ashamed of being in a medical profession that couldn’t provide good care for these patients,” Nisly says.

Such discrimination can be stressful, increasing the risk for mental health disorders (depression, anxiety, eating disorders) and suicide, substance abuse, smoking, obesity, and cardiovascular diseases. Individuals who identify as LGBTQ also may be susceptible to some cancers because they are not getting the appropriate screenings. Women who have sex with women still need Pap tests and HPV screenings, but they may postpone or avoid seeking care for fear of discrimination and mistreatment.

“Language is so important, especially to trans people. So often they’ve been discriminated against or have this perceived negative reaction to health care. The encounter could be ruined so quickly depending on the language providers and health care staff use,” Imborek says.

Once they decided to start the LGBTQ Clinic and received solid backing from UI leadership, including then-President Sally Mason, and health care administrators, Nisly and Imborek collaborated closely with the local LGBTQ community, especially transgender people.

“They helped train the entire care team on terminology and the health and social needs unique to the gender-nonconforming population,” Nisly says.

In her core curriculum lectures on LGBTQ health, Imborek discusses terms, definitions, and disparities with first-year medical students. With second-year students, she covers preventive measures including screening recommendations and medications such as pre-exposure prophylaxis (PrEP) for HIV, a treatment known to few in the at-risk population and to even fewer providers.

Imborek first raised awareness of LGBTQ health issues 10 years ago as a UI medical student. She established the student organization MEDIQS (Med Iowa’s Queer Students), which over the years has brought in speakers, promoted health care awareness campaigns, and guided the college in changes to its curriculum. Imborek continues as a faculty advisor to MEDIQS.

Besides lectures, the UI medical curriculum addresses LGBTQ health issues when students practice taking a sexual history with standardized patient-actors, as well as when they do their internal medicine clerkship, which can include the LGBTQ Clinic under Nisly’s supervision.

Interdisciplinary approach

Volker Thomas of the UI College of Education’s Couple and Family Therapy Program works with the LGBTQ Clinic.

Nisly stresses the LGBTQ Clinic’s team approach to care, including a dedicated pharmacist as well as mental health experts from the UI College of Education’s Couple and Family Therapy Program. These professionals mentor providers-in-training and often lead workshops for current providers.

The Couple and Family Therapy Program’s doctoral students are licensed marriage and family therapists. Once they obtain the PhD, they likely will land faculty positions at any of the roughly 200 master’s programs for marriage and family therapists around the country.

“There is a lack of training and competence of many licensed marriage and family therapists in working with the LGBTQ community, especially with trans clients,” says Volker Thomas, PhD, UI professor of couple and family therapy in the Department of Rehabilitation and Counselor Education. He is director of the doctoral program, which expects to graduate its first class in 2016.

“Most people and most health care providers are straight and cisgender—they identify with the gender assigned to them since birth. There is this underlying assumption in all of us that everybody is that way. The first step for these therapists is to become more aware of the differences and then work with them, rather than ignoring them or being afraid of them.

“When family therapists feel that lack of training, lack of confidence, and lack of competence, it creates insecurity and anxiety in working with that population when they realize, ‘Oh, no, they’re different than I am,’” Thomas says.

Under the guidance of Thomas and other faculty, doctoral students conduct the psychosocial assessment for each patient pursuing gender transitioning. This assessment before patients undergo hormone therapy and surgery is the standard of care recommended by the World Professional Association for Transgender Health.

Thomas and his team have counseled about 150 patients— including 120 transgender people—since partnering with the LGBTQ Clinic in April 2013.

“Our job as cisgender straight people is to not place the responsibility for learning about trans people on trans people. The more aware and sensitive we become, the easier it will be for us to work with them and the more open we can be,” Thomas says.

Michelle Miller, PharmD, counsels the clinic’s patients on hormone therapy and other medications and monitors patients’ lab results. Often she advocates for patients when their local pharmacist questions a prescription or their insurance won’t cover medications without prior authorization. As an adjunct assistant professor in the UI College of Pharmacy and coordinator of the Ambulatory Care Pharmacy Residency Program at UI Hospitals and Clinics, she teaches residents and fourth-year pharmacy students who rotate through the clinic.

“When a patient expresses gender dysphoria, I think some providers feel it’s so much different than if they were to use hormones in a cisgender person, and it’s not. The key is making sure current and future providers understand that you aim to treat this person with the respect and competence that every patient deserves,” she says.

More learning opportunities

As issues related to gender identity and sexual orientation spark more conversations, the University of Iowa has discovered increasing opportunities to engage in education around these topics.

LGBTQ Clinic providers have presented at national conferences and departmental grand rounds. The UI Department of Internal Medicine’s nearly 140 residents are trained to provide inclusive care for LGBTQ patients as part of the core curriculum presentation by Nisly, the department’s diversity officer who formerly served as interim UI chief diversity officer and associate vice president. The training is being expanded to include physicians in internal medicine fellowships.

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LGBTQ Clinic physicians Nicole Nisly and Katie Imborek

Beginning this year, residents in family medicine and pediatrics will rotate through the clinic after completing the UI Safe Zone Project, where participants learn to model support, affirmation, and inclusion of LGBTQ people. Safe Zone workshops are open to all UI faculty, staff, and students, as is access to CultureVision, a web-based tool that allows instant access to information about more than 50 ethnic and cultural groups across 12 clinical and nonclinical areas.

UI Health Care faculty, staff, and students also can enroll in webinars on LGBTQ patient-centered care or more specialized topics for clinicians, available through the Human Rights Campaign that has endorsed UI Health Care as a Leader in LGBT Healthcare Equality.

“It really showcases, as an academic medical center, the amount of influence we can have,” says Nisly, who also gives training on the care of LGBTQ individuals to prison directors, correctional officers, and wardens across Iowa and the Midwest.

“The next generation of residents and fellows, and students in medicine, pharmacy, nursing, physician assistant studies, law, and psychology will feel comfortable creating a welcoming space for these patients.”

Award-winning providers

HEI 2014_bug finalFor three consecutive years, University of Iowa Health Care has been recognized as a Leader in LGBT Healthcare Equality by the Human Rights Campaign, whose Healthcare Equality Index is the national benchmarking tool that evaluates policies and practices related to the equality and inclusion of LGBT patients, visitors, and employees.

UI Carver College of Medicine faculty members Nicole Nisly, MD, and Katie Imborek, MD, who co-founded the LGBTQ Clinic at UI Hospitals and Clinics—Iowa River Landing in 2012, were recognized in 2013 with the UI Diversity Catalyst Award for promoting the development of an inclusive, diverse campus community. Imborek also received the award in 2007 as a medical student. Nisly was honored with the UI’s Jean Y. Jew Women’s Rights Award in 2013.

Law project advises on ID documents

Not all concerns that patients bring to the LGBTQ Clinic are medical.

“I realized a lot of transgender patients had needs that pertained to the legal arena, such as how to change their gender mark on a passport, birth certificate, or voting card,” says Nicole Nisly, MD, clinic co-director.

University of Iowa clinical law students prepared step-by-step instructions for patients in “The Iowa Guide to Changing Legal Identity Documents,” which is available on the LGBTQ Clinic website, in the “resources for patients” section. The guide tells how to change a legal name and how to change name and gender on a birth certificate, Social Security record, driver’s license, U.S. passport, citizenship and immigration documents, as well as financial and other personal records.

The guide is one of several initiatives of the Rainbow Health Clinic, which is managed by the UI’s Law and Policy in Action Clinic Project, directed by Len Sandler, UI clinical professor of law.

More to explore

University of Iowa LGBTQ Clinic
Gay and Lesbian Medical Association
World Professional Association for Transgender Health
Centers for Disease Control and Prevention
National LGBT Health Education Center
Center of Excellence for Transgender Health
4th Annual LGBT Health and Wellness Conference, March 2016, Des Moines
43rd Annual Refresher Course for the Family Physician, April 2016, Iowa City
3rd Annual Culturally Responsive Health Care in Iowa Conference, June 2016, Iowa City