Rainbow Health 101

Key points:

  • Providing more inclusive care for the Rainbow Community starts with the first points of contact to your practice–your website, your waiting room, your enrolment forms, and every staff member a patient encounters.  Do the mahi and make sure your practice and your staff are well trained to provide inclusive and accessible care to our LGBTQIA+ whānau

  • Don’t make assumptions–you can’t tell someone is gay or trans just by looking at them and you also cannot assume you know their gender or pronouns either.  You must be comfortable asking questions!

  • Ask questions respectfully and for information and clarification purposes but don’t rely on your patients to educate you.  You should be doing that yourself (and that’s what we’re here for!)

  • If you’ve met one rainbow patient you’ve met…one rainbow patient.  Don’t assume that everyone thinks, feels, looks, or acts the same way.

  • Don’t confuse sexual orientation with gender identity. The former refers to the types (gender/sex) of people someone is attracted to or wants to have sexual relationships with. The latter refers to how a person identifies and experiences their own gender.

Definitions

  • LGBTQIA+ Stands for “lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual  PLUS all the other identities that fall under the rainbow umbrella.  These identities are defined as follows: 

    Lesbian:  A person who identifies as a woman and whose sexual/romantic attractions are primarily or exclusively with other women.  Some people also define lesbian as “non-men who are attracted to other non-men.”

    Gay:  A term which was originally applied to men who had sexual/romantic attractions for other men but over the years has become a more general term that applies to people of any gender whose attractions are primarily to others of their same gender.

    Bisexual:  People who have sexual/romantic attractions to ‘both’ genders.  Some people prefer to define bisexual as having attractions to people of the same gender or a different gender to one’s own.

    Transgender:  A person whose gender identity is different from that of the one they were assigned at birth.  A person may identify as transgender (or trans or trans*) regardless of whether they ever undergo any type of social or medical transition.

    Queer:  An umbrella term for members of the rainbow community which some people prefer to use for themselves and others don’t.  It has been commonly used as a slur and many people in the rainbow community have taken it back as a term of pride.  However, unless you identify as queer yourself, it’s best not to use the term to refer to other people and definitely don’t use it to describe a person if they don’t like the term. 

    Questioning: People who are uncertain about their sexual orientation or gender identity. (This can include people of any age.)

    Intersex:  A person who has one of a number of conditions affecting their sex chromosomes or hormones which may give them typical characteristics of different sexes.  Not everyone with an intersex condition identifies as intersex or identifies as part of the rainbow community.  Intersex people can also identify as any gender or sexual orientation.

    Asexual: A person who has no sexual attraction to anyone. People who identify this way do not view this as a stage of life or a phase but as an enduring part of their sexuality.  Asexual people may engage in sexual activity for a variety of reasons.  Being asexual does not mean a person does not have a sex drive. 

  • Sexual orientation refers to the people one is attracted to sexually.  In addition to the terms lesbian, gay, bisexual and asexual defined above, there are several other terms you may hear.

    Heterosexual:  A person who identifies as a particular gender and who is attracted primarily or exclusively to members of the opposite gender.  It is important to note that many trans people identify as heterosexual.  In general this refers to the gender identity of the partners they choose, not their anatomy.  However, the reality is not always that straightforward. 

    Homosexual:  A person who identifies as a particular gender who is attracted primarily or exclusively to members of the same gender.  This term isn’t commonly used anymore.

    Pansexual: A person who may identify as any (or no) gender who is attracted to people of any gender or attracted to people regardless of gender. Note: you may see some debates between people in the rainbow community about the difference between bisexual and pansexual.  Clarify if you need to but don’t argue with a person about the terms they use to self-identify.

    Aromantic: A person who has no interest in romantic relationships with anyone.

    Demi-sexual: A person who only has sexual interest in another person after they’ve formed an emotional connection.  They may develop sexual feelings only for people of a particular gender or genders, or people of any gender. 

  • Gender identity refers to the gender (male, female, or other) that a person identifies with.  In general, when babies are born, a determination is made as to their sex based on their genitalia or (if available) their karyotype.  Children are raised and socialised according to certain cultural customs and norms (which may differ between families) to adopt characteristics relevant to the gender they were assigned at birth.  Many children will identify themselves with that gender but others will not.  Here are some terms you should know that relate to gender identity: 

    Cisgender:  Someone who identifies as the gender they were assigned at birth.

    Transgender: Someone who does not identify as the gender they were assigned at birth.

    Gender binary:  The notion that there are only two genders, male and female, and that they fall at opposite ends of a spectrum.

    Non-binary:  Someone who does not identify with the gender binary and may see themselves somewhere in the middle or outside of it entirely. This term can encompass a whole range of other gender identities.

    Gender fluid: Someone whose gender identity can shift and change, sometimes from day to day.

    Agender: Someone who does not identify with any gender.

    Genderqueer: Similar to queer, this is a term used by many people who do not identify with the social structures around gender.  They may identify as a particular gender or not and some may identify as cisgender but express themselves in ways that do not always fit within cultural ‘norms’ for gender expression.

    Transsexual: This is an outdated term that used to refer to trans people who had undergone some sort of transition. 

    AFAB: Stands for Assigned Female At Birth.

    AMAB:  Stands for Assigned Male At Birth.

  • Gender expression is the ways in which  people dress and act relating to their gender.  Everyone expresses gender, whether they think about it or not.  People who were raised as a particular gender and always identified with that gender may never have given their gender expression much thought.  However, people who have grown up and realised that the gender roles or norms they have been taught do not fit with their identity may make intentional choices to express their gender in certain ways. Some terms that relate to this include:

    Butch: A person who expresses themselves in a sterotypically masculine way, regardless of their gender identity or sex assigned at birth.

    Femme:  A person who expresses themselves in a stereotypically feminine way, regardless of their gender identity or sex assigned at birth.

    Transfeminine: An AMAB person who identifies and expresses themself in a more feminine way (but may not necessarily identify as female)

    Transmasculine: An AFAB person who identifies and expresses themself in a more masculine way (but may not necessarily identify as male)

    Androgynous:  A person who expresses themselves in a gender-neutral or gender-ambiguous way.

    Our language is so binary that it is difficult to define these terms without resorting to stereotypes of male or female.  However, when discussing gender identity with patients, it is important to listen and observe what they say and do rather than making assumptions based on the way they look or what they are wearing.

  • Gender dysphoria:  This is a sense of dissatisfaction or dis-ease that a person might have because either their body parts or the way they appear to others (or both) don’t match their gender.  Not every trans person experiences dysphoria!

    Gender incongruence: This is a more updated term that refers to a general sense that parts of a person’s body or the way they are perceived do not match their gender. This may or may not cause a person to feel dysphoria

    Misgendering:  Making the wrong assumption about a person’s gender, expressed by things like using the wrong pronouns or title or referring to them as the wrong gender. This is a common cause of dysphoria

    Deadnaming: Using the name a person was known by prior to changing their name to fit with their identity.  They may not have legally changed their name but using the wrong name or seeing it on documents can be a source of dysphoria. 

    Pronouns:  Words that stand in for nouns or names (such as I, me, you, it, they, he, she).  Third person pronouns (he, she, they) are often gendered so it’s important to use the correct ones.  Some people who want a gender-neutral option use the “they” as a singular pronoun. This is grammatically correct and has been used this way for centuries when the gender of the person referred to is unknown or being concealed.  (Example, “Go find that person, they left their umbrella behind.”)

    Neo-pronouns: Pronouns that aren’t commonly used in English that people use to refer to themselves, such as ze and hir.  

Making your practice Rainbow-friendly

From the very first point of contact with your practice, LGBTQIA+ patients will be on the lookout for signs of safety and acceptance.  They need to know that all staff, including receptionists, nurses, doctors, and anyone else they might encounter are going to treat them with respect and have at least some awareness of how to provide appropriate care.  Unfortunately, many LGBTQIA+ patients are so accustomed to feeling marginalised, excluded, misunderstood, or outright discriminated against. 

  • Your practice website may be the first point of contact. Simple things, such as having staff profiles include pronouns, can make a difference.  If there are medical providers who are particularly interested in Rainbow health or transgender care, make sure to make that known.  Making an effort to make language more inclusive will also go a long way.

    Displaying a rainbow flag in your reception area shows that you are a practice that welcomes LGBTQIA+ people and indicates that you are at least making an effort to be inclusive.  

    Make sure items on display in your waiting area reflect the diversity of individuals and families.  Try to be aware of too many images of heterosexual couples and families.  Just as with ethnicity, people notice when they don’t see themselves reflected in any of the practice’s promotional or educational materials.

    Have the staff wear name badges with their pronouns

    Have a sign at reception that invites people to share their pronouns.

    If the patient has already enrolled, make sure there are appropriate alerts on files so that staff know how to address patients, so that misgendering and deadnaming do not occur (for example, making sure a doctor or nurse does not announce the patient’s deadname to the entire waiting room).

    Make sure new patient forms show that you are inclusive of all gender identities and family types. Instead of a M/F tick box, have a blank to fill in for gender.  If your practice management system does not allow for the patient’s gender, you might need to explain that but do so in private and make sure the patient understands the problem, then put appropriate alerts on files so that patients are addressed appropriately.

    Record pronouns in the file. Normalise asking people’s pronouns even when you’re sure you already know. 

    Use inclusive language when asking about a patient’s partner(s).  Don’t make assumptions about the gender of a person’s partner or the identity of any support people in the room.  (For example, MANY lesbians report being asked if the female accompanying them is their sister, mother, daughter, or friend when it is actually their partner. On the other hand, it is highly unlikely that male partners accompanying female patients are asked if they are the brother, father, son, or friend of the patient.)

    A VERY important point to remember during this whole process is: If you don’t know something, ask BUT don’t make your patient be the one to educate you about everything related to the rainbow community.

  • Make sure to keep a very open mind and non-judgmental attitude at all times.

    For the most part, the method of taking a medical history is the same regardless of the gender or sexuality of the patient.  If you have discovered that your patient is LGBTQIA+, carry on with the history as you normally would, asking the same questions you would to any patient.  The differences come in when discussing issues specifically relating to sex and gender.

    It might be helpful to have a medical history form to fill out first, including information such as sex assigned at birth and any surgeries they have had. This way you already know what body parts they have (for screening recalls) and can avoid asking awkward, irrelevant, or upsetting questions that might result from making the wrong assumption about a person’s anatomy based on their perceived gender. 

    On the intake form or in person, having a social history that includes a person’s own description of their sexual orientation can be useful. While you can’t use it to make assumptions about the gender/sexuality of the person’s past, present, or future partners, it is an important detail about your patient and will send them the message that you are a safe person to be their real selves with.  An important cause of health disparities for LGBTQIA+ people is their inability to be honest with the doctor because of fears of bias and discrimination.

  • Taking an inclusive history can seem tricky at first but it’s really not. It just requires thinking outside of the heteronormative (penis-vagina) sex paradigm.

    Don’t make assumptions– a person’s identity doesn’t tell you who they have sex with.  For example, sometimes lesbians have sex with men, and sometimes married people are polyamorous (ie they have more than one partner with the consent of all parties).  A person’s identity also says nothing about the kinds of sexual practices they engage in or enjoy.

    As with any consultation, start by asking the patient if they have anything they want to talk about. If they feel comfortable, they might tell you everything without you even having to ask any awkward questions.

    Start open-ended and general and explain why you’re asking the questions.  Say, “I would like to ask you some personal questions about your sexual history. It’s important so I know what kinds of screening tests you might need.”  Ask if they are currently in a sexual relationship with one or more people. It’s nice to know the genders of the partners but for the purposes of a sexual history, it’s more important to know the anatomy of the partners.  While acknowledging that you realise the question might be a bit awkward, explain that it’s important for you to know so that you have an understanding of their sexual health needs.

    Ask about prior partners the same way

    If you have concerns about traumatic or harmful sexual practices, ask questions in a sensitive and open-minded way to ascertain whether there is coercion or abuse going on.  

    Ask about safer sex practices as needed. This includes condoms and barriers with toys as well as actual body parts.  It can also mean asking about sufficient lubricant use, and consent.  

    Once you’ve gotten a clear picture of what kinds of sex the patient is having, and with whom, you can move on to assessing health needs such as contraception, STI screening, PrEP. Click here to be directed to the Sexual Health page

  • If you’ve asked the right questions on your intake form or initial visit you’ll have an idea of the patient’s gender identity and if they’ve got any particular needs related to that.

    If they are seeking gender-affirming healthcare you can find out more by clicking here

    If they identify as trans (or not cis) and are not seeking anything in particular, it’s important to just be able to reassure them that you and your practice staff will do everything you can to ensure that correct name and pronouns are used.  It’s helpful if you acknowledge limitations in your IT systems and ensure that you will work around them the best you can.

    If they need sexual or reproductive health services you can find more information by clicking here.