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Creating Space: LGBT Patients and Families

Posted By Jess Goodman, Erin Sesemann, Wednesday, October 5, 2016

This post is a nod to the upcoming, opening plenary address at the 2016 CFHA Conference in Charlotte, NC. 



The health of children and adults who identify as lesbian, gay, bisexual, or transgender (LGBT) has the potential to be greatly impacted by their family, health care system relationships, and the broader context of where they live. The research tells us this can be done in both tremendously helpful and hurtful ways. Let’s take a deeper look…

Meet Jenna:

Growing up, it was common to have my mom accompany me and help me fill out forms detailing my personal information when I went to see my primary care provider. The forms provided my healthcare team basic background information like my demographics (i.e., gender, age, or ethnicity) and personal/family medical histories (i.e., history of smoking, heart attacks, or cancer). But, what if this basic information isn’t actually so basic? What if my mom didn’t really know everything about me? What if it’s because I couldn’t tell her everything about me?

Through all these background forms we completed in my childhood, I didn’t tell my mom that I’m transgender. I didn’t tell my mom I didn’t feel like a girl. I didn’t tell my mom that I wanted the world to know and see me as a boy. No one knew the emotional turmoil I kept inside me. No one knew about the anxiety and depression I felt every time I was called a girl. The sigh I breathed and how I hung my head every time I had to check the female box on my background forms.


This doesn’t reflect all family dynamics and reactions to children who identify as LGBT. There are many warm, accepting families that would adjust and support Jenna sharing her identification as transgender. They might listen and validate her struggles of being called, categorized, and labeled as female when she actually felt and considered herself male.


A supportive family might even walk with Jenna as she explores changing her name, preferring to be acknowledged by the pronoun "he” rather than "she”, wearing different clothes, or beginning hormone replacement therapy. They might, again, return with Jenna to the primary care healthcare team to help start the conversation about what options are available to address not only the physical symptoms, but also address the anxiety, depression, and lifestyle changes.


But what if our patients do feel similar to Jenna? What if our patients’ families are dismissive or rejecting? What if they don’t understand and/or wouldn’t accept their LGBT family members? Maybe there are some themes from Jenna’s story that do apply to our patients.


If so, are there ways we can communicate acceptance and safety in our offices to the LGBT community when they may be too afraid to start that conversation? Are there resources/handouts available to patients who might be secretly struggling? Are we, as the healthcare team, able to offer patients safe spaces to begin talking about the issues that so far they can only communicate about through their physical ailments?

At one primary care health care center, I spoke with a healthcare team that included 2 primary care providers (PCPs), a nurse, and case worker. Through this conversation I realized there are many small acts that healthcare teams are already doing that communicate care and support. This can be done in a more indirect approach, such as asking teens about dating both boyfriends and girlfriends at child-well checks, or it can be more direct, such as asking specifically about a patient’s sexual orientation in relation to their physical or mental health symptoms.


Within the family context there are also some ways that a healthcare team can intervene to help restructure the family’s communication about the patient identifying as LGBT. The specific intervention or treatment approach will differ based on the personality and preference of the PCP, nurse, or case worker but there are some general tips to keep in mind when attending to patients who identify as LGBT:


Barriers to Consider and Possible Interventions

LGBT youth can lack power within the family system to have control over their lives or access to their prescribed treatments

  • Gently ask LGBT youth about family reactions to their identity to assess for level of family rejection, if any, and related health risks
  • Ask questions such as: "Who are you out to”?
    • If out to family, "How has your family reacted to you coming out to them, or sharing this part of your identity with them”?
    • If not out to family, "What do you think is getting in the way of coming out to, or sharing this part of your identity with your family”?
  • Provide psychoeducation to families of LGBT youth about the health risks associated with lack of support for the youth based on sexual orientation and gender identity, and ways to be supportive and engaged4.5,6,7,8
  • Provide a safe, non-reactive space for LGBT patients to share through active listening and empathic statements
    • Become familiar with medical and behavioral health providers in your are that have experience working with LGBT populations
    • Provide information about LGBT community and support groups in your area that can offer peer support and mentorship
  • Based on age, safety, and level of independence of patient, it may be appropriate to help connect LGBT patients to public transportation, local community resources that provide transportation, or mail-delivered prescriptions, if appropriate and legal (Consult with PCP, pharmacist, and other health care providers as needed).
  • Refer patient and/or families to trained family therapy providers, strength-based support groups or peer counseling, and on-line credible resources for families of LGBT youth; follow-up with youth and families ongoing


LGBT youth and adults may remain in silence or denial about LGBT identity due to assumptions or fear of experiencing dismissive or rejecting reactions from the healthcare team, which may prolong physical and mental health symptoms

  • Display posters or flyers in your clinics that include LGBTQ youth, same-sex couples, and symbols1
  • Train all staff on LGBT health and competencies1
  • Offer single stall, gender- neutral bathrooms1
  • Include gender identity and sexual orientation in non-discrimination policies1
  • Allow patients to identify their sexual orientation and gender identity, as well as preferred name and pronouns on appropriate forms1
  • Develop office policy in compliance with local laws regarding confidentiality for un-emancipated minors1
  • Assess health history as a conversation, not a check list1
  • Treat sensitive topics, such as sex and substance use, as routine questions for all patients, using non-judgmental tone and body language1
  • With youth, use the mnemonic H.E.A.D.S.2 for taking social and behavioral history
  • Normalize questions about gender and sexuality, and don't make assumptions
    • Use questions and statements like:
    • I am going to ask you some questions about yourself and I want you to tell me how you feel, not how you think others see you or how others think you should feel. These are questions I ask all my patients.1
    • Are you attracted to boys/men, girls/women, or both? 1
    • How do you feel about your attractions?1
    • What words do you use to describe your sexual identity?1
    • What gender do you consider yourself to be regardless of what body parts you may have?1
    • How do you feel about your gender? 1


LGBT patients may lack a social support system due to family and/or community cultural values or religious beliefs that do not accept, tolerate, or embrace LGBT identification

  • Screen for support needs in a respectful way by inquiring about the presence and types of social supports of patients
  • Create opportunities for disclosure of relationships and supports, including respectfully inquiring about patients’ relationships with others accompanying them at appointments, keeping in mind it may or may not be family members or local friends/family
  • Connect patients with LGBT community resources and trained behavioral health specialists in LGBT care, as needed
  • Connect patients with supportive online/social media LGBT resources
  • Use validation and normalization statements to increase LGBT patients’ communion with others from the broader LGBT community and local healthcare center
  • Utilize Motivational Interviewing3 techniques to assess and promote different ways patients’ may exercise their agency within their context. Examples may include:
    • Use open-ended questions to help patients verbalize how they are making meaning about the possible discrepancies between their personal identification and cultural or family or religious values
    • Provide affirmations to patients’ strengths throughout the encounter, such as his/her courage to self-disclose in healthcare center


LGBT patients quit taking medications for symptoms (such as depression or anxiety) because they do not believe the medications will help treat the root of their problems (i.e., stress of identifying as a sexual or gender orientation minority, family rejection, community isolation, etc.)

  • Be respectfully curious about the reason they have stopped taking their medication
  • Provide validation for patients’ experiences without expressing agreement
  • Assess for possible additional personal or cultural biases related to medications that may inhibit their willingness to adhere to treatment (i.e., medication = disease, illness)
  • Educate patients on the health risks associated with stopping medication, stress, and lack of social support
  • Discuss alternatives to medication, including journaling, meditation, increasing activity levels, individual and family counseling, and offer LGBT community resources and supports



Think about a patient you’ve seen in the past that you may or may not have asked about their sexuality or gender identity. How did knowing or not knowing this information impact the care you provided? Were you curious about their sources of support? Did you make assumptions about the sources of support they had, or did you ask about it? How did it help to know the answer, or why do you wish you would have known?


If you didn’t ask about these things, what do you think got in the way? What do you think it will take for you to be able to ask these questions?


Regardless of our beliefs, we need to be prepared to have conversations that foster openness and understanding with all patients. The healthcare team is uniquely positioned to assess for social support needs and work with patients and their families or families of choice to access the care and services they need for whole health. Take a moment to think about your office and the ways you can better create a safe space for your LGBT patients and their families, help patients utilize social support for better health and healing, reduce the health disparities and discrimination, and promote every aspect of our LGBT patients’ health.


Additional resources for providers support LGBT adults and their social support networks:

- Fredriksen-Goldsen, K. I., Hoy-Ellis, C. P., Goldsen, J., Emlet, C. A., & Hooyman, N. R. (2014). Creating a vision for the future: Key competencies and strategies for culturally competent practice with lesbian, gay, bisexual, and transgender (LGBT) older adults in the health and human services. Journal of Gerontological Social Work,57(2-4), 80-107.

- Lim, F. A., Brown Jr, D. V., & Kim, S. M. J. (2014). CE: Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: A review of best practices.AJN The American Journal of Nursing,114(6), 24-34.

Additional resources for providers supporting LGBT youth and their families:

- Ryan, C. (2009). Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children. San Francisco, CA: Family Acceptance Project, Marian Wright Edelman Institute, San Francisco State University.

- Ryan, C., & Monasterio, E. (2011). Providers’ guide for using the FAPrisk screener for family rejection & related health risks in LGBT youth. San Francisco, CA: Marian Wright Edelman Institute, San Francisco State University.

- Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). A practitioner’s resource guide: Helping families to support their LGBT children. HHS Publication No. PEP14-LGBTKIDS. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.



1The National LGBT Health Education Center. Caring for LGBTQ youth in clinical settings. Retrieved August 8, 2016 from

2Goldenring, J. M., & Rosen, D. S. (2004). Getting into adolescent heads: an essential update.CONTEMPORARY PEDIATRICS-MONTVALE-,21(1), 64-92.

3Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. New York: Guilford Press.

4The National LGBT Health Education Center. Resources and suggested readings. Retrieved September 19, 2016 from

5Bouris, A., Guilamo-Ramos, V., Pickard, A., Shiu, C., Loosier, P.S., Dittus, P., Gloppen, K., & Waldmiller, J.M. (2010). A systematic review of parental influences on the health and well-being of lesbian, gay, and bisexual youth: Time for a new public health research and practice agenda. Journal of Primary Prevention, 31, 273-309. doi:10.1007/s10935-010- 0229-1

6Ryan, C., & Chen-Hayes, S. (2013). 13 Educating and Empowering Families.Creating Safe and Supportive Learning Environments: A Guide for Working With Lesbian, Gay, Bisexual, Transgender, and Questioning Youth and Families, 209.

7Ryan, C., Huebner, D., Diaz, R.M., & Sanchez, J. (2009). Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123, 346-352. doi: 10.1542/peds.2007-3524

8Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT young adults.Journal of Child and Adolescent Psychiatric Nursing,23(4), 205-213.

Jessica Goodman received her M.S. in Family Therapy from the University of Massachusetts in Boston. She is currently a Ph.D. Student in the Medical Family Therapy program at East Carolina University. Her present research goal is to develop an evidence-based integrated care protocol for the ED to reduce health disparities among minority and underserved populations experiencing diverse concerns in an emergency setting. 

Erin Sesemann is a current Ph.D. Student in Medical Family Therapy at East Carolina University. She has experience working in community mental health agencies, private practice, and integrated behavioral health care in primary care. She graduated with her M.S. in Marriage and Family Therapy from Oklahoma State University in Stillwater, OK.

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