How to Practice LGBTQI+-Centered Healthcare
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Dr. Kevin Wang shares his own journey as a gay physician and offers advice on how health systems can be more inclusive.
Many healthcare organizations are now taking steps to support health equity for the LGBTQI+ (lesbian, gay, bisexual, transgender, queer and intersex) community. And yet, research suggests there is still much work to be done to eliminate the health disparities that LGBTQI+ individuals continue to face.
Provider Solutions & Development sat down recently with Dr. Kevin Wang, the medical director of Swedish health system’s newly established LGBTQI+ Program, to talk about his work in this area.
Here, he shares his own coming out story, discusses the importance of providing gender-affirming healthcare for the LGBTQI+ community and gives tips on what providers can do to make their own practice more inclusive.
Provider Solutions & Development: Hi Dr. Wang! Can you tell us a little bit about how you got involved with this work?
Dr. Kevin Wang: Absolutely! During medical school and residency, I noticed we didn’t get much, if any, training on how to serve the LGBTQI+ patient population. When I started working as faculty at Swedish First Hill Family Medicine in 2010, I began developing curriculum at their residency program in part due to my own experiences and in part due to medical student and resident interest. The occasional lecture quickly grew to an integrated curriculum. This led to the development of a conference focusing on LGBTQI+ healthcare which caught the attention of leadership. I could tell this was an opportunity for Swedish.
In June 2019, a few colleagues and I presented a plan to Swedish leadership. This led to the Swedish Foundation granting funding for an LGBTQI+ Initiative, which started in January 2020, to perform a current state assessment of what our LGBTQI+ community needs and how Swedish can partner to provide healthcare to the LGBTQI+ community. We got to work, learning everything we could about how the best programs in the country are doing this. We had conversations with people at Harvard, the Fenway Institute in New York, Oregon Health & Science University and others. We examined best practices, worked with local LGBTQI+ community leaders and said this is what we think we can do. And Swedish said, let’s go all in! Swedish made our initiative into a permanent program, which lives under Swedish Health Services’ newly formed Office of Health Equity, Diversity and Inclusion. It’s pretty exciting!
That is so great. What were your takeaways from the year-long initiative?
We had four big takeaways:
We need to provide clinical support for providers, so they can provide comprehensive services to the LGBTQI+ community.
We need to get better at data gathering, input and reporting. Right now, we don’t collect enough data on LGBTQI+ patients, so it makes it hard to understand what services we need to prioritize and how we’re doing from a general population health perspective.
We need to implement big culture change, focusing on advocacy, education, cultural awareness, historical trauma, conducting listening sessions with our patients, and compensating them to tell us what we can do better.
We need to improve our care coordination by increasing accessibility for LGBTQI+ patients with Swedish and the surrounding healthcare institutions.
Can you tell us about your personal story?
I am a child of Chinese immigrants and coming out to my family was really hard. My Mom actually asked me if I was gay, because she had just watched an amazing episode of The Golden Girls, where Blanche’s brother came out. My Mom took it hard. She worried about the burden being gay would be for me and how my father would take the news, given that he would focus on passing on the family name. I didn’t end up coming out to my Dad until years later, and he didn’t take it too well, either.
But the first time I came out, I was in high school. I remember getting chased out of the school by bullies, and this guy who was a year older would scare the bullies away. We became friends, and I felt safe with him. He used neutral language when we talked. Looking back on it now, he was quite ahead of his time! He’d say, ‘Who do you like?’ When I came out to him, he hugged me and said, ‘You’re my friend; you’re great. Even if your parents kick you out, you can come to my house.’ I will never forget his kindness and how he accepted me. I will forever be grateful! Now I am very open about who I am. I am proud to identify as a gay family physician.
Are there misconceptions about Coming Out?
Yes, I think many people don’t realize Coming Out is a process, it’s not a single, one-time event. LGBTQI+ folks come out over and over again their whole lives. There’s that first experience of coming out, and for many, that’s to a friend who they feel safe around. They come out to their family, which can be difficult. And then they come out again, every time they move to a new city, or start a new job, or make a new friendship. The main thing I want allies to know is if someone comes out to you, you should see it as a privilege, because it’s not easy.
When LGBTQI+ patients are not receiving compassionate, inclusive healthcare, what damage is being done?
I can give you a personal example. When I was a kid, I would see my family doctor, and he’d ask me if I had any crushes on girls in my class or if I had a girlfriend. I already knew I liked boys. And it made me feel like, ‘Oh, is there something wrong with me?’ I didn’t feel like I could be open with him.
Another example: When I was interviewing for a spot in a residency program, I was told I wouldn’t be a good fit for the program after I came out to the interviewer.
Now as a doctor myself, I think some of the best examples are when physicians have stereotypes influencing their care. Let’s say a cis-gender, gay male comes in and they tell their provider they’re gay. And that provider says, ‘Oh, we should be testing you for HIV, gonorrhea, chlamydia and syphilis.’ They make an assumption the patient is promiscuous, when he could be in a committed relationship. On the other hand, a straight person comes in, and no one even has that conversation with them, because it is assumed they’re monogamous. Or a patient tells her doctor she’s a lesbian, and the assumption is made she has never had sex with a man, and no one recommends cervical cancer screening or HPV vaccination.
Medically speaking, a transgender or non-binary patient might come in and request hormonal therapy. Many providers still are not comfortable providing hormones. It’s not something traditionally taught in medical school or in a lot of residency programs.
What do healthcare organizations need to do differently?
They need to do the internal work first. It’s not just about terminology. It’s understanding the history of the LGBTQI+ community. We are working on this now, creating modules to inform our caregivers at Swedish about the disparities the LGBTQI+ community has faced, and faces, when it comes to policies and legal rights — and how it all impacts the ability to access healthcare. Things are better now, yet in 2021, we have seen the highest number of legal threats to LBGTQI+ rights. Knowing this history is a key foundation for setting up a safe space in healthcare organizations.
What can providers and clinics do to create an inclusive environment?
When I meet a new patient, there are little things I do to sort of lay a breadcrumb trail, so if they do identify in the LGBTQI+ community, they will feel comfortable talking to me about it. I say, ‘Hi I’m Dr. Kevin Wang, and I use he/him pronouns. How would you like me to address you?’ I use gender-neutral language, and I ask the same questions of every patient about their relationships. These breadcrumbs can open doors, so if someone is exploring their gender identity, they may discuss it with me later when they feel comfortable.
We also need to have more inclusive patient-facing materials and policies. Registration forms could have open-ended questions for gender and sexuality. There is so much potential for creating inclusive clinical environments.
How has the pandemic made this work even more important?
Great question. Because our healthcare system doesn’t do a good job of collecting SOGI (Sexual Orientation and Gender Identity) data, we really don’t know what impact COVID has had on this community. At the beginning, some thought the Queer community was faring relatively well. But it’s hard to say, isn’t it, because no one is asking the question. We don’t know if they’re having higher rates of COVID, because the data isn’t collected. The LGBTQI+ patient population once again becomes a hidden community despite increased visibility in recent years, and resources don’t get allocated where they might be very much needed. This is why SOGI data are so important, and we are working on this at Swedish. We want to gather these data on every patient.
I’ll tell you a quick story about this. At the beginning of the pandemic, I did a shift at an urgent care clinic. My first patient I met there, I asked about their pronouns, and they said they were non-binary. I tested them for COVID, and at the end of the visit, they started crying. I asked, ‘Are you OK?’ And they said, ‘No doctor has ever asked me that before. Now I know it matters to Swedish.’ It was a very meaningful moment.
What are the top 3 things every physician or APC can start doing today to create a better environment for their LGBTQI+ patients?
Be comfortable not knowing what you don’t know.
Before you start providing LGBTQI+-centric care, figure out if everyone in your clinic is prepared to create this space. You could do all the medical work but if you don’t have an environment where it’s safe, it won’t take. Do your foundational work first. Learn the history. Talk with your community to see what they want you to prioritize.
Know there is probably an LGBTQI+ community organization that would love to partner with you and set everyone up for success. There are lots of online resources on gender-affirming hormonal therapy and healthcare, and evidence-based protocols. Check out these amazing websites:
UCSF Guidelines for Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People
What gives you hope?
I think just the fact that there’s more representation everywhere now, in pop culture and in elected positions. We have Dr. Rachel Levine, the Assistant Secretary for Health at the Department of Health and Human Services, the first openly transgender federal official to be confirmed by the Senate. Representation matters – we’re at the table for these discussions. It’s beyond just healthcare, it’s bringing attention to historical discrimination. I think what gives me hope is it feels like the dam has broken, and our society is asking, ‘Where do we go now?’ I see people who are inspired not just to do good work, but to do the hard work.
Another thing that makes me feel hopeful is medical students and residents. Those of us who are older and will be retiring in however-many years, we look to students and residents as our future leaders. Many of them see this as an opportunity to give back to their community and make things better. It’s a transformative time. That, to me, is the most exciting thing.
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