Talking with clients

Language matters enormously.

As a healthcare provider, your words are one of the most important and immediate ways of establishing trust with LGBTQ clients. Your choice of words, your degree of openness and empathy, and your level of comfort when discussing gender and sexual identities, behaviours and practices, can make a huge difference to your LGBTQ clients and the quality of their healthcare.

Talking about client sexuality is a learned, not innate, skill. Don’t be afraid to tell your clients if you aren’t familiar with a term or a topic.  Your willingness to learn about it will stand out and be appreciated. With repeated practice and experience, healthcare providers can become increasingly comfortable in raising and discussing these topics with all clients, and can improve access to healthcare for people who are often alienated from it.

Terminology

• Ask clients how they would like to be addressed. For example, “What name do you prefer me to call you? What gender pronouns do you prefer?” Note this information on the front of the client’s chart.
• Take your client’s lead and mirror their own language when it comes to naming identities or behaviour. For example, you can say, “People identify themselves in different ways: male, female, straight, gay, lesbian, transgender, etc. How do you identify yourself?”
• Ask your client to clarify any unfamiliar terms or behaviours. You can repeat a client’s term and articulate your own understanding of its meaning, to make sure you have no miscommunication.
• Many LGBTQ people may use words such as “queer,” “dyke” and “fag” to describe themselves. Be aware, though, that these and other words have been derogatory terms used against LGBTQ folk. Although the LGBTQ community may have reclaimed these terms, they are not appropriate for use by healthcare providers who have not yet established a trusting and respectful rapport with LGBTQ clients. If you are in doubt as to how to refer to a client, ask what word or phrase he or she prefers.

Taking a sexual history

When taking a sexual history:

• Let your client know that taking a sexual history is a routine part of your practice for all clients, and that it’s important in order to provide the best possible health and preventive care.
• Revisit the sexual history each time you see a client: partners and practices may change. Don’t make assumptions about past, current or future sexual behaviour. For example, a client who identifies as lesbian or discloses that she has a female sexual partner may also have had male partners. Or, her partner may be a trans man. Similarly, many men who have sex with men identify as heterosexual.
• Discuss sexual practices and behaviours openly, empathetically and nonjudgmentally.
• Use gender-neutral language when referring to partners or significant others. Don’t assume that a person has a partner, or that he or she has only one partner. For example, instead of asking, “Are you married or single?” you can ask, “What is your current relationship status?”
• Focus on sexual behaviours, rather than sexual identity. For example, instead of asking, “Are you gay or bisexual?” you can ask, “Are you currently sexually active, and do you have sex with men and/or women?”
• Make sure that the questions you ask apply to all clients, and ask only for information you need. This is particularly relevant in terms of questions to trans people about gender-affirming hormones, surgeries, etc. Explain why you are asking the questions you ask. For example, you can say to a trans man, “Hormones like testosterone can make Pap tests more difficult to read. To help me assess your health risks and needs, can I ask you to tell me about any hormones you’re taking?”
• Don’t assume that LGBTQ clients do not have children or that they don’t plan on having children. Don’t assume that a “femme” lesbian is any more likely to plan to get pregnant than a “butch” lesbian, or that a trans man has no plans to become pregnant.
• Ask, “Are you comfortable with your sexuality? Do you have any concerns related to your gender identity or to your assigned sex?”
• Be mindful of the terms “biological/biology,” especially when talking to trans clients. Often, these terms can be offensive in that they imply that a sex or gender assigned at birth is “natural” or “real” and that a trans gender is not. For example, instead of talking about someone’s “biological sex,” you can ask about their “assigned sex at birth.” When talking about someone who is not trans, you can say “not trans” or “cis,” rather than “biologically male or female.”
• Similarly, avoid referring to certain body parts as “male” or “female”: some men may have vaginas, while some women may have penises.
• Bisexual clients may have specific concerns or sensitivities around sexual history. Be aware that sexual behaviour of bisexual clients may not differ significantly from that of heterosexual or lesbian/gay people. Bi clients may be monogamous for long periods of time and still identify as bisexual; they may be in multiple relationships with the full knowledge and consent of their partners. They may be on guard against healthcare providers who assume that they are confused or promiscuous  simply because they have sexual relationships with people who identify as male or female.
• Respect a client’s wishes not to answer certain questions. Offer to discuss the issue at a later date.
• If a client seems offended by something you’ve said, apologize and briefly explain why information is necessary. Ask what terminology the client prefers and note that information in the client’s chart.

Be aware that gender identity and sexual orientation and desire are not the only influences on sexual behaviour and access to affirming healthcare. LGBTQ clients also come from a diverse range of socioeconomic status, cultural and religious backgrounds, racial/ethnic communities, ages, physical abilities, education levels and geographic backgrounds, all of which play into sexual behaviours and practices, as well as the language used to describe them.