The LGBTQ+ care gap starts in the exam room

FigureEvery June, health care systems update their logos. A rainbow overlay here, a Pride month post there. And LGBTQ+ patients keep skipping their annual physicals. I think about this every year, because the data do not point where most people expect. This is not primarily an insurance problem or an access problem. Study after study show that LGBTQ+ adults avoid care because of what they anticipate will happen once they get there. They have learned, from experience, to expect dismissal. They decide before the visit even starts what is safe to share and what is not. They leave practices after a single negative encounter and sometimes they do not find another one. And they do not come back. I want to be clear about what I mean when I say affirming care, because the term has gotten diluted. It is not the rainbow lanyard. It is not changing your profile picture in June. Those things are fine, but they are not clinical. Affirming care is the intake form that collects preferred name and pronouns, used by a provider who actually reads it before walking into the room. It is a sexual health history that does not assume heterosexuality as the default. It is knowing to offer preexposure prophylaxis (PrEP) without waiting for the patient to bring it up, because most patients who need that conversation have already learned not to expect it. Every one of these is a learnable clinical behavior. Literature about the stress faced by historically marginalized populations gives us a clinical framework for why this matters beyond patient satisfaction scores. Chronic exposure to discrimination has measurable physiological effects: cortisol dysregulation, elevated inflammatory markers, higher cardiovascular risk. The guarded patient in your exam room is not being difficult. That is a learned response to a system that has not been reliable. One good visit can start to shift that. One careless one confirms everything they were afraid of. NPs are well-positioned here, and I do not think we talk about that enough. We spend more time with patients than almost any other provider type. We were trained to think about the whole person. For a lot of LGBTQ+ adults, we are the only consistent clinical relationship they have. That is real leverage, and it is worth using on purpose. June is a good time to ask honest questions about what our practices actually feel like from a patient's perspective. Not the poster on the wall. The intake form. The rooming process. What our documentation assumes by default. Affirming care is good primary care. That is all it is. I look forward to hearing your thoughts on this issue and the conversations we should be having about closing this gap.FigureEfrat “Dr. E” LaMandre, PhD, FNP-C Editor-in-Chief [email protected]