At Upstream, we believe true patient-centered care is gender-inclusive contraceptive care. On this Transgender Day of Visibility, we celebrate our health center partners who are leading the way in providing exemplary care to LGBTQIA+ patients, including Fenway Health in Massachusetts and Tri-County Community Action Agency health centers in Rhode Island.
Founded in 1971 as part of the free clinic movement by students who believed that “health care should be a right, not a privilege,” Fenway Health started as a small drop-in clinic providing free blood pressure checks and sexually transmitted diseases (STD) screenings. Today, Fenway is a freestanding, Federally Qualified Community Health Center (FQHC) with a staff of more than 600 and a patient population of more than 33,000. Their mission is to enhance the wellbeing of the LGBTQIA+ community and all people in Boston’s Fenway neighborhood and beyond through access to the highest quality healthcare, education, research and advocacy.
Fenway has had a Transgender Health Program for 26 years, which aims to integrate gender-affirming care into primary care and improve access to healthcare for Trans and gender diverse individuals. All primary care providers are trained in gender-affirming care and are expected to be confident and competent in providing this care to patients.
According to Julie Thompson, PA‑C, the Medical Director of Trans Health at Fenway:
Integrating gender-affirming care into primary care and contraceptive care reduces stigma by acknowledging gender diversity and self-authenticity as an important aspect in the lives of all people. Creating a welcoming, judgement-free, and anatomy-based space to discuss sexual health, parenting intention, and specific aspects of reproductive functioning can allow patients to safely explore their goals, realistic outcomes, and options for care.”
Because integrating gender-affirming care into patient care is crucial at Fenway, the Upstream Quality Improvement team partnered with Fenway’s contraceptive care champions to ensure the language being used to start conversations about birth control was inclusive of all genders, and also opened the door for further discussions about diverse healthcare needs. The solution was to choose a Pregnancy Intention Screening Question (PISQ) that focuses on Parenting intention — “Would you like to become a parent in the next year?”
PA Thompson said:
Language is a powerful tool that can influence the way people see their options and understand their limitations. Asking only about pregnancy intention may miss those individuals who may not want to carry a pregnancy but may want to donate their gametes to a partner, adopt, or become a parent in another way. Adjusting the question to parenting intent welcomes a discussion around all of the options that might entail, creating a space for discussion and education.”
Initial, open-ended and gender-inclusive questions around options can lead to more dialog and opportunity to understand an individual’s goals and knowledge of realistic expectations. Adapting the language of the PISQ is one way Fenway and Upstream have worked together to incorporate truly inclusive, patient-centered care into contraceptive counseling at the health center.
Tri-County Community Action Agency
Tri-County Community Action Agency is an agency with wraparound services for an array of needs. Founded in 1964, Tri-County has been serving Rhode Island communities with housing insecurity, job training, and senior and disabled adult services. They also have two health centers based in North Providence and Johnston, which serve patients with medical and dental services.
Starting about three-and-a-half years ago, Chief Medical Officer, Dr. Wilfredo Giordano-Perez led the shift in care at Tri-County to become more gender-inclusive. It started with changing the sign-in and patient intake forms to ask about pronouns and gender identity rather than just sex assigned at birth. This first step towards a more inclusive language for patients quickly transitioned into developing a LGBTQ+ health program which includes tailored services such as behavioral health, where mental health providers have specific training in individuals who are LGBTQ+ identifying.
According to Dr. Perez:
We recognize that the LGBTQ+ population has been a population that must be outreached to in particular. [It is] a population that has a well understood distrust in the health care system, rooted in a long history of abuse, discrimination and human rights violations. We are committed to creating a space that is safe and affirming for all people regardless of how they identify but especially for those who identify as LGBTQ+. And we want to do everything we can to make that very clear to our community.”
Some approaches Tri-County uses to make sure their LGBTQ+ patients feel welcome include:
- Marketing to the Rhode Island community that they are a safe space by advertising in local magazines.
- Putting a large rainbow flag outside of the health center—which Dr. Perez notes is a rare sight in conservative Johnston.
- The entire staff wears pronoun pins and rainbow stickers on their ID badges.
He goes on to explain:
We know that those individuals who are not white, cis-gender, heterosexual men, are at highest risk for some of the greatest health disparities in our country. And so, gender inclusivity is a crucial component of the care we provide at our health centers in order to promote health equity and advance access to those who are often denied it. [Additionally,] there are no federal laws protecting against discrimination for LGBTQ individuals, so it is a population that is largely not protected. And when you lack those basic protections, you put people in a very difficult situation, and they don’t know who to trust or where to go.”
And this is why he says that providing those “little tweaks” in how they represent their health center make a big difference. And ultimately, it’s “just providing good care.”
Making your practice more inclusive
Both Julie Thompson and Dr. Perez offered some advice for those wishing to make their healthcare practice more inclusive:
- Recognize that gender-affirming care is not specialty care. According to Julie Thompson, “It should be expected that any care provider affirms their patient’s identities and truths as they are presented and shared. Gender identity should be no exception. We know that failing to affirm an individual’s gender and decreasing access to health care leads to poorer health outcomes. Medical schools and health centers should incorporate gender-affirming care trainings and CMEs into their annual provider education programing.”
- Hold your colleagues accountable for creating a safe space where patients can express themselves however they choose. As Dr. Perez explains, “We have an environment here where if someone were to refer to a patient by the wrong pronoun, accidentally, that another staff member who knows the correct pronoun is expected to speak up and correct that staff member right then and there. Oftentimes it’s by mistake, but if a patient hears it, it can be taken as an offense, and felt as a microaggression.”
Trans healthcare is a priority, even and especially in a climate where Trans youth are being denied care. At Upstream, we are committed to making gender inclusion a part of our work by continuing to center the voices of LGBTQ+ identifying patients. We have focused on integrating more gender-inclusive language into our contraceptive care model, we’ve brought in subject matter experts to guide our work, and leaned on our partners who are skilled in providing care to this population.
We are committed to ensuring that our partners prioritize safe and inclusive reproductive health conversations between patients and their providers. To help make this happen, we are increasing representation of queer and trans identities in the case study scenarios used in our trainings, facilitating conversations around trauma-informed examinations, and creating intentional space to further unpack and combat coercive practices with LGBTQ+ patients.
We know there is more work to be done and recognize that the work we do to uplift Trans folks and their needs should be done every day — not only once a year. At Upstream, we are committed to the process of learning, growing, and improving to ensure that gender-inclusive contraceptive care is standard practice, and that our work and the work of our partners support the needs and voices of LGBTQ+ identifying patients. Follow us on Twitter and LinkedIn to join the conversation.