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19 Articles in Volume 19, Issue #6
Arthrofibrosis: Targeting Hormones after Childbirth to Relieve Frozen Shoulder, Inflamed Joints
Can CGRP Help Clarify Why Migraine Is More Common in Women?
Case Report: Managing Chronic Pelvic Pain in Men
CGRP Monoclonal Antibodies for Chronic Migraine: Year 1 of Clinical Use
Chronic Pelvic Pain as a Form of Complex Regional Pain Syndrome
Correspondence: Continuing the “Pain Specialist” Dialogue
Endometriosis and its Misunderstood Etiology
Evolving Management Strategies for Osteoarthritic Pain
Gamma PEMF Therapy: A Pilot Study For Its Use in Managing Opioid Addiction
Guest Editorial: Sex Differences in Pain
How to Provide Effective Pain Management to LGBTQ Individuals
Interscalene Peripheral Nerve Stimulation for Post-Operative Chronic Shoulder Pain
New ICD-11 Codes Set to Improve Pain Care in the Primary Setting
Perspective: Could NGF Antagonists Be the Safest, Most Efficacious Class of Drug We Have to Treat Pain?
Rheumatoid Arthritis and Cognition: Is There a Genetic Link?
Targeting Nerves Provides Alternative to Opioids for Joint Arthroplasty
The Sex Question in Primary and Pain Care
What is capsaicin’s role in treating osteoarthritis?
When Pain Clinicians Have to Be the Villain: Communication Strategies to Bridge the Divide

How to Provide Effective Pain Management to LGBTQ Individuals

Danielle Weitzer, DO, shares her personal and clinical experience regarding the care of this vulnerable patient population.
Pages 56-57

One of the most discussed factors in pain care today has to do with the interface between mental health and chronic pain, and one community that faces some of the most significant barriers in this area is the transgender population.1 Not only is clinical depression heavily reported among transgender individuals, but additional concerns include suicidality due to transitioning and substance use disorders, which are significantly higher among this patient group compared to the general population.2

When Discrimination Leads to Healthcare Avoidance and Mental Health Struggles

When considering mental health, anxiety levels have been shown to predict pain severity and pain behavior in patients with both acute and chronic pain.3 Anxiety reduction techniques and anxiolytic drugs have been reported to be successful in ameliorating pain associated with medical procedures.4 A positive correlation exists between mental health and pain, such that an individual who is depressed or anxious is significantly more likely to report higher levels of pain. Although research of the transgender population is lacking when it comes to chronic pain, it is thought that transgender individuals are prone to — or at more risk of — the same pain conditions as the general population. In addition, extensive surgeries are usually performed in this population, which makes monitoring of post-operative pain an important consideration. Due to the above factors of post-operative pain and higher levels of reported mental health problems, transgender individuals are likely to report higher levels of pain.

Unfortunately, unique barriers exist in this community that may prevent transgender patients in pain from even getting evaluated. Simply put, discrimination and the perception of discrimination both exist when it comes to the healthcare of transgender individuals.

By way of example, a large number of transgender individuals face discrimination or mistreatment in some aspect of their lives, whether at work,5 school, or in public, which usually leads to avoidance behaviors. For instance, they may not seek care when needed and when they do opt for care, they may be reticent to share their full medical history. One study correlated perceived homophobia among physicians by patients with decreased frequency of engagement with providers.6 This type of avoidance likely places additional stress on the patient, which may help to explain the higher prevalence of mental health and substance use disorders faced by transgender people. In this regard, it has been shown through retrospective data that transgender youth accessing community-based clinical services had a two-fold to three-fold increased risk of depression, anxiety disorder, suicidal ideation or attempt, and self-harm without lethal intent.7

Transgender individuals are also likely to feel more comfortable with physicians and group practices when there are external signs that promote a well-caring, non-judgmental environment.(Source: Unsplash)

How Clinicians Can Break Down Barriers

Some clinicians may feel uncomfortable providing care to Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) patients due to insufficient training and/or a lack of knowledge about this population’s specific healthcare issues.8 If providers feel discomfort when assessing for pain in this population, however, it may lead to bias when treating for pain. For example, other vulnerable patient groups such as racial and ethnic minorities have been shown to be at particularly high risk of receiving inadequate pain relief.9 These disparities likely stem from medical school, where formal training in LGBTQ issues does not currently exist.10

The medical community can help to eliminate this cycle, however, and improve healthcare access and adequacy. For starters, an increase in the amount of time that curricula focus on LGBTQ healthcare may bridge these gaps. For example, the University of Louisville found that medical students’ presented more favorable attitudes towards LGBTQ patients and had more knowledge of their specific healthcare concerns after participating in an interdisciplinary program that addressed this population directly.11 In general, a growing number of medical students saw transgender identities as being a natural expression of gender after the training. Furthermore, most of the participants stated they would feel comfortable if they were to become known among their peers as a health professional who cares for LGBTQ patients. To provide additional experience in medical education, specific interview skills and practice case formulations involving the LGBTQ population may be helpful. For example, students were more likely to positively view their ability to provide care to LGBTQ patients if they practiced in sexual history taking. This step alone could lead to more comprehensive exams, better clinical attitudes toward LGBTQ patients, and greater knowledge of LGBTQ healthcare concerns.12

In addition to noting patient’s sexual history as part of initial assessments, providers may improve healthcare engagement for this unique population by including an optional gender and/or sexual orientation box in patient surveys/medical history intake forms—beyond the traditional male or female sex checkboxes. One study found that a majority of medical providers are unaware of their patients’ sexual orientation—only 37% of doctors are aware of having lesbian patients, only 5% ask about sexual history, and only 11% are aware of lesbian-specific healthcare concerns.13 Another study found that, when presented with “gay-friendly” providers, patients were more likely to disclose their sexual orientation and other medical concerns.14

Transgender individuals are also likely to feel more comfortable with physicians and group practices when there are external signs that promote a well-caring, non-judgmental environment. This welcome may come in the form of a publicized statement of equality and diversity on a provider’s website or within the practice’s standard-of-care forms. Careful attention to bedside manner is always important as well and assumptions should never be made. If a physician is unsure about terminology, or a definition of some sort, it is always better to ask, allowing the patient to share how important or relevant the topic may be. However, no one person responds to a set situation in the same way, so context clues should be taken into consideration to best individualize care. Assessing the need for social and personal support may be worth discussing with patients as well; such needs may present as a limiting factor that prevents adequate follow-up.

Last but not least, to better serve the transgender population—and, truthfully, all patient groups—pain needs to be better understood and approached through interdisciplinary care. In one hospital study, for example, small discussion groups involving providers across disciplines resulted in increased knowledge levels of pain management and decreased biases toward specific patient populations.15 The addition of a psychiatrist to pain management teams may be additionally beneficial as identifying and addressing mental health issues may significantly reduce pain-related issues. By eliminating or decreasing confounding variables (eg, depression, anxiety) that may be influencing the perception of pain, clinicians may make greater strides toward isolating precise pain levels.

From Knowledge to Comfort and Care

Taken together, these approaches may not only improve clinicians’ comfort levels and bedside manner when working with transgender individuals and other members of the LGBTQ community, but also reduce fears of discrimination on the part of the patients, thereby reducing patient avoidance. In the end, taking small steps to build a well-developed doctor-patient relationship may help to knock down key barriers that continue to impact access and care of both vulnerable and often discriminated-against populations.

Read the author's personal journey on our Patient site.

More on breaking down barriers in our HealthyWomen Pain Summit coverage.

Last updated on: October 7, 2019
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CGRP Monoclonal Antibodies for Chronic Migraine: Year 1 of Clinical Use
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