When Lea Cordova, MA, MS, a retired Duke University biomedical scientist, came out as transgender in 1995, she says she faced some “awful surprises” while navigating the health care system. She recalls that during her transition, her appearance was perceived as confusing and offensive to some people at the Duke Health clinic where she received care.
“I had an instance in which I came to a receptionist, and the receptionist looked at me and walked off … and never came back,” Cordova recalls. “I was so hurt that I burst into tears in the doctor’s office.”
Her doctor called the IT department and asked for the sex designation on her chart to be changed from male to female, and she says things changed after that.
"From then on, I had no problems. ... No major problems," she clarifies. "It all had to do with the fact that I’m trans."
Cordova’s experience isn’t unique. A long history of anti-LGBTQ+ bias in health care continues to affect this population’s access to care, according to a March 2016 report by the National LGBT Health Education Center. LGBTQ+ is an acronym for Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, and others — sometimes also referred to as LGBT or LGBTQ. It describes a population of people united by having gender identities or sexual orientations that differ from the heterosexual and cisgender majority. See a glossary of terms on the Duke University School of Medicine Office of Diversity & Inclusion website.
According to research conducted in 2010 by Lambda Legal, almost 56 percent of lesbian, gay or bisexual individuals and 70 percent of transgender and gender non-conforming individuals report having experienced discrimination in health care settings. Additionally, 31 percent of gay and bisexual men report not having a regular place to receive medical care, or a regular physician, according to research conducted in 2014 by the Henry J. Kaiser Family Foundation.
Lesbians and bisexual women get less routine health care — including colon, breast and cervical cancer screenings — than heterosexual women, according to the American Cancer Society. And 50 percent of transgender individuals report having to teach their providers about some aspect of their health care needs, according to the National Transgender Discrimination Survey Report on Health and Health Care.
The health disparities don’t stop there, and in response to the sobering statistics, two Duke family medicine resident physicians have dedicated much of their time in residency to a project with the ultimate goal of enhancing the quality of care experienced by Durham’s LGBTQ+ identified individuals.
“I know that this population is at risk and I want to be a part of making sure that LGBTQ+ people get good care,” says Tiffany Covas, M.D., MPH, a third-year resident in the Duke Family Medicine Residency Program.
Expanding the Clinical Practice
Covas, who will join the faculty in October, and Jessica Lapinski, DO, a second-year resident, are spearheading an effort to expand the clinical practice at Duke Family Medicine Center to include an LGBTQ+ Patient-Centered Medical Home, in coordination with key Duke University stakeholders and the local LGBTQ+ community. Duke Family Medicine Center, located in the Marshall I. Pickens Building at 2100 Erwin Road, is following a framework created by the National LGBT Health Education Center: “Building Patient-Centered Medical Homes for Lesbian, Gay, Bisexual, and Transgender Patients and Families.”
The clinic will continue to offer its comprehensive family medicine services — annual physicals, ongoing care for chronic conditions, women’s health, low-risk obstetrical care, well-child visits, geriatrics, social work, immunizations and more — and will also offer services geared toward the specific needs of the LGBTQ+ population, including hormone replacement therapy, healthy lifestyle support including weight loss, screening for sexually transmitted diseases/infections and more, all with a focus on culturally sensitive and knowledgeable care.
Covas and Lapinski hope the Duke Family Medicine Center, a Duke University Hospital-based clinic within the Division of Family Medicine in the Department of Community and Family Medicine, can be a medical home for the local LGBTQ+ population once the initiative is rolled out over the next year, and feel a significant impact can be made in terms of reducing health disparities.
“We know the disparities exist, we know that the population wants help, and we know that they often don’t trust us,” Lapinski says. “It comes down to first acknowledging and then addressing the health disparities, and making sure that everyone is treated with dignity and respect.”
Covas says there will be a continued focus over the next year on quality improvements in the clinic, and that a shift in cultural and clinical competencies of the staff and providers is expected.
“By the end of 2018, it is our hope that the LGBTQ+ community of Durham will see us as a premier clinic for caring for them, and advocating for their health care needs throughout the larger Duke system,” Covas says.
Contributing to Population Health
The Duke Family Medicine Center’s LGBGTQ+ Patient-Centered Medical Home initiative is the result of a required Duke Family Medicine Residency project — the longitudinal Population Health Improvement through Teamwork (PHIT) project — which Covas began in her second year of residency and Lapinski began working on in her first year.
PHIT projects must involve collaboration with non-clinical partners from outside the clinic, and should have the potential to benefit individuals beyond the clinic, says Mina Silberberg, Ph.D., associate professor of community and family medicine and vice chief for research for the department’s Division of Community Health. Residents complete a diverse range of projects that reflect their interests, skills and creativity.
“Tiffany and Jessica’s project, both in its goals and its execution, exemplifies what we are trying to accomplish with the PHIT project,” says Silberberg, who serves as PHIT project director. “We want the residents to have a significant educational experience and at the same time to contribute to health at the population-level.”
Covas says her interest in the health care of this population is a result of experiences she’s faced in her own life and through the lives of people she has known in the LGBTQ+ community.
“I got involved at a pretty young age with HIV prevention and sexual health, and just found that it’s really grown as a passion for me,” Covas says.
Lapinski shares a similar passion for working with the LGBTQ+ population, saying she learned at a young age, as a first generation U.S. citizen, that not everyone is afforded the same rights and privileges.
“Certain members of society are viewed as less and suffer great injustice,” Lapinski says. “That is how I became passionate about working with the LGBTQ+ community — I was tired of seeing the marginalization and I wanted to dedicate my life to trying to improve the lived experience of my community.”
Duke Family Medicine Residency Program Director Viviana Martinez-Bianchi, M.D., FAAFP, says training physician leaders who partner with health care and community teams to meet the health needs of patients and populations is a core value of the residency program.
“Achieving health equity is at the heart of this value,” says Martinez-Bianchi, assistant professor of community and family medicine. “If all residents and students training at Duke family medicine learn how to sensitively and appropriately care for members of the LGBTQ+ community, and then upon graduation from Duke go on to work in other places in the country, there will be a positive impact in other communities, as well.”
Utilizing Authentic Community Engagement
There are approximately 250,000 LGBT adults living in North Carolina — including more than 18,000 same-sex couples — accounting for roughly 3 percent of the state’s population, according to 2010 census data analyzed by the Williams Institute at UCLA. Durham ranks second in the state for the number of same-sex couples per 1,000 households, and based on estimates Durham’s LGBT population ranges from 5.8 to 9.7 percent of the population.
However, there is not currently a health care center in Durham specifically focused on meeting the distinct needs of this population. Some patients are traveling as far away as Charlotte and Atlanta to receive care, Covas says.
To lay the groundwork for this effort, Covas and Lapinski began by reaching out to the LGBGT+ community in Durham, including the LGBTQ Center of Durham and other community-based organizations, to get to know the key stakeholders and learn more about the needs of the local community.
“A lot of our focus has been on authentic community engagement, and making sure that we focus on building those partnerships,” Lapinski says. “That means showing up to community-sponsored events, making sure that people know who we are, know that we are actually interested, and that we care.”
Additionally, Covas and Lapinski conducted two community forums at the Duke Family Medicine Center to hear directly from people in the Durham LGBTQ+ community about what barriers they face when seeking care. A third community forum was also hosted by the Durham Gender Alliance.
Lapinksi says culturally competent and knowledgeable providers are needed, access to care is a barrier, and people want to be treated with dignity and respect.
“People don’t feel like there are providers who know how to take care of them,” Lapinski says. “Also, a lot of people feel like when they come to different clinics, they’re misgendered, or being judged based on their sexual orientation or gender identity.”
J. Lloyd Michener, M.D., professor and chair of the Department of Community and Family Medicine, says the department has long been providing care to members of Durham’s LGBTQ+ community as part of its commitment to diversity, inclusion and caring for underserved populations, however the community engagement aspect of this initiative is what sets this project apart from previous efforts.
“The solutions work best when they come from members of the group we’re trying to work with,” he says. “If we’re going to have healthy people and healthy communities, we need to be able to partner with very diverse groups, as a routine.”
Covas and Lapinski also have formed partnerships within Duke, such as with the Duke Center for Child and Adolescent Gender Care, which provides quality, comprehensive and compassionate family-centered care to transgender youth, gender-expansive youth, and children with differences of sex development. The clinic opened in 2015 and has seen an increase in patient volume since opening, seeing patients at a half-day clinic on Wednesdays and a full-day clinic on Fridays, says clinic social worker Kristen Russell, MSW, LCSW.
Russell says through a partnership with the Duke Family Medicine Center the adolescent gender clinic will refer local patients to the family medicine clinic when they age out of the pediatric clinic. She believes that family medicine is an ideal fit for this population to have a safe space to continue getting not only their transitioning and transgender-related care, but also just their primary care.
“[Family doctors] are qualified, they’re capable, and I think [the partnership is] really going to open up access to care for this population, not just the transgender population, but LGB, too,” Russell says.
Training Duke’s Clinicians
Michener agrees that family medicine clinicians are equipped to care for the needs of this vulnerable population, but says that the training is lacking. According to a 2015 study by UCLA published in the American Journal of Public Health, 52 percent of academic faculty practices do not offer LGBT health training for clinic providers and staff.
“Family doctors are trained to take care of people regardless of race, age, sex, ethnicity, or the nature of their problems,” he says. “[LGBTQ+ care] is not something for which many of us have been trained, because it may not have been part of training programs at the time we went through it, but it’s certainly part of many people’s lived experience.”
Cordova, originally from Chile, says it would be a “gift from the gods” if clinic providers were trained on her specific health care needs. Referring to herself as a "professional transgender person," she has volunteered at Duke for 20 years as a Spanish medical interpreter/translator and has served as a panelist at hospital sensitivity trainings. She is the facilitator of a local transgender group, volunteers at the Duke Center for Child and Adolescent Gender Care, and remains an active member of various Duke diversity and inclusion task forces and councils.
“Even [at Duke] there’s a limited number of physicians that are trained in diversity and inclusion and LGBT issues,” says Cordova. “I’ve been teaching providers since I came out, and I hear the same story from other trans people.”
Michener sees the LGBTQ+ Patient-Centered Medical Home initiative as an opportunity for Duke to give a larger institutional response.
“Members of the LGBTQ+ community have long been coming to Duke for care and we haven’t always been aware that they were here,” Michener says. “I’m hoping this will continue to raise awareness.”
Judy Seidenstein, associate dean and chief diversity officer of the Duke University School of Medicine, says she is aware of discussions and planning at the institutional level about how to offer education and training on LGBTQ+ specific health care needs in the most effective way across the health system.
“To truly serve all patients in excellence with exceptional patient care, it’s important to focus in and intentionally educate ourselves on identity groups who perhaps in the past have been invisible or silenced based upon real or perceived potential for discrimination,” Seidenstein says.
She says she is very hopeful that the work being done by Covas and Lapinski will help lead the institution in a positive direction, stating that oftentimes change is stimulated by the school’s learners.
“I think residents and all of our learners are a reflection of the future that we’re trying to create and align with our mission of research, education and patient care,” Seidenstein says. “I think it’s their fresh and meaningful perspective and vantage points around topics such as LGBTQ+ inclusion … that can often create a really positive ripple effect.”
Ongoing Clinic Efforts
Through the LGBTQ+ Patient-Centered Medical Home initiative, Duke Family Medicine Center will be training staff and clinicians to provide high-quality, knowledgeable patient-centered care in a positive institutional environment. In-house education and awareness has already begun, and a multidisciplinary task force meets bi-weekly to work on quality improvement strategies in the clinic. Additionally, Duke University Hospital offers ongoing cultural competency training for managers and staff, and a certain percentage of clinic leadership is required to go through LGBTQ+ health care training.
Covas says that in addition to training medically-knowledgeable providers who are aware of the specific health care needs of this population, the Duke Family Medicine Center will work to make sure LGBTQ+ patients are treated with the respect they deserve — something Cordova says is the most important factor in LGBTQ+ health care.
“Everyone needs to be treated with respect — regardless of language, gender, race, sexual orientation — from the moment that they open the clinic door to the time they see their provider and nurse, to when they receive labs and x-rays,” Covas says.
Lapinski stresses that the effort at Duke Family Medicine Center is ongoing and there is plenty of work to still be done.
“Our entire team is excited about this ongoing effort,” she says. “The only way to do this is to work hand-in-hand with our community and ensure that their voices are at the center of all we do."
More Information and How to Contribute
To continue to build programs to increase access to and quality of care for the LGBTQ+ population in Durham, the Department of Community and Family Medicine will rely on the generosity of individuals who share its vision and passion. Philanthropic giving will be a driving force behind the LGBTQ+ Patient-Centered Medical Home’s success. Consider donating to Duke Health’s LGBTQ Health Disparities Fund to support this project and others at Duke Health with similar missions.
For more information about the planned LGBTQ+ Patient-Centered Medical Home at Duke Family Medicine Center, e-mail firstname.lastname@example.org.