An Eye on Inclusivity

I first developed an interest in healthcare policy and equity surrounding the LGBTQ+ community in my first year of medical school, when I volunteered at the Gay and Lesbian Community Centre of Baltimore. I came out as gay during my college years in a very open and permissive environment, but working at the GLCCB made me realize that not everybody grows up in New York City, where diversity is (mostly) embraced. I am now an oculoplastic surgeon at the University of Pennsylvania and have become an advocate for the LGBTQ+ community. Although LGBTQ+ health and ophthalmology may not seem directly linked at first, there are many little-known factors that impact quality health care.

Inclusivity at work
 

LGBTQ+ inclusivity consists of two distinct factors. The first is respecting LGBTQ+ diversity within our patients and accommodating their unique healthcare needs. The second is ensuring that we create friendly environments for our colleagues. In most societies, it is okay to talk about gender and sexual identity if you are cisgender and heterosexual, but these conversations quickly become taboo if you identify outside these constraints. A report commissioned by the Human Rights Campaign (1) found that 46 percent of LGBTQ+ workers are closeted at work and a further 31 percent report being depressed or unhappy in the work environment. Although improvements are being made, the report indicates that there is a long way to go.

Losing talent
 

This marginalization affects not only workers, but also employers. Many employers’ anti-LGBTQ+ biases spur valuable employees to change jobs. LGBTQ+ individuals often lie about their personal lives, avoid work events because they are reluctant to bring a significant other, and eventually seek other employment. Normalizing openness and acceptance with respect to gender and sexual identity in the workplace would go a long way toward decreasing the stigma that often accompanies it. There is an unfortunate social mindset, that by speaking about sexuality and gender, you are implicitly referring to inappropriate and tawdry topics. This couldn’t be further from the truth. When we speak about our husbands and wives, even in heterosexual relationships, we are speaking about sexuality and gender. This is where the double standard lies.

Implementing change
 

There are simple changes we can make to welcome people of all genders and sexual orientations. Avoiding specific gendered markers when greeting someone is easy; there is no need to use “Ma’am” or “Sir” when offering help. People are sometimes uncomfortable asking questions regarding pronouns in case they offend someone – but I think not asking risks even greater offense if your guess is wrong. A cisgender individual might take offense at being asked, but there are ways to diffuse this type of situation. One example would be making it a policy to ask for pronouns in your practice or workplace. That way, it’s clear that you ask everyone, rather than suggesting that certain individuals’ gender presentation may not fit into binary norms.

Improving ophthalmology
 

Ophthalmic evaluation has the benefit of being highly objective, but it is important not to underestimate the importance of a thorough social history. Determining whether a patient is trans, has HIV, or is undergoing hormone therapy is important for managing repercussions that may affect a patient’s eye health. Creating a space in which patients feel comfortable telling their stories is therefore essential. Although not solely a LGBTQ+ problem, the issue of intimate partner violence (IPV) is also important to acknowledge in ophthalmology; Erin Shriver talks more about this in an article she published (2) about orbital fractures born of IPV. Unless changes are made and questions become the norm, patients could go back to dangerous environments without the opportunity to voice their situation and seek help. Socioeconomic factors must also be considered. The LGBTQ+ community is not monolithic, but multifaceted and varied; in the USA, for instance, trans women of color are more likely to be in poverty, making it important to explore finances and to recommend affordable, accessible treatment when needed. We recognize many important social determinants of health in internal medicine; they should be equally recognized in ophthalmology. I think that, the more we can educate ourselves about our patients’ social situations, the better we are as providers.

Small Steps
 

The talk I gave at the American Academy of Ophthalmology (AAO) a few years ago about communicating with trans patients was the first of its kind at the AAO(3). I have since worked with a dedicated group of physicians and staff at the AAO on live and video sessions that specifically deal with treating marginalized patient populations. When the AAO launched their online community platform, they also created a space dedicated to LGBTQ+ members who wished to seek mentorship, share their experiences, and develop communities. These things may seem like small steps but, in a surgical subspecialty (especially in the US), they are significant. There is still work to be done – but if we make the pursuit of progress part of our everyday lives, we can create more inclusive working environments that benefit both patient and practitioner.