A doctor for LGBTQ+ health needs [PODCAST]

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“It is uncomfortable to be publicly vulnerable with my story. I wish the statistics and research were enough to change the field of medicine for patients and physicians. I want people to care about the experience of their patients and colleagues enough to examine their own implicit bias and privilege without having to hear my traumalouge, but we aren’t there yet. People often need to connect with an individual to reflect and consider change, so I hope you take this moment to consider creating a more inclusive, affirming health care system.”

Crystal Beal is a family physician.

They share their story and discuss their KevinMD article, “A doctor for LGBTQ+ health needs.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. On today’s show, we have Crystal Beal. They are a family physician, and their KevinMD article is titled “A doctor for LGBTQ+ health needs.” Crystal, welcome to the show.

Crystal Beal: Thank you so much for having me, Kevin. I’m really glad to be here.

Kevin Pho: So we’ll get into the article a little bit. First off, just briefly share your story and journey to where you are today.

Crystal Beal: For sure. I think, like so many physicians, growing up I kind of had a vague notion of just wanting to help people with my career. Fast forward to being in college: I had almost finished a degree, actually, in food and nutrition science around dietetics work, and I looked at the job opportunities that would be available to me once I finished that degree and thought, “This just really isn’t what I want to do.” And I thought, “If I don’t try to go to medical school, 40 years from now I’ll look back and wonder, could I have done it? Would it have worked out? What would have happened?”

And so I spent a few extra years in undergrad and got my prerequisites, and then went to Florida State University College of Medicine, which was a lovely place and a great fit for me personally. Then I did family medicine residency out in Washington state at Valley, and I ended up staying in the Seattle area after residency to practice, because it’s a beautiful part of the country, certainly.

Kevin Pho: Yeah. So tell us a little about your practice.

Crystal Beal: So my practice, I actually started my own practice back in 2018, and it was fully telemedicine-based before that was cool. That was pre-COVID times, and everyone kind of wondered, “How are you going to have a clinic that’s just online?” But I had gotten to work with Kaiser doing both their PrEP care clinic and some trans health care there, and I really saw how all of Kaiser’s PrEP work is done through phone visits, actually, not even video visits. And so I really got to see how, when you have a narrow scope of practice, that can work really well through virtual care, particularly in the Kaiser system, where they’re already established with a PCP, so they’re getting their greater health care needs met that way.

So I thought, “I’m pretty sure I can open a practice that focuses on LGBTQ health through a video visit platform, and it will actually serve the needs of the community better by increasing access to care.” So many LGBTQ people who don’t live in a major metropolitan area don’t have access to specialized providers, or providers who are part of the community and have lived experience. And so my thought process was that telemedicine would kind of change that experience for my community. In addition, for me as a millennial medical school graduate with a ton of student loan debt, it would allow me to open a practice without the financial burden of paying for a physical space, which is really a huge barrier in small private practices these days.

Kevin Pho: So let’s talk about your KevinMD article titled “A doctor for LGBTQ+ health needs.” You open up your article, quote, “As a queer, nonbinary, poly, and kinky person, medicine has been a challenging field to fit into, both as a patient and a physician.” Now, before you talk about that article, talk about some of the challenges that you faced.

Crystal Beal: Right. I think any marginalized group can have some similarities in that context. Medicine is a very white, hetero-cis-normative, male-dominated field, although obviously more females have been getting into medical school than males over the past, I want to say, 10 to 15 years, right? I feel like when I went to med school we were right at that 50/50 margin, and I think since I’ve been there, we’ve kind of flipped over. However, the field definitely has that dominant culture. It really has those undertones of a professional field, and I feel like a lot of our concepts of professionalism really come out of colonialism and white supremacy. For people who don’t have those same values and don’t live in that culture, it’s just kind of a culture clash every day that requires a lot of code-switching to fit in or to get places professionally.

So specifically, I think I just ran into not having mentors that looked like me, or faculty that looked like me or shared my life experience. I very frequently was too outspoken and just not what people expect. I can’t tell you how many times I would walk into a patient room, and my patients would say, “You don’t look like I thought my doctor would look,” right? And my response, depending on the patient, obviously the patients I knew better over time, I would say something kind of like, “Well, I’m never going to be a middle-aged white man, so we’ll move on.” Obviously, with patients I don’t know, you don’t necessarily say things like that.

And I do think, you know, one of the comments on the article was about how, as physicians, the experience of health care shouldn’t be about us, right? And I don’t disagree with that statement. I get asked when I present to medical students and health care providers, students of all kinds, because I’m so openly out online in my identities. They’re often like, “You know, we talk about self-disclosure to patients, and whether or not it’s appropriate, and when it’s appropriate.” And I always frame it for them: I do not sit in a patient visit and talk about my identity. I share it openly online so that patients are able to see it and know a little bit about me before they come see me, because we do have some research, not in queer communities but in communities of color, that shows patients actually get higher-quality health care when they see people with a shared identity.

And so I give them the opportunity to have that choice and know a little bit about me up front, which every major health care system does. Every Swedish, Kaiser, all the big systems put profiles of their physicians up and share a little bit about them. So I don’t think there’s anything wrong with that, but I’m not sitting in a patient encounter telling them my stories or talking about myself, because, absolutely right, that’s not what a patient is there for at all.

Kevin Pho: So go more into your article, “A doctor for LGBTQ+ health needs.” For those who do get a chance to read it, just summarize it for my audience.

Crystal Beal: Right. I just talked about my experience as a queer person going through the health care system, both as a patient and as a medical learner and a physician. And really, I just had a lot of negative experiences as a patient in particular. That was a big motivation for me to open up my own practice, so many of my physician encounters. The story I shared about being misdiagnosed with an STI was maybe the worst case of discriminatory care I experienced, and I literally got lectured by my provider on my lifestyle choices, which was a monogamous relationship with a female.

Kevin Pho: So tell us about that interaction. When that clinician lectured you, what was that like? And when you were sitting there listening to this, what were you thinking?

Crystal Beal: You know, I was in my first year of medical school, so I was maybe 25 or 26, and I think I was in shock the whole time. I had never had an experience with a physician where they took me to their office instead of an exam room, so just that contextual change was so confusing to me as a young adult who had very little experience navigating the world or the health care system. And it really changes the power dynamic too, right? Here’s this person with authority who has the information I need about my body and the treatment I need for my body, sitting behind a desk where all of their degrees are on the wall, all their accomplishments are behind them, and they’re really in charge of that situation and that narrative. It just felt kind of like being in the principal’s office, you know, like I was in trouble for something that was literally just me dating someone I loved.

So now, knowing what I know about health care now, and knowing about the kind of care I try to provide for my patients, it’s kind of appalling. Also, the diagnostic missteps there were really, really bad, which we won’t go into the details of, but what I had was a very obvious casebook, or a textbook case, of something that I can’t believe he misdiagnosed. And then to just have him never even acknowledge the fact that he had made a mistake, that I had gotten unnecessary treatment that was ineffective, and also to really never know, if I hadn’t asked him why I wasn’t getting better, if he would have ever addressed that issue for me. And then I got the pleasure of being his student in my fourth year of medical school, so I got to rotate back through his practice as a learner. And I found out later on he’s a Seventh-day Adventist and a rather conservative person, which made the story make more sense.

Kevin Pho: Tell me some of the unique challenges that the LGBTQ population faces in the exam room.

Crystal Beal: A lot of the research shows that a quarter of all LGBTQ patients will have experienced an episode of discrimination seeking health care within the past year. Over 50 percent of trans people will have a story in the past year of health care discrimination as well. And unfortunately, we know any discriminatory experience increases someone’s likelihood of delaying seeking care, and every provider knows delayed care causes poorer health outcomes. Couple that with the minority stress that causes increased rates of cardiovascular disease and depression and anxiety and substance use disorders in our community, and we just see overall poor health outcomes.

And so I think it’s getting better in a lot of places, but it starts before patients even come into the space. People’s social media, people’s websites, their waiting rooms: When they don’t reflect affirming and inclusive imagery and language for all marginalized groups, we already can’t see ourselves there, and we’re already not sure if you’re going to be a safe provider that we can actually talk to about our concerns, right? And so things like diverse imagery of LGBTQ people, of people of color, of people with disabilities, of people of different communities, is so important on social media and websites and artwork on the wall and educational patient handout materials in the office. And then in the forms, making sure they include all sexual orientations and identities, right?

I remember being in med school, and the big affirming question for sexual health care screening was, “Do you sleep with men, women, or both?” And that was a big move away from “Are you married?” which is a very common question in the South, where I grew up and where I trained, right? And our medical school was so proud of themselves for taking that step, right? And it is, like, language evolves and care evolves, but that’s still falling short for so many people, right? Because none of the people I’m in partnership with or have romantic or sexual relationships with identify as men or women. And so you’re just leaving out such a huge swath of the population. And so I think just even being visible is a huge step, and a huge problem LGBTQ people face in seeking health care, and then having not just a kind provider but a knowledgeable provider.

A big part of my mission in starting my practice was really to change the experience of care, particularly for my trans community. Often the bar for a trans or gender-diverse patient seeing their provider is that their provider will just use the appropriate name and pronouns for that patient. They don’t expect that provider to actually know how to manage any of their health care needs. So many trans and gender-diverse patients go to their doctor’s office with printouts, like, “This is how to take care of me. I found this for you.” And I just think that in no other health care condition that I provided care for as a primary care physician was that the model of care: my patient telling me how to manage their health care, right?

I definitely have had patients bring in, like, they saw a drug on a commercial, or they heard about this weird thing that they thought they might have, and they would bring me some information about it. And no, I wasn’t familiar with it, but never did I say, “Let me take the information you give me and decide right here, right now.” I said, “You know, I don’t know very much about this. Give me a couple weeks. I’m going to do some research and maybe reach out to some specialists, and we’ll make an appointment two weeks from now, and I’ll have more information to help support your care.”

And so I just think that so often one of the ways to approach people is, like, with curiosity, but I don’t actually think that’s appropriate. I think with kindness, with inclusivity, but it’s our job as providers to either go and get the information we need to take care of people, or to have a really good referral resource that we’ve already vetted where we can send people on. You know, I couldn’t do a joint injection to save my life in primary care, so I had a colleague who was great at them, and that is where I sent people when that was what they needed, right? And he sent me every IUD and Nexplanon that he saw. We make relationships with our colleagues who have the skills we don’t for a reason.

Kevin Pho: Now, what are some resources that you could recommend, perhaps educational resources or resources online that clinicians can turn to?

Crystal Beal: Oh my gosh, so many amazing resources. I will of course do a self-promotional plug. I have an online platform called QueerCME.com, which is all CE/CME-certified content for providers who are interested in improving their gender-affirming or transgender health care offerings. We release new content every month, where we do live content and you can ask questions, so that’s a really great resource. That is a paid subscription, although the live events are free for all.

The National LGBTQIA+ Health Education Center is a completely free resource, also CE/CME-certified. You just have to create an online account, and then you have access to hundreds of hours of free CE/CME on all kinds of LGBTQ health care topics. It’s a phenomenal resource.

And then those are kind of both online and asynchronous. There are some great conferences out there as well. WPATH is obviously one of the major organizations in trans health care, but the PTWC is a really great conference as well. I’m involved in organizing that one, the Philadelphia Trans Wellness Conference. And then I think Harvard and Fenway usually co-host a transgender-affirming health care conference, maybe every other year. That is also really a phenomenal conference. I highly recommend all of those resources.

And then another really great online resource is TransLine Zendesk. If you’re taking care of trans or gender-diverse patients and really have a question you can’t answer, they have a free e-consult option, which is phenomenal. You just fill out the form, send in your question, and you get a response within a couple of days. So it’s a phenomenal resource. Similarly, Seattle Children’s Hospital has an adolescent gender clinic, and you can do a phone consult to their providers, and you’ll get a response within 24 hours. Your patient does not have to be in Washington. So those are amazing free resources for supportive care.

Kevin Pho: We’re talking with Crystal Beal, who is a family physician. Their KevinMD article is titled “A doctor for LGBTQ+ health needs.” Crystal, short of doing all that CME and going to all those conferences, if a primary care physician like myself sees a gender-diverse or queer patient, what are some of the most impactful things that we can do to help facilitate that interaction?

Crystal Beal: Yeah, I think first off, how you introduce yourself to your patients is step one. Any time I introduce myself to a new patient, I say, “I’m Dr. Beal, Dr. Crystal, or Crystal. Any of those are fine. I use they/them pronouns. What would you like me to call you?” So off the bat, I’m giving them the information and the knowledge that I’m aware that we don’t all go by our legal names, and that pronouns matter, and I’m not going to assume your pronouns based on your presentation. So that automatically sets a tone of an affirming and inclusive environment.

I also give patients the option to use my title. So many people have been traumatized and harmed by physicians, and that word can actually be triggering. Some physicians have really strong feelings about being addressed as a doctor, and I definitely understand. I worked in addiction medicine quite a bit as well. [Remark removed by the editor.] So I think giving patients the option, so they can avoid trauma triggers, is really important.

And then if you have trans patients who want health care and you’re not sure how to do it, and it doesn’t fit into the time and energy you have in your office or clinical setting, just having a really good vetted resource where you can send them, I think, is super, super important. Not everyone has to prescribe testosterone or estrogen for trans or gender-diverse patients, but they need to be able to send someone to those resources.

And I think from a primary care perspective, you do want to know primary and preventative health care needs. And so there is definitely a one-hour webinar on the National LGBTQ Health Education Center on preventive care for the gender-diverse population, right, which is a phenomenal resource for primary care providers, and it will help you think about it. When so many of our preventive care screenings are sex-based, it will help you make decisions about when do I do screenings on cholesterol or bone mineral density or breast cancer in someone whose endogenous hormonal milieu and then exogenous hormonal milieu have shifted through the years. And so I think that’s a lecture worth sitting through.

Kevin Pho: And my final question: Any take-home messages that you want to leave for the KevinMD audience?

Crystal Beal: Yeah. I think I never found more joy and fulfillment in my work than I did when I started really showing up as my authentic self. I think I got the message for so many years from medicine that my authentic self really wasn’t welcome or wanted. And for me, it did involve creating my own practice and my own space, but it’s been a world of difference for me in the context of burnout and the joy I get from my career. I think until I started this practice and worked within my own community, I really questioned my decision to go to medical school. I really, really thought, “If I could do this over again, there’s no way I would have given up this much of my life and this much of my money to do this thing that makes me feel small and unvalued.” So I think that would be my biggest message to any provider out there: There is a space for you here in medicine and in health care, and we need diverse voices, because our patients are diverse voices.

Kevin Pho: Crystal, thank you so much for sharing your story, time, and insight. Thanks again for being on the show.

Crystal Beal: Thanks for having me.

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