“Doc, your next patient is nonbinary.” I say some version of this to physicians when I teach about LGBTQ+ affirming care, then ask, “What is the first thought that comes to mind?” The responses come quickly: “I freeze.” “Oh, God. We were never taught that.” “I don’t know what to say.” “I don’t want to say the wrong thing.” Sometimes there is nervous laughter. Sometimes there is silence.
These are highly trained physicians. They manage complicated diagnoses, interpret difficult laboratory findings, deliver devastating news, and make life-and-death decisions. Yet three words, “patient is nonbinary,” can create uncertainty, hesitation, and sometimes dread. So I ask another question: “By show of hands, how many of you received formal training in medical school or residency on caring for LGBTQ+ patients?” The hands tell another story. None.
Then I ask the question I have been asking physicians for years: “What is your biggest challenge when it comes to affirming your LGBTQ+ patients?” Again, I hear versions of the same answers: “I don’t know enough.” “I don’t know what questions to ask.” “I’m afraid of offending someone.” “I don’t want to say the wrong thing.”
For years, we have treated this primarily as a knowledge problem, responding with pronoun guides, terminology sheets, lectures, modules, and clinical guidelines. We need those resources, no doubt, but I have come to believe something else is happening. While we weren’t formally trained in medical school, we were extensively trained by society.
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Long before we met our first openly gay, lesbian, bisexual, transgender, queer, or nonbinary patient, we had already completed another curriculum, systematically taught to us by our families, religion, television, politics, jokes, and communities. Some of us were taught overt silence; others received a mixture of messages skewed toward negativity. We learned which identities could be discussed openly and which were whispered about, and which people were considered “normal” and which were “different.” We heard stereotypes and misinformation, including messages that LGBTQ+ identities were immoral, pathological, dangerous, confusing, or simply something respectable people did not discuss.
Then we entered medicine, where many of us received little formal education that challenged what we had already absorbed. Silence became part of the curriculum, too. Today, about 9 percent of U.S. adults identify as LGBTQ+, more than twice the proportion Gallup measured a decade ago, and LGBTQ+ identification is considerably higher among younger adults. These patients are already in our waiting areas, on our examination tables, and wearing hospital gowns in procedure rooms. When physician uncertainty enters the examination room, they can feel it.
I have seen how easily this happens. A patient comes for something completely ordinary: a sports physical, abdominal pain, a headache, an annual examination. Then the clinician discovers the patient is nonbinary, and the encounter changes. Questions that would have been routine become uncomfortable, so the clinician may avoid asking anything for fear of offending the patient. Or the opposite happens, and every question suddenly becomes about gender, transition, genitalia, or sexual behavior, even when none of it is relevant to the reason for the visit.
The physician may leave thinking, “I handled that pretty well,” while the patient leaves thinking, “I never want to go back there.” That gap between intention and impact deserves our attention. KFF found that one-third of LGBT adults reported being treated unfairly or disrespectfully by a health care provider in the previous three years, compared with 15 percent of non-LGBT adults. Other national data show particularly concerning experiences among transgender and nonbinary patients, including avoiding needed medical care because they fear mistreatment.
This is where uncertainty becomes clinical risk. A pause, avoidance, an assumption, overfocus, and silence all communicate something. The physician may be thinking, “I don’t want to make a mistake,” while the patient may be asking, “Am I safe here?” Silence is still communication.
I now describe physician uncertainty with an equation: (Lack of education + bias) squared times societal pressure. Lack of education leaves the gap. Bias, including the messages we absorbed long before medical school, influences what fills it, while societal pressure amplifies both. Then comes the fork in the road. The moment we come face to face with our uncertainty, we can withdraw, avoid, assume, refer away, say nothing, or we can engage.
Engagement can sound like, “I’m not familiar with that term. Would you tell me what it means for you?” or “I want to make sure I address you correctly.” We can ask, “Has anything changed in your identity since your last visit?” and “How can we help you feel safer today?” When we get something wrong, we can simply say, “Thank you for correcting me. Let me try that again.”
Affirming care is not perfect care, and the goal is not certainty. The goal is learning how to practice through uncertainty without transferring our discomfort to the patient. I teach this through a simple framework: Find me. Feel safe. Trust me. Can patients find evidence that we are prepared to care for them before they ever enter the examination room? Once they arrive, do they feel safe enough to tell us their truth? Have we created enough trust for them to return, disclose what we need to know, and partner with us in their care?
Because the patient is a conversation, we can’t diagnose information we never receive, address risks patients don’t disclose, or build therapeutic partnerships while avoiding the conversations that allow us to understand the people we serve. Physicians were never promised certainty; we practice through uncertainty every day. LGBTQ+ care should be no different.
Our responsibility is to recognize what we were taught, interrogate what we absorbed, learn what medical education failed to teach us, and choose engagement when we reach that fork in the road. Our patients are already watching what we choose. Silence has been the curriculum long enough. It is time for a new one.
First, do no further harm.
Uchenna Umeh is a pediatrician.
