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This piece by Casey Quinlan originally appeared on The Establishment, an independent multimedia site founded and run by women.

Despite political gains for same-sex couples and more recognition of LGBTQ people, sex workers, and kink-oriented people in the media, doctors still struggle to communicate with patients who fall outside of what they may consider their “default” patient   —  cisgender, straight and sexually “vanilla.”

Health care professionals still receive little training to address the health concerns of LGBTQ patients, especially as it relates to sexual health, and may struggle to speak to patients whose work is nontraditional or illegal. Sex workers often face a very different level of judgment when communicating with doctors about their sex lives compared to those working outside the industry. Research shows that both doctors’ failure to communicate properly with anyone they consider outside the norm, and patients’ justifiable fear that they will be treated differently, affect the quality of care patients receive.

Moving toward sex-positivity and LGBTQ awareness

Queer health educator Bianca Palmisano’s national education consulting organization, Intimate Health Consulting, is one of the organizations trying to change that.

Intimate Health Consulting is a resource for health care providers who want to address patients in a sex-positive way that is inclusive of all genders, orientations, and sexual interests. By becoming comfortable initiating conversations about sexual activity, medical professionals will be able to talk frankly and effectively about sexuality and pleasure. This openness, says Palmisano, leads to better health outcomes than treating sex as a taboo topic  —  fewer sexually transmitted infections, fewer unplanned pregnancies. But medical providers don’t always know how to start.

By becoming comfortable initiating conversations about sexual activity, medical professionals will be able to talk frankly and effectively about sexuality and pleasure.

“There is understanding in the wider public that the health community is failing us and that it isn’t having these conversations with their patients,” Palmisano said. “But providers were a lot slower to realize that this is something people expect of them, which is kind of funny because there is plenty of literature out there suggesting as much. Essentially providers and patients are playing this cat and mouse game where the doctors think if it’s important the patient will bring it up, and the patient thinks if it’s important the doctor will bring it up.”

In a webinar released last October, Palmisano, who identifies as queer, explained how pleasure-centered sex education can reduce HIV, STIs, and unplanned pregnancies. In the webinar, she first encourages health care providers to drop their assumptions  —  about how many partners and encounters is “appropriate,” for example  —  and to move forward with the attitude that sex is meant to be pleasurable and that it’s okay for patients to want to have it. This sets the tone for avoiding other leaps, such as the idea that the “norm” is a straight cisgender man having vaginal intercourse with a straight cisgender woman. Health care providers must clarify the gender of the patient and kind of sex they are referring to when they describe sexual activity.

Palmisano highlights the example of a doctor who sees a patient who is a bi woman. This woman performs oral sex with a condom on male partners but gets fisted by and gives analingus to female and trans partners, but the doctor assumes she is straight and monogamous and asks questions accordingly. In that situation, the doctor may not ask her the right screening questions to assess her risk for contracting STIs.

Knowing a patient’s sexuality doesn’t mean knowing their life.

Doctors may also have the reverse problem, where they do know a patient’s sexuality but overgeneralize from that information, assuming that all health problems are related to a patient’s sexuality.

Michael, who asked to be identified only by his first name, said that after returning to the U.S. after a summer job in Israel, he went to see a doctor for a throat infection. The doctors, who knew Michael is gay, kept referencing oral sex and asking him about the man he dated in Israel. Without any evidence, the doctors began speculating that he had HIV, which he said “scared me to death.”

The doctors’ intense focus on his sexuality wasn’t just dehumanizing  —  it caused him to panic unnecessarily.

“I eventually learned that my condition had nothing to do with any of the men I was seeing nor with any of the countries I had visited,” Michael said. “I had an abscess in my throat that was slowly becoming infected over a long period of time. Being on a lot of planes probably helped the infection get worse.” The doctor’s intense focus on his sexuality wasn’t just dehumanizing  —  it caused him to panic unnecessarily.

Doctors may also wrongly assume that gay women don’t need Pap smears. A 2012 University of Maryland School of Medicine study found that four out of 10 lesbians were not regularly screened for cervical cancer.

Learning how to talk to trans and gender-nonconforming patients

Health care providers also continue to misgender patients. Lydia X. Z. Brown has experienced multiple uncomfortable experiences with their doctors. Brown, who is a genderqueer, nonbinary person, shared a particularly frustrating experience where their doctor misgendered them multiple times.

“One or two times during the appointment, he misgendered me and kept saying ‘lady’s health,’” Brown, a writer and advocate for disability justice, told me in a phone interview. “He would also use the incorrect pronoun when he referred to me to staff.”

Reproductive health care providers are still considering how to use gender-neutral language when discussing procedures usually associated with cis women, such as abortions. Sometimes health care providers use the term “people with uteruses,” for example, to discuss what Brown’s doctor labeled “lady’s health.”

Transgender and gender non-conforming patients often deal with deadnaming and incorrect use of pronouns, as Lydia experienced. Doctors also minimize the importance of hormones for trans patients by flippantly asking trans patients to come off of them for any major medical issue.

Judgment of the kink community

Doctors should ask different questions or frame sexual health issues differently for people who enjoy kinkier sex as well. For example, Palmisano said the use of condoms should be framed as a way to prolong an erection and can even be described as sex toys. The act of teasing a partner by having non-penetrative sex is another way to portray safe sex as kinky, she explained. Furthermore, people who practice BDSM can use protection as a way to dominate the submissive partner by rejecting their bodily fluids.

In addition to framing conversations about safe sex differently, doctors could trust patients when they tell them that a bruise is just part of their sex life. Patients who enjoy BDSM say they are hesitant to tell their doctors that a bruise is part of the kink, partly out of concern for how they will be judged, and partly because doctors may assume they are being abused. A 2016 studyfound that fewer than half of kink-oriented people were out to their health care provider, citing the anticipated stigma as the most common reason.

Patients who enjoy BDSM are hesitant to talk to their doctors, partly out of concern for how they will be judged, and partly because doctors may assume they are being abused.

Anna M. Randal, executive director of The Alternative Sexualities Health Research Alliance, told HuffPost Canada there are good reasons to let a doctor know why you have certain injuries because if left untreated, some of them could lead to complications.

“Big bruises can develop into hematomas, for example,” she told the Post. “There are rare injuries from rough sex that may lead to serious complications, such as torn vaginal tissue or scrotum injuries, and because more risky sexual BDSM behaviours may include controlling the breathing of a partner, those with asthma face real risks if they’re not treated for attacks immediately.”

Sex workers’ barriers to accessing health care

Health care settings can also be hostile places for sex workers, who have myriad concerns when they meet with a health care provider. Sex workers are aware that they will be met with judgment and assumptions about why they are sex workers, who they have sex with, and what they know about safe sex. They also have reason to be worried that they could be reported to law enforcement. U.S. federal policy identifies health care settings as a place to identify and assist trafficking victims, and sex workers may worry that they will be considered victims, no matter what they tell their health care provider. Doctors should never make paternalistic assumptions that sex workers must want to leave the industry and be aware of their own prejudices, Palmisano stressed in her seminar on safe sex and pleasure.

LGBTQ people may delay or avoid medical treatment because they are reluctant to encounter bias in health care settings.

The Human Rights Campaign’s Equality Index keeps track of health care providers who offer the best treatment to LGBTQ people. GLMA: Health Professionals Advancing LGBT Equality built a tool for LGBTQ people looking for providers who have a good reputation of being welcoming to LGBTQ people. It’s a bit more challenging for sex workers to find the right health care provider, but local organizations, especially those in urban areas, can help sex workers find the best provider for them. It’s particularly challenging for people who aren’t cisgender, straight, or adhere to expectations about how sex should be to access high-quality and reduced-bias health care in rural areas where there are less options.

The stakes are high when it comes to health care for those who fall outside the parameters of the “typical” patient. It’s a serious problem that LGBTQ people delay or avoid medical treatment because they are reluctant to encounter bias in their health care settings. A landmark 2009 study by Lambda Legal found that 73 percent of transgender respondents and 29 percent of lesbian, gay, and bisexual respondents said they thought they would be treated differently by health care providers because they are in the LGBTQ community.

Medical schools still struggle to talk about sex and gender. In many medical schools, students areencouraged to treat questions about sex in particular as a naturally uncomfortable conversation. Education on how health care providers should monitor LGBTQ patients’ health is often limited to just a few hours set aside for a day, instead of as something that should be interwoven into all relevant classes.

Organizations like Palmisano’s are starting to correct some of this imbalance  —  and will hopefully make medical care more accessible and effective for underserved patients.

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