Creating an Inclusive Dental Practice for the LGBTQ+ Patient

According to recent Census data, roughly 20 million adults in the United States identify their sexual and/or gender orientation as lesbian, gay, bisexual, or transgender.¹ Over the past decade, the US has experienced a significant increase in diverse populations, including lesbian, gay, bisexual, transgender, and queer (LGBTQ+) individuals.

As the LGBTQ+ population expands, the US Department of Health and Human Services has also prioritized improving the health of this community and ensuring they receive equal access to health services.² This population is at a higher risk for poor health outcomes due to a reduced access to health insurance and social disadvantages.

Health and dental professionals should have the necessary knowledge to provide culturally competent, patient-centered care of LGBTQ+ patients.^3–7 Flynn and Sarkarati⁸ define cultural competency as “understanding cultural identities that shape the priorities and preferences of individual patients and affect health outcomes.”

To provide inclusive care, oral health professionals should understand LGBTQ+ terminology and note the medical and dental disparities faced by these individuals. Awareness of their own implicit bias and consideration of the patient’s past medical and dental experiences may impact the dental appointment. This information may guide dental professionals in the shared decision-making process and use of evidence-based treatment decisions for individuals who identify as LGBTQ+.

Terminology

An understating of gender and sex is important. Sex assigned at birth refers to one’s biological identity as either male or female and is associated with physical characteristics such as chromosomes, hormones, and external/internal anatomy. Gender refers to the roles, behaviors, and attributes that a society defines appropriate for men and women.⁹

Sex and gender can vary based on an individual sense of being male, female, or neither which is known as gender identity.⁹ Gender identity is also often termed cisgender (gender identity conforms with sex assigned at birth), transgender (gender identity does not conform with sex assigned at birth), or nonbinary (gender identity does not conform with binary belief of gender, not exclusively male or female).

A transgender person may identify as a transgender male (assigned at birth as female and transitioned to male) or transgender female (assigned at birth as male and transitioned to female). Individuals may choose a specific gender identity; however, their gender expression may differ from what society attributes to their gender. Gender expression refers to the way individuals choose to communicate their gender identity (femininity, masculinity, or neither) through clothing, hairstyles, voice, or behaviors.⁹

Sexual orientation refers to an individual’s physical, emotional, and/or romantic attraction to another person.¹⁰ Terms to identify sexual orientation include: heterosexual (physical, emotional, and/or romantic attraction to those of the opposite sex); homosexual (physical, emotional, and/or romantic attraction to those of the same sex); bisexual (physical, emotional, and/or romantic attraction to both sexes, male and female); and pansexual (physical, emotional, and/or romantic attraction to all gender identities).

Labels may be used to describe an individual’s sexual orientation. The most common are lesbian (women attracted to women), gay men (men attracted to men), and bisexual people (men or women attracted to both sexes, male and female). Some individuals may use different labels than these or also choose to use none. Table 1 provides descriptions of additional terms.⁹

Social Determinants of Health

According to the National Institute of Dental and Craniofacial Research’s Oral Health in America: Advances and Challenges, LGBTQ+ individuals are an underserved population subject to social stigmas and discrimination, leading to a negative effect on overall health and oral health.^10–13

The minority stress model explains the relationship between members of a minority population — in this case the LGBTQ+ community — and their struggles related to their sexual orientation or gender identity and health disparities. This model by Meyer¹⁴ suggests stresses experienced by this minority population may result in poorer health due to fear of potential rejection and discrimination, internalized hatred toward one’s sexual orientation or gender, and prejudicial experiences. These issues may also impact mental and physical health.

LGBTQ+ individuals often face social disparities including legal discrimination in accessing health insurance, employment, housing, marriage, adoption, and retirement benefits as well as poorer healthcare.^3,15 This community also experiences a higher risk of poor mental health, smoking, substance abuse, sexually transmitted diseases (STDs), and violence.^16–20

LGBTQ+ individuals face barriers to high-quality healthcare such as limited availability, past negative experiences, and lack of providers with the necessary knowledge and cultural competence.^3,21 A study surveyed a sample of 3,453 LGBTQ+ adults with various race and ethnicity backgrounds regarding personal experiences with discrimination and found 57% of LGBTQ+ adults have experienced slurs related to their sexuality or gender and 53% have been subjected to offensive comments in their lifetime.²² LGBTQ+ individuals may experience this discrimination from healthcare professionals making them less likely to seek treatment.^16,23

Some LGBTQ+ patients will seek gender affirmation surgeries or gender facial reconstruction, which may involve oral health professionals. Facial reconstruction (masculinization or feminization) and gender affirmation surgeries are often not covered by health insurance.²⁴

Implications for Dental Hygiene Treatment

Health conditions common to LGBTQ+ individuals include anxiety and depression, eating disorders, and STDs, which may affect oral health. Smoking is also common among the LGBTQ+ population.^25-29 An increase in dental anxiety due to explicit or implicit biases may also prevent LGBTQ+ patients from seeking care or maintaining regular preventive appointments.^26,27

In 2018, the US Centers for Disease Control and Prevention identified the LGBTQ+ community as a priority population needed for tobacco cessation efforts.²⁹ The high prevalence of tobacco smoking in this population can be linked to a history of targeted advertisement by tobacco companies; increased use in places such as bars and clubs; stress; and being in the environment of others who smoke.^30,31

Oral health professionals should question this population during the medical history regarding frequency and quantity of tobacco use in order to support treatment planning for tobacco cessation education. Additionally, prior knowledge of patient tobacco use may assist with differential diagnosis during intra- and extraoral examinations, should a lesion be found. As smoking may also increase the incidence of caries and exacerbate periodontal diseases,¹¹ the clinician may consider increased fluoride use and possible nonsurgical periodontal therapies or more frequent periodontal maintenance appointments to manage disease.

Alcohol, heroin, and opioids are often misused in this population.³² The clinician should ask questions regarding their use during the medical history as it may affect dental care appointments should local anesthesia, nitrous oxide, or laser bacterial reduction therapy be recommended. Oral health professionals often see patients more frequently than primary care physicians and can provide the appropriate referral should the patient present with these lifestyle behaviors.

While oral health is linked to overall health, it may also be linked with mental health. Mental illnesses, such as anxiety and depression, may lead to poor oral health due to malnutrition and poor oral hygiene, comorbid substance abuse, and oral side effects from medications used to treat these illnesses.³³

Xerostomia is one of the most common side effects of anti-anxiety and anti-depressant medications, and may increase the instance of dental caries and periodontal diseases.³⁴ Eating disorders are also common among LGBTQ+ individuals due to gender dysphoria, fear of rejection by family and friends, and experiences of victimization, bullying, or violence.^12,25 These disorders may affect oral health by causing enamel erosion, caries, and gingivitis related to nutritional deficiencies and vomiting.³⁵

LGBTQ+ individuals are also at increased risk for contracting sexually transmitted infections (STIs) or STDs. Human immunodeficiency virus (HIV), human papillomavirus (HPV), syphilis, and gonorrhea are common among LGBTQ+ populations.²⁸ HPV causes more than 70% of oropharyngeal cancers in the US.³⁶ As such, oral health professionals should routinely perform intra- and extraoral examinations and refer to an oral surgeon or other specialist should a suspicious lesion be detected.

During the medical history, the clinician should also discuss T-cell counts and neutrophil counts to determine immunosuppression if LGBTQ+ patients are HIV+. As prevention specialists, dental hygienists should be knowledgeable in educating LGBTQ+ populations who may present with STIs that affect the oral cavity.³⁷ Oral signs of STIs include intraoral and extraoral lesions that may include white or red discoloration of the soft palate, tongue, or tonsils and swollen lymph nodes.^36,37 Recommending at-home intra- and extraoral examinations between recare appointments may also help LGBTQ+ patients recognize an oral issue early.

Strategies for Support

Using appropriate and safe language and developing a supportive practice culture in which all oral health professionals in the practice are culturally competent in regard to the LGBTQ+ population are important steps toward creating an inclusive environment. This may include learning and using gender-neutral language and preferred pronouns.³⁸

Health documents and consent forms should include options for preferred name and preferred pronouns. However, many insurance companies and legal entities do not recognize a number of genders/sexes, so it is important the practice still has access to the legal name and sex for insurance, billing, and correspondence documents.³⁸

Avoiding binary references when treating LGBTQ+ patients may facilitate a more comfortable and affirmative conversation. For example, oral health professionals can use the term “partner” instead of “husband or wife” when discussing the patient’s spouse to avoid unnecessary assumptions.

Oral health professionals may want to learn about resources that support LGBTQ+ individuals in their area. This provides the opportunity to build a trusting and safe patient and clinician rapport as well as an opening to offer referrals and resources beyond dentistry.¹²

Regular and frequent cultural competency training may assist in providing optimal oral care to this population. The US Surgeon General points to the need for culturally competent oral health professionals to increase access to care and enhance oral health, especially in minority groups such as LGBTQ+ individuals.³⁹

In addition to cultural competency training, practices may consider simply displaying LGBTQ+ friendly stickers or flags to alert patients the practice is a safe environment. Providing inclusive restrooms for all genders may also make LGBTQ+ patients feel more comfortable in the dental office.⁴⁰ Oral health professionals should also create an accountable environment by politely correcting colleagues if they make insensitive comments or use non-inclusive language.⁴¹ Practices that encourage and support LGBTQ+ inclusivity make a commitment to equitable care which may improve access to quality oral care.

Conclusion

Healthcare services, including dental hygiene care, should be delivered impartially regardless of gender, race, sex, ethnicity, religion, or culture. The American Dental Hygienists’ Association’s Code of Ethics also supports this ideal stating the dental hygienist must “serve all clients without discrimination and avoid actions toward any individual or group that may be interpreted as discriminatory.”⁴² Oral health professionals should provide culturally competent and informed care to reduce the health and dental disparities among the LGBTQ+ population.

References

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From Dimensions of Dental Hygiene. July/August 2023; 21(7):36, 39-41.