History taking in gynecology revisited.

Nepal is one of the first South Asian countries to include anti discrimination laws against LGBTQ community, yet they face disparity in all sectors, including health. This group has special reproductive and sexual health needs, which has to be assessed and treated on an individual level. Most gynecologist in Nepal have not been trained to care for this vulnerable group and thus are not comfortable having them in clinical settings. History taking is essential to reach to an accurate diagnosis however, since the first year of medical school, history taking has been based on heteronormativity. To end disparities in reproductive health, learning modules for history taking for LGBTQ community is necessary for medical students, residents and for gynecologists. This would help display confidence and openness towards them and focus on individualized care.

To the Editor,

Nepal became the first country in South Asia to recognize transgender identities in 2007(1). Lesbian Gay Bisexual Transgender and Queer (LGBTQ) Survey 2013 has shown 4.196% LGBTQ population in the country (2). The government has included anti-discrimination laws to protect this minority community but still, the majority of them face and accept discrimination as a fact of life (3).

LGBTQ is a vulnerable group with their own reproductive health care needs but they face stigma and discrimination based on their sexual orientation. Most people of the LGBTQ community delay health care visit because of neglect, disparities, and poor treatment experienced in health care setups (4).

Reproductive history taking in the medical school curriculum has always been designed for heterosexual and cis-gendered clients. In 2011, the American College of Obstetricians and Gynecologists (ACOG) published its guidelines for transgender, lesbians, and bisexual individuals (5). A decade has passed since then, and many gynecology clinicians are still not confident dealing with this minority in clinical settings. Majority of gynecology practitioners are not trained for the specialized care for this group during their residency or thereafter and are thus not comfortable dealing with them (6). This holds true for gynecologists in Nepal as well.

We cannot deny the importance of history taking in reaching an accurate diagnosis and providing optimum care. Asking the gender, marital status, sexual history is a routine, taught since the first year of medical school and this has been taught on the basis of heteronormativity. History taking, which includes menstrual and obstetrics history, tends to be direct, based on the assumption that the client is heterosexual. This might pose a problem for a transgender person who does not have menstruation or a gay lesbian couple who cannot or do not have children. Their reproductive health problems might not be related to menstruation or childbirth at all. The use of gender-neutral terms in a sensitive and inclusive language is not yet a trend among health practitioners in Nepal.

LGBTQ community has special needs. Like those assigned females at birth may have problems of sexually transmitted infection (STI), abortion, contraception, and polycystic ovarian syndrome (7). Their needs range from hormone therapy to gender-affirming hysterectomies or fertility treatments. LGBTQ adolescents are another vulnerable group which has a higher need for contraception. They have more risk of exposure to HIV and STI and less access to needed information (8). Significant number of individuals in this group face violence and mental health issues (9), which need to be addressed as a part of reproductive health assessment.

To increase clinical competence in the care of the LGBTQ community, sexual and reproductive history taking needs to be revised. It has been shown that including MBBS curriculum intervention in the form of lectures and briefing regarding history taking for sexual and gender minorities has increased students’ confidence in dealing with these clients (10). Learning intervention is required for the postgraduate training as well so that inclusive history taking and care is practiced from an early career.

This learning module would teach students and trainees to avoid assumptions during history taking and ask about sexual identity, display confidence, and openness to their sexual behavior and needs, build trust and rapport, and focus on individualized care.

Literature identifying knowledge and attitude gaps on sexual and gender minority (SGM) among gynecologists in Nepal is sparse. This gap needs to be identified so that it can be bridged through training modules. Publishing working guidelines from national professional bodies and commitment of institutions to this cause would help in eliminating substandard care for this vulnerable community.

Gynecologists can play a major role in eliminating health disparity amongst LGBTQ. For this, orientation is required from the beginning of medical school. We need to evolve from a heterosexual history taking procedure and create a non-judgmental and affirming history-taking practice inclusive for SGM. This will help create a safe space for them.