Dr. Keaster
Andrew Keaster, MD, is a hospitalist with The Ohio State University Wexner Medical Center in Columbus, Ohio, who also takes some shifts at the gender-affirming care clinic that he helped found. There, trans and gender-diverse people can get hormone treatments or general medical care in a safe and supportive environment. “If we have any group of patients with a need, we try to identify it and provide care,” he said. “It doesn’t hurt the bottom line, and it provides opportunities for learners.”
Providing sensitive environments is key. A sizable proportion of LGBTQIA+ adults report negative experiences in healthcare settings, such as being treated with disrespect or having their family not recognized by practitioners. Many members of this community also face a variety of increased health risks from marginalization and stigmatization.1 Research, education, and quality of care have improved over the last few decades, but politicization of health concerns in this population, especially for trans individuals, has set back some of the most recent gains.
Dr. Streed
Carl Streed, Jr., MD, MPH, FACP, FAHA, a primary care physician and researcher specializing in LGBTQIA+ health at Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, both in Boston, said, “In the current political climate, our patients do not necessarily have to have personal experience of discrimination targeted at them individually for it to have a real impact on their health.”
Dr. Khanijow
Keshav Khanijow, MD, is a hospitalist and an assistant professor of medicine at Johns Hopkins University School of Medicine in Baltimore. He noted that, in light of current political rhetoric and current events, some patients might not be forthcoming about their medical history for the sake of safety. Unfortunately, this climate can damage the patient-physician relationship and contribute to patients avoiding the healthcare system, which can lead to more severe presentations at the time of treatment.
“For some people, the hospital setting may be their only interaction with the healthcare system. Showing that we care about people as human beings, no matter their sexual orientation or gender identity, does help cultivate the patient’s perspective on whether healthcare is a safe space for them,” Dr. Khanijow said.
Hospitalists and hospital systems can do a lot to continue to increase this trust, improve the mental and physical health of these individuals, and continue to advocate for their needs, even while operating within systemic restraints.
Research Gains, Setbacks, and Challenges
Population-specific research is critical because it reveals population needs and the ways that health systems might be falling short for specific groups. Without research focused on LGBTQIA+ people, clinicians operate on assumptions that may not apply, which can lead to missed diagnoses, inappropriate treatment, and erosion of patient trust.
Over the past several decades, a body of evidence has demonstrated that marginalization and stigmatization lead to adverse health consequences. Under this Minority Stress Theory, first described by Virginia Brooks in 1981, chronic, high-level stress from external pressures or internalized stigma can lead to anxiety, depression, or maladaptive coping behaviors, which carry negative health consequences (e.g., smoking, excess alcohol use, isolation, and inactivity) and poorer overall health.2
Differences and disparities that are never investigated are unlikely to be recognized. Dr. Streed said, “We have to continue to develop rigorous research results to inform how best to improve population health.”
Dr. Streed explained that the largest areas of research to date in the LGBTQIA+ population have focused on human immunodeficiency virus or mental health. Thankfully, over the last few decades, research has grown around additional conditions, such as substance use and cardiovascular health.
For example, some of Dr. Streed’s work has focused on cardiovascular research in gender-diverse and transgender people, identifying higher cardiovascular disease risks and increased cardiovascular mortality in this specific population. These risks may be largely driven by chronic stress from discrimination, stigma, and internalized transphobia, contributing to factors such as smoking, excess alcohol use, and depression, compounded by structural inequalities such as lower employment levels and poorer access to healthcare.3
These minority stress factors can affect every system of the body. Moreover, for trans populations, differences in hormonal milieu and additional factors can lead to impacts on the body that differ somewhat from data gathered from cis populations. Researchers have begun to explore beyond cardiovascular health. For example, research has identified specific impacts in chronic liver disease, cancer, and bone health,4-6 but many areas are yet to be explored.
These gaps in existing research can directly impact clinical decision making. For example, Dr. Streed pointed out that clinical decision-aid tools such as the Predicting Risk of Cardiovascular Disease EVENTs (PREVENT™) calculator do not work very well for trans adults, so clinicians should be aware of these limits if utilizing them.7 “We don’t yet have large cohort studies to inform how best to modify those tools,” Dr. Streed said.
Another major challenge is the loss of federal funding for research centered on LGBTQIA+ populations. Dr. Streed pointed out that the administration is also trying to erase public data previously collected by the Centers for Disease Control and Prevention (CDC) with respect to sexual orientation and gender identity (SOGI), eliminating the possibility of using these data in future research studies.
Under political pressure, such information is also at risk of being removed from electronic health records (EHRs) in medical systems. This was an area of progress in the last two decades, with many medical systems making changes to allow SOGI data to be easily collected and displayed in their EHR, along with other key information such as patients’ preferred names and pronouns.
Rita Lee, MD, FACP, is a professor of medicine and a co-founder of the UCHealth integrated transgender care program in Aurora, Colo. She explained, “A lot of medical systems pull their quality initiatives data from the EHR. If LGBTQIA+ people don’t have the opportunity to identify themselves [via SOGI], they become an invisible population, and then it’s impossible for us to know where there are inequities.”
Dr. Lee
Dr. Lee noted that even for systems that easily allow for the collection of SOGI, this data isn’t always collected and entered in the EHR in real-world settings. This can limit future research possibilities, but it can also directly impact patient experience and clinical care. She also points out that many population-based national surveys have never included information on SOGI.
Studies have demonstrated that improved access to gender-affirming hormone therapy in transgender, nonbinary, and gender-diverse adults improves mental health outcomes, but funding ongoing work is a challenge.8
Dr. Schoenberger
Alexandra Schoenberger, MD, MSEd, is the med-peds chief resident at the University of Cincinnati Medical Center/Cincinnati Children’s Hospital Medical Center in Cincinnati and a part of the LGBTQIA+ Health workgroup at her institution. “We are going to keep supporting the research showing that this is evidence-based medicine and keep providing evidence-based care, which is what we should do for all of our patients, regardless of their identity.”
Dr. Streed said, “Our ability to provide competent clinical care and do rigorous, appropriate population-level research requires politicians to get out of the way of the science, to allow it to be based on the rigorous scientific method.”
Education
Ongoing education is another key element for ultimately improving health in LGBTQIA+ people. Ideally, this should include education at all levels of medical training, as well as training for other health professionals and healthcare personnel, adapted for different roles’ needs. Chelsea Marion, MD, FAAP, a pediatric hospitalist with Children’s Healthcare of Atlanta in Atlanta, pointed out that patients’ perception of an environment depends not just on a physician’s knowledge and affirming attitude, but also on the practices and tone of other personnel.
Dr. Marion
Dr. Streed believes training on these topics is falling short in many ways and at many levels of career training, e.g., on hormone management for trans people and human immunodeficiency virus pre-exposure prophylaxis (see our article on PrEP and PEP on page 12). Additionally, he noted that continuing medical education requirements do not include significant training on these issues, even though many of these physicians learned very little about LGBTQIA+ health during their medical school or residency.
Medical systems can offer additional education and training in LGBTQIA+ health to interested clinicians, e.g., through opt-in journal clubs, training pathways, and fellowships. Although such education and collaboration are essential for creating expertise and ultimately contributing to quality research and clinical care, opt-in training often misses the people who most need education in these topics.
Dr. Schoenberger noted that it is critical to integrate LGBTQIA+ education into an ongoing curriculum, as they have done at the University of Cincinnati. For example, one could include an LGBTQIA+ individual in a noon conference case study, even if that might not be medically central to the case. It’s important to analyze knowledge gaps, e.g., in a class of residents, and find ways to address those areas through ongoing repetitive educational opportunities.
“Just like we expect everyone to manage acutely compensated heart failure, we should all be able to recognize that a woman who is tachycardic while on estrogen for gender affirming hormone therapy might have a pulmonary embolism,” Dr. Schoenberger said. “We want people to view this education not as something extra for those who are interested, but as something that is within our scope of practice.”
Dr. Khanijow, who has worked with SHM on continuing medical education opportunities, noted that employing a humble, empathetic, non-shaming attitude is important when engaging with trainees at all levels of education on LGBTQIA+ health and cultural topics. He pointed out that many want to do the right thing for LGBTQIA+ patients, but some may not have had the culturally affirmative training to do so, whether they went to medical school in the U.S. or abroad. For learners with very little experience, it can help to start with basic information.
Still, Dr. Schoenberger acknowledges that learning about some of these topics can be uncomfortable for some learners. “But a lot of the things we are talking about are not hard, like asking someone’s preferred name and pronouns,” she said. “Just because we are not super comfortable taking in-depth sexual histories doesn’t mean we shouldn’t be doing it.”
Hormone Education
One potential knowledge gap for many clinicians is hormones for transgender patients, as a significant proportion will be on regimens at the time of inpatient admission. For example, feminizing hormone therapy—typically estrogen combined with an anti-androgen—carries a modestly elevated risk of venous thromboembolism, particularly with oral estrogen formulations.
Several of the hospitalists and experts recommended being very cautious about stopping these hormones, not doing so unless it is truly medically necessary, which usually isn’t the case.
Dr. Keaster noted that although it might be advisable to hold estrogen in a context such as venous thromboembolism, via a process of shared decision making, the default should be to continue the primary hormone. One potential exception to this is spironolactone, sometimes prescribed in relatively high doses for its anti-androgenic effects, which may need to be temporarily held during hospitalization because of risks of acute kidney injury.
Dr. Lee agrees on the key importance of shared decision making in this context, emphasizing that stopping these hormones unnecessarily can be both physically and emotionally traumatic for patients.
Dr. Schoenberger pointed out that some physicians may feel uncomfortable managing hormones because of politicization or lack of training during medical school, but these are the same medications used in many other medical settings. “We should seek out the information and education we need to provide this care,” she said.
Dr. Schoenberger also pointed out that caring for LGBTQIA+ patients doesn’t require a vastly different approach, although clinicians may need to be more cognizant of certain aspects. In fact, many of the general best practices for caring for this population—being affirmative and non-judgmental, inquiring about personal connections, not making assumptions, addressing people in the way they prefer, taking comprehensive medical histories—apply to patient care more broadly.
Communicating Support
In addition to providing informed, up-to-date clinical care, providing a supportive medical environment for LGBTQIA+ individuals requires both innovations in medical systems and a proactive attitude by physicians to help meet gaps.
For example, pronouns and preferred names should be prominently flagged in the EHR, appearing on wristbands, room signage, and patient handouts if possible. SOGI fields should be embedded in the EHR registration workflow, and they should be collected consistently and non-judgmentally. Even if systems don’t easily include such information, clinicians should strive to document it and utilize it, as it can have major impacts on the patient’s experience.
Dr. Marion shared how heartbreaking it can be for patients to be repeatedly called by the wrong name. “Some of them make multiple corrections, and still, staff members or even sometimes physicians do not make those adjustments,” she said.
“If you don’t give them that space to tell you that they’re trans or they have a preferred name or other things, then you may not know that important piece of information about your patients,” Dr. Keaster said. It’s critical, Dr. Marion added, not to make assumptions, to ask open-ended questions, and to be professional and level in one’s response.
General hospital policies can also make a difference in the patient experience, e.g., preferentially granting trans patients or non-binary patients single rooms, if available, or housing them with someone with the same gender identity, noted Dr. Lee.
Visually affirming environments, e.g., with inclusive art or a sign on inclusive care, can also help people feel more comfortable. “The onus is on us to provide a comfortable environment for patients rather than patients teaching us about how to provide them a comfortable environment,” Dr. Khanijow said.
It’s also important for hospitalists and hospital systems to accommodate individuals’ social support systems and family of choice, as this might or might not include their family of origin. This should include asking about patients’ medical power of attorney, Dr. Lee advises, to ensure that their selected person could make medical decisions, if that became necessary.
Communicating with patients about local resources is also key. As in any hospital discharge, hospitalists should loop in the primary care physician or attempt to connect the patient to a practitioner who is likely to serve this patient’s needs well, if not already established.
Dr. Marion strongly recommends getting to know one’s local outpatient resources, which might or might not be ones with specific labeling as LGBTQIA+. Unfortunately, in some environments, these resources may be limited, especially currently with respect to trans minors, but it’s still important to know what options are available for patients at different ages.
Sometimes, it’s possible to take initiative and help create that outpatient resource, as Dr. Keaster worked to do while an intern. Dr. Keaster points out that in addition to its benefits for patients, the gender-affirming clinic provides a learning environment for trainees from multiple backgrounds while also providing a potential setting for helpful research studies. Dr. Keaster shared that there are now multiple such centers in Ohio and neighboring states.
It’s also critical to have ongoing conversations with the LGBTQIA+ community. The inclusion of SOGI information on patient satisfaction surveys, for example, can help provide feedback for improvement. Dr. Schoenberger also emphasized the importance of having ongoing conversations in an active way, like having one-on-one conversations with patients about what they want out of their medical care. Sometimes, these conversations reveal areas of improvement that clinicians haven’t even considered, some of which might not be difficult to meet.
Ongoing communication and advocacy with the broader community are also critical.
Hospitalists can be “stewards against misconceptions,” Dr. Khanijow said, reliable experts who can help teach others and defend LGBTQIA+ patients. Dr. Marion said, “We must be willing to educate people and meet them where they are without judgment. Understand how important your voice is and how much it might impact someone.”
Ruth Jessen Hickman, MD, is a graduate of the Indiana University School of Medicine in Bloomington, Ind., and a freelance medical writer.
References
- Montero A, et al. Poll finding: LGBT adults’ experiences with discrimination and health care disparities: findings from the KFF survey of racism, discrimination, and health. Kaiser Family Foundation website. https://www.kff.org/racial-equity-and-health-policy/lgbt-adults-experiences-with-discrimination-and-health-care-disparities-findings-from-the-kff-survey-of-racism-discrimination-and-health/. Published April 2, 2024. Accessed April 22, 2026.
- Brooks VR: Minority stress and lesbian women. Lexington, MA: Lexington Books; 1981.
- Streed CG, et al. Assessing and addressing cardiovascular health in people who are transgender and gender diverse: a scientific statement from the American Heart Association. Circulation. 2021;144:e136–e148. doi:10.1161/CIR.0000000000001003.
- Nguyen TN, et al. Chronic liver disease and hepatology care in transgender and gender diverse populations. Lancet Gastroenterol Hepatol. 2026;11(4):334-344. doi:10.1016/S2468-1253(25)00287-0.
- de Blok CJM, et al. Breast cancer risk in transgender people receiving hormone treatment: Nationwide cohort study in the Netherlands. BMJ. 2019;365:l1652. doi:10.1136/bmj.l1652.
- Giacomelli G, Meriggiola MC. Bone health in transgender people: A narrative review. Ther Adv Endocrinol Metab. 2022;13:20420188221099346. doi:10.1177/20420188221099346.
- Khan SS, et al. Development and validation of the American Heart Association’s PREVENT equations. Circulation. 2024;149(6):430-449. doi:10.1161/CIRCULATIONAHA.123.067626.
- Reisner SL, et al. Gender-affirming hormone therapy and depressive symptoms among transgender adults. JAMA Netw Open. 2025;8(3):e250955. doi:10.1001/jamanetworkopen.2025.0955.