Utilizing the Four Tenets of Osteopathic Medicine as an intersectional framework for approaching sexual orientation and gender identity disclosure as a provider

Tenet One: the body is a unit; the person is a unit of body, mind, and spirit

For the purposes of this article [7], body is defined as the physical structure that houses a person, made of cells, tissues, organs, and systems [14]. Mind is defined as the thoughts, consciousness, attitudes, beliefs, and feelings of a person [14]. Spirit is defined as the essence of each individual, the breath of life in a person that gives them a sense of power, virtue, love, and truth [15].

Professor Kimberlé Crenshaw coined the term “intersectionality,” which outlines how a person’s identities expose them to various prejudices that compound to deepen health inequity [16]. While intersectionality as a framework can be utilized for numerous identities and populations, this article focuses specifically on the LGBTQI+ community. The multilayered aspects of intersectionality are complex, and discussing every identity and combination of multiple identities would be outside the scope of this paper; rather, the authors will address why coming out to a provider may not be straightforward and that various factors such as cultural, religious, familial, and situational factors may influence someone’s decision to choose to come out or not. Baby boomers openly identifying as LGBTQI+ declined from 2.7 to 2.4% between 2012 and 2017 [17]. Memories of discrimination and fear of social isolation can compound during end-of-life care (EoLC) in this group [18, 19]. Respondents reported that their sexual orientation and/or gender identity were a valuable part of the personal narrative; further, they reported that opposition to their sexual orientation and/or gender identity diminished their quality of health care [20, 21]. Generational differences can play a role in someone’s choice to come out. A study of three generations of Italian LGBQ+ people found that the older group (61–80 years) disclosed their sexual identity later compared to younger groups [22]. Among respondents who identified as Catholic, 67% had come out to their religious community, and 84% of older adults surveyed were more likely to disclose their sexual orientation to this specific community than young adults (48%) surveyed [22].

We believe that support for self-disclosure and open communication, regardless of age, will be helpful in fostering a healthy connection between body, mind, and spirit. Coming out may be considered a step toward identity affirmation, improving self-esteem, and life satisfaction [23, 24]. It can also be a stressor that increases risk of victimization and abuse due to increased visibility [25]. For young adults, negative parental reactions to coming out can manifest as a form of rejection and avoidance of further discussion, increasing the likelihood of developing depression in those who choose to come out [26]. In a study examining the coming out process in Hispanic sexual minority youth (SMY) and young adults, many respondents discussed how certain factors such as “machismo” and “marianismo” (defined as a set of socially constructed behaviors in Hispanic culture that reinforces male vs. female gender roles), familism, and religious beliefs influenced their decision to come out [27]. Fear of being forced out of the home and feeling as if their safety would be compromised were also concerns that respondents raised, emphasizing the importance of considering timing and context when an individual chooses to come out or not [27].

One author recalled when an 11-year-old Hispanic male expressed his fear of having AIDS, and reportedly kept his fears from his non-affirming family while “waiting to die.” The patient’s family told him that all gay men had AIDS. He deduced, as a gay child, that he had AIDS, and misinterpreted his eczema as Kaposi’s sarcoma. This experience highlights how negative attitudes toward LGBTQI+ persons can impact health at any age.

Various studies emphasize the prominence of LGBTQI+ invisibility, where members of this community find difficulty coming out to their providers because they have lingering concerns, like skepticism toward healthcare providers’ awareness of the intricacies of intersectionality in their identities [28–30]. The goal of FTOM in this context is to reduce stressors, to provide patients with resources, and to investigate, utilize, and/or foster the patient’s social support system.

Tenet Two: the body is capable of self-regulation, self-healing, and health maintenance

When applying Tenet Two [7] to a patient coming out in a healthcare setting, the provider’s goal is to create a space where the patient can feel supported to heal and maintain health. “Disclosure stress,” or the stress experienced by sexual minority people because of expectations of rejection after coming out, can be a source of anxiety and a detriment to mental health [31]. This added stress can affect an individual’s quality of life and mental health, making it crucial for healthcare providers to partner with the patient to mitigate this stress. Studies have also shown that, compared to gay men and lesbians, bisexual youth are at an increased risk for depression [31]. Bisexual women also reported higher levels of internalized sexual stigma than lesbian women [25]. Bisexual individuals face a unique stigma that is different from those experienced by their gay and lesbian counterparts, including rejection by both homosexual and heterosexual people and lack of validation and visibility in relationships, which is known as biphobia [32]. Transgender individuals can also experience a unique process of disclosure known as “transgender identity disclosure” [32]. In a study analyzing 240 transgender identity disclosures on social media, participants shared that healthcare providers were on average some of the very first persons to whom respondents disclosed, with some describing the experience as “anxiety provoking” and “emotionally draining” [32].

Globally, there is a high prevalence of self-harm and suicide attempts (SA) in the general adolescent population [33]. Studies have shown that negative experiences of discrimination, stigma, and victimization contribute to the increased risk of developing psychosocial health problems for SMY [34]. SMY report higher levels of isolation and impaired self-concept, along with increases in anxiety, depression, and aggression [35]. An analysis of high school students in the United States found that among 6,790 participants, 4% reported sexual orientation discordance; these discordant students were 70% more likely to have suicidal ideation or SA compared to concordant students [36]. Other studies show that family rejection correlates to the highest associated risk of SA and substance misuse in transgender and gender nonconforming persons, as compared to factors like employment status, education, and income [37].

In a study by Rossman et al., respondents reported feeling comfortable when disclosing their LBGTQ identity to providers who exemplified knowledge and understanding of LGBTQ+ patients and demonstrated respect in their communication during the health encounter [38]. In an author’s experience at a pediatric endocrinology practice, transgender patients who chose to come out to an affirming physician reported appreciation in using their chosen name and undergoing the appropriate treatment. These patients reported feeling more accepting of themselves. The authors believe this response to be a testament to the desire of the body and mind to self-heal and self-preserve when receiving care from an affirming physician. Discordance through “being in the closet” can be seen as dysregulation of the whole person, and providing a space for the patient can allow for congruence, facilitating healing and self-regulation.

Tenet Three: structure and function are reciprocally interrelated

Tenet Three pertains to the idea that the structures of the body work together to determine function, and if cohesive function is dysregulated or inhibited, somatic dysfunction occurs [7]. Similarly, if a patient decides to come out to a provider (function), this decision is influenced by multiple extrinsic factors, such as cultural, societal, and social factors (structure). From this tenet, the authors extrapolated that society and its inherent structures influence the function of individuals.

When a patient comes out in the clinical setting, intersectionality allows for a better understanding of how an individual’s social identities affect their willingness to come out. Latino American, Asian American, and African American persons experience stigmas exacerbated by social and cultural expectations that may be obstacles from them seeking medical care [5, 28–30, 39]. LGBTQ Latino persons have certain specific facets of their identities regarding traditional perceptions of masculinity, language barriers, and undocumented status that can affect communication and patient-provider transparency [28]. By making concerted efforts to improve communications and addressing personal and structural barriers, providers can work toward providing the best possible medical care.

Whereas the first two tenets focus more on the personal, micro-leveled approach to the relationship between intersectionality and coming out in the LGBTQI+ community, the authors contend that Tenet Three takes a more macro-leveled approach. Sociologists like Emile Durkheim and Alfred Radcliffe-Brown coined the term “structural functionalism,” postulating that disruptions in an individual’s social network and relationship with society can affect psychological well-being [40]. This theory parallels Tenet Three by examining how an individual’s societal relationships influences coming out in a clinical setting. Certain populations uniquely navigate the overlapping complexities of cultural, familial, and religious factors. For example, a study found that Korean gay men respondents utilized a method termed “narrative of convenience” in which they come out to their family and together construct a story that builds a heteronormative image of the self to keep their homosexual identity hidden from the wider community when appropriate [41]. Studies suggest that such practices place stress on individuals, but this stress can be ameliorated by having an integrated identity that promotes overall health and well-being due to increased self-esteem and decreased internalized conflict [30].

Trying to find the intricate balance between the individual and the demands of society can cause strain on a person; however, the authors believe that this stress can be mitigated by the provider. One author met a 14-year-old girl who came out as a lesbian during the patient interview. She said she was “too scared to come out to [her] family because they were super conservative and Christian.” Utilizing Tenet Three and the concept of intersectionality, the author was able to give space by listening to the patient’s reservations around coming out, answered her questions, and provided relevant resources such as those in Table 1.

Osteopathic medicine emphasizes how somatic dysfunctions are due to biomechanical restrictions, which are categorized by their myofascial “freedom of motion” [42]. Adapting this principle, when a person comes out to a provider, that person moves into the “freedom of motion,” helping to restore structural and functional balance. The holistic approach requires the providers to consider how structure and function, both at bodily and societal levels, impact the patient at the intersection of their identities.

Tenet Four: rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function

Tenet Four is a call to practice evidence-based medicine with a holistic approach [7]. The authors believe that the healthcare setting can be made more accepting of the coming out process. Prominently displayed inclusive LGBTQI+ policies and items such as pride flags, reading materials, provider and staff training in the use of gender-neutral and inclusive terminology, expanding intake form options and categories, and a commitment to acceptance and inclusion can be utilized to make a practice more affirming [43, 44]. A study found that medical professional students who complete LGBTQI+ patient care competence training report increased knowledge and comfort levels along with changed attitudes toward LGBTQI+ patients [45]. The authors founded a student organization focused on LGBTQI+ whose mission includes educating learners about the nuances of care centered on LGBTQI+ through structured courses and activities. Participants frequently report that the training helps them facilitate positive patient encounters and that they feel able to offer guidance in this area to senior practitioners.

In the authors’ experience, a patient’s coming out can range from a matter-of-fact statement made from a position of personal acceptance to one made under duress. Guidance regarding how to bridge difficult conversations with patients is well documented [46, 47].

The LGBTQI+ community has a unique vocabulary that has evolved over time [48]. Cultural humility as defined by its originators is the process of “incorporat[ing] a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-provider dynamic, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations” [49]. Thus, we propose that a practitioner who utilizes cultural humility will be more equipped to engage with the evolution of the LGBTQI+ population.

Limitations and future directions

By their nature, intersectionality, sexuality, and gender are multifaceted. The number of possible identities is infinite, and patients may express their sexual orientation and gender identity differently over time. Furthermore, literature regarding the coming out process and intersectionality remains sparse. Similar to the proposal in Tenet Four, the authors suggest an approach of cultural humility, in which constant learning, adapting, and flexibility are undertaken over time in an effort to continually improve understanding the patient.