LGBTQI in Healthcare: Q&A with Nina Metsovaara, FNP

Not many people look forward to doctor’s appointments. But for LGBTQI and gender non-binary individuals especially, the experience is often dreaded. From ill-informed doctors to outright refusal of treatment, many LGBTQI people face significant barriers to basic healthcare. According to a 2017 survey by the Center for American Progress (CAP), eight percent of lesbian, gay, and bisexual individuals and 29 of transgender respondents reported that a healthcare provider had refused to see them because of their sexual orientation or gender identity. Meanwhile, a study by the National Center for Transgender Equality found that 33 percent of trans respondents had a negative interaction with a healthcare provider because of their gender identity. And both surveys found particularly high rates of discrimination towards LGBTQ people of color. The CAP survey, for instance, found that LGBTQ people of color were more than twice as likely to avoid the doctor’s office than white LGBTQ individuals due to fears of discrimination.

With this in mind, we sat down with San Francisco provider, Nina Metsovaara, FNP, who identifies as queer herself, to discuss the LGBQI healthcare experience, as well as the intersectionality of race and sexual orientation. Metsovaara, a third generation Mexican American, specializes in trans and LGBTQI care.

A: I grew up in a working class environment where many families, including mine, didn’t have healthcare access or health insurance. By the time I reached my teens and began exploring my sexuality, I was learning about reproductive and sexual health in our standard health education class. Unfortunately, I recall feeling confused by the non-inclusive sexual education I was receiving. This lack of representation of brown bodies and LGBTQI individuals within the classroom and health materials founded my interest in sexual health. Then I attended a liberal Vincentian Catholic private university that emphasized service-learning and community involvement. The radical student-based organizations there focused on feminism and LGBTQI rights politicized my worldview. Similarly, the university’s emphasis on diversity and inclusion shifted my understanding of racism and institutional injustice. Ironically, although not uncommon, I spent the first 18 years of my life without the vocabulary to describe the reality of the racism I had grown up experiencing as a Latinx. I learned about reproductive justice movements that are founded on racial inclusivity and third wave feminism. I volunteered at a reproductive health access center in Chicago which drew in people from all over the midwest and exposed me to a variety of people and circumstances. It was around this time that my career path within health care and passion for reproductive justice was formalized. By the time I turned 20, I had my first queer relationship and came out to family and friends. From there I worked in a variety of health settings, including as an HIV test counselor and community health educator at the Broadway Youth Center (BYC), within Howard Brown Health Center. The BYC served as a safe haven for LGBTQI street-based youth. Working with street-based youth taught me about the challenges affecting black and brown young adults, particularly trans youth. It highlighted areas of invisibility within our community, and emphasized the harmful erasure of the diverse LGBTQI BIPOC experience. I started to question what racial justice looked and felt like within health care and how one could honor the reality of the young people I was meeting everyday. Having grown up with similar intergenerational trauma, I realized that I was seeing myself reflected in these young people. Serving as the youth mentor I never had helped me heal my own inner child. Ultimately it was the culmination of all these experiences that motivated me to pursue a career in nursing and primary care. As a family nurse practitioner, I have the opportunity to connect with others over a common experience and use my voice to advocate for the health care needs of the marginalized communities who raised me.

A: As a queer feminine of center person, I wanted to provide health care to the LGBTQI community. More specifically, I wanted to strive toward eliminating healthcare disparities and integrating the realities of my loved ones. During my Master’s program in nursing, I was awakened by the limited exposure students have to a range of sexual and reproductive health topics. For instance, a majority of health professional program dedicate little to no classroom time to curriculum focused on contraception management, HIV medicine, and transgender health. Realizing that I was going to need to seek out these topics outside of the classroom, I narrowed my first post-graduate job search to LGBTQI health centers. Not knowing where to begin, I Googled a national list of transgender clinics and looked for nurse practitioner job listings. I began working at Lyon-Martin Health Services, which is a community-based organization providing health services to women, gender non-conforming and transgender people of all sexual identities. I had no idea what I was doing moving across the country from the Midwest to California, but I really wanted to learn transgender medicine and I did. All of the community work I had done prior with street-based and trans youth set the foundation for this one position. Ultimately, I wanted to practice compassionate, empathetic, and human-driven healthcare that maintains people’s dignity.

A: I grew up not really knowing anyone who was out. My generation didn’t have the same media LGBTQIA+ representation that today’s generation Z has. I had this idea growing up that being queer meant I had to look a certain way, which was based on untrue stereotypes. I didn’t see myself in those stereotypes. It took me longer to come out because I didn’t know that queer people could look, walk, and talk like me. As a teenager, I wasn’t even familiar with what the term “queer” meant. As a feminine queer primary care provider, I want to increase visibility of all genders and create an uplifting inclusive space for queer femininity. And at the same time, as a brown person growing up in a Latinx family, I saw the impact of intergenerational trauma and the ways institutionalized race-based violence leads to individual and collective suffering. My desire to become a health provider was motivated by the grief and loss that I witnessed in my community. To me, hearing the stories that often go unheard gives voice to collective struggle. Witnessing and connecting also gives my job more purpose and meaning. I think we can see parts of ourselves in every narrative. Everyday I also learn how to navigate my own health and develop a greater understanding of well-being. I don’t think that we should hide from that unifying human experience. Instead, I think we should talk about our diverse lives and find places to connect.

A: It varies, but one, as previously mentioned, is representation. It is common, depending where people live and work, for individuals to have fear about being honest about their sexuality in the workplace. At One Medical, I’ve never felt like I couldn’t be myself since there are other out LGBTQI people who work here. But there are lots of people in other places who worry that their coworkers may think differently of them because of their sexuality or feel that they won’t have the same opportunities. I personally have passed up opportunities to learn in the past because I was afraid of the microaggressions and macroaggressions I would experience.

Second, would be the lack of training on LGBTQI topics (and I would add BIPOC cultural fluency). There are many healthcare workers who want to subspecialize in LGBTQI health topics. Yet due to the lack of diversity in our educational curriculum, we have to put in additional time and effort to first find learning opportunities and then be trained on how to serve our communities. That in itself impacts your workplace experience and your career satisfaction. It can be disheartening, especially when it’s related to a personal identity that you take very close to the heart.

A: One of the biggest barriers is obviously the lack of LGBTQI+ health and specifically trans competent providers. Across the board, there just isn’t enough training in trans care in medicine. I completed a dissertation in my last year of graduate school that was about homophobia and transphobia within medicine. While there are examples of explicit homophobia and transphobia within medicine, implicit bias includes doctors not being properly trained in LGBTQI medicine, not knowing what to do and thus doing things incorrectly, or passing the responsibility of care on to someone else. These biases are harmful and discriminatory. We as a society, get lost in all these social constructs of what we think makes someone different. To me, difference can be a beautiful thing that we celebrate. Helping people feel seen is a part of the healing process. Ultimately the healthcare system needs to normalize conversations about gender and sexuality. In terms of all of the forms that go with healthcare, many places don’t have proper documentation for pronouns and gender identity. Health care systems are also limited in terms of clinically competent providers for hormone therapy. That really limits connections. Take going to a therapist for instance. If you’ve been told there are five therapists in the whole city, what happens if you don’t like one of them or all five of them? In order to get your health needs met you have to try to establish a therapeutic relationship with someone that maybe you don’t even connect with.

A: I would say that it means when I’m talking to patients, I try to not make assumptions. I ask questions in a way that creates spaces for people to disclose information that’s relevant for them, while also not interrogating them. The questions I would ask someone who is coming in for a pap smear, for instance, are not the same questions I would ask a patient who is in for a vaccine. It also means that I practice consent-based exams. I try to be person-centered and ask people what they need. For example, I had someone come in who was anxious about a medical procedure and she told me she was going to put on headphones to listen to music to reduce her anxiety. What’s amazing is that she had the courage and self-awareness to advocate for herself and to say that to me. We then had an amazing visit where she listened to her music, sang, and talked while I did her procedure. It was a great bonding moment. To me, that’s what makes an exceptional healthcare experience. It’s that moment where you feel just like you’re hanging out with a friend that just happens to be giving you healthcare. That comfortability is really important to me. I like to think that by practicing empathy and a certain element of openness, my patients then feel empowered to be open, share, and say what they need in those moments of vulnerability.

A: Yes, many patients don’t access health care unless it’s absolutely necessary, at times leading to serious health consequences. When people do come to see a provider, they might be cautious to disclose their sexuality or gender identity as a means to avoid discriminatory care, stigma, or even violence. I try to put things up in my office that indicate that this is an LGBTQI friendly-zone. For instance, I have a poster that says, “Trans is beautiful” next to my desk and I have a pin with my pronouns. Things like that let people know that it’s okay to disclose personal information about sexuality and gender.

A: First, I avoid making assumptions about anyone’s gender identity or sexuality. For instance, I politely ask people about their pronouns and name during introductions. When it is relevant to the topic of the visit, such as with sexual and reproductive health, I ask for consent before inquiring about their sexual health practices and only ask questions required to make safe patient-centered and collaborative medical decisions. Generally, I use consent based language in my exams and implement trauma informed practices during genital exams. This includes asking someone permission to make physical contact, using gender-neutral language unless otherwise specified by the patient, and asking how people refer to their body parts, or asking how you can support someone during a vulnerable moment. When initiating hormone therapy, I practice by an informed consent model and follow WPATH standards of care. Unfortunately, a lot of people who engage with health care for transgender specific services are retraumatized by being asked to defend their gender. I try to avoid these unnecessary conversations. If personal information is necessary to advocate for a patient, I start those difficult conversations by acknowledging the uncomfortable nature of those health care questions. I want to learn what makes a patient feel centered and cared for. Patients feel more at ease when you are open to feedback and listen to their health needs. Plus, let's not forget that a lot of routine health visits and activities of daily living have nothing to do with being queer!

A: I always tell people to do their research before they show up someplace if they can. I find most LGBTQI patients find their provider from word of mouth in community or from partners, or internet community/boards. One Medical bios are helpful as patients can select a provider whose profile indicates "LGBTQI health" or "transgender care" as a specialty. Narrow down your options by gender and race if you have a preference. I also say that if you have things that you know you already want to talk about, write them down. A lot of patients come with a support buddy whether it be for a pap or just for meeting a new provider. I also usually remind people that they have the right to not like someone and not see them ever again if they don’t work out. You’re not stuck with someone. When I send my patients out for referrals, I ask them to let me know how their experience went. We want to be able to refer our patients to people that are going to take good care of them. And if they don’t have a good experience, I’ll ask the patient if they want me to relay their feedback to that specialist.

A: We start by hiring diverse staff and providers who identify as LGBTQI themselves. We also have a team of people who have prioritized transgender fluency and are working on how to better meet the needs of patients. This includes training other providers on transgender care and the practicing an Informed Consent Model, which reduces pathologization of gender and eliminates barriers to hormone therapy. We are also creating an inclusive onboarding training for all staff, and developing EMR (electronic medical records) features that allow us to capture and document the identification markers of our patients in our communication with patients and external referrals.