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Let’s Talk About Sexual Orientation and Gender Identity – a Quality Improvement Project to Enhance LGBTQ+ Inclusivity in a Resident Clinic

July 22, 2022

In a recently released issue of Pediatrics, a team from the University of North Carolina Department of Pediatrics led by Dr. Tyler McKinnish used quality improvement (QI) methodology to bring enhanced screening and documentation of adolescents’ SO/GI (sexual orientation and gender identity) to those patients seen in their resident continuity clinic (10.1542/peds.2021-052125). The authors remind us that youth who identify as lesbian, gay, bisexual, transgender, queer and other gender identities (LGBTQ+) are less likely to present for routine preventive health care, yet rate their health more poorly than non-LGBTQ+ peers and are at higher risk for multiple medical morbidities including but not limited to eating disorders, depression, suicidal ideation, HIV, and experiences of violence.1,2 Pediatricians have an opportunity to collect SO/GI information in a respectful and confidential manner early in acute care visits, which increases the potential to provide meaningful, timely and needed help. Acute care visits were selected for this QI project because chart review showed that SO/GI was already being documented for well care visits. This author team tackled the challenge of how to accomplish their planned project in a busy clinical setting with multiple providers.

The authors clearly articulate their primary aim, which was to use QI methodology to “systematically and confidentially document SO/GI and pronouns for at least 90% of acute care visits for teens”, and to do so early in the encounter so appropriate help could be offered. Their secondary aims were to provide a more welcoming environment for LGBTQ+ youth, improve clinician and staff self-efficacy in care of LGBTQ+ youth, and improve risk factor screening. The QI team included a highly diverse group of 14 stakeholders, including health providers, clinic staff, electronic medical record specialists, content experts, a patient identifying as transgender and their parent, and others. The PDSA (Plan-Do-Study-Act) cycles, which are the foundation of QI work, included extensive staff and provider education, role playing, and electronic record modification. A method for confidential collection of SO/GI information including pronouns was initially elusive, as the authors honestly describe. Through multiple PDSA cycles, the team ultimately found their way to a unique brief “card” screener that also asked other key questions related to mental health and social needs. The card is provided to teens in the waiting room, given to the nurse at triage and then to the doctor prior to the encounter, and is depicted in a figure at the end of the article. 

There’s so much more in this article to share! This QI project was highly successful, and the positive results were sustained despite clinician and staff turnover, which are inevitable in a busy clinic setting that includes resident physicians. Reading this article is empowering and inspiring! It provides a roadmap for your office or clinical setting to make similar changes that have the potential to positively impact the lives of LGBTQ+ youth. As Dr. McKinnish and colleagues note, by gathering SO/GI information, staff are now able to address patients correctly, which promotes an inclusive environment that can improve patient care and offers the opportunity to identify psychosocial support needs – all key components of serving patients and families well.  Let us know if you too find this article a springboard for action and how you are screening for SO/GI in your practice.


  1. Johns MM, Poteat VP, Horn SS, Kosciw J. Strengthening Our Schools to Promote Resilience and Health Among LGBTQ Youth: Emerging Evidence and Research Priorities from The State of LGBTQ Youth Health and Wellbeing LGBT Health. 2019 May/Jun;6(4):146-155. doi: 10.1089/lgbt.2018.0109. Epub 2019 Apr 8. PMID: 30958731; PMCID: PMC6551982.
  2. Macapagal K, Bhatia R, Greene GJ. Differences in Healthcare Access, Use, and Experiences Within a Community Sample of Racially Diverse Lesbian, Gay, Bisexual, Transgender, and Questioning Emerging Adults. LGBT Health. 2016 Dec;3(6):434-442. doi: 10.1089/lgbt.2015.0124. Epub 2016 Oct 11. PMID: 27726496; PMCID: PMC5165667.
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