The Road to Inclusive Care: Insights into Urologist's Attitudes Towards LGBTQ+ Patients - Alex Xu

August 2, 2023

Ruchika Talwar interviews Alex Xu regarding his research on the attitudes of urologists towards LGBTQ+ patients. Dr. Xu, a member of the LGBTQ+ community himself, emphasizes the importance of understanding patients' sexual orientation to provide optimal care. He found that while most urologists believed this to be important, many struggled to ask about it directly. His survey-based study also revealed that urologists feel they need more education on this topic, indicating room for improvement in the field. Dr. Xu's research underscores the need for standardized patient intake forms to capture sexual orientation data, highlighting the potential benefits for both the patient and the provider. The goal, as Dr. Xu states, is to create a safe space for these patients, ultimately leading to improved healthcare outcomes.


Alex Xu, MD, NYU Langone Health, New York, NY

Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN

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Ruchika Talwar: Hi everyone and welcome back to UroToday's Health Policy Center of Excellence. My name is Ruchika Talwar and I'm joined today by Dr. Alex Xu, who's a resident at NYU. Dr. Xu is going to be discussing research focused around LGBTQ+ care in the field of urology and I'm really excited to embark on this discussion with him today. Thanks for joining us.

Alex Xu: Absolutely. Thank you so much for having me Ruchika.

Ruchika Talwar: So let's cover the background of this really important topic. Tell me about what got you interested in looking at urologist's attitudes towards treating patients who are within the LGBTQ+ population?

Alex Xu: Absolutely. Research has been a big part of my journey as a resident. I really wanted to take the time as a resident to explore all corners of research in urology because there are a lot. But my personal interest has been career-wise in reconstruction and I'll be continuing my training next year at Case Western as a fellow in their reconstruction as well as gender affirmation surgery program. And as a member of the LGBTQ community myself, this really was a passion project that I took on starting last year. And I reached out actually to Dr. Amarasekera as a cold call after I read the piece that featured him in the New York Times. And I was really drawn to his work and there was not really anyone else that I knew of, personally, who was involved in this research.

He was very happy to have me on board, introduced me to the rest of the team, and gave me a project that I could lead. So I think this was a really great foray into multi-institutional work. I think that's increasingly important in urology, which is a relatively small field. And as residents we can feel very siloed into our individual institution. So it was very nice to see that, that collaboration worked very well and it really was a project that I think was born out of my own interest and my own life path to urology that I also hope to continue on into fellowship.

Ruchika Talwar: Thanks and thanks for being a champion of this important topic. I think it's really been neglected for far too long and your data suggests that we do have a lot to learn. So let's jump right in. What exactly was your hypothesis and what were your methods for this study?

Alex Xu: Sure. So this was a survey based study. We designed a 35 question survey based on other research in the field, basing our questions around some validated questionnaires that were already out there. And we emailed these surveys to all program directors across the United States and asked them to distribute to faculty at their institutions. So this was really meant to be a hypothesis generating study. We were not necessarily expecting to answer any questions with any great clarity, but we really wanted to demonstrate that there is a lot of room to go in this field and to start to create some jumping off points that other researchers can maybe pick up on at their own institutions and drive this field forward. And I think that the reception has been very good, which has been a testament to urologists forward-thinking and their desire to improve their best practices. And I think a big part of this has just been demonstrating to me as well as the community that there is room for this scholarly research, which has certainly been very, very reassuring and speaking with you today is just another testament to that as well.

Ruchika Talwar: Thanks. Let's discuss a little bit about what exactly the survey was assessing.

Alex Xu: Sure. So the survey was split into essentially four parts. The first part was demographics. We really wanted to capture who were the people that were responding to this survey. I think that is very important in any qualitative study and in this one in particular. We found that our respondents tended to be more female than compared to the 2022 AUA census and tended to be more academic as well as gay identifying, which probably is not surprising, but also represents a limitation in some ways of this study. The second part examined urologist attitudes towards their LGBTQIA+ patients. This sort of focused on history taking, how urologists attempt to gather history, whether they make any changes in the way that they gather history, whether their offices have intake forms, so more automatic ways of getting this history in order to gain rapport and elicit important health history from patients who may be LGBTQIA+.

The third part of the study looked at how urologists felt they had been educated on this topic. So how many hours they had spent in medical school devoted to LGBTQ care and whether they were open to more care, or learning more about how to care for this group of patients. And then the final piece looked at some best practices. So we went ahead and directly asked these respondents some very pointed questions. Some of them do have some research backing, so we called those knowledge base questions and other questions were far more open-ended, we recognize that there's very little research behind these questions, but we wanted to see the range of answers and certainly there was a large range, which hearkens back to what I said at the beginning, that there's certainly a lot to learn. And that was part of the purpose of the study so just to demonstrate that there is a wide range even with regard to questions that are quote unquote, objective.

Ruchika Talwar: Very comprehensive survey. Let's discuss the results a bit. What did you find?

Alex Xu: Right. So I think we touched on the demographic piece. With regard to the second portion, we found that urologists do struggle a little bit in the history taking portion of the visit to elicit a patient's sexual orientation directly. Many urologists stated that they did not have intake forms and that they didn't feel the need to directly ask patients their sexual orientation. However, contrary to this, they did feel it was important to know their patient's sexual orientation in order to provide the best care. So there's this discordance between what they believe and their actions. And we recognize it's very difficult to ask some of these sensitive questions. And as ideas around gender and sexual orientation change, the vernacular also changes and it can be difficult to keep up and there can be a fear around potentially offending patients.

So it's very important to remain educated on the vocabulary and how to approach this. I think many urologists felt that they would ask the question if it was relevant to the clinical picture at hand. I think that this ends up putting a lot of onus on both the patient as well as the provider to determine whether sexual orientation is relevant to the clinical matter at hand. The truth is that, that sexual orientation, gender identity really does play a pervasive role in that patient's history. So it's very difficult to identify when this might be relevance. So I think it does indicate that potentially there needs to be a more standardized way to ensure that this information is shared and that patients feel comfortable sharing this information.

Regarding the education piece, we found that the majority of respondents reported between one and five hours of formal education during the course of their training. So that included medical school residency and even beyond. Which it's heartening to see that this is certainly being built into the curriculum. I know that I certainly had this experience in medical school, I graduated in 2019, so very recently. But it's nice to see that this exists. But most urologists feel that they need more education and they're open to gaining more education, which again is a very positive point that we found on our survey.

And then regarding the last portion, I won't go into the specifics, but I would say that the overarching finding was that, there is a wide range of best practices and many urologists do not consider that there may be differences between heterosexual patients potentially and gay and lesbian identifying patients, especially looking at prostate cancer, which is where we focus this. That thinking about, for instance, the prostate as a source of sexual pleasure, as a source of sexual stimulation was something that was not considered when counseling patients about some of the potential side effects of say, a radical prostatectomy. So certainly a lot of content there that is missing that we would like to encourage more discussion of.

Ruchika Talwar: Yeah. You hit so many important points there. And so I want to backtrack just a bit and highlight something that you covered. So first, I think your point about meeting standardized surveys, that is so important. I think a lot of times having baseline information to draw upon gives the urologist or any healthcare provider, for that matter, an understanding before they even walk into that clinic door. And this way, you do remove that burden of entry for both the patient divulging information or the urologist who we all know maybe packed in a full day of clinic trying to run from patient to patient, we understand the demands of day-to-day clinical practice. But getting those standardized questions ahead of time or at least having an understanding of what information we should be collecting would be helpful. Because if you think about it, especially in the prostate cancer population, we're already administering baseline surveys like the shim score or assessing urinary function or urinary symptoms for patients.

We can build this in and I think what you said is so important. The next piece is regarding education. So I do think that the medical schools are doing a great job of keeping up and providing the education for students to at least have an understanding that the LGBTQ+ population has a certain... First of all, it helps to make you feel comfortable asking these questions. But second of all, there are specific health assessments that we should be taking in this population. Just like we ask different folks from different socioeconomic backgrounds or racial ethnic backgrounds on specific questions.

However, in urology residency, we have no specific education here. And you bringing up those points, for example, as they relate to radical prostatectomy, that is so important. And we clearly there's a paucity of data here we have not done well in this realm so far. So thank you for this work. I think it's just one step in the right direction. Clearly we have a long ways to go, but the fact that we're even having this conversation, I think is a step in the right direction. Now tell me, urologist reads your study in the Gold Journal. What are the big takeaways that you would like to impart for practicing urologists and physicians to treat LGBTQ+ patients?

Alex Xu: Yeah, I think that the understanding has come a long way as you alluded to. I think most urologists understand, believe that there is a difference when counseling patients of different gender identities of different sexual orientations. I think now we have to take that a step further and start to understand what are the specific differences? How do patients want to be counseled? What is important to patients after radical prostatectomy, for instance? And we can only start to do that if we start to ask these questions of our patients. I think it's nothing to be afraid of, although it can be a certainly a barrier. As you alluded to time, you're already counseling the patients on many, many other aspects. But I think one of the big first steps is to create these validated questionnaires so that we can begin to do rigorous studies in this area.

But for the average practicing urologist, I would start off if you have an LGBTQ patient in your clinic, start by asking them questions. What have I missed today? What are some other questions that you might have related specifically to the sexual practices that you may have that maybe we didn't get to today? I think a lot of this is simply showing that you wish to create a safe space, you're making an attempt to, and I think that that will really open a lot of doors in terms of counseling and building that patient rapport outside of these big clinical studies that we're talking about. I think from an individual neurologist perspective, these are small steps that can really make a big difference.

Ruchika Talwar: All great points. And again, I want to congratulate you on taking on this really important topic. It's great to see that we're able to publish on this work. It's an area, like I said earlier, that's been neglected for far too long and I'm excited to see how you're able to continue this work throughout your career. So thank you for taking the time to join us, Dr. Xu.

Alex Xu: Absolutely. Thank you so much for having me Ruchika.

Ruchika Talwar: And to our UroToday audience, thanks for listening and we'll see you next time.