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

The Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and other (LGBTQI+) community continues to experience health inequity and unmet needs. This manuscript examines the application of the Four Tenets of Osteopathic Medicine (FTOM) during a patient’s selfdisclosure of their sexual orientation and/or gender identity to the provider, also known as coming out. Tenet One discusses the interplay between intersectionality and coming out. Tenet Two elucidates how coming out moves toward a balance of homeostasis and self-healing. Tenet Three examines how structure and function can be understood on a personal level and how society influences coming out. Tenet Four explains the resources available to facilitate the previously forementioned changes. By applying the Four Tenets, the provider may more readily understand what “coming out” means on personal and social levels and what implications they may have on their patients’ health.

an increase from 4.5% in 2017 [2]. Conversely, the percentage of Americans that reported some discomfort toward LGBTQI+ situations did not change from 2015 to 2016, remaining at 14% [2]. Another study of 489 LGBTQ adults found that more than one in six LGBTQ respondents reported avoiding seeking health care due to anticipated discrimination, and one in five respondents reported personally experiencing discrimination specifically because of their identity [3]. Furthermore, 50% of racial and ethnic minorities reported experiencing microaggressions, slurs, and threats [3].
Individuals who identify as transgender have poorer healthcare outcomes due to lack of access to health care, anticipated discrimination, and perceived discrimination from providers [4]. A survey including bisexual and lesbian Asian-Pacific Islander women demonstrated various reasons why they chose not to disclose their sexuality, including provider responses, attitudes, and beliefs [5]. In a study analyzing the perspectives of LGBTQI+ adults aged 18-29 years old on their healthcare experiences, transgender and queer/questioning participants were specifically found to have more negative experiences and delays in seeking care compared to LGB participants [6]. These findings suggest an abundance of barriers, including coming out in a healthcare setting, faced by individuals of the LGBTQI+ community not experienced by their majority counterparts. The authors suggest utilizing an FTOM framework to assist in navigating the coming out process in the healthcare setting.

Methodology
A qualitative systematic review was undertaken with a focus on osteopathic medicine and the LGBTQI+ community. The key terms searched included "intersectionality," "health care," "health providers," "discordance," "sexual identity disclosure," "gender identity disclosure," "LGBT," and "osteopathic tenets" through databases including PubMed, ScienceDirect, Gallup, and NCBI. These terms yielded 205 articles. Each author sorted through the articles to ensure relevance to the topics of LGBTQI+ health care, coming out in the healthcare setting, and/or the FTOM. The authors collectively decided to utilize the 49 articles referenced in this paper. We included papers written between January 2005 and April 2021. Papers outside of this period were included purely to cite primary sources. Reviewed articles and the authors' clinical experiences were utilized to propose the osteopathic tenets as an approach to responding to patients coming out in a healthcare setting.

Clinical summary
We recommend that practitioners utilize FTOM as a holistic approach to the LGBTQI+ patient encounter. Table 1 outlines recommendations suggested for each tenet. No one tenet is more important than another, and thus all should be given equal deference when understanding sexual orientation and gender identity disclosure.

Discussion
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][29][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 selfregulation, 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 selfpreserve 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][29][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 genderneutral 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.

Conclusions
As increasing percentage of Americans identify as LGBTQI+, sexual orientation and gender identity disclosure will be a more common topic discussed in the healthcare setting. However, sexual-and gender-minority individuals continue to face discrimination and barriers to health care. The authors propose that acknowledging intersectionality is required when understanding the limitations and prejudices these patients face when coming out. The FTOM provides a framework for providers to approach sexual orientation and gender identity disclosure more appropriately in the healthcare setting.
Research funding: None reported. Author contributions: All authors provided substantial contribution to conception and design, acquisition of data, or analysis and interpretation of data. All authors drafted the article or revised it critically for important intellectual content. All authors gave final approval of the version of the article to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Competing interests: None reported.