Disclosure and comfort during genetic counseling sessions with LGBTQ+ patients: An updated assessment

Disclosure is the act of sharing a stigmatized identity, and members of the LGBTQ+ community make decisions related to disclosure multiple times throughout their life. Disclosure in medical settings can impact perceptions of care and outcomes for LGBTQ+ patients; however, little is understood about the process of decision‐making regarding disclosure in the genetic counseling setting. As such, this study aimed to explore LGBTQ+ experiences in genetic counseling sessions and their disclosure behaviors. Fifty‐five LGBTQ+ individuals who attended a genetic counseling session and 91 genetic counselors completed online surveys. The patient survey assessed for disclosure behaviors, experiences of discrimination, and comfort in genetic counseling sessions. The counselor survey evaluated comfort with the LGBTQ+ population in a counseling setting, whether counselors facilitate disclosure in sessions, and whether counseling is tailored for the LGBTQ+ population. Eighty‐two percent of genetic counselors “rarely” or “never” ask about sexual orientation, and 69% “rarely” or “never” ask about gender identity. The majority of patients indicated they were not asked about their sexual orientation (87%) or gender identity (80%). Some patients reported experiencing discrimination or homo/transphobia in their genetic counseling sessions, with 6.12% of LGBQ+ patients experiencing discrimination and 24.1% of trans+ patients reporting discrimination. Over half of genetic counselors reported receiving training in LGBTQ+ healthcare and the majority reported comfort with providing care to LGBTQ+ patients. However, discrepancies between patient‐reported experiences and genetic counselors' descriptions of their care for the LGBTQ+ population warrant further research and suggest additional training or changes in practice may be necessary.


| INTRODUC TI ON
The LGBTQ+ community is not a homogeneous group, representing a diverse mixture of racial, ethnic, socioeconomic, and cultural backgrounds. Members of the LGBTQ+ community have historically been marginalized and pathologized by both medical and psychological systems. Members of this community also have higher incidence of risk factors for disease (Blosnich et al., 2014;Boehmer et al., 2012;Dahlhamer et al., 2016;Fredriksen-Goldsen et al., 2013), likely due to stress from negative experiences, such as stigma, prejudice, and discrimination which impact health (Meyer, 2003). Approximately 7.1% of adults identify as part of the LGBTQ+ population (Gallup, 2021). However, in the medical realm patients often experience "institutionalized heterosexuality," the assumption that the patient is heterosexual and often, cisgender.
This has been posited to burden sexual minorities with the decision to share or mask their minority status (Venetis et al., 2016).
LGBTQ+ individuals are less likely to utilize the healthcare system (Bergeron & Senn, 2003;Sequeira et al., 2020) due to multiple barriers.
Despite recent efforts to better understand the experience of non-heterosexual and transgender or gender non-conforming patients with healthcare, there remains a paucity of research about counselor-patient interactions within genetic counseling for this population. Recent research on this topic indicates genetic counselors feel unprepared or lack necessary experience to counsel patients with identities that fall under the LGBTQ+ umbrella Glessner et al., 2012;Sheehan, 2018;Zayhowski et al., 2019) while expressing a desire for additional training to meet the needs of this population Glessner et al., 2012;Nathan et al., 2019;Ruderman et al., 2021). (Note: throughout this manuscript, we will use umbrella terms, such as LGBTQ+, LGBQ+ and trans+ to refer to individuals with identities outside the binary conceptions of gender, sex, and sexual orientation).
Disclosure, or the sharing of a stigmatized identity that is not easily discovered by another person (Chaudoir & Fischer, 2010) is a decision many LGBTQ+ individuals make multiple times over countless interactions in their lives. The act of disclosure in the medical or psychological setting contributes significantly to perceptions of care and outcomes for LGBTQ+ patients (Durso & Meyer, 2012;Fish et al., 2019;Law et al., 2015;Rossman et al., 2017;St. Pierre, 2012). Foundational work in the realm of disclosure and sexual orientation by Meckler et al. (2006) found that 66% of lesbian, gay, and bisexual youth thought it was very or somewhat important that physicians know their sexual orientation to provide the best care possible (Meckler et al., 2006).
Disclosure has been positively associated with greater satisfaction in healthcare settings for rural and urban lesbian women in the South (Austin, 2013). Women in a Canadian study who were "out" to their healthcare provider were more likely to follow preventative care standards and utilize their healthcare system (Bergeron & Senn, 2003).
Sexual orientation and gender identity disclosure are associated with a variety of psychosocial factors, and the decisionmaking process around disclosure is mediated by frameworks around stigma and trust. In a NYC study of lesbians, gay men, and bisexuals, non-disclosure behaviors in healthcare settings were associated with poor psychological well-being at 1-year follow-up (Durso & Meyer, 2012). Other studies have found a link to additional psychological burden associated with nondisclosure, including regret (Lisy et al., 2018).
The decision to disclose or to not share sexual orientation and gender identity information is modified by several different factors, including environmental factors, such as inclusive wording on forms or clinic brochures, fear of homophobia, discrimination, or changes in care following disclosure (Brooks et al., 2018;Kamen et al., 2014;Lisy et al., 2018), as well as previous perceptions of positive or negative interactions with a provider (James et al., 2016;Law et al., 2015;Lisy et al., 2018). Nondisclosure is more prevalent among lesbians who are also women of color or immigrants (Durso & Meyer, 2012). Transgender and gender nonconforming patients reported prior negative experiences with healthcare professionals caused anxiety around scheduling a genetic counseling appointment, and contributed to fear of discrimination regarding their gender identity (Rolle et al., 2021). In a study of transgender youth, 47% indicated that they wanted their healthcare provider to initiate the conversation around disclosure, and of the youth who did not disclose to their healthcare provider, 65% mentioned "not knowing how to bring it up" (Sequeira et al., 2020). Similarly, a meta-analysis of lesbian, gay, and bisexual individuals in cancer healthcare found participants suggested the onus of facilitating disclosure should be on the healthcare provider (Lisy et al., 2018).
After stigma, one of the largest barriers to disclosure is healthcare providers not directly asking about LGBTQ+ identity (Rossman

What is known about this topic
Disclosure of aspects of personal identity such as being part of the LGBTQ+ community can impact healthcare.
Research conducted over 10 years ago indicated that genetic counselors lacked experience caring for LGBTQ+ patients and did not engage in discussions about disclosure with their patients.

What this paper adds to this topic
Patients report not being asked about or discussing their gender identity or sexual orientation. Although genetic counselors report education about and experience caring for LGBTQ+ patients, discrepancies between patient experiences, and genetic counselor experiences indicate additional training may be warranted. et al., 2017), which may be tied to provider bias and/or lack of knowledge about LGBTQ+ healthcare.
Disclosure is not unambiguously positive in all situations.
Entrapment is a disclosure strategy where the person disclosing their identity perceives they are forced to share the information. Venetis et al. (2016) hypothesized that entrapment may occur in medical situations where patients feel that they have no choice but to disclose due to a medical rationale. By disclosing a minority status, a patient is placed into a vulnerable position where the provider might respond in discriminatory fashion (Lisy et al., 2018).

The research teams of Erin Vanden Langenberg and Heather
Glessner completed foundational work on the intersection of genetic counseling and care of non-heterosexual patients including an assessment of the attitudes of genetic counselors and lesbian, gay, and bisexual patients regarding sexual orientation disclosure from both parties in a session, the comfort of genetic counselors in counseling lesbian, gay, bisexual, and transgender patients, and any differences in approach to a session with a patient who identified as lesbian, gay, bisexual, or transgender . A majority (90.1%) of the 213 genetic counselor participants reported having counseled at least one patient from the community. Almost half (44%) felt they lacked experience, and 25.5% were concerned about offending a patient. The majority of genetic counselor participants (71.8%) reported not changing anything about their counseling for sessions for lesbian, gay or bisexual individuals, which was reflected by 93.1% of patient participants noting they had not been asked about their orientation.
An accompanying publication  described follow-up phone interviews with lesbian, gay, and bisexual survey participants which yielded suggestions to improve the experience of patients, such as providing medically inclusive forms, inquiring about orientation in a sensitive way if it is medically pertinent, and verbal inclusion and recognition of a patient's partner in session.
In the 9 years since these publications, there have been major shifts in the world of LGBTQ+ rights, visibility, and inclusion, including the legalization of gay marriage (Obergefell v. Hodges, 2015) and the Supreme Court decision that sexual orientation and gender identity are protected from workplace discrimination (Bostock v. Clayton County, 2020). These changes as well as the omission of transgender patients in the original research, and recent collection of research illustrating limited genetic counselor knowledge related to LGBTQ+ populations highlight a need for renewed characterization and understanding of disclosure behaviors in genetic counseling sessions in a current sociocultural context.
The present study is a reevaluation of disclosure behaviors in genetic counseling, both from the counselor and client perspective based on the research originally conducted by VandenLangenberg and Glessner. As such, the purpose of the current study was to reevaluate disclosure behaviors by non-heterosexual patients and genetic counselors to assess if there have been any changes and extend the research to include gender identity as well as gender diverse patients.

| ME THODS
This study utilized a mixed-methods approach to assess disclosure behaviors as well as perceptions by LGBTQ+ patients and genetic counselors in a genetic counseling session. The study was reviewed and granted an exemption by the institutional review board at the University of North Carolina at Greensboro (IRB #21-0131).

| Recruitment
Practicing genetic counselors were recruited through the National Genetic counselors who provided patient care in clinical settings within the last 2 years were eligible to participate, whether they were aware of having counseled a member of the LGBTQ+ community or not. LGBTQ+ patient participants were eligible to participate if they identified as a member of the LGBTQ+ community and had attended a genetic counseling session. Several questions at the beginning of the patient survey screened for these eligibility criteria.

| Survey instruments
Surveys were obtained from the authors of the original paper, "Are Genetic Counselors and GLBT Patients "on the Same Page"? an Investigation of Attitudes, Practices, and Genetic Counseling Experiences" . The surveys were evaluated and adjusted for language and relevance for current application. Both the genetic counselor and patient surveys underwent evaluation and editing from members of the LGBTQ+ community to ensure language and concepts were inclusive and incorporated modern terminology. Survey reviewers represented multiple races, ethnicities, sexual orientations, and gender identities; they were distributed across the United States and the majority were under 30 years old. Their feedback guided revisions to the survey used by Glessner et al. (2012), including separation of gender identity from sexual orientation, additional opportunities for open-ended answers, and inclusion of a story completion prompt.
Language was amended to more closely reflect current best practices in sexual orientation and gender identity collection as well as including more specific language for gender diverse populations.
Both patient and genetic counselor surveys were collected using Qualtrics to allow for digital access as well as to utilize skip-logic to target members of different LGBTQ+ subcategories, intended to reduce question fatigue. Both surveys began with definitions of types of sexual orientations and gender identities, genetic counseling, as well as terms used in the survey, such as microaggressions, sourced from the Human Rights Campaign glossary of terms.

| Patient survey
The patient survey included demographic questions assessing sex assigned at birth, gender identity, sexual orientation, age, race/ethnicity, and state of residence in the United States. Three questions inquired about the type of genetic counseling utilized. Individuals who identified as non-heterosexual were presented questions specific to the experience with genetic counseling as it relates to their sexual orientation, and those who identified as gender diverse were presented questions about gender identity. Survey-respondents were asked to rate 11 different reasons why they may or may not have disclosed their sexual orientation and/or gender identity to the genetic counselor. A series of questions also addressed their disclosure behaviors in other areas of their life and in other medical settings. Respondents were given the opportunity to provide clarification to their answers with text boxes for several questions.

| Genetic counselor survey
The genetic counselor survey included six demographic questions assessing sex assigned at birth, gender identity, sexual orientation, age, race/ethnicity, and area of practice. Survey takers were asked how long they have been practicing, and whether they have seen patients in the last 2 years. Questions investigated whether genetic counselor participants had counseled LGBQ+ or trans+ patients, whether counselors were more comfortable counseling patients of their own sexual orientation or gender identity, and comfort counseling different patient populations. All genetic counselor participants were asked to respond to eight questions inquiring about whether they asked patients about sexual/gender identity and how comfortable they perceived their patient population were with disclosure, while genetic counselors who identified as gender or sexually diverse received additional questions about their own disclosure practices. Genetic counselors answered a sliding scale question paired to the patient survey about how likely they were to disclose their own sexual/gender identity to a patient and one that explored perceptions around counseling the LGBTQ+ population. Perceived utility of knowing a patient's LGBTQ+ status was evaluated, as was interest in training, contact with the LGBTQ+ community outside of the work environment.

| Story completion
Both the patient and genetic counselor surveys included a story completion prompt at the outset. Story completion offers the beginning of a story and a character prompt, allowing patient and genetic counselor participants to fill out what they believe would happen next in the scenario. This methodology was chosen to circumvent social desirability bias by allowing the participant to reveal what they thought may happen through a hypothetical situation told in the third person (Clarke et al., 2017). After determining eligibility, but before the definitions, LGBTQ+ patient participants were given the following prompt and asked to complete the story: Elliot, a nonbinary individual who was assigned female at birth, has arrived at the genetic counseling clinic to discuss their genetic risks for disease. Elliot has been using testosterone for the last few years, binds his chest, and usually presents masculine-of-center. Elliot walks up to the front desk, and begins the check in process, including navigating the discussion of a name not in the medical record. What happens next? How do the receptionist and genetic counselor react, and how does Elliot feel about it?
Similarly, after determining eligibility but before definitions were provided, genetic counselors were presented the following story completion prompt: Sarah is a genetic counselor in an adult clinic in a medium-sized city. She is on her fourth and final case of the day, and it is an indication that she is comfortable with and counsels often. She is ready to be done with patients for the day, fill out her clinic notes, and go home. Sarah goes out into the waiting room to bring in her patient, calls out the name, and is surprised: the person who responds does not look like the gender of the patient she expected. She briefly wonders if the wrong person responded, and scans the room for her expected client. The person who responded walks up to Sarah, and says "I usually go by ______________now." What would Sarah do next?
What might this session look like for her?

| Data analysis
Story completion data were analyzed for all participants who provided a response. Responses to the story completion were coded using an iterative process. The primary coder (R.V.) was a genetic counseling student at the time; she is part of the LGBTQ+ community and has also participated in LGBTQ+ trainings as both an attendee and a presenter. Responses were initially coded into three total broad themes: Knowledge, Emotion, and Action responses.
Knowledge responses included what a respondent knew about how to respond to the situation (i.e.: pedigree notation). Emotion responses addressed how different members of the story might respond emotionally to the scenario, and Action responses were steps taken, such as asking for pronouns. Written responses were assigned to each category; all codes were reviewed by and discussed with T.N., an expert in qualitative research and a member of the research team.
Only surveys with responses to at least 80% of the displayed questions were included in the quantitative analysis. The total number of responses collected will be noted for each question described in the results section. Statistical analysis consisted of descriptive statistics.

| Participants
One hundred and fifty people in the LGBTQ+ community responded to the survey, with 49 completing it fully. Ninety-one genetic counselors responded, with 65 complete surveys. All participants were given the opportunity to mark more than one option for each question about sexual orientation and gender identity. Table 1 provides a summary of gender identity, sexual orientation, sex, and the setting for genetic counseling for all participants. LGBTQ+ patient participants reported a variety of identities that are not commonly reported in the general population. Genetic counselors' reported identities were more diverse than has been described in the National

Society of Genetic Counselors' Professional Status Survey (PSS).
This may be due to more identity options provided in the survey or may indicate a greater variety of identities in our study sample compared with others.
Counselors described patients as disclosing identity information before being asked about it; many of the genetic counselors reported a patient disclosing sexual orientation (n = 65; 81.25%), and a little over half had a patient disclose gender identity (n = 47; 58.02%). No genetic counselor, including the five who identified as non-cisgender and the 36 who identified as non-heterosexual reported disclosing their own sexual orientation or gender to a patient in session. The majority of genetic counselor respondents have seen a patient that is LGBQ (n = 80; 96.39%) or gender nonconforming (n = 59; 71.08%).

Comfort
Genetic counselors were asked if they were generally more comfortable counseling a patient of their own sexual orientation or gender identity. A minority were more comfortable counseling patients of their own sexual orientation (39%) or their own gender identity (49%). This indicates that the majority are equally comfortable counseling all patients, regardless of sexual orientation or gender identity. Genetic counselors perceive themselves as people to whom patients would be comfortable disclosing, with most stating that their patients would be "very comfortable" (n = 16; 19.75%) or "somewhat comfortable" (n = 42; 51.85%) disclosing sexual orientation. Similarly, most believed their patients would be "very comfortable," (n = 8; 9.88%) or "somewhat comfortable" (n = 44; 54.32%) disclosing gender identity. No counselors indicated that their patients would be "very uncomfortable" disclosing either sexual orientation or gender identity to them during a genetic counseling session. Genetic counselors reported being comfortable with counseling patients in general, with the majority (n = 80, 98.8%) being "comfortable" or "very comfortable" counseling. On a scale of 0-100 of comfort, counseling patients in the LGBQ community counselors scored a mean of 87.9, and 80.1 for the trans+ population.

Knowledge
Genetic counselors reported using gender neutral and inclusive language in sessions, with 53.16% indicating they "always" did, while 37.97% "usually" do so. and Action, genetic counselors were more likely to report that the counselor in the story, "Sarah," would respond with knowledge and action roles in the story. Knowledge themes included assum- ing Sarah would ask about gender affirming treatment, use different pedigree notation, as well as considerations of whether she would change counseling based on the discordant presentation between the patient's name in the record and information provided in the session. Many reported that they would keep counseling the same (n = 18), others indicated that they would change counseling (n = 15), and some might change the counseling (n = 10). The most common actions taken were confirming and noting the name provided as well as asking for pronouns. The descriptions of emotions Sarah would experience could all be considered "negative" and rooted in fear, such as embarrassment, worry, discomfort, and "feeling thrown off." Apologize, smile warmly, and say, "Nice to meet you, ____" and add that she will make sure to update their name in their file. I imagine she might feel some embarrassment that would require a quick readjustment of her emotional state/feelings, but otherwise the session would probably go well (though might also require on-the-spot recalculation of risks) (Cisgender female who identifies as bisexual, gay, lesbian, and queer; works in general genetics)

| Survey
Disclosure Sixty-two LGBTQ+ patient participants responded to questions about disclosure during genetic counseling. The majority of patients (n = 35; 56.5%) reported that they were not asked about their sexual orientation or gender identity: 23.6% were asked about their sexual orientation, and 20% about their gender identity in a genetic counseling session. When asked if the genetic counselor presumed that they were heterosexual, 30.9% agreed, and 63.6% experienced that the genetic counselor assumed that they were cisgender. When asked if they disclosed their identity during the session, regardless of if the genetic counselor asked, 61.8% reported that they disclosed their sexual orientation, and 18.2% disclosed gender identity.
The majority (83.6%) reported that their genetic counselor did not disclose sexual orientation or gender identity to them during the session.
The LGBTQ+ patient participants were then asked how often they share their sexual orientation or gender identity with general healthcare providers. The majority of the 38 respondents (82.61%) "always" or "sometimes" disclose sexual orientation, and 55.55% "always" or "sometimes" disclose gender identity. When asked a series of questions about the circumstances under which they would be more likely to disclose their gender identity, LGBTQ+ participants indicated only one situation-when directly asked by the counselor.
The majority of patient participants described the attitudes of their healthcare providers about sexual orientation were "very important" (45.65%) or "important" (28.26%) to them, while a healthcare provider's gender identity was "very important" to 34.62% of patient participants and "important" to 7.69%.

Comfort
Sixty-nine LGBTQ+ patient participants responded to questions about comfort during genetic counseling. Patient participants reported that they did not see (34.5%) or were not sure if they had seen (32.7%) inclusive medical forms with words like "partner," or spaces for pronouns. Similarly, 45.5% reported not seeing inclusive media, while 30.9% were not aware if they had seen any. Genetic counselors were described as using gender neutral language by 49.1% of LGBTQ+ patient participants. Thirty-seven LGBTQ+ patient participants disclosed their identities to the genetic counselor. The majority of those who disclosed their sexual orientation or gender identity to the genetic counselor described their response as "About the same as other health professionals" (62.1%), while 21.6% of LGBTQ+ patient participants felt the genetic counselor was "More positive than other health professionals" and one participant felt the genetic counselor's reaction was "More negative than other health professionals." Fifty-seven respondents shared their preferences regarding a genetic counselor with their same sexual orientation or gender identity. The majority indicated that they would either not prefer a genetic counselor with the same sexual orientation (38.6%) or felt it would not make a difference (24.56%). Nineteen percent were unsure, and 10 respondents (17.54%) said that they would prefer a genetic counselor with the same sexual orientation. Twenty-seven LGBTQ+ patient participants (47.37%) would not prefer a genetic counselor of the same gender identity, 28.01% would prefer a genetic counselor with corresponding gender identity, 15.8% indicated that it made no difference to them and 5.26% were unsure. One individual expressed that they were afraid to disclose but hoped that there would be no discrimination, stating "I didn't reveal my gender identity, but I would be hopeful that the counselor would have been fine regardless, though due to the fear of the situation being otherwise, I pretended to be cisgender." LGBTQ+ patient participants were able to provide additional insight into their preference. A cisgender female who identifies as bisexual and queer and who attended a prenatal GC session stated, "Personally, I don't care about the counselor's identity as long as they are accepting of mine." A transgender woman who is gay and attended an assisted reproduction genetic counseling session shared, "Seeing a genetic counselor who is also trans, genderqueer, [gender non-conforming] etc would be lovely. Their particular gender wouldn't make a difference to me." Thirty-six LGBTQ+ patient participants responded to the question about genetic counselor attitudes about sexual orientation. The majority of LGBTQ+ patient participants expressed that genetic counselor attitude toward sexual orientation did not influence care (55.6%), while 22.2% communicated that they did not disclose and TA B L E 2 Genetic counselor participants' response to: How Might Knowing Sexual Orientation and Gender Identity Aid in Counseling?

Categories N (%) Example
Psychosocial knowledge or building rapport n = 31; 41.3% "Properly using the patients preferred name, gender pronouns, and knowing their sexual orientation can help build rapport and allow the patient to feel they can be themselves and/or more willingly share relevant medical/social/family history." Risk assessment n = 30; 40.0% "Knowing biologic status is important for risk counseling (pap smears for people with cervixes, breast cancer screening for people with breast tissue, awareness of someone who is physically capable of pregnancy)" Useful for cancer GC n = 15; 20.0% "I work in cancer, so sex assigned at birth, which organs someone has, and hormone use impact cancer risk assessment. I also inquire about plans for reproduction, especially for patients with gene mutations, and knowing sex assigned at birth/gender identity of their partner facilitates this discussion" Practice area relevance n = 24; 32.0% "Since I work in prenatal, for example when I have a lesbian couple come in and one of them is pregnant, it is helpful to know if IVF was done, if a donor egg was used, information about the donor sperm, etc. I will ask different/more questions than if this was a spontaneous pregnancy by a heterosexual couple." "I'm in pediatrics so it is not relevant to every patient at a young age.
But for teens or adults, knowing whether procreating will involve a gamete donor or a person might be relevant." Would change language n = 9; 12.0% "It would help me not misgender or dead name them, and it could help a patient feel more rapport and trust." Accuracy of counseling n = 5; 6.7% "Knowing gender identity may aid in organ-specific screening and accurate pedigree/gene recurrence counseling." Avoid bias n = 3; 4.0% "Knowing this information might help me prevent making assumptions, but I really should be avoiding assumptions ANYWAY." Change pedigree n = 3; 4.0% "If a person's gender identity is different from their sex assigned at birth that can change discussions about cancer risks. It can also affect how they are represented in a pedigree." so it was not an option. Of the 17 LGBTQ+ patient participants who responded about genetic counselor attitude toward their gender identity, 64.7% indicated that genetic counselor attitude toward gender identity did not influence care, while 23.5% described that they were concerned that it would and therefore did not disclose; 11.7% related that they did not disclose and were assumed to be cisgender. Forty-nine LGBTQ+ patient participants responded to the question asking if they experienced homophobia or microaggressions during the genetic counseling session. Three (6.12%) said that they did, three (6.12%) described that they did not disclose, 41 (83.67%) said that they did not, and two (4.08%) were unsure.
Twenty-nine LGBTQ+ patient participants answered the questions asking if they experienced transphobia or microaggressions during the genetic counseling session. Seven (24.1%) responded that they did experience transphobia or microaggressions. Nineteen (65.52%) did not experience transphobia or microaggressions, two (6.90%) were unsure, and one individual commented that they did not disclose their gender identity.

| Story completion
Responses from the LGBTQ+ patient participants (n = 35) were more likely to focus on the emotional responses to the encounter from the various characters in the story, particularly the protagonist, Elliot. They delineated feelings of the receptionist, Elliot, and of the genetic counselor. The most frequent emotion attributed to the receptionist was confused (n = 7), and all positive emotions were accompanied by qualifiers such as, "I hope" (i.e., "I would hope they [the receptionist] would react respectfully as well as place a note in Elliot's chart that he uses he/him pronouns"). Elliot, the patient in the story, was most likely to be referred to as anxious (n = 10), upset, or frustrated, (n = 6) although four responses had feelings labeled comfortable and respected. The genetic counselor was most likely to be described as understanding and supportive (n = 5). The most common action was of the receptionist placing names and pronouns into the electronic medical record (EMR) (n = 9), and the genetic counselor acting as if "everything is normal" (n = 3). Elliot was only assigned one action, which was researching if the counselor and office was LGBTQ+ friendly. One patient participants' story completion stated: "I would hope that the receptionist starts by asking for preferred pronouns. Then pass that info to the counselor before the appointment. Which would make Elliot feel respected and accepted" (Cisgender female who identifies as gay, lesbian, and queer; attended ART and prenatal genetic counseling).

| DISCUSS ION
Although LGBTQ+ patients are a significant minority of the total number of patients seen in genetic counseling practice, most genetic counselors report providing care for sexually diverse and/or gender diverse patients for a variety of indications (Ruderman et al., 2021).
Understanding the disclosure behaviors of this group of patients is important for providing culturally sensitive and appropriate care.
This study builds upon previous exploration of disclosure in genetic counseling  by surveying 65 genetic counselors and 55 members of the LGBTQ+ community about comfort and

Theme & category N Example
Would not n = 35; 51.5% "I do not think having a better understanding of our patients would hinder our ability to take care of them." Counselor might have bias/ assumptions/microaggressions n = 9; 13.2% "I may make unconscious biases or assumptions." Counselor afraid of saying the wrong thing n = 7; 10.3% "I think it could make a counselor less confident because they do not want to say the wrong thing or make a mistake that the patient would take the wrong way. In turn, the patient may not get the best session." Counselor is unable to connect or uncomfortable n = 6; 8.8% "I am sometimes uncomfortable because I am not LGBTQ+, so I feel like I might offend someone or use wrong language/terms." Counselor might struggle using preferred pronouns n = 3; 4.4% "Due to lack of experience addressing gender identity, I might struggle to use preferred pronouns that differ from the traditional, binary "she/her/ hers" & "he/him/his"." TA B L E 3 Genetic counselor participants' response to: How might knowing sexual orientation/gender identity hinder counseling? disclosure in the genetic counseling setting. Our study cohort was slightly larger than those surveyed by Glessner et al. (2012), and included gender diverse individuals, which were not represented in the previous study. More genetic counselors reported receiving training regarding LGBTQ+ issues than in the original paper; however, this was not appreciated by the patients who experienced discrimination and discomfort during sessions.
The majority of patient respondents indicated their genetic counselor did not ask about their sexual orientation or gender identity. This is consistent with the genetic counselor survey results revealing that they rarely or never ask about sexual orientation or gender identity in session and the story completion prompts where only a subset of genetic counselor participants described asking "Sarah" about pronouns or offering their own. Although counselors recognized there were benefits of asking patients about gender identity including to aid in risk assessment, particularly for cancer genetics, and for accurate counseling regarding reproductive options and organ-specific screening, genetic counselors do not facilitate disclosure in their sessions. Previous surveys of patients indicate they are willing to answer questions about sexual orientation and gender identity, and do not seem to be more sensitive to providing this information than other routinely collected demographic information (Bjarnadottir et al., 2017). Indeed, with our study population, a little over half of LGBQ patients reported disclosing their sexual orientation during a genetic counseling session, while approximately a third of gender diverse patient participants disclosed their gender identity, often to decrease anxiety or because the counselor asked. This is lower than reported disclosure in the literature, with 83% of patients disclosing during genetic counseling  and 79% of individuals in a literature review disclosing their LGBT identity to a cancer care provider (Kamen et al., 2014). The lower disclosure rate may be associated with some members of the LGBTQ+ community indicating that they were uncomfortable with disclosing their identities over concern of discrimination or a distressing encounter. Genetic counselor participants did not anticipate that patients would feel uncomfortable with disclosure of either sexual orientation or gender identity to them in a genetic counseling session.
The majority of genetic counselors did not disclose their own sexual orientation or gender identity during a session either, consistent with the patient-reported experience. While there has not been an investigation into genetic counselor self-disclosure in sessions self-disclosure of LGBTQ+ identity by psychotherapy counselors is recommended on a case-by-case basis-dependent on many variables including the length of time in therapy and the content of the sessions (Hearn & West-Olatunji, 2015). Disclosure is described as potentially beneficial and impactful on the course of therapy, but counselors endorsed feelings of anxiety and vulnerability leading up to the time of disclosure (Hearn & West-Olatunji, 2015).

Gender inclusive language in conversation and on medical forms
can indicate that a medical institution and the practitioners within have knowledge of and provide inclusive care, which may support patient disclosure. Although most genetic counselors reported using gender neutral language often, fewer than half of LGBTQ+ patient participants reported their genetic counselors using gender neutral language. Few patients reported medical forms with inclusive language or inclusive media in the genetic counseling office. This was reinforced by the genetic counselors, of whom more than half reported that their forms do not use gender neutral language or ask for pronouns. A minority of LGBTQ+ patient participants recalled seeing inclusive forms or media in the genetic counseling office.
Presumably, more inclusive media might be memorable or meaningful for this patient population, and so we hypothesize that those who did not recall whether media or forms were inclusive might have remembered had they been demonstrably LGBTQ+ friendly in some way. There were several differences between the findings described in the original Glessner and colleagues' paper (2012) and this study.
A minority of their participants reported that the genetic counselor assumed that they were heterosexual, whereas a majority of our study's patient participants reporting their genetic counselor assumed that they were heterosexual. Approximately the same percentage of genetic counselors reported being comfortable counseling non-heterosexual patients in the two cohorts. Slightly more LGBTQ+ patients in our survey reported being asked about their sexual orientation than in the original study. Ninety-three percent of the participants surveyed by Glessner et al. (2012) reported that they did not experience discrimination due to sexual orientation in the original study, which is similar to our patient cohort.

| Study limitations
This study has certain limitations that may reduce generalizabil-

| Practice and training implications
Engaging in practices that create a comfortable space for patients to disclose if they so desire is of utmost importance. Genetic counselors should amend paper intake forms to more accurately represent gender identity through providing spaces for gender identity, birth sex, legal sex, preferred name and pronoun fields (Barnes et al., 2020). Brooks et al. (2018) found that inclusive language on forms facilitates disclosure, as well as visual clues in the healthcare setting, such as leaflets, stickers, and posters deemed LGBTQ+ friendly. Not having visual cues can make it more difficult for individuals to feel comfortable disclosing their LGBTQ+ status due to fear of social or structural stigma. Disclosure can also be facilitated through routine collection of sexual orientation and gender identity from all patients, normalizing the collection as irrespective of the patient's (apparent) LGBTQ+ status or chief complaint (Barnes et al., 2020;Maragh-Bass et al., 2017). Collecting information about sexual orientation and gender identity is generally not distressing to patients (Rullo et al., 2018). Many genetic counselors are comfortable asking about a gender diverse individuals' pronouns . Routinely offering their pronouns to all patients is another alternative that promotes conversation around gender diversity and represents LGBTQ+ healthcare knowledge to patients.
Visual representation through stickers or a "badge buddy" on nametags or badges that represents their pronouns and can provide nonverbal communication of openness to LGBTQ+ patients.
Our findings compared with those from Glessner et al. (2012) suggest that the number of genetic counselors who have received training regarding LGBTQ+ healthcare has increased over time, which coincides with an increase in available educational resources, including those available from the National Society of Genetic Counselors (Bennett et al., 2016;Koeller et al., 2018;Liaquat & Sheets, 2019). The impact of healthcare professionals receiving training regarding the LGBTQ+ patient population has been demonstrated to reduce bias by learner populations in several different fields (Boysen, 2010;Burke et al., 2015) and have been found to be highly effective in increasing knowledge about non-heterosexual people (Bartoş et al., 2014).  (Warren, n.d.) are useful for practicing genetic counselors, though an updated version that includes more than one LGBTQ+ case would be valuable for greater understanding and guidance. Additionally, a single education experience may not be sufficient to overcome existing biases or discomfort with caring for LGBTQ+ patient. Increasing the amount of education may increase awareness of health issues and increase positive attitudes about LGBTQ+ patients (Arthur et al., 2021).

| CON CLUS IONS
Contrary to the previous article by Vandenlangenberg, Glessner, and colleagues (2012) we found that LGBTQ+ patients and genetic counselors are not "on the same page" regarding disclosure. Genetic counselors believe LGBTQ+ patients to be much more comfortable with disclosure than patients report, and genetic counselors are not routinely engaging in practices that allow for disclosure such as asking their patient population about sexual orientation or gender identity, offering pronouns, or making intake forms more inclusive. Genetic counselors endorse more benefits than hindrances in knowing sexual orientation and gender identity information about patients, and there are potential positive impacts on counseling, risk assessment, and building rapport. Further research is necessary to determine the best ways to facilitate disclosure in a genetic counseling session, whether it be through inclusive forms, symbols on name tags, directly asking every patient about their sexual orientation and gender identity, or other action identified as valuable by patients themselves.

CO N FLI C T O F I NTER E S T S TATEM ENT
Rozalia Valentine, Rachel Mills, Tracy Nichols and Lauren Doyle declare that they have no conflicts of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.

H U M A N S TU D I E S A N D I N FO R M E D CO N S E NT
This study was reviewed and granted an exemption by the University of North Carolina at Greensboro Institutional Review Board. All procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Implied informed consent was obtained for individuals who voluntarily completed the online survey and submitted their responses.

A N I M A L S TU D I E S
No nonhuman animal studies were carried out by the authors for this article.