Implication of LGBTQ on Medical Care
1. Introduction
Often the unfamiliar is overlooked, but in the context of the LGBTQ population, their healthcare needs and care disparities are often magnified because their needs may be different, and their lifestyle brings about an innate suspicion or overt discrimination. Even though our society is making progress in accepting the variety of human diversity, prejudices still exist and the social stigmatization faced by the LGBTQ community puts them at higher risk for certain health issues. It is clear that when compared with the general population, the LGBTQ community has different health concerns which are a direct correlation of the social stigmatization they face. This requires a healthcare system that accommodates their specific needs. Currently, there are few physicians who are competent to work with LGBTQ patients. Many physicians are uncomfortable addressing sexual orientation and gender identity and are not sensitive to the concerns of the LGBTQ population. Medical students receive very little training about LGBTQ patient care, and as a result, there are very few physicians who are competent to meet the needs of the LGBTQ population. Choosing to disclose their sexual orientation or gender identity is a tough decision for an LGBTQ patient because they have to assess their physician’s acceptance of their identity and their comfort level with treating them. Failure to discern a patient’s sexual orientation or gender identity can lead to substandard care. This is particularly important for the LGBTQ population who have health issues directly related to their identity. For example, a gay man who needs screening for sexually transmitted infections may not receive proper care if he is not comfortable discussing his sexual practices with his physician. The sense of alienation or embarrassment may cause him to delay seeking care or actually decide not to obtain care because of a negative healthcare encounter in the past.
1.1 Background of LGBTQ community
Lesbian, gay, bisexual, transgender, and queer (LGBTQ) community in the United States represents a diverse range of people with distinct health needs. To some, LGBTQ is the acronym for “quality” medical care. HHS has recognized the health disparities of the LGBTQ community and has made it a goal of Healthy People 2010 – Essay Writing Service: Write My Essay by Top-Notch Writer to improve the quality of services provided to such individuals. Research has shown that there are subpopulations of these people that have additional specific health needs due to the limits of healthcare access and availability, and they experience a disproportionate burden of many health conditions. In addition, medical doctors or other healthcare providers may hold biased attitudes and beliefs about people based on such characteristics as race, ethnicity, or sexual orientation. These biases can have a negative impact on the patient’s health and the quality of medical treatment that they receive. It is crucial to address these special populations’ health needs and eliminate the bias and discrimination in order to improve overall health status. This is not to say that improvement hasn’t been made in providing equal opportunity care over the last 10-15 years, but simple changes in laws and regulations do not change views held by society and even healthcare providers. It is important that the implications of the LGBTQ community on medical care be studied in order to have adequate and suitable healthcare for them in the future.
1.2 Importance of studying LGBTQ implications in medical care
With the minority stress theory, it is revealed that some ailments disproportionately affecting the LGBTQ community may be in fact caused by the social conditions of stigmatization and marginalization. It is thus paramount that the medical community cease its historical disenfranchisement of this population and work towards treating LGBTQ patients with the respect and understanding they deserve, if for nothing else, to provide equal treatment for equal ailments and advance knowledge on these conditions. Due to this, all evidence of the systematic differences in treatment and intrinsic lesser worth placed upon gay patients compared to their heterosexual counterparts must be addressed in a forceful and infuriating manner. The implications of the preceding reasons are reasons themselves why there is a distinct LGBT health movement. As described by Dr. Daphne R Taylor, the primary care interface is often an uncomfortable experience for these patients and is likely a site where some have experienced continual and marked insensitivity to their needs. There are myriad ways in which a suboptimal clinical encounter for LGBT patients. Steps have been made from the Institute of Medicine to advise creating an evidence-based roadmap for the reduction of disparities in this population; however, much work is still to be done. Thus, it is of the utmost importance that physicians in training and current practitioners understand the implications of treating LGBTQ people and how they can work towards the betterment of care for this community.
In many cases, however, gay individuals have chosen to avoid medical care or obtain it in insidious ways that are detrimental to their health, due to anticipation or experience of homophobia from healthcare professionals. The general tendency of medical literature to neglect the gay population may thus be sustained in part by sampling biases, conducting studies on a near exclusively heterosexual patient group and ignoring those who conceal their sexual orientation in fear of discrimination, and/or those who would choose gay doctors for the same reasons lesbian women choose lesbians. Despite the lack of sustainable data, qualitative assessments provide evidence of disparate treatment of gay patients. And as stated by Dr. James J Mahoney, the dearth of attention given to medical problems and symptoms common in the gay and lesbian communities is disquieting. This clearly reflects an unjustified lesser worth placed upon the health of homosexuals, still translating into the unique health disparities experienced by such individuals. The sheer poverty of clinical resources for homosexual patients compared to their heterosexual counterparts is one more token of the lesser concern. The extrapolation of this is behaviors of medical care providers often consciously or unconsciously discouraging gay patients from seeking certain treatments.
In existence for centuries, literature reports on homosexual individuals are scant compared to their representation in societal demographics. Few cameos are found in fictional and non-fictional works reflecting everyday or intimate interpersonal lives of such individuals, whether in the form of characters’ passing references or major or minor plot points. The absence of substantial gay literature, in comparison to the plethora of literature devoted to homosexual people penned by social scientists and mental health professionals, has political implications. It suggests an absence of interest among gays or a lack of recognition on their part concerning their personal and interpersonal lives in the larger society. This, in turn, may be related in part to the internalization of societal attitudes about the marginal significance of gay people and issues, and an ethos of self-silencing on matters not directly related to attaining legal rights.
2. LGBTQ Healthcare Disparities
LGBT individuals continue to face disparities in accessing healthcare services. The Healthy People 2020 initiative identified that, in the US, access to comprehensive health care services is integral in the prevention of disease, promotion of health, and increased quality of life. High costs and lack of health insurance coverage are barriers for many in need of health services. Data on the uninsured rates of LGBT people, collected during the 2010 – Essay Writing Service: Write My Essay by Top-Notch Writer-2013 National Health Interview Survey, demonstrated that, though the uninsurance rate for adults of the age 18-64 in the US was 17.3%, the uninsurance rate for adults of the same age who self-identified as LGBT ranged from 21.7% – 30.8%. This suggests that LGBT individuals have a disproportionately higher uninsurance rate than the general population. New data from 2015 – Research Paper Writing Help Service shows a significant drop in the uninsured rate for the general population, prompting further research into uninsurance rates for LGBT people during the Affordable Care Act. As Obamacare is at risk of being repealed, uninsurance rates for the LGBT may increase. The Healthy People 2020 initiative also recognized sexual orientation as a social determinant for health. A study by Heck, et al. found that gay men and lesbians are less likely to receive regular medical care than heterosexuals because of the cost and are more likely to postpone medical care. Another study by Rostosky, et al. also found that young adult gay males are less likely to seek medical care. This is often a result of LGB individuals anticipating or experiencing stigma and discrimination in health care settings, and fear of coming out to their providers. Being denied or provided limited access to health services due to one’s sexual orientation has also been linked to higher rates of mood and anxiety disorders.
As they continue to face discrimination and stigmatization, the LGBTQ people experience barriers into accessing healthcare, and are at greater risk of certain medical conditions. Discrimination against LGBT persons has been associated with high rates of psychiatric disorders, substance abuse, and suicide. They are at a greater risk for a number of diseases, largely due to the high rates of tobacco use, and an increase in stress-related illnesses. The Healthy People 2010 – Essay Writing Service: Write My Essay by Top-Notch Writer, a health initiative by the Department of Health and Human Services, listed LGBT health as a priority and identified the following risk factors that affect the gay and transgender population: an increase in violence and hate crimes, higher rates of substance abuse, depression, and suicide among their youth. Steps have been taken in recent years to address inequities in health care for the LGBT population, notably in 2011 with the Institute of Medicine’s Report on LGBT health.
2.1 Lack of access to healthcare services
LGBTQ people have less access to healthcare, largely due to the fact that discrimination is still a significant problem in society. This can often deter LGBTQ people from seeking medical care, leading to a delay in the diagnosis and treatment of conditions which can exacerbate the problem further. A study examining the need for healthcare services among lesbians found that they felt they would need to educate their providers about their healthcare needs and that they often encountered providers who assumed that a lesbian does not need any gynecological care. In a recent survey, transgender respondents were asked about their experiences with health care providers. Nearly one-fifth (19%) reported being refused care due to their gender identity, with even higher numbers for transgender people of color. Respondents also encountered providers who were ignorant of transgender health needs; one respondent wrote, “I was misdiagnosed because the doctor assumed that since I was a transsexual, I must be HIV positive.” When asked about the impact of such experiences, another participant wrote, “It’s had a huge impact on my health. I have postponed care…and I try to avoid hospitals and doctors as much as possible. I don’t even want to get HRT [hormone replacement therapy] because I’m afraid the doctor won’t give me the right prescription or monitor my health properly.” Postponing hormone therapy, which is medically necessary for many transgender people, due to fears of discrimination can worsen the mental and physical effects of gender dysphoria. This same survey also found that for HIV-positive transgender people, the consequences of discrimination can be life threatening; 2% of respondents reported that they had been denied hormone therapy or surgery because of their HIV status.
2.2 Discrimination and bias in healthcare settings
Negative experiences with healthcare providers can unfortunately be quite common for LGBTQ individuals. A 2010 – Essay Writing Service: Write My Essay by Top-Notch Writer Lambda Legal survey reported that 63% of the 5,000 respondents had experienced some form of discrimination from healthcare professionals. Discriminatory behaviour towards LGBTQ people can manifest in many different ways, including: refusal of care, condescension, blaming health issues on sexual orientation, and harsh or abusive language. Less obvious forms of discrimination can include a general lack of understanding and knowledge about LGBTQ specific health needs which can lead to substandard care. In a study of family physicians, 91% were unable to recognise risk factors for LGBT health, and many reported that they would provide suboptimal care for an LGBT individual. Harassment is also a significant problem for transgender individuals, 19% of respondents in the national transgender discrimination survey reported being refused care, and 28% experienced harassment in a medical setting. Discrimination or prejudice experienced in healthcare settings can result in avoidance of medical care for fear of further stigma, in the 2010 – Essay Writing Service: Write My Essay by Top-Notch Writer US Transgender Discrimination Survey 28% of respondents reported postponing medical care due to discrimination and 48% postponed care because they could not afford it. On a more severe note the experience of stigma and discrimination can also result in avoidance of necessary medical treatment, in the same survey 33% of respondents reported mistreatment following hospitalization or surgery including being refused care or experiencing harassment from hospital staff.
2.3 Mental health challenges faced by LGBTQ individuals
A common mental health issue among LGBTQ members is depression, which is due to consistent experiences of discrimination and rejection. In a longitudinal study of sexual minority women, although many psychological disorders were found to decrease over time, depression was found to consistently occur at higher rates than for heterosexual women. This suggests a chronic prevalence of depression in the LGBTQ community. Another study found that lesbian, gay, and bisexual individuals experience major depression at a rate over twice that of their heterosexual counterparts. Meyer’s (2003) findings in his study of gay men suggested that depression was a result of internalizing social stigma and having expectations of rejection.
Mental health problems are highly prevalent among the LGBTQ community. In an attempt to explain the disproportionately high rates of mental health problems among the LGBTQ community, Meyer (2003) conducted a minority stress model for gay men. Mental health issues among the LGBTQ community can be attributed to coping with prejudice and discrimination, as well as a possible internalization of negative perceptions and stereotypes. This can lead to isolation, exclusion, and a high risk of psychological distress, and thus self-destructive behavior. A nationwide study of Canadian high school students found that sexual minority youth were 3 to 4 times more likely than heterosexual youth to have attempted suicide. Furthermore, homosexual and bisexual individuals were found to disproportionately experience a number of mental health problems and substance abuse.
3. Strategies for LGBTQ-Inclusive Medical Care
Implementing policies and practices to create institutional change is vital. Policy development should be guided by the input of LGBTQ patients, as well as research on best practices. Policies will only be effective if staff are aware of them; thus, training on new policies is an essential step. Regular assessments of LGBTQ patient satisfaction and monitoring of climate and treatment within the institution are also key strategies to ensure that policies are having their intended effects.
Creating “welcoming environments” is also important. This involves sending a clear message to LGBTQ patients that they are accepted by displaying symbols (e.g., rainbow stickers) and posting non-discrimination policies. This can also be achieved through using inclusive language and asking patients about their sexual orientation and gender identity in a professional and culturally sensitive manner.
Training healthcare providers on LGBTQ cultural competency is an important strategy for creating an inclusive medical environment. Research has shown that most health care providers are not adequately trained to address the specific health needs of LGBTQ patients. This lack of training often leads to a climate of discrimination and reinforces health disparities.
3.1 Training healthcare providers on LGBTQ cultural competency
Healthcare providers not only need to be knowledgeable about issues relevant to the health of LGBTQ people, but also to remain aware of the social and structural determinants of health that often influence their lives and create barriers to healthcare access and utilization. Contributors to health disparities public policy often contributes to the discrimination and denial of civil rights to LGBTQ individuals—often by excluding on the basis of sexual orientation, gender identity, or gender expression. Some LGBTQ patients avoid seeking medical care due to their negative experiences with providers in the past. More effort is needed to reduce the impact of social and structural stigmatization on the lives and well-being of LGBTQ people. Health education curricula along with professional training programs should implement an LGBTQ-health framework that addresses health issues within the context of the minority stress that LGBTQ individuals experience. This would entail teaching current and future providers how to understand the impact that social and political marginalization has had on the health of their patients. Simulation trainings can prepare providers to better address the needs of LGBTQ patients. One study shows how a cultural competency simulation training can increase medical students’ self-rated preparedness and comfort to care for LGB patients along with knowledge and skills in taking a sexual history. Another possible tool for training providers is the use of standardized patients. An assessable accreditation system should be implemented to ensure that providers have the necessary knowledge and skills to effectively treat LGBTQ patients. These standards could be integrated into the license renewal process and continuing medical education.
3.2 Creating safe and welcoming environments for LGBTQ patients
The LGBT health program model, cited above, has also instated a variety of changes within the UCSF system in order to create a completely safe space for its patients. This includes revisions to all new patient forms and all questions asked to patients by providers in order to make sure that the language is sensitive to all genders and sexual orientations.
Maingi and Yetman stress the importance of including the families of LGBT patients in order to create a truly inclusive environment. Many LGBTQ patients have been alienated from their families or feel that their families will not be welcome in more traditional healthcare settings. By hosting support groups, pride events, or providing advertisements showing same-sex couples or LGBTQ families, healthcare institutions can alert both patients and families of their inclusive stance.
This section focuses on the importance of creating environmentally safe healthcare settings where LGBTQ patients, who often have suffered, can feel comfortable. Meyer and colleagues suggest implementing a recognition and response strategy in which patients who have experienced past healthcare discrimination can identify themselves in order to be redirected to inclusive providers. This method, although not foolproof, has been seen as a positive first step in increasing patient comfort. They also suggest providing guidance for LGBTQ patients who are traveling to areas where their sexual orientation, gender identification, or HIV status could pose a risk to their safety. This can be in the form of educational material or links to government websites that offer information.
3.3 Implementing inclusive policies and practices in healthcare institutions
An area that requires significant attention for many healthcare institutions is the education of staff, without which policies of inclusivity may have limited effect. A study by the Gay and Lesbian Medical Association revealed that 39% of medical school curricula provide no education about LGBT patient care. In contrast, with increasing comfort and proficiency in care for LGBT individuals, greater exposure to LGBT patients and health issues was associated with more positive attitudes toward LGBT individuals. This suggests that education and training on LGBT health issues for healthcare providers have the potential to greatly impact care for LGBT patients. There are various potential avenues of education including online resources, cultural competency seminars, and integration of LGBT issues into medical and nursing school curricula. Organizations such as GLMA and American Medical Student Association provide resources and advice for healthcare institutions seeking to improve LGBT inclusivity. A method of assessing cultural competency of staff members is the use of the Gender, Sexuality, and Health Questionnaire. It can be used as a research tool to assess staff attitudes and knowledge over repeated intervals or as an educational tool to identify gaps in the knowledge of certain employees.
In any clinical setting, an institutional mission to eliminate healthcare disparities related to sexual orientation and gender identity is the foundational step for creating an inclusive environment. This involves assessment of facilities’ wide policies and attitudes within the organizational leadership. Policies prohibiting discrimination based on sexual orientation and gender identity are a pivotal first step; it ensures equitable treatment for LGBT patients and staff. An organization should develop a written non-discrimination policy which is widely publicized and easily accessible to all patients and employees. The status of gay and transgender friendly should be marketed to the community and in various LGBT organizations. This is essential in developing partnerships with LGBT communities and representing a commitment to serve them. Regular assessment to ensure the non-discrimination policies are being followed is also an important process. A potential leverage point is the Joint Commission which is a large accreditation body for health organizations. They have published a field guide for addressing health disparities which is relevant to care for LGBT individuals. This can be used as a resource to promote LGBT inclusive policies within an organization (Grainger-Monsen and Oriel, 2010 – Essay Writing Service: Write My Essay by Top-Notch Writer). A very recent Institute of Medicine report has also recommended that sexual orientation and gender identity be added to the list of demographic data routinely collected from patients.
…Implementing inclusive policies and practices in healthcare institutions.
3.4 Providing specialized healthcare services for transgender individuals
“Transgender individuals often avoid seeking healthcare out of fear of being discriminated and stigmatized or because they had a previous negative healthcare experience.” This relates to the minority stress model, which states that minority groups are exposed to more stress, and this additional stress can lead to an increase in health problems. Transgender individuals are at increased risk for several physical and mental health issues. Belonging to the transgender community in and of itself is a health issue. Transgender individuals have high rates of HIV infection, hormonal therapy usage, and smoking. Each of these carries its own set of health complications. HIV is a chronic illness requiring complex medical care, and the prevention of adding additional stress to the individual who is already dealing with minority stress due to his/her gender identity is very important. Hormonal treatment for transgender individuals, whether it’s testosterone injection for female-to-male individuals or birth control pills for male-to-female individuals, can lead to many complex health issues with biological systems that are out of the scope of this paper. Transgender individuals will often self-medicate with hormones to expedite physical changes before they can be seen by a doctor. This can be very dangerous, and so access to a doctor who is knowledgeable in treating transgender individuals is vital to prevent long-term health complications from unsupervised hormone usage.
4. Future Directions and Recommendations
As previously discussed about the US National Health Interview Survey and Healthy People objectives, the implementation of these measures is pivotal to the improvement of LGBTQ health in the US. The inclusion of sexual orientation and gender identity measures in national and state health surveillance helps identify LGBTQ health disparities and monitors the effect of policy changes and interventions designed to improve LGBTQ health. Inclusion of LGBTQ-focused objectives with targets and deadlines in Healthy People or a similar national health initiative provides guidance for future health policy and identifies areas of improvement for the health of the LGBTQ population. An environment for policy change can be facilitated by a National Center for Lesbian, Gay, Bisexual, and Transgender Health Research, and improvement of health for LGBTQ people in the US can be promoted on an international stage by contributions to global health research and collaboration with governments and organizations in other countries with the goal of improving health for their LGBTQ populations.
4.2 Policy changes to improve LGBTQ healthcare
Suggested new areas of research in this field concern the different LGBT population subgroups: identifying the varying health status and health behaviors among lesbians, gay men, bisexuals, and transgendered people. This holds importance in identifying the needs for each subgroup and tailoring healthcare and health promotion/education campaigns to the specific needs of each subgroup. A study of bisexual and transgendered individuals could address the absence of bisexual and transgender-specific health and prevention interventions and the lack of information about the health issues and status within these two populations. This would hopefully counteract the current issue of bisexual and transgendered individuals being assessed and treated from the perspective of a homosexual person. Measures of sexual orientation and sexual identity are rarely included in data, and any interventions aimed at homosexuals are usually focused on gay men, and therefore the health of lesbians has often been overlooked. A study identifying the health status, health behavior, and health needs of lesbians is an important step to eliminating LGBTQ health disparities and equips healthcare providers with the information needed to address and improve health among lesbians. Measures to improve the health of LGBTQ persons are hindered by the gap in knowledge surrounding their health status and health needs compared to the general population. This is a reflection of an absence of LGBTQ-focused research and also an absence of sexual orientation and gender identity data in general health research. A population-based approach comparing an LGBTQ sample to the general population would identify the disparities in health status and health needs, providing clear information to guide changes to health policy and improvements in healthcare provision for LGBTQ people. Studies that draw a comparison between US LGBTQ populations and those in countries with differing LGBTQ rights and protections may identify the impact of social and legal determinants of health on the health status of LGBTQ people. A final area of research recommended for better understanding the health status and health needs of the global LGBTQ population is a study of the health of LGBTQ refugees, immigrants, and asylum seekers. This group, often escaping from countries with anti-LGBTQ policies and cultures, may have differing health issues and needs compared to non-LGBTQ immigrants, and the host LGBTQ community may have an increased awareness of discrimination and minority stress issues, questioning the impact on their health.
4.1 Research gaps and areas for further exploration
4.1 Research gaps and areas for further exploration
Future research should continue to explore generalist, specialist, and mental healthcare utilization, assessing differences between LGB and transgender populations. It will be essential to link policy measures, such as the inclusive medical anti-discrimination policy that we studied in Massachusetts, with healthcare utilization in an ongoing and changing policy environment. Given the uncertainty of the current political climate and its impact on state-level policy changes and the mixed findings on policy changes on LGB and transgender healthcare, it will be important to understand policy changes for the LGB and transgender community in various states and the resulting impact on healthcare access and utilization. In order to assess the full impact of policy changes, studies examining multi-level factors that affect healthcare access will be needed. Additional research should seek to identify the unique healthcare needs of transgender populations and to improve access to gender identity specific services. With a better understanding of healthcare access, utilization, and impact of policy changes on the LGB and transgender communities, it will be possible to employ targeted interventions to improve healthcare access and ultimately the health of these populations.
4.2 Policy changes to improve LGBTQ healthcare
Research has demonstrated that LGBTQ identified individuals’ health is substantially worse than the health of their heterosexual counterparts. Given the large disparities between sexual minority and non-sexual minority individuals, it is clear that changes need to be made. One strategy to improve healthcare for LGBTQ individuals is to change policies within the healthcare system. This includes integrating sexual orientation and gender orientation into non-discrimination policies, creating more inclusive and targeted programs and services, incorporating sexual and gender minority competencies into medical education and training, and increasing federal data collection on sexual orientation and gender orientation.
In a recent report focusing on the health inequalities of LGBTQ identified individuals, the Institute of Medicine presented a detailed plan for how to improve healthcare for sexual and gender minority individuals. This plan was based on the evidence of stigma and its health effects, as well as evidence that healthcare quality could be improved with policy changes. The plan detailed the need for better data collection, the need for training on LGBTQ competency, the need for increased access to LGBTQ health resources, and a need to incorporate sexual and gender orientation into the design and testing of health interventions. The IOM commissioned this report with the intent of informing federal agencies and providing them with specific guidance on reducing LGBTQ health inequalities and increasing LGBTQ health quality. This plan has the potential to greatly improve the health and healthcare of LGBTQ individuals if properly implemented.
4.3 Collaboration between healthcare providers and LGBTQ organizations
The future of collaboration between LGBTQ organizations and healthcare institutions is in helping healthcare providers understand the needs of LGBTQ patients and work to eliminate the inherent prejudices in the system that serve to limit access and quality of care. An ongoing partnership will work to continually address the concerns and needs of LGBTQ patients and survivors and will work to increase the political advocacy and capital of LGBTQ organizations in the realm of healthcare.
An excellent example is the Gay and Lesbian Medical Association’s (GLMA) steps in developing cultural competency curricula aimed at medical and nursing students, pharmacy students, and physician assistant students. Training healthcare students to be competent in treating LGBTQ patients ensures the continuation of sensitive healthcare to LGBTQ individuals in the future. This would also work to increase the number of open LGBTQ healthcare providers and increase the overall comfort of LGBTQ individuals in seeking healthcare. Another form of collaboration is legislative. LGBTQ organizations can work to advocate and lobby for health policies and laws that would work to increase access to care and decrease the discrimination experienced by LGBTQ individuals in healthcare settings. An example is Equality Maine’s work with the Maine legislature to increase funding for an HIV drug assistance program and expand Medicaid coverage to transgender patients.
Perhaps the most necessary and immediate shift in the future of LGBTQ healthcare is the partnership between health providers and LGBTQ organizations. In the Bryant and Ritz study, an increase in institutional support was suggested to improve the healthcare for LGBTQ individuals. This would involve the development or invitation of LGBTQ-specific organizations within healthcare facilities that would serve as a bridge between the medical system and the LGBTQ community they serve. This would work to ensure that healthcare interventions are culturally sensitive, competent, and relevant to the needs of LGBTQ patients. A first step to establishing LGBTQ healthcare would be inviting these organizations to facilitate cultural competency training for healthcare providers.
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