While lesbian, gay, bisexual, transgender, or queer or questioning (LGBTQ) people have made strides in securing their rights and acceptance, the fight for equality is far from over. This community continues to face discrimination and inequalities, especially in health care.
“They not only have barriers to accessing care and receiving care, but also, even when they do receive care, they can receive inferior quality and have worse outcomes,” says Nicole Nisly, MD, professor of internal medicine. , Director of the Associate Department of Diversity and Inclusion, and Co-Director of the LGBTQ + Clinic at the University of Iowa Health Care.
The problem starts early in life, and it’s something Nisly saw in her own practice. “You see a young person introducing himself to his family, and there is a huge risk that he will be evicted from his home and lose his entire support system,” she says.
With the loss of housing and support, there is more stress and less access to health care. The results can be profound.
LGBTQ youth are at higher risk of suffering from depression, post-traumatic stress disorder (PTSD), substance abuse, physical or sexual violence, and sexually transmitted diseases (STDs). They are almost three times more likely to think about suicide and almost five times more likely to act on these thoughts than cisgender (cis) heterosexual youth.
What are the obstacles?
In the past, people identified as LGBTQ were routinely denied health insurance. Being transgender was seen as a pre-existing condition that health insurance companies used as an excuse to deny coverage, says Paula M. Neira, JD, registered nurse and clinical program director at the Johns Hopkins Center for Transgender Health.
“Personally, I was denied health insurance when I went to law school, and I ended up having to get a catastrophic plan with an outrageously high deductible,” she says.
The Affordable Care Act, which came into effect in 2010, has prevented insurance companies from denying coverage to transgender people. But housing and employment issues, along with social stigma and discrimination, often make it more difficult for people who identify as LGBTQ to gain equal access to health care.
As a result, they are more likely to delay seeking care or not seeking it at all. “Because of a well-documented history of discrimination in healthcare, people don’t trust their doctors,” says Neira.
Just walking into a doctor’s office can present barriers for a transgender person. “Let’s say you go to your doctor and the only toilets available to you are either male or female,” says Nisly. “It seems incredibly difficult for someone who identifies as transgender.”
And if you’re a trans man in need of ovarian or uterine cancer screening, you might be stopped by a telephone programmer who is intrigued by what he thinks is a disconnect between your voice and a need for gynecological care.
Once you enter the doctor’s office, you may find the reception less welcoming. You may be denied care, receive substandard care, or face a lecture about your gender or gender identity. “You end up teaching your provider to take care of you,” says Neira.
Almost 40% of transgender people surveyed said they had experienced harassment or discrimination when trying to access health care.
Much of the problem is that doctors and other healthcare professionals are not well trained on how to care for LGBTQ people. That is starting to change, as medical schools introduce programs on treating sexual minorities, says Kenneth Mayer, MD, director of medical research and co-chair of the Fenway Institute and professor of medicine at Harvard Medical School. “I think things are improving a lot, but we still have a long way to go.”
Being more inclusive starts with doctors understanding that LGBTQ people may have unique health care needs because of their gender orientation and gender identity. “It’s important that providers approach patients in an open way, in a way that shows their interest and acceptance,” says Mayer.
Impacts of discrimination on health
Reduced access to high-quality health care has real and measurable effects on the health of LGBTQ people. Lesbian and bisexual women are more likely to be overweight, obese and suffer the consequences, including diabetes, heart disease and arthritis. They are also less likely to have the mammograms they need to find early breast cancer.
Gay men are at greater risk of contracting HIV and other STDs, especially gay men of color. Transgender people are more prone to HIV, mental health problems, violence and suicide than cis people.
Tobacco, alcohol and drug use are also big problems in this community. “Part of the reason is the sheer amount of depression, violence, lack of access to mental health care and homelessness. People then resort to alcohol and drugs, ”says Nisly.
COVID-19 has only deepened the divide. About 75% of LGBT people say the pandemic has had a negative impact on their mental health, compared to 49% of those who are not LGBT.
One positive outcome of the pandemic has been an increase in telemedicine. It could help people who don’t have an affirming provider access LGBTQ-friendly care, says Neira.
Change the system
Nisly believes the burden should be on the health care system to improve equality. Just as hospitals are evaluated based on infections and surgical outcomes, they should be evaluated based on their inclusiveness, she says. “I would go back to regulatory institutions and accrediting bodies to say that this is a minimum requirement to be considered a good hospital.”
The training of medical providers is also important. At Nisly Hospital, everyone, from doctors to receptionists, is trained to respect everyone who walks through the door.
“Preferred pronouns and names are the laws of the land,” she says. Medical records include the pronoun “they”. Rather than mentioning “husband and wife”, the forms refer to “partner A and partner B.” And everyone is placed in a room that matches their gender identity.
At the Fenway Institute, medical forms specifically ask patients about their sexual orientation and gender identity. “Providers have an idea from the start of the specific issues to think about,” says Mayer.
Being more inclusive and welcoming has had a positive impact on the Nisly clinic. “Now they know this is my clinic,” she said. “There is a relationship and a trust, and they feel like they belong.”
Find the treatments that are right for you
Until the medical industry changes, there are steps you can take to make sure you get the care you need and deserve. The first is to search the Gay and Lesbian Medical Association’s trusted supplier directory for a doctor.
Defending yourself is also important. “Not only do you wait, but demand to be treated with dignity and respect, and that your health care needs be met,” says Neira. “You have to speak up. As Harvey Milk said,“ Rights are won by those who make their voices heard. “”
“We want to make sure that we give people the opportunity to live their healthiest lives,” she adds. “No one should ever be denied the opportunity to access medically necessary care simply because of someone else’s harm.”
Our sincere thanks to