"Not Good Enough (Or Even Close)" : Healthcare Disparities and Differences Among the LGBTQ+ Community

In the discussion of sex-and-gender-based medicine (SGBM), we often turn a blind eye to the healthcare disparities and differences in the LGBTQ+ community. In an attempt to make SGBM more "digestible", it becomes easier to align with the heteronormativity that forms the basis of medicine instead of pursuing medicine that is considerate of differences among sexual and gender identity while ensuring the patient-physician relationship is supportive and high-quality, insured (under private healthcare industries like the US) healthcare is accessible. For this week's post, I wanted to shed some light on three important aspects: access to healthcare, healthcare outcomes, and potential solutions. 

The LGBTQ population is less likely to have health insurance or have their prescriptions filled, more likely to delay getting care, and more likely to be refused healthcare and be harassed by healthcare providers. They are also significantly more likely to report negative effects after disclosing their identity compared with cisgender, heterosexual patients in a 2016 study. In terms of relationships with physicians, the queer community experiences high rates of systemic discrimination. A survey by the Center of American Progress showed 8% of lesbian, gay, and bisexual participants and around 30% of transgender respondents had been denied care as a result of their identity while similar numbers of participants reported having had a healthcare provider use harsh or abusive language when they sought out care. Finally, in a survey of nearly 30,000 transgender individuals, 33% of respondents had experienced a negative interaction with a healthcare provider. The magnitude of these numbers should highlight a crucial point: access to care is far from equitable and among the LGBTQ+ community, especially trans individuals. Obviously, to avoid this discrimination and institutional bias, trans individuals are hesitant to seek out care in the first place. Coupled with the lack of physician education and training, clinical research, and overall minority status of this community, the discrepancies are incredibly apparent. 

Even across states, the anti-discrimination policy is varied with few states prohibiting health insurance discrimination, and medical services for trans individuals are rarely covered and sometimes explicitly excluded under medical coverage in some states. Under the Affordable Care Act, there was some progress made in regards to discrimination being prohibited in terms of access to healthcare. But, recently, there were many setbacks, and language about LGBTQ+ discrimination became vaguer and easier to contest if it was against a healthcare provider's "religious belief or moral conviction". Specific states including Illinois, Mississippi, and Tennessee have created legislation that goes against even the limited progress that was made under the Affordable Care Act. Even if members of the LGBTQ+ community try to get medical care, many physicians have no LGBTQ+ competency training with 52% of US medical schools having no form of this training. Many, especially in more rural areas, do not have access to LGBTQ-friendly providers or care that takes into account their specific healthcare needs which will be discussed in more depth later. Traveling tens of miles is not reasonable for many members of the community given the higher likelihood of poverty and financial instability that they face. The heteronormativity in our society permeates deeply and leads to the systemic lack of access to healthcare, let alone high-quality, individualized healthcare.

As we often discuss with one's biological sex, which is dependent on one's genes at birth, gender, a person's self-representation based on biopsychosocial factors, and sexual identity can affect one's healthcare outcomes and needs. Members of the LGBTQ+ community are at higher risk of mental health struggles including suicidal ideation, mood disorders, eating disorders, and anxiety, substance abuse, and eating disorders and/or body dysmorphia. Lesbian and bisexual women have higher rates of breast cancer, obesity, intimate partner violence, and gynecological cancers. Gay and bisexual men have high rates of intimate partner violence, body dysmorphia, and certain sexually transmitted infections. The trans community also encounters many of these issues. Therefore, we need to have healthcare professionals who are knowledgeable and experienced in establishing a trusting relationship with their LGBTQ+ patients as is done for their straight counterparts. An important distinction is that these differences in healthcare risks CAN NOT be weaponized as a means of discrimination as they have been done for countless years. Members of the LGBTQ+ community, like everyone else, need healthcare providers that are knowledgeable about their health concerns and can provide them with sufficient information about fertility options (if desired), preventative treatments like PrEP and tests like Pap smears and STI panels, options about gender re-affirming surgery and medications, and can provide reliable education about these concerns.

In terms of solutions, we need to have a wide-range. On the legislative side, the Human Rights Watch has made numerous suggestions to the United States Congress, Department of Justice, Department of Health and Human Services, and State Legislatures including laws that prevent discrimination, religious exemptions by medical professionals to provide care, and enacting the Equality Act. Now, in my opinion, I think change needs to be a lot deeper. Firstly, the language that is chosen for the legislation has to be incredibly thorough and clear to clearly protect those with any gender or sexual identity. Secondly, the education of medical professionals needs to include experiential and clinical knowledge on the healthcare differences among the LGBTQ+ community that were described above and more. Next, there needs to be a lot more research on the health of those that are not cis and heterosexual, more inclusion in clinical trials and in the basic research stages. Finally, given that poverty and discrimination in the workplace are significantly higher for these individuals, we need to have change that targets these deeper inequities and marginalization that help inform the medical ones. Because our current system is not good enough or even close - we NEED to do better. 

Thanks for reading, 

Janvi :)

Here are the sources I used: 

https://www.liebertpub.com/doi/full/10.1089/lgbt.2015.0124 

https://www.hrw.org/report/2018/07/23/you-dont-want-second-best/anti-lgbt-discrimination-us-health-care - This post was incredibly helpful and provided the basis for a lot of the data

https://www.hopkinsmedicine.org/health/wellness-and-prevention/transgender-health-what-you-need-to-know

https://www.cigna.com/individuals-families/health-wellness/lgbt-disparities