Although people who are lesbian, gay, bisexual, transgender or queer or questioning (LGBTQ) have made progress in gaining rights and acceptance, the battle for equality is far from over. This community still faces discrimination and inequality, especially when it comes to health care.
“Not only do they have barriers to access and use of care, but when they receive care they can be of lower quality and get worse results,” says Dr. Nicole Nisly, professor of internal medicine, assistant director 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 Nisly has seen that in her own practice. “You see a young person coming to live with their family and there is a great risk that they will be kicked out of their home and lose their entire support system,” she says.
With the loss of home and support, there is more stress and less access to health care. The results can be profound.
LGBTQ adolescents are at higher risk of depression, post-traumatic stress disorder (PTSD), substance use, physical or sexual abuse, and sexually transmitted diseases (STDs). Cisgender heterosexual teenagers are almost three times more likely to think of suicide and almost five times more likely to react to these thoughts.
What are the barriers?
In the past, people who identified as LGBTQ were routinely denied health insurance. Being transgender was seen as a pre-existing condition health insurers used as an excuse to deny coverage, says Paula M. Neira, JD, nurse and clinical program director at the Johns Hopkins Center for Transgender Health.
“When I went to law school, I was personally denied health insurance and ended up having to get a contingency plan with an incredibly high deductible,” she says.
The Affordable Care Act, which went into effect in 2010, prevented insurance companies from denying insurance coverage to transgender people. Housing and employment problems, as well as social stigma and discrimination, often make it difficult for people who identify as LGBTQ to have equal access to health care.
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As a result, they are more likely to delay care or not seek it at all. “Because of a well-documented history of discrimination in healthcare, people don’t trust their doctors,” says Neira.
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Just going to a doctor’s office can be an obstacle for someone who is transgender. “Let’s say you go to your doctor and the only toilets available to you are either men or women,” says Nisly. “That feels incredibly difficult for a person who identifies as transgender.”
And if you’re a trans man needing evaluation for ovarian or uterine cancer, you may be stopped by a phone planner confused about what he thinks is a disconnect between your voice and a need for gynecological care.
Once you get to the doctor’s office, the reception desk may be less welcoming. You may be denied care, given substandard care, or given a talk about your gender or sexual identity. “In the end, you teach your provider how to take care of you,” says Neira.
Almost 40% of transgender respondents said they had been harassed or discriminated against while attempting to access health care.
A big part of the problem is that doctors and other health professionals are not well trained in caring for people with LGBTQ. That is starting to change as medical schools introduce programs to treat sexual minorities, says Dr. Kenneth Mayer, director of medical research and co-chair of the Fenway Institute and professor of medicine at Harvard Medical School. “I think things will get a lot better, but we still have a long way to go.”
To be more inclusive, doctors need to understand that LGBTQ people may have special health needs because of their sexual orientation and identity. “It is important that providers deal openly with patients, show interest and show acceptance,” says Mayer.
Effects of Discrimination on Health
Limited access to 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 faced with the consequences – including diabetes, heart disease, and arthritis. They are also less likely to get the mammograms they need to find breast cancer early.
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Gay men are at greater risk for HIV and other sexually transmitted diseases, especially gay men with the color of skin. Transgender people are at higher risk of HIV, mental health problems, violence and suicide than CIS people.
Tobacco, alcohol and drug use are also big issues in this community. “Part of the reason for this is the huge amount of depression, violence, lack of access to psychiatric care and homelessness. People then resort to alcohol and drugs,” says Nisly.
COVID-19 has only widened the gap. 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 was an increase in telemedicine. That could help people who don’t have a verifying provider access to LGBTQ-friendly care, says Neira.
Change system
Nisly believes that the health system should be strained to improve equality. Just as hospitals are classified according to infection and surgical outcomes, so should they be classified according to inclusivity, she says. “I would leave it to regulators and accreditation bodies to say that this is a minimum requirement to be considered a good hospital.”
Training medical providers is also important. At Nisly’s Hospital, everyone from the doctors to the front desk people are trained to respect everyone who walks through the door.
“Pronouns and preferred names are the law of the country,” she says. Medical records contain the pronoun “she”. Instead of mentioning “husband and wife”, forms refer to “partner A and partner B”. And everyone is put in a room that matches their gender identity.
At the Fenway Institute, patients are specifically asked about their sexual orientation and gender identity using medical forms. “Right from the start, the providers have a sense of which specific topics they need to think about,” says Mayer.
Being more inclusive and welcoming has had a positive impact at Nisly’s clinic. “Now you know this is my clinic,” she says. “There is a relationship and there is a trust and you feel a part of it.”
Find care that suits you
Until the medical industry changes, there are things you can do to make sure you are getting the care you need and deserve. One option is to search for a doctor through the Gay and Lesbian Medical Association’s Directory of Trusted Providers.
Standing up for yourself is also important. “Don’t just expect, but demand to be treated with dignity and respect and to meet your health needs,” says Neira. “You have to get in touch. As Harvey Milk said, ‘Rights are won by those who make their voices heard.'”
“We want to make sure we give people the opportunity to live their healthiest lives,” she adds. “Nobody should ever be denied access to medically necessary care just because someone else is prejudiced.”
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