The US healthcare system isn’t doing enough for vulnerable LGBT communities

Julio Yoaris Alvarez’s transition surgery, like all other healthcare in Cuba, will be free.
Julio Yoaris Alvarez’s transition surgery, like all other healthcare in Cuba, will be free.
Image: Reuters/Claudia Daut
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It’s hard to believe that, not that long ago, treating lesbian, gay, bisexual and transgender (LGBT) patients was seldom discussed among US healthcare providers. Twenty years ago, when I was studying to become a nurse practitioner, I remember doing both online and library journal searches about lesbian and gay healthcare; I was disappointed to find only a handful of articles and research studies out there that addressed our health issues.

Of the few articles that were around, most focused on homophobia among healthcare professionals; lesbian and gay patients’ negative experiences; and the high rates of youth suicide. There was virtually nothing about transgender health.

This reality was summed up well by my own experiences in the early 1980s. As a young lesbian patient, I went to a new doctor for a physical. She asked the usual question, “Are you sexually active?” When I answered “Yes,” she followed automatically with “What are you using for birth control?”

“Nothing,” I said. “I don’t need birth control. I’m a lesbian.”

Her response made me very uncomfortable. She gasped very audibly and said, “Well, I don’t see why that’s any of my business.”

Of course, I wasn’t a healthcare provider yet, in fact a medical career wasn’t even on my radar. Thirty years later, after 18 years of providing primary care, I can’t imagine making a patient feel uncomfortable or embarrassed for revealing anything personal about his or her life—and yes, your sexuality is my business if you choose to share it with me.

Sadly, for decades, denial of services, hostile responses and downright rude comments were fairly common among many LGBT people who sought medical care. There are many places where LGBT patients, particularly transgender patients, are still treated poorly. This is unacceptable, and the law and ethics back this up, even though human nature can lag behind. In places where we have gained respect and acceptance, it’s now time to educate healthcare providers and those of us who have been disenfranchised from the healthcare system about our healthcare needs.

Few outside of LGBT communities are aware of the various health disparities that exist within them. For example, there continues to be very high suicide rates for LGBT people, particularly LGBT youth. Studies also indicate that nearly two-thirds of transgender individuals have attempted suicide at some point.

Meanwhile, lesbians are theorized to be at higher risk for breast cancer, possibly due to their higher rates of smoking and obesity, lower likelihood of having children, and lower likelihood of accessing preventive healthcare. Lesbians are also the only demographic group with an increased rate of smoking as they get older. And lesbian women, like all females, need to be routinely screened for HPV and cervical cancer, but there are still many patients, as well as providers, who do not realize that lesbians are at risk. Some gay men also have a higher risk of HPV and anal cancer.

In the case of transgender patients, many have very specific needs that require the care of knowledgeable primary care providers or specialists, such as endocrinologists, for proper hormone treatment. Yet due to a variety of reasons—past negative encounters with healthcare providers, fear of being treated poorly, a lack of sympathetic practitioners, lack of health insurance that will cover their needed services—many transgender patients are not comfortable seeking care from the proper channels.

Instead, some transgender people resort to treating themselves with hormones they acquire on the street or via the internet. I’ve known both patients and friends who have gone this route, either because they couldn’t afford to go to healthcare providers or were afraid to. Without access to medical care, they were unable to access the lab work and other monitoring services recommended for safe hormone use.

Educating providers about LGBT health issues and the various sensitivities involved is a critical first step. We need safer healthcare environments where LGBT communities feel comfortable going to a healthcare provider. Medical history questions need to be tailored in such a way that they are inclusive of lifestyle changes and sensitive to transgender association (for example, preferred name/preferred pronoun).

The good news is that as LGBT patients become more visible and open, and as studies increasingly show the disparities in healthcare for this largely under-served population, there has been increased interest in this topic. On a national level, the groundbreaking Mar. 2011 Institute of Medicine report The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding highlighted many of the specific healthcare needs of LGBT patients.

The authors of that report call on the National Institutes of Health (NIH) to include sexual orientation and gender identity questions in federally funded studies. The Joint Commission, a nonprofit organization that accredits more than 20,000 healthcare organizations and is often a requirement for state licensure and reimbursements, now requires hospitals to include LGBT status in their non-discrimination policies.

For the first time, we have genuine buy-in for LGBT-targeted research and know substantially more about LGBT health than we did two decades ago. Hopefully, the NIH initiative will yield even more important data in the coming decades. With attention finally directed toward the topic and mandates to provide culturally competent care, healthcare organizations and schools will likely find themselves seeking qualified experts on LGBT health to take leadership roles—proving the importance of training and education at all levels as we continue to work towards equal, quality care for all Americans.