Closing the LGBTQ+ Gap in Health Care

Access to health care has been a notoriously controversial topic in political and legal systems, and many inequities within health care are pervasive. In this instance, we are going to explore the relationship between healthcare and the LGBTQ+ community. There has been an extensive history of anti-LGBT discrimination within healthcare that continues to shape access to healthcare for members of this community as well as exacerbating disparities in health conditions. In fact, homosexuality was categorized as a disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1973 and transgender identity was recently changed to “gender dysphoria” in the latest edition from 2013. Even more recently, the Trump-Pence administration sought to make it easier for health care providers to discriminate against members of the LGBTQ+ community using religious exemptions, despite the Obama administration and several court rulings explicitly protecting against discrimination in health care based on gender identity and sex stereotypes [1]. Furthermore, for patients who are turned away by providers, it is difficult to find alternatives, especially given a shortage of medical providers in rural communities as well as in critical fields such as mental health care [1]. Members of the LGBTQ+ community may face legal discrimination in access to health insurance, housing, employment, marriage, and adoption, and there are a lack of laws protecting against bullying in school and fostering social programs for this community [3]. As a result, many LGBTQ+ individuals are unable to find medical services or forego care, and are more likely to face numerous health disparities, such as increased risk of depression and chronic conditions, as a result of discrimination [2].

One of the most dangerous results of discrimination against the LGTBQ+ community in health care is the delay or denial of necessary medical care, which may result in members of this community avoiding medical care as a whole. There have been instances of physicians refusing to provide HIV medications, misgendering transgender patients, or even turning away pediatric patients with same-sex parents, which are just some examples of the discrimination that this community faces [1]. Data from a 2017 survey found that 8% of LGBTQ+ respondents had a healthcare provider refuse to see them because of their sexual orientation and 7% had a provider who refused to recognize their family, including a child or a same-sex partner [1]. On the same survey, it was found that 29% of transgender respondents had a healthcare provider refuse to see them and 23% were intentionally misgendered or dead-named [1]. This type of discrimination deters individuals from this community. As a result, 1 in 4 transgender people and 8% of LGBQ patients avoided seeking essential health care due to fear of discrimination [1].

Furthermore, there are marked disparities in health within the LGBTQ+ community, such as high rates of psychiatric disorders, substance abuse, and suicide, with LGBTQ+ youth being 2 to 3 times more likely to attempt suicide [3][4]. LGBTQ+ youth are also more likely to be homeless, less likely to get preventative screenings for cancer, and are at higher risk of HIV and other STDs [3]. One of the major health concerns in the LGBTQ+ community is sexually transmitted infections. In particular, almost half of the incidences of all sexually transmitted infections in the United States affect MSM (men who have sex with men), despite the fact that MSM constitute 2% of the U.S. population [3]. It is also important to note the even larger disparities among black and other non-white members of the LGBTQ+ community who are at a larger risk for HIV/STDs and other health conditions. Ultimately, it is essential for healthcare providers to understand these disparities and become knowledgeable in the history of discrimination against the LGBTQ+ community that has led to such concerning disparities, so that these individuals can access the health care that they deserve.

Protections for the LGBTQ+ community are uneven despite the federal protections from the Obama administration, with 37 states in just July of 2018 not having an explicit ban against health insurance discrimination on the basis of sexual orientation or gender identity [2]. Much effort is still needed to ensure these protections and to eliminate medical disparities, including providing medical students with proper training to increase culturally competent care, implementing anti-bullying policies in schools, providing accessible social services to reduce suicide and homelessness among youth, and treating HIV and STIs with effective interventions [3]. Until all these needs are met, it is important to shed light on these disparities and talk about critical issues among the LGBTQ+ community so that one day every patient can get the help they need, no matter who they are or who they love.

References

[1] Shabab Ahmed Mirza and Caitlin Rooney. “Discrimination Prevents LGBTQ People From

Accessing Health Care.” Center for American Progress, 5 Mar. 2021, www.americanprogress.org/issues/lgbtq-rights/news/2018/01/18/445130/discrimination-prevents-lgbtq-people-accessing-health-care/.

[2]“US: LGBT People Face Healthcare Barriers.” Human Rights Watch, 28 Oct. 2020,

www.hrw.org/news/2018/07/23/us-lgbt-people-face-healthcare-barriers.

[3] “Lesbian, Gay, Bisexual, and Transgender Health.” Lesbian, Gay, Bisexual, and Transgender

Health | Healthy People 2020,

www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health.

[4] Ard, Kevin L, and Harvey J Makadon. “IMPROVING THE HEALTH CARE OF LESBIAN,

GAY, BISEXUAL AND TRANSGENDER PEOPLE: Understanding and Eliminating Health Disparities.” Improving the Health of LGBT People, The Fenway Institute, www.lgbtqiahealtheducation.org/wp-content/uploads/Improving-the-Health-of-LGBT-People.pdf.

Words Matter: The Impact of COVID-19 on Gender-Affirming Surgeries

“Due to the COVID-19 pandemic, we have been advised to cancel all elective procedures. Your surgery will be rescheduled when conditions allow.”

This is the kind of message that millions around the world have received over the past year as the pandemic has ravaged our health systems. After reading through a list of steps to take if they find themselves experiencing life-threatening symptoms of the virus, patients are once again reminded that their care is elective and has been deemed nonessential. Expansive resources have been dedicated to determining the effects of these cancellations, but one continuously overlooked group is the transgender and gender nonconforming (TGNC) community who have had their gender-affirming procedures indefinitely postponed or even cancelled.

Gender-affirming surgeries include a wide range of procedures that are designed to align an individual’s body with their gender identity. The American Medical Association (AMA) has classified gender-affirming services as medically necessary in an effort to reduce barriers to care for TGNC patients [1]. (That said, it is important to note that not all members of the community choose to undergo medical procedures.) Despite being deemed a necessity, these procedures are still classified as elective, which has left them vulnerable to blanketed cancellations throughout the pandemic.

An AMA panel comprised of LGBTQ health experts weighed in on the impacts that the COVID-19 pandemic has had on TGNC individuals. The cancellation of surgeries has led to major disruptions in people’s lives and has compounded upon the effects of social isolation, leaving this population especially vulnerable to adverse outcomes in both their physical and mental health [2]. To be clear, these issues weren’t brought on by the pandemic. They were simply exacerbated and illuminated by it. While this panel highlighted several systematic issues related to gaps in insurance coverage, it also forced me to consider a larger issue in our classification system as a whole: our language.

From a societal standpoint, the term “elective” is often equated with “cosmetic” and perceived as frivolous and unnecessary. In reality, most hospitals classify elective surgeries as those “that can be scheduled in advance” and can include anything from the removal of a mole to the treatment of a cancerous tumor [2]. This gap in understanding between the medical community and the general population is especially damaging to members of the TGNC community who may interpret the classification of their life-saving care as “elective” to mean that it is unimportant.

The classification system, as well as general cost and insurance coverage, are all long-standing barriers to gender-affirming care that we ought to work towards dismantling, but they are reinforced by policies and loopholes that will take time to overcome. That being said, our language and its perception in the general population are sizable ethical concerns, but ones that can be easily addressed. Even if we can’t immediately change the surgical classifications themselves or ensure that access to these life-affirming surgeries won’t be interrupted in the future, we at the very least have the responsibility to make sure that our language is clear and isn’t causing harm to those we are trying to help.

In these times of uncertainty when so much feels that it is out of our control, the one thing that can be certain is that our words matter.

References [1] American Medical Association. (2019). Talking Points: Health insurance coverage for gender affirming care of transgender patients. Retrieved February 21, 2021, from https://www.ama-assn.org/system/files/2019-03/transgender-coverage-talking-points.pdf [2] American Medical Association. (2020, June 15). How gender affirming surgeries have been impacted by the pandemic. Retrieved February 21, 2021, from https://www.ama-assn.org/delivering-care/population-care/how-gender-affirming-surgeries-have-been-impacted-pandemic [3] Johns Hopkins Medicine. (2021). Types of surgery. Retrieved February 21, 2021, from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/types-of-surgery

The Opioid Epidemic: a multi-faceted crisis

Drug overdose is a pressing issue in the United States, being one of the leading causes of death. In 2019, more than 70,000 Americans died from drug overdose, including illicit drugs and prescription opioids(1). Overdose of opioids has adversely affected the entire country, but certain demographic groups have been affected more than others. Data has revealed that overdose is rising rapidly for minority groups in particular. In 2017, non-Hispanic Blacks had the highest percentages of opioid-related overdose deaths and total drugs deaths attributed to synthetic opioids compared to other race and ethnicities (2). These disparities are intimately linked to psychosocial determinants of health including racism, poverty, limited access to treatments and services, and socioeconomic status. Furthermore, there exist ethical problems related to prescription practices, naloxone availability, and clinician regulations. Prescription of opioids by clinicians, while used to ease the suffering of patients, is a source of potentially dangerous and addictive drugs.

In order to tackle the opioid crisis on a public health level, greater attention to the ethics of opioid prescription and regulation is necessary. Furthermore, the social determinants underlying this issue must be thoroughly analyzed and assessed. Factors such as economic conditions and social conditions create problems of accessing drugs in a proper manner for many minority populations (2). This then results in drugs being administered in an unsafe environment, which increases the likelihood of a negative outcome. Drug behavior can be heavily influenced by the drug use context, such as the setting or location under which it is administered. The stigma surrounding opioid use and addiction can also increase negative health outcomes. Stigma often prevents people from seeking help, due to fear of the social and legal repercussions. In order to address this issue, the discourse surrounding this topic needs to change. Those with opioid addiction need to have access to a safe, judgement-free space to share their experiences and spread awareness. Furthermore, the language used to describe opioid users needs to incorporate more person-centered language and acknowledgement of addiction as a disease requiring medical intervention. In order for the opioid crisis to be improved on a population level, there needs to be a social shift towards spreading awareness and destigmatizing addiction—factors not necessarily directly related to disease condition itself.

References

1. National Institute on Drug Abuse. Overdose Death Rates. [internet].; 2021 Jan 29 [cited 2021 Feb 20]. Available from: https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates

2. Centers for Disease Control and Prevention (CDC). 2019 Annual surveillance report of drug-related risks and outcomes —United States. [internet]. Atlanta, GA: CDC National Center for Injury Prevention and Control; 2019 Nov 1 [cited 2021 Feb 20]. Available from: https://www.cdc.gov/drugoverdose/pdf/ pubs/2019-cdc-drug-surveillance-report.pdf