Duke Medical Ethics Journal
The Current State of Modern Healthcare Regarding Sexual Gender Minority Patients
Where we are and where we need to be
Regardless of our skin color, sexuality, economic position, or our culture,
we all deserve an equal opportunity to maintain our health. But in the
past, the sexual gender minority (SGM) population (consisting of the
LGBTQI+, intersex, and other individuals identifying as gender
minorities) has been consistently deprived of such rights, with the
heteronormativity of the healthcare system being a consistent
perpetrator. Although strides have been made since the HIV/AIDS
campaigns of the 80s, major health inequities potentially exacerbated
by our medical systems have yet to be addressed. Modern healthcare
providers have been proven to not understand SGM individuals, and the
implications can be detrimental: SGM patients have reduced access to
healthcare and have greater burdens for a myriad of diseases compared
to cis-gender heterosexual individuals. These diseases are not necessarily
sexual, with substance abuse, mental health concerns, and certain cancers seen disproportionately affecting the SGM population. When addressing health inequities, an equality-based approach to treating patients can still be detrimental to the mental and physical health of minorities like the SGM population, regardless of the intentions of the provider. Unfortunately, this “one size fits all” perspective on treatment has been widely accepted across healthcare systems, sustaining the heteronormative nature of medicine that continues to perpetuate the health disparities of the SGM population.
"Being forced down a heteronormative pipe in the healthcare machine is something SGM individuals must experience every time they seek care."
II. The Implications of Heteronormative Healthcare Systems on SGM Health
As a pre-med student, the largest pill to swallow about my future career is being integrated into a machine that is the modern healthcare system. The interpersonal aspects of medicine have been significantly reduced since the early 20th century when home doctor visits were the norm. Nowadays, patients are funneled through predetermined routes, and their personal information is reduced to files for the sake of efficiency . It is no surprise, then, that this indifferent system caters to the majority: the “ideal patient” is better able to traverse efficiently through the system, benefiting the provider by saving time and money.
Minority populations are thus overlooked as the system was not designed to take their unique circumstances into account: in a recent article published by the New York Times, physicians have been reluctant in accepting patients with disabilities due to time-related concerns . The same can be applied to the SGM population, with the harmful “one size fits all” perspective on care persisting throughout healthcare workers. One study even suggests that 6 in 10 social care practitioners with direct responsibilities in patient care (such as nurses) agree that sexual and gender identities are not significant in the care of the patient . However, the experiences of SGM patients suggest otherwise: lesbian couples reported feelings of “invisibility, uncertainty, and awkwardness” as their providers ignored their orientations . Some workers do adjust their care for their SGM patients but only do so when regarding sexual health . Reducing SGM patients’ needs to just HIV/AIDS concerns is highly demoralizing and again does not address the majority of health inequalities they may experience.
Being forced down a heteronormative pipe in the healthcare machine is something SGM individuals must experience every time they seek care. The sentiments above may not necessarily have bad intentions: a physician can theoretically give the same care to all patients for the sake of efficiency. Yet, negative intentions are still present in our systems, as instances of microaggressions to queerphobia have been reported by as much as 50% of trans patients while receiving medical care . But perhaps the more startling fact is that healthcare workers witness discriminatory remarks against SGM patients made by their colleagues, yet up to 20% of healthcare workers are not confident in challenging such remarks in the workplace .
In addition to patients feeling discomfort, medical workers are also uncomfortable addressing SGM patients. A survey of nurses revealed that a significant proportion felt uncomfortable treating SGM health concerns, with one responder explaining “…I don’t know if I am necessarily prepared or what issues are necessarily important to them because I haven’t been trained in that” . Physicians are also reported to feel discomfort when treating SGM patients, greatly affecting their abilities to administer the right methods for care . The patient-provider relationship is already strained through the interpersonal healthcare system and adding this additional layer of discomfort does nothing to address the health inequalities experienced by the SGM population.
SGM individuals already suffer from structural injustices that prevent access to healthcare, mainly affecting the financial capacity to afford an appointment. However, the culture of our medical systems mentioned above adds yet another hurdle for SGM patients, with a significant proportion postponing or avoiding care due to the fear of discrimination . Although it is difficult to determine if the avoidance of care is a cause or effect of SGM health inequalities, the fact that millions of Americans are willing to avoid their right to care due to discrimination should not be overlooked.
III. Addressing SGM Health Inequalities Through Education
How can we combat this heteronormative healthcare culture? If SGM patients are teaching healthcare workers about their needs, SGM-specific education in medical and nursing schools seems like the logical choice. But how effective is education in increasing the comfort of healthcare providers? Turns out, they are very effective. Pilot studies of SGM health-related courses have seen increases in the comfortability of their students in treating SGM patients, along with understanding their identities [11, 12]. Even single learning experiences, lasting just a couple of hours, have significant improvements in knowledge of SGM health issues and patients .
Many institutions have taken notice of the significance of SGM-specific health courses. Recently, medical schools have been incorporating SGM health-related courses into their curriculums, averaging around 5 hours of material . To little surprise, improvements were still seen in the participants, with the majority of programs increasing the confidence of the students in providing effective healthcare to SGM patients. The same results are seen in nursing schools, with the Johns Hopkins School of Nursing successfully formulating course formats with positive results from participants. Some courses go a step further than just addressing SGM-specific health concerns: the University of Louisville School of Medicine implements communication skills, social determinants of health, gender-affirming care, and other specific/interdisciplinary components into their 50.5-hour curriculum .
Compared to just 10 years before, there have been major improvements in addressing SGM health material in our educational institutions. However, many schools offer these courses as optional electives, rather than required material [16, 17]. Students today can still successfully graduate and practice medicine without a single hour of SGM health education. To prevent this, educational institutions should require SGM health-related courses to ensure that their students are confident in treating SGM patients. Additionally, attempts to incorporate SGM health-specific materials in continued education are not as prevalent as the attempts in pre-professional education. To improve the comfort of our current physicians and SGM patients, efforts must be made to include SGM-specific health materials in continued education materials.
SGM patients already experience massive hurdles to obtaining healthcare. The modern healthcare system is no help in alleviating these hurdles and instead subjugates SGM patients to the same care as cis-gender heterosexual patients. As the opinions of SGM patients reveal, this can exacerbate the discomfort felt during their visits to such a degree that they may postpone receiving care. Every day, SGM patients brave the discomfort caused by the heteronormative culture of healthcare providers, with patients having to experience forms of queerphobia for their right to good health. Healthcare workers too are not comfortable treating SGM individuals, due to their lack of training and knowledge to treat SGM health concerns. This dual discomfort has always been present but has not been explicitly addressed through education until recently. However, many institutions mark SGM-specific courses as optional, allowing students to still graduate without any knowledge of how to treat SGM patients. For the sake of addressing health inequalities of the SGM population, more universal and comprehensive educational efforts should be implemented into pre-professional and continued education, so that providers can supply comfortable environments of care that the majority of the population has experienced for hundreds of years.
Review Editor: Devin Mulcrone
Design Editor: AJ Kochuba*, Amber Smith**
 Cassell, E. J., & Siegler, M. (1985). Changing values in medicine. University Publications of America, Inc.
 Kolata, G. (2022, October 19). These doctors admit they don't want patients with disabilities. The New York Times. Retrieved November 28, 2022, from https://www.nytimes.com/2022/10/19/health/doctors-patients-disabilities.html
 Somerville, C. (2015). Unhealthy attitudes: the treatment of LGBT people within health and social care services. Stonewall.
 Spidsberg, B. D. (2007). Vulnerable and strong – lesbian women encountering maternity care. Journal of Advanced Nursing, 60(5), 478–486. https://doi.org/10.1111/j.1365-2648.2007.04439.x
 Beagan, B., Fredricks, E., & Goldburg, L. (2012). Nurse’s work with LGBT patients: “They’re just like everybody else, so what’s the difference. Can J Nurs. Rev, (44), 44.
 Mcneil, Jay & Bailey, Louis & Ellis, Sonja & Morton, James & Regan, Maeve. (2012). Trans Mental Health Study. Scottish Transgender Alliance, Edinburgh
 Somerville, C. (2015). Unhealthy attitudes: the treatment of LGBT people within health and social care services. Stonewall.
 Carabez, R., Pellegrini, M., Mankovitz, A., Eliason, M., Ciano, M., & Scott, M. (2015). “Never in all my years…”: Nurses' education about LGBT Health. Journal of Professional Nursing, 31(4), 323–329. https://doi.org/10.1016/j.profnurs.2015.01.003
 Sabin, J. A., Riskind, R. G., & Nosek, B. A. (2015). Health Care Providers’ implicit and explicit attitudes toward lesbian women and Gay Men. American Journal of Public Health, 105(9), 1831–1841. https://doi.org/10.2105/ajph.2015.302631
 Grant, J. M., Mottet, L. A., Tanis, J., Harrison, L., Herman, J., & Keisling, M. (2011). National transgender discrimination survey report on health and health care. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force.
 Holthouser, A., Sawning, S., Leslie, K. F., Faye Jones, V., Steinbock, S., Noonan, E. J., Martin, L. J., Weingartner, L. A., Potter, J., Davis, J., Eckstrand, K. L., & Ann Shaw, M. (2017). Equality: A process model to develop an integrated, comprehensive medical education curriculum for LGBT, gender nonconforming, and DSD Health. Medical Science Educator, 27(2), 371–383. https://doi.org/10.1007/s40670-017-0393-5
 Sherman, A. D. F., McDowell, A., Clark, K. D., Balthazar, M., Klepper, M., & Bower, K. (2021). Transgender and gender diverse health education for future nurses: Students' knowledge and attitudes. Nurse Education Today, 97, 104690. https://doi.org/10.1016/j.nedt.2020.104690
 Vanderleest, J. G., & Galper, C. Q. (2009). Improving the health of transgender people: Transgender Medical Education in Arizona. Journal of the Association of Nurses in AIDS Care, 20(5), 411–416. https://doi.org/10.1016/j.jana.2009.07.003
 Obedin-Maliver, J., Goldsmith, E. S., Stewart, L., White, W., Tran, E., Brenman, S., Wells, M., Fetterman, D. M., Garcia, G., & Lunn, M. R. (2011). Lesbian, gay, bisexual, and transgender–related content in undergraduate medical education. JAMA, 306(9). https://doi.org/10.1001/jama.2011.1255
 O’Leary, K. B., & Kunkel, G. H. (2021). Restructuring LGBTQ curriculum in medical schools. Academic Psychiatry, 45(4), 487–490. https://doi.org/10.1007/s40596-021-01414-1
 NYU's nursing school creates LGBTQ+ Health Course. NYU's nursing school creates LGBTQ+ health course | NYU Rory Meyers College of Nursing. (2022, June 2). Retrieved November 28, 2022, from https://nursing.nyu.edu/news/nyus-nursing-school-creates-lgbtq-health-course
 Kowarski, I. (2022, November 8). LGBTQ health issues: How to choose a medical school at the forefront. Retrieved November 28, 2022, from https://www.usnews.com/education/best-graduate-schools/top-medical-schools/articles/lgbtq-health-issues-how-to-choose-a-medical-school-at-the-forefront