Based on an article by Novid Parsi from the AMT Pulse, Summer 2022.
More Americans identify as lesbian, gay, bisexual, transgender or queer/questioning (LGBTQ+) than ever. (The plus refers to other orientations and identities not specifically mentioned by the acronym, such as asexual.) The proportion of U.S. adults who identify as something other than heterosexual has reached roughly 7% to 8%—at least double the amount from when Gallup first tracked figures in 2012. That number is even higher among younger people; more than 1 in 5 Generation Z Americans identify as LGBT.
But the increasing visibility of the LGBTQ+ population belies a stark reality: Too often, they do not receive adequate healthcare. “LGBTQ+ people have an access-to-care problem,” says Jessica Halem, an LGBTQ+ healthcare consultant based near Boston.
Over one-third of LGBTQ+ people say they have had negative experiences with healthcare providers, compared to about one-fifth of straight people, according to a 2021 Kaiser Family Foundation (KFF) study. When getting medical care, higher rates of lesbian women (44%), bisexual women (45%) and gay men (32%) report experiencing unfair treatment than straight women (32%) and straight men (23%), a 2022 UCLA study found. Additionally, 15% of LGBTQ+ Americans, including nearly 3 in 10 transgender individuals, report postponing or avoiding medical treatment due to discrimination, according to a 2020 Center for American Progress study.
A federal civil rights law to prohibit healthcare discrimination based on sex didn’t exist until recently: Section 1557 of the Affordable Care Act, which provides protections for gender identity and sexual orientation in healthcare, went into effect in 2016. Because LGBTQ+ people’s experiences with healthcare often have involved fear, discrimination and harassment, many tend to avoid the healthcare system, which leads to more serious health issues. That includes higher rates of serious physical and mental health conditions—despite the fact that this population tends to be younger.
“LGBTQ+ people experience a variety of health inequities related to societal stigma and discrimination that can lead to decreased engagement in primary care and to mental health and physical health problems,” says Alex Keuroghlian, MD, MPH, director of the Psychiatry Gender Identity Program at Massachusetts General Hospital in Boston.
Competency Hearings
To provide the healthcare that LGBTQ+ individuals need and deserve, healthcare workers—including allied health professionals—need to deliver culturally competent care that meets patients’ cultural, social and linguistic needs. “It’s not just about being nice, though that’s an important first step,” Halem says.
For LGBTQ+ people, culturally competent care involves acknowledging their sexual orientation and gender identity, as well as their histories with healthcare. “The bedrock of culturally competent care is understanding the history of stigma and shame that LGBTQ+ people as individuals and as a community have faced around their bodies, sexual relationships and gender identities,” Halem says.
From the start, healthcare workers should ask all patients their chosen names and preferred pronouns, regardless of what the patient’s chart or ID says. “We should respect people’s preferred pronouns; that’s huge for patients coming into healthcare facilities,” says Ken J.A. Griffin, senior director of Provider Network Performance and Communications at Centene in Burr Ridge, Illinois.
When healthcare workers ask about patients’ sexual and social histories, they should resist making kneejerk assumptions about the patients’ gender or anatomy. Rather than assuming the patient is straight, monogamous and has only one partner at a time, healthcare workers should ask open-ended questions. The scripts that healthcare workers use, and the assumptions they make, can have life-or-death consequences.
“Even asking about sexual orientation, gender identity and sexual partners in a welcoming and inclusive way can signal to patients that they’re in a safe environment, that the provider values them as people and won’t discriminate against them,” says Lindsey Dawson, associate director of HIV Policy and Director of LGBTQ Health Policy at KFF in Washington, D.C.
Technology can also play a helpful role in culturally competent care. Healthcare providers need to train staff in using electronic health records to collect sexual orientation and gender identity information for all patients—and to harness that information for clinical support. For instance, a healthcare provider can track a patient’s body modifications and retained organs for preventative cancer screenings instead of basing such medical decisions “in a cruder way on the binary sex on a person’s ID,” says Keuroghlian, whose organization offers free resources on culturally competent care at lgbtqiahealtheducation.org.
Many transgender individuals report encounters with doctors who tell them, in effect, “I was not trained in this. I have to refer you out,” Halem notes. “But this is just a human being with the same anatomy you learned in school.” The health professional can instead say, “I haven’t provided this kind of transgender healthcare before, but I want to be your provider—can you be patient with me as I learn?” At the same time, healthcare workers shouldn’t place the educational burden entirely on their patients, either. Too many LGBTQ+ patients find they have to teach their own healthcare providers, Halem says.
There’s also a fairly simple way to get educated on culturally competent care for this patient population: Bring in a health expert from the LGBTQ+ community. “Have someone from the community come in and provide education. That’s imperative,” Griffin says.
A healthcare organization also has to communicate to LGBTQ+ people that it provides the care they need. Communication should be clear and consistent— and involve more than just recognizing Pride Month. “Let the LGBTQ+ community know: We see you, we appreciate you, we understand you, please get your care here,” Halem says.
A Welcoming Workplace
LGBTQ+ workers have also faced discrimination—and, until 2020, more than half of U.S. states didn’t have anti-discrimination laws for this population. Ultimately, providing better care for LGBTQ+ patients begins with establishing more welcoming and inclusive spaces for LGBTQ+ workers.
Healthcare organizations can help combat discrimination, to the benefit of both their staff and their patients, by creating nondiscrimination policies that explicitly include sexual orientation, gender identity and sex development, Keuroghlian says. “Don’t just have these on the books, but prominently post and enforce them.”
Organizations also need to consider LGBTQ+ concerns when they hire and onboard new employees. “It’s important to think about recruiting staff who are representative of the LGBTQ+ communities we serve,” Keuroghlian says. A more purposeful hiring process can help ensure that employees engage respectfully with others. The onboarding process should train everyone in inclusive behavior. Keuroghlian also recommends providing equitable healthcare benefits that include, for instance, gender-affirming medical care.
When he first joined Centene in 2021, Griffin was impressed with an onboarding process that included a half-day session on the organization’s diversity, equity, and inclusion (DEI) initiatives and employee resource groups for LGBTQ+ and other populations. Having that kind of welcome made a difference, he says. “Inclusivity is something you feel or don’t feel.”
In addition to sexual orientation and gender presentations, an inclusive employer can encourage other markers of acceptance. Workers can wear rainbow buttons or sport dyed hair, piercings and tattoos, so they don’t feel they have to engage in code-switching, the act of presenting different images of oneself to suit other groups. This type of policy not only makes the individual workers feel more accepted, but it signals to everyone that the organization recognizes and values the LGBTQ+ community.
Plus, greater psychological safety can lead to greater productivity, Halem says. “Workers are only able to fully participate when they can fully bring themselves to work.”