Despite recent victories for Lesbian, Gay, Bisexual, Transgender (LGBT) rights including more vocal public support and the landmark United States Supreme Court cases of 2013 and 2015, the LGBT population continues to face worse health outcomes compared to the general U.S. population. Many of these poor health outcomes are attributable to the health care disparities that sexual minorities and non-gender conforming individuals face. In 2011, the Institute of Medicine (IoM) released a major report on LGBT health that summarized the existing research in the field, identified knowledge gaps, and proposed future research agendas. In this report, the IoM outlined two major types of health care disparities. Personal-level barriers are created by the attitudes and beliefs of individuals, including both providers and patients. Meanwhile, structural barriers operate at an institutional-level and would exist regardless of the actions of specific individuals (Institute of Medicine (US) Committee on Lesbian, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011). Six years since the IoM report was published, the LGBT population continues to face both personal-level barriers such as stigma and structural barriers such as limited health insurance coverage and gaps in provider knowledge that hinder access to health care; solutions to mitigate these health care disparities could involve changes to increased sensitivity training for health care professionals and reforms to medical education.
Personal-level Barriers to Care
Historically, sexual minorities and non-gender conforming individuals have faced significant stigma and persecution. While these hostile attitudes have lessened over time, with 92% of Pew surveyed LGBT adults expressing that society has become more accepting over the last decade, discrimination continues to persist (Drake, 2013). The stigma that results can take many different forms but ultimately, negatively affects health care seeking behavior. Past studies have documented cases of explicit stigma from health care professionals in the form of verbal abuse, disrespectful behavior, and the refusal of treatment to LGBT individuals. Implicit stigma or the unconscious preference for heterosexual people from providers can also lead to poor health care experiences for LGBT patients. Lastly, the fear of stigma or desire to hide their sexual orientation may lead many LGBT individuals to avoid interacting with the health care system. (Institute of Medicine (US) Committee on Lesbian, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011) LGB patients are roughly twice as likely as heterosexual patients to delay seeking care or not seek care at all. {Krehely, 2009, #85879}
Structural Barriers to Care
In the United States, the majority of people are insured through employer-sponsored health insurance. Traditionally, same-sex partners of employees were ineligible or faced restrictions in accessing this type of insurance. Data from California revealed that partnered gay men and lesbians were more than twice as likely to be uninsured as married heterosexuals (Ponce, Cochran, Pizer, & Mays, 2010). Even as more companies have extended their benefits to same-sex partners of employees, previous federal law did not recognize same-sex marriages. As a result, any partner insurance benefits were subject to taxes that would not be applied to benefits that heterosexual spouses received (Dawson, Kates, & Rae, 2016).
Within the last four years, a few major policy changes have helped to lessen the disparities in accessing employer-sponsored health insurance. In 2013, United States v Windsor ruled that the Defense of Marriage Act, which had defined marriage as between a man and a woman, was unconstitutional. As a result, legally married same-sex couples could now receive tax-exempt health insurance benefits through their employer. However, it was not until Obergefell v Hodges in 2015, that the Supreme Court legalized same-sex marriage nationwide. This ruling replaced the patchwork of state regulations regarding the recognition of same-sex marriage. It is expected that these Supreme Court cases will help to improve access to health insurance; however, the rulings are not a mandate that companies must provide equal coverage. A 2016 study by the Kaiser Family Foundation found that less than half of firms that offer opposite-sex spousal coverage also offer same-sex spousal coverage. More encouragingly, 84% of workers have access to these benefits. This is explained by the fact that the vast majority of large firms offer these benefits, however, coverage decreases amongst smaller companies (Dawson, Kates, & Rae, 2016).
While it is expected that both Windsor and Hodges will level the playing field and increase the quantity of LGBT individuals with access to health care, the quality of the services covered remains in question, especially in regards to transgender health. In the past, transgender health services such as gender-confirming surgery or sex reassignment surgery (SRS) has been viewed as a cosmetic and unnecessary procedure and been explicitly barred from many public and private health plans. A growing body of research, however, supports the use of SRS and hormone therapy in improving health and well-being and alleviating gender dysphoria, which refers to the distress associated with the difference between an individual’s expressed or experienced gender and socially assigned gender. Many professional associations including the American Medical Association and the American Psychological Association have publicly endorsed the care for transgender patients and urged health insurance plans to cover treatment for gender dysphoria. In 2012, the US Department of Health and Human Services released a statement affirming the ban on discrimination due to gender identity and sexual orientation. Despite this public support, it remains to be seen if more health plans will cover services specific to transgender and LGB people (Stroumsa, 2014).
Expanding health insurance coverage is only one step in mitigating health care disparities; delivering culturally competent and relevant care remains another challenge. For example, in 2012, there were only six U.S. surgeons who performed genital reconstructive surgery (Stroumsa, 2014). In addition to specialized procedures being largely inaccessible due to a shortage of trained physicians, access to more routine care also suffers because of a lack of provider knowledge. In the past, medical schools taught little about sexuality and LGBT health. As a result of the HIV/AIDS epidemic, the delivery of this kind of health care largely occurred through specialized clinics and health centers that catered specifically to LGBT populations. In recent years, however, much of this care has moved into the mainstream and is being incorporated into the general health care system (Butler et al., 2016). Consequently, it is more important than ever for physicians to be trained in the unique health needs of the LGBT population and learn to deliver culturally competent care.
Currently, there have been several proposed solutions aimed in addressing the lack of physician knowledge regarding LGBT health. These include educating hospital staff on the history and experiences of LGBT communities and providing training on the unique risk factors and health disparities this population faces. Sensitivity training on the use of gender-neutral language and advising providers on how to collect sexual and social history without making assumptions about a person’s sexual orientation or gender identity may also improve provider-patient relationships, thereby encouraging more LGBT individuals to seek care (Butler et al., 2016). Perhaps the biggest impact can be made by reforming medical education. A 2015 study found that a third of medical schools have zero required hours of clinical instruction on LGBT health. Given this, it is of no surprise that a national survey of medical students found that 70% of students rated their schools’ LGBT-related curriculum as “fairâ€, “poorâ€, or “very poorâ€. Focus groups with medical students revealed that among LGBT health-related topics, students feel especially unprepared to treat transgender patients. There is a clear need for a standard curriculum related to LGBT health and increased clinical exposure to LGBT patients during medical training (White et al., 2015). By providing these experiences to young physicians early on, they can better enter the workforce and deliver quality and compassionate care to all patients regardless of sexual orientation or gender identity.
Given the long history of stigma and persecution of the LGBT community in the United States, there remains significant health care disparities amongst the population. Many of these disparities are the result of explicit and implicit stigma that both providers and patients may have. Other barriers include structural inequalities that limited access employer-sponsored health insurance and the lack of provider knowledge on how to treat LGBT patients. Targeted training and education could help current health care providers better meet the health needs of the LGBT population. Meanwhile, reforming medical education to include a standardized curriculum addressing LGBT health could help future generations of physicians care for this medically vulnerable sub-population.