A Road Map to a New Day for LGBT Health

The picture of LGBT health is far from complete, and without it, policy makers still cannot draft health care policies that account for the full range of challenges we face. But we at least now have the beginning of a roadmap.
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Lesbian, gay, bisexual, and transgender (LGBT) Americans are as diverse as America itself. We are woven throughout the very fabric of our society -- all ages, races and ethnicities, rich and poor, urban and rural. That may not be the image we see in the media much of the time, but we truly are the rainbow so often used as a symbol of our communities. The one thing, however, that does connect us is that we are rarely treated as equals by our society and by the law.

And in this regard, the health care system is no exception. What we see when we look at the treatment of LGBT populations in health care is similar to the broader picture for other minorities: vast disparities in the quality of care. Yet for far too long, the federal government has not substantively researched LGBT health care, as it has done for other minority populations including African-American and Hispanic communities. Most of what we know about LGBT health comes from non-government studies of lesser quality. This is because, with few exceptions, federal surveys have not included measures of sexual orientation and gender identity. And because sample numbers are small, LGBT people are often lumped together. Differences among groups cannot be detected, and other characteristics like race or ethnicity cannot be teased out.

What a difference a week -- and a supportive administration in Washington, DC -- can make. Last Friday, the Department of Health and Human Services issued a set of recommendations calling for a major, well-funded effort to include LGBT people in its research, and address the health care disparities that exist throughout our population. The day before, the Institute of Medicine (IOM) released a report, The Health of Lesbian, Gay, Bisexual, and Transgender People, that finally provides a comprehensive picture of the state of our community's health, and of the challenges we face in pursuing comprehensive treatment and medical care of every portion of the LGBT population. It is about time -- because on multiple levels, those disparities are too significant to ignore.

Just a few of the IOM report's findings: LGB youth are at increased risk for suicidal thoughts, attempted suicide, and depression, and early indications are that the same is true for transgender youths. Compared to heterosexuals, LGB elders may have higher rates of tobacco and alcohol use; research on tobacco and alcohol use among transgender elders is largely lacking. And compared to heterosexual women, lesbians and bisexual women have reported higher rates of breast cancer and obesity, a factor associated with cardiovascular disease.

And the paradigm has changed -- the medical and health care communities are now focusing on the roots of so much of the stress for LGBT populations -- homophobia, prejudice, discrimination and stigma. As we tackle those we will see better mental and physical health outcomes for our community and as a result be a healthier nation.

When we look at this full range of health issues, vast disparities become apparent in multiple areas. First of all, as the statistics above show, there are significant disparities between the LGBT population and the population as a whole, including access to care, suicidality, mental health, tobacco, use of alcohol and other drugs.

These inequalities can largely be attributed to the discrimination that many LGBT people constantly face. Even when we are not confronted with homophobic rhetoric or violence, many of us, due to widespread cultural stigma, are afraid to tell medical professionals about the most important details of our lives. And many of us do not have accepting family members on whom we can rely when facing medical crises. Any approach to LGBT health care would be remiss in not accounting for these structural disadvantages faced by LGBT people -- all of which are heightened depending on individual factors such as income, education, age, and more.

And that point leads to the reality of significant disparities amongst different LGBT subgroups. Lesbians, gay men, bisexuals, and transgender men and women suffer from different medical problems at different rates. LGBT people who are also members of other minorities already tend to face multiple forms of discrimination -- including structural income and employment inequities, which impede or prevent their access to insurance and proper health care. Among the report's findings: LGBT individuals face financial barriers, limitations on access to health insurance, and widespread ignorance and insensitivity on the part of medical providers. Lesbian and bisexual women are less likely to have regular checkups than heterosexual counterparts, reporting negative experiences of their own and what they have heard from others. Although very little research has been conducted on the quality of care experienced by sexual and gender minorities, limited data suggest that when transgender-specific services are accessible from knowledgeable providers, transgender patients report high satisfaction rates. A recent data fact sheet from the CDC reports that black gay men and other men who have sex with men (MSM) are at greater risk of HIV infection than Caucasian counterparts; among young MSM, young black MSM bear the greatest HIV/AIDS burden -- twice that of white or Hispanic counterparts.

As these figures indicate, while LGBT people are all adversely affected to one degree or another by the same structural problem -- discrimination - the differences within our own community are vast. There is no one-size-fits-all approach that can possibly work. Medical providers to the LGBT community, and medical researchers as well, must tailor their approaches to take into account age, gender, race, and economic status, rather than putting us all under a standardized "LGBT" umbrella. This is not a task that can be accomplished overnight. But it must be done.

That is why it is so crucial that the HHS has recognized both the size of the gaps in research, and the need to fill them. As its document notes, "LGBT people have been denied the compassionate services they deserve," and that in treating LGBT people, we must "recogniz[e] that diverse populations have distinctive needs." And they have outlined some smart steps toward achieving this goal: an overall increase in the number of federally funded health surveys that track sexual orientation and gender identity; a new effort from the CDC to ensure that questions about sexual orientation and gender identity are asked; and crucially, a goal of addressing LGBT health care disparities through the Healthy People 2020 initiative, driven by both existing data and the input of the LGBT community.

The significance of the HHS calling for these steps is enormous, as it has never before called for LGBT inclusion or conducted disparity research on anything resembling this scale -- or for the funding that such an effort requires. And as for the IOM report, no government-affiliated organization has ever produced a report that documents the state of LGBT health this comprehensively, and its release would have been unimaginable during any prior administration.

The picture of LGBT health is far from complete, and without it, policy makers still cannot draft health care policies that account for the full range of challenges we face. Yet taken together, these two documents constitute an excellent road map for the future of LGBT health. Our challenge is now to ensure that their recommendations are heeded -- so that all LGBT Americans can have a better, healthier future.

Judith Bradford, PhD is Director, Center for Population Research in LGBT Health and Co-Chair of The Fenway Institute. Bradford was on the advisory committee that created the IOM report.

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