A need for structural change to improve the safety and well-being of LGBTQ people

In a previous post on LGBTQ care, Dr. Carlene MacMillan called attention to the importance of respecting patients’ pronouns. As she points out, discrepancies between patients’ chosen names/pronouns and gender markers on official documents can pose real challenges to providing patient-centered care. Even if health care providers know their patients’ self-determined identities, electronic health records and insurance claims can still betray them.

The issue of compassionate and competent care for LGBTQ patients — especially transgender patients — continues to be a relevant issue. According to a recent report from the New York Times, the Trump administration is considering a regressive definition of gender that would roll back federal recognition and protections of the estimated 1.4 million trans people in the U.S. The new definition of gender would be binary (male or female) and based on “immutable biological traits identifiable by or before birth.” This interpretation of gender is not only wrong but also inhumane. It would effectively deny the existence of many trans and non-binary people.

As a public health student and queer non-binary person, I recognize the need for structural change to improve the safety and well-being of LGBTQ people. This group is disproportionately burdened by poverty, social isolation, mental health problems, and substance abuse, among other health-related issues. Discriminatory policies and everyday acts of exclusion and violence against LGBTQ people, especially towards trans individuals, give rise to or exacerbate many health issues. In health care settings, bias, disrespect and providers’ lack of knowledge on LGBTQ issues prevent many trans and queer people from seeking care. From street harassment to the denial of gender-affirming health care, many LGBTQ people struggle for their right to live healthy and fulfilling lives.

To improve health care for queer and trans communities, we must take systemic action across institutions. One such action is harnessing the power of data, specifically on sexual orientation and gender identity (SOGI). To solve a problem, we must know the problem. SOGI data would give health care providers and policymakers better insight into the diverse attributes and needs of LGBTQ communities. Despite the “LGBTQ” umbrella term that is meant to unite people with marginalized sexualities and genders, subgroups have different health concerns and outcomes. These health issues and outcomes are further stratified by race, age, socioeconomic status, etc. LGBTQ health is not a monolith, and gathering data on LGBTQ individuals will illuminate important cross-group differences (and similarities). Furthermore, data could aid in the allocation of government resources to communities most impacted by health disparities.

However, SOGI data, by and large, are not collected in state or national surveys, making it challenging to count the number of LGBTQ Americans and assess their health needs. Several national health surveys have begun collecting SOGI data in the last decade. But the status of this data collection remains fraught as the Trump administration stalls plans to add SOGI questions to the 2020 Census. As David Stacy, government affairs director for Human Rights Campaign, said: “If you are not counted, you don’t count.” Without SOGI data, LGBTQ people face continued erasure of our social, political, economic and health needs.

Improving care for queer and trans people also means improving the medical education system. Medical institutions are not immune to the idealization of heterosexual and cisgender people in dominant culture. Thus, it is important to train future physicians and health care providers to be advocates for their LGBTQ patients, who already deal with stigma and discrimination outside of the clinic. However, little time is dedicated to LGBTQ health competencies in medical education. According to a survey of 132 medical schools in the United States and Canada, the median amount of time spent on LGBTQ-health related content totaled to only five hours. Of these schools, 83 schools taught half of the LGBTQ curriculum defined as essential. Only 11 schools covered the entirety of essential curriculum. To improve health care for LGBTQ patients, medical schools must commit to institutional transformation of what is taught and thus what are considered important clinical competencies.

Reforming medical education should be a priority in improving LGBTQ health care. In accordance with the humanist ethics of the medical profession, medical education should help students develop the knowledge and skills to work compassionately with and for their LGBTQ patients. Using guidelines and best practices from the Association of American Medical Colleges to implement curricular and institutional climate changes, medical schools can implement and/or strengthen their curricula with LGBTQ health-related topics (e.g., transgender care, trauma and resilience, disparities in mental health and legal and ethical issues affecting this community). It is also crucial for future health professionals to learn how to communicate sensitively and effectively with LGBTQ patients. This can be achieved through skills-based training and hearing from queer and trans community members themselves. It is essential that medical education bolsters students’ technical and interpersonal understandings of health across a range of sexual orientations and gender identities.

Last but not least, we cannot improve health care for LGBTQ patients without buy-in from health care organizations. The mission, vision and values of health clinics should reflect a commitment to social justice. From organizational behavior to leadership and governance, health care organizations must champion equity in all levels of their operations. Making organizational policy transparent is especially important if health care facilities wish to promote LGBTQ equity. The National LGBT Health Education Center recommends including the terms “sexual orientation,” “gender identity,” and “gender expression” in nondiscrimination and employment policies. Additionally, clinics can and should collect SOGI data if they do not already. This information allows providers to get to know their patients better and provide appropriate services. Intake forms and social history questions should reflect the diversity of LGBTQ people and their families. Health care organizations can also commit to improving LGBTQ health care through other avenues, such as the recruitment and retention of LGBTQ leadership, internal cultural/structural competency training and ensuring the physical environment is welcoming towards all people (e.g., gender-neutral bathrooms). In addition to data collection and medical education, organizational policy and management can provide important tools to improve health care for LGBTQ people.

Michelle Chen is a public health student. 

Image credit: Shutterstock.com

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