Though people who are lesbian, gay, bisexual, transgender, or queer or questioning (LGBTQ) have made progress in gaining rights and acceptance, the struggle for equality is far from over. This community still faces discrimination and inequality, especially when it comes to health care.
"They not only have barriers to accessing care and receiving care, but also, even when they are receiving care, they may receive a lower quality and have worse outcomes," says Nicole Nisly, MD, professor of internal medicine, associate department chair of diversity and inclusion, and co-director of the LGBTQ+ Clinic at University of Iowa Health Care.
The problem starts early in life, and it's something Nisly has seen in her own practice. "You see a young person coming out to their family, and there is a huge risk that they will get kicked out of their house and lose their entire support system," she says.
With the loss of home and support come more stress and less access to health care. The results can be profound.
LGBTQ youths are at greater risk for depression, posttraumatic stress disorder (PTSD), substance use, physical or sexual abuse, and sexually transmitted diseases (STDs). They’re nearly three times as likely to think about suicide, and almost five times as likely to act on those thoughts than are straight, cisgender (cis) youths.
What Are the Barriers?
In the past, people who identified as LGBTQ were routinely denied health insurance. Being transgender was considered a preexisting condition that health insurance companies used as an excuse to deny coverage, says Paula M. Neira, JD, a registered nurse and clinical program director of the Johns Hopkins Center for Transgender Health.
"I personally was refused health insurance when I went to law school, and I ended up having to get a catastrophic plan with an outrageously high deductible," she says.
The Affordable Care Act, which became law in 2010, has prevented insurance companies from denying coverage to transgender people. But housing and employment issues, along with social stigma and discrimination, often make it harder for people who identify as LGBTQ to get equal access to health care.
As a result, they’re more likely to delay getting care or to not seek it at all. "Because of a well-documented history of discrimination within health care, people don't trust their doctors," Neira says.
Just walking into a medical office can present obstacles for someone who’s transgender. "Let's say you go to your doctor, and the only restrooms available for you are either male or female," Nisly says. "That feels incredibly difficult for a person who identifies as transgender."
And if you're a trans man who needs screening for ovarian or uterine cancer, you might get stopped by a phone scheduler who’s puzzled by what they think is a disconnect between your voice and a need for gynecologic care.
Once you get into the doctor's office, you may find the reception less than welcoming. You could be refused care, given substandard care, or face a lecture about your gender or sexual identity. "You wind up teaching your provider how to take care of you," Neira says.
Nearly 40% of transgender people surveyed said they’ve faced harassment or discrimination when trying to access health care.
A big part of the problem is that doctors and other health professionals aren't well trained in how to care for people who are LGBTQ. That's starting to change, as medical schools introduce programs on treating sexual minorities, says Kenneth Mayer, MD, medical research director and co-chair of The Fenway Institute and professor of medicine at Harvard Medical School. "I think things are getting much better, but we still have a long way to go."
Being more inclusive starts with doctors understanding that LGBTQ people may have unique health care needs because of their sexual orientation and identity. "It's important that providers approach patients in a way that's open ended, in a way that shows interest and shows acceptance," Mayer says.
Impacts of Discrimination on Health
Reduced access to high-quality health care has real and measurable effects on the health of LGBTQ people. Lesbian and bisexual women are more likely to be overweight, have obesity, and to face the consequences -- including diabetes, heart disease, and arthritis. They’re also less likely to get the mammograms they need to find breast cancer early.
Gay men are at higher risk for HIV and other STDs, especially gay men of color. Transgender people are at greater risk for HIV, mental health issues, violence, and suicide than are cis people.
Tobacco, alcohol, and drug use are also big issues in this community. "Part of the reason is the huge amount of depression, violence, lack of access to mental health care, and homelessness. People then resort to using alcohol and drugs," Nisly says.
COVID-19 has only increased the divide. About 75% of LGBT people say the pandemic has had a negative impact on their mental health, compared to 49% of those who aren’t LGBT.
One positive result of the pandemic has been an increase in telemedicine. That could help people who don't have an affirming provider access LGBTQ-friendly care, Neira says.
Changing the System
Nisly believes the burden should be on the health care system to improve equality. Just as hospitals are graded on infections and surgical outcomes, they should be graded on inclusivity, she says. "I would turn it around on the regulatory institutions and accreditation bodies to say that is a minimum requirement to be considered a good hospital."
Training medical providers is also important. At Nisly's hospital, everyone from the doctors to the people at the front desk are trained to respect everyone who walks through the door.
"Pronouns and preferred names are the laws of the land," she says. Medical records include the pronoun "they." Rather than mentioning "husband and wife," forms refer to "partner A and partner B." And everyone is placed in a room that matches their gender identity.
At The Fenway Institute, medical forms specifically ask patients about their sexual orientation and gender identity. "Providers have a sense at the outset what specific issues they need to think about," Mayer says.
Being more inclusive and welcoming has had a positive impact at Nisly's clinic. "Now they know, 'that's my clinic,'" she says. "There is a relationship and a trust, and they feel like they belong."
Finding Care That Fits You
Until the medical industry changes, there are things you can do to ensure you get the care you need and deserve. One is to search for a doctor through the Gay and Lesbian Medical Association's directory of trusted providers.
Advocating for yourself is also important. "Not only expect, but demand to be treated with dignity and respect, and to have your health care needs met," Neira says. "You've got to speak up. As Harvey Milk said, 'Rights are won by those who make their voices heard.'"
"We want to make sure that we're giving people the opportunity to live their healthiest life," she adds. "No one should ever be denied the ability to access medically necessary care simply because of the prejudice of someone else."