After reading the article, the learner will be able to:
1. Identify causes of healthcare disparity in the LGBT population.
2. Name risks that are increased in LGBT groups.
3. Suggest changes to increase LGBT access to primary care.
Healthcare providers are trained to identify patient populations who experience health disparities and to educate patients about their individual risks. Health disparities are described as differences in health status that often result from some form of disadvantage. Reasons for the differences may be based on race, gender, immigrant status, disability or sexual orientation.
The World Health Organization defines risk factors as "any attribute, characteristic or exposure that increases the likelihood of developing a disease or injury."1 Some common health risks are tobacco use, alcohol abuse, obesity and physical inactivity. Providers also identify risk based on genetic or familial tendencies such as cardiovascular disease, hyperlipidemia and breast or colon cancer. Once identified, we educate patients about ways to modify behavior to decrease disease risk, and we monitor them to identify any change that may indicate a need for increased investigation. Improved health outcomes are a direct result of risk identification, behavior modification, and continued surveillance.
Importance of the History
Health disparities and unidentified risks exist for many reasons, including poverty, inadequate access to healthcare, environmental threats, and individual factors. One important potentially unrecognized weakness is obtaining the appropriate health history information in a nonjudgmental setting and manner. Each provider should act as a concerned practitioner, looking out for the well-being of each patient. Providers should ask open-ended questions, encourage patients to share important but potentially risky behaviors, and listen in a nonjudgmental manner.
A primary care provider may be aware that certain patients are lesbian or gay, or that certain heterosexual patients have high-risk sexual practices. It is important for a provider to talk openly and objectively with these patients about potential risk factors.
But the attention to parity should go beyond conversation to fixtures and practices. Health history forms may contain presumptive language about sexual partners. Staff members may exhibit a bias based on a patient's appearance or way of speaking. Can these factors lead to missing a potential diagnosis or unintentionally cause someone to refrain from sharing important information? Will this unease or discomfort prompt them to never return for care?
In 2010, Lambda Legal surveyed 4,916 lesbian, gay, bisexual and transgender (LGBT) patients about access to healthcare.2 More than half of respondents had experienced at least one form of discrimination in healthcare. These negative experiences included physical roughness; being addressed in harsh or abusive language; being refused care; and even providers refusing to come in direct contact with the patient.
A goal of Healthy People 2020 is to increase the health, safety and well-being of LGBT people.3 Yet sexual orientation and gender identity questions are not included on most health history forms.
The National LGBT Health Education Center has published suggestions for improving healthcare environments for LGBT patients.4 One suggestion is to post a nondiscrimination policy, signed by the staff, in plain view of patients. A nondiscrimination policy helps ensure an environment in which all people are valued and respected and provides an opportunity for staff members to examine their own beliefs and assumptions about race, age, sex, gender and marital relationships. Another suggestion is to provide an area where local LGBT resource information can be displayed. This area can include information on local counseling options, food pantries, support groups and general information on a specific practice location in addition to the LGBT-specific information.
According to the Gay and Lesbian Medical Association (GLMA), LGBT patients may assess an office to determine what information they should share with their provider.5 The utilization of an intake form that allows a patient to provide personal information in a nonjudgmental manner will set the tone for quality patient-provider interactions. The inclusion of domestic partnership under the "relationship status" of a history form, as well as options for transgender including Male-Female or Female-Male, may help patients feel more comfortable sharing this information. Additional suggestions are to provide more inclusive options for screening questions, open-ended questions, and use of the term "partner" rather than "spouse."
Making assumptions about expected behavior of others is a perilous undertaking. When a provider assumes that a particular person, group or community has a characteristic or action, he or she risks overlooking potential conditions. Asking the patient about his or her definition of behavior, sexual activities, language or terminology helps prevent misperceptions that endanger health. An example is people who do not consider themselves in terms of sexual orientation and have sex with both genders. Or someone may identify as heterosexual yet have sex with people of both genders. Assuming that a lesbian, or her female partner, has never had intercourse with a male partner or never been pregnant is another example of this way of thinking.
To obtain pertinent health-related information, it is important to obtain a complete sexual history during a nonjudgmental discussion and to assure confidentiality. If staff members will be obtaining this information, a privacy statement should be displayed in the office and/or provided to patients. This sexual history form should be used with all patients in the healthcare practice.
It is important to understand that some patients may have different sexual practices on business trips or vacations, or their sexual practices in general may have recently changed. Many forms in use today assume heterosexual and monogamous behavior. A change of the form to include gender rather than sex, and providing the options male, female, transgender or both, to questions about recent sexual partners, recognizes that alternative relational patterns exist. This provides patients with the opportunity to provide accurate information.
Health Risks in LGBT Patients
LGBT patients have many of the same risk factors as any patient, but they additionally have risk factors and healthcare disparities that require special consideration. Social stressors contribute to increased rates of mental health issues, suicide, substance abuse, obesity and victimization in this population. In 2014, the CDC reported that 26.6% of LGBT adults smoked, compared to 17.6% of heterosexual adults. This resulted in guidelines to assist in cessation in the LGBT population.6 Although actual rates of substance abuse are not known, the Substance Abuse and Mental Health Services Administration (SAMHSA) reports rates of substance abuse in this population at of 20% to 30% -versus 9% for the general population.7
More than half of new HIV infections in the United States are among gay men, who also have a higher risk of contracting sexually transmitted infections.8 Lesbian and bisexual women are less likely to obtain routine care and are more likely to be overweight or obese.9Although research and public advocacy groups cluster LGBT patients into categories, variances exist among each group, as do potential ethnic and familial risk factors. These compound the serious nature of LGBT health risks.
Coren et al have discussed the need for self-evaluation to decrease the portrayal of negativity, lack of knowledge and assumptions of heterosexuality.8 Sensing negativity may cause patients to withhold important information about sexual identity or to avoid returning for follow-up care. It is important that personal belief systems be mutually exclusive of the healthcare relationships with all patients, including LGBT patients, to avoid influencing the interaction and quality of healthcare provided.
Healthcare professionals receive minimal education about the needs of the LGBT population. The National LGBT Health Education Center has published resources and maintains a website with webinars and learning modules.10 Knowledge of basic terms and definitions will assist in establishing a mutual understanding and increasing communication with LGBT people.11,12
In addition to self-education and national guidelines, healthcare providers and their patients benefit from identifying specialty providers familiar with LGBT concerns and risks and knowledge of local LGBT-friendly resources. Displaying sensitivity to the healthcare needs of all patients is an important step in decreasing healthcare disparity in the United States. Continuing education with a focus on human sexuality, sexual minorities and specific aspects of LGBT healthcare can increase knowledge and provider/staff comfort, as well as decrease bias.
Cheryl Jackson is an assistant professor in the School of Nursing at Bloomsburg University in Bloomsburg, Pa. She has completed a disclosure statement and reports no relationships related to this article.
1. WHO. Health topics risk factors 2016. http://www.who.int/topics/risk_factors/en/
2. Lambda Legal. When healthcare isn't caring 2010. http://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf
3. Healthy People 2020. Lesbian, Gay, Bisexual and Transgender Health. https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health
4. National LGBT Health Education Center. Ten Things: Providing an inclusive and affirmative health care environment for LGBT people. http://www.lgbthealtheducation.org/lgbt-education/continuing-education/?y=114 5. Gay & Lesbian Medical Association. Guidelines for care of lesbian, gay, bisexual and transgender patients. http://glma.org/_data/n_0001/resources/live/GLMA%20guidelines%202006%20FINAL.pdf
6. LGBT HealthLink. Identifying and Eliminating LGBT Tobacco Disparities. http://www.lgbthealthlink.org/Assets/U/Documents/tobacco_disparities.pdf
7. Redding B. LGBT substance use-Beyond statistics. Social Work Today. 2014;14(4):8.
8. Association of American Medical Colleges. Ongoing LGBT Health disparities. https://www.aamc.org/newsroom/reporter/april2014/378180/lgbt-health-disparities.html
9. Coren JS, et al. Assessing your office for care of lesbian, gay, bisexual, and transgender patients. Health Care Manager. 2011;30(1):66-70.
10. Fenway Institute. Providing Welcoming Services and Care for LGBT People. A learning guide for health care staff. http://www.lgbthealtheducation.org/wp-content/uploads/Learning-Guide.pdf
11. University of California Davis. LGBTQIA glossary. http://lgbtqia.ucdavis.edu/educated/glossary.html
12. Berkeley University of California. Gender Equity Resource Center. http://geneq.berkeley.edu/lgbt_resources_definiton_of_terms#Bisexuality