Provider implicit bias can also prevent risk identification in the LGBTQ population. Bias can stem from religious or cultural backgrounds, fear of the unknown or unfamiliar, 16,17 and preconceived ideas from media representation. If the healthcare community in general or individual caregivers have a preconceived concept of gender as male or female, sexual orientation as based on gender at birth, or sexual activity as between heterosexual individuals, and do not venture from this idea, information will be missed that may affect the health of an individual. Provider discomfort with inquiry into sexual orientation, gender identity, and sexual activity may inhibit an open discussion on sexual risk factors. There also may be a lack of awareness of the risks of LGBTQ patients or a desire to remain impartial and avoid cultural discussions. 18 In both cases, providers may potentially miss important information. In examining disparities in healthcare, it is crucial to consider patient factors such as access to care. Is the population (or person) able to receive care? There are a variety of factors that can affect the ability to access care, including the following: insurance coverage or the financial means to pay for care; ability to access
the care, which can relate to location, transportation, finances, and/or desire; and locating a qualified provider one feels comfortable with, which may vary according to culture, gender, race, and sexual identity to name a few. Additional difficulties can arise in small tight-knit communities and rural areas where decreased access to care, lower incomes, and lack of public transportation may already exist. 19 Transgender people in particular report difficulty finding gender- affirming healthcare. 20,21 While these examples are mainly interpersonal/ relational, there are also system/institutional barriers. Smith and Turell 22 identified several themes in their study, including substandard care, lack of determinants for quality care, heteronormativity in forms, extra documentation for partner participation in care, geographic barriers to LGBTQ-friendly care, and inadequate insurance. Under the Winsor & Obergefell ruling, federal and state employees with same-sex married spouses are guaranteed the same benefits as heterosexual married couples. 2 However, 45% of the LGBTQ population lives in states that do not have LGBTQ-inclusive insurance protection. 23
HEALTHY PEOPLE GOALS
A goal of Healthy People 2020 was to increase the health, safety, and well-being of LGBTQ people. 24 Progress has focused on population-based data systems to increase their collection on Healthy People objectives, or recommendations for LGBTQ or states and territories to increase their data collection in the Behavioral Risk Factor Surveillance System. 25 Additional important goals are to increase the quantity and uniformity of data collected on transgender individuals. The inclusion of sexual orientation and gender identity questions on health history forms is an excellent beginning to open discussions in the healthcare setting. LGBTQ objectives for Healthy People 2030 fall under the major goal of improving the health, well- being, and safety of LGBTQ people. 26 The objectives
are then classified under the following categories: adolescents, drug and alcohol use, mental health, infrastructure, and sexually transmitted infections. Within these categories, there are a variety of objectives including reducing bullying, illicit drug use, and increasing the number of entities collecting data on LGBTQ health. 25 The focus of the adolescent objectives is to reduce bullying, both in-person and cyberbullying. The 2019 Youth Risk Surveillance Survey found that 32% of adolescents who identify as a member of a sexual minority group report they were bullied at school and 26.6% report being cyberbullied. Almost twice as many students who are lesbian, gay, or bisexual compared to their heterosexual peers reported missing school because of concerns for their personal safety. 27
ACCESSING OR AVOIDING HEALTHCARE
Quality of care is important for all patients and providers and is paramount to achieving positive outcomes. Part of the healthcare experience results from the patient-provider relationship along with the general experience of the patient in the healthcare setting, whether clinic, hospital, or community. A qualitative study by Smith and Turell 22 examined the differences in expressed needs of different groups (lesbian, trans woman, gay, and HIV+ gay men) seeking healthcare in the LGBTQ community. Participants had a wide range of feelings on topics and several areas of agreement. First, there were differences regarding identity disclosure to providers, with the HIV+ group noting the importance of informing the clinician on their positive status. Levels of comfort on disclosure varied from no concern “for the straight people’s discomfort” 22 to great concern about how one’s healthcare would be affected by
disclosure and how the information would be stored and shared. 22 Participants also shared that they experienced lapses in confidentiality such as using incorrect pronouns, physician sharing HIV+ status with family at bedside rounds after surgery, and other situations that eroded patient trust. Although this study has several limitations, including small sample size (n=26) and exclusion of persons of color/trans men, similar findings were identified in other studies. 2,28,29 Participants also perceived discomfort and heteronormative expectations of healthcare professionals. These examples ranged from unfamiliarity with terms of address, lack of knowledge of LGBTQ health needs, too much focus on sexual health, and implicit bias such as assuming that a woman needed birth control because she is sexually active, that a lesbian’s partner is her “husband,” or that gays or lesbians do not have children. Participants
Book Code: CT24CME
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