_____________________________________________ Promoting the Health of Gender and Sexual Minorities
Other measures (introduced in Arkansas, Michigan, Rhode Island, South Dakota, Texas, Vermont, and West Virginia) would allow pharmacists and other healthcare providers to refuse treatment or medication to anyone by citing ethical, moral, or religious grounds. Georgia law already states that “it shall not be considered unprofessional conduct for any pharmacist to refuse to fill any prescription based on his/her professional judgment or ethical or moral beliefs” [94]. Some progress has been made, however. For example, in 2003, a California appeals court ruled that healthcare providers cannot discriminate against patients based on their sexual orientation. The decision was the result of a lawsuit filed by a gay woman who perceived discrimination based on the religious beliefs of providers at an infertility clinic [95]. The controversy surrounding same-sex marriage has led to unique healthcare access debates and decisions, including extension of health and other employment benefits to an employee’s same-sex partner. Along with the Supreme Court ruling state-level same-sex marriage bans unconstitutional on June 26, 2015, there have also been significant changes to healthcare laws. Starting in 2015, any insurer that offers healthcare coverage to opposite-sex partners must also offer coverage to same-sex partners [96]. Married same-sex couples are also ensured the same tax credits and out-of-pocket costs as married opposite-sex couples on private plans in all states. AMA Resolution 414 calls for recognition of the healthcare and other needs of the LGBTQ population, while acknowl- edging that more professional knowledge and skills about the LGBTQIA population are needed [13]. Health concerns among the LGBTQIA population include: cancer; family con- cerns, including domestic violence; immunizations; infectious diseases, such as sexually transmitted infections (STIs), HIV/ AIDS, and hepatitis; mental health, including suicide, body image, and eating disorders; substance use; and violence [8; 9]. Bisexual Health Issues Existing research about bisexual health is scarce in large mea- sure because the health issues that directly affect the bisexual population have either been ignored or treated as identical to the issues that affect heterosexuals or gay men and lesbians. Bisexuals have been found to experience greater health dispari- ties and a greater likelihood of experiencing depression than the broader population [97]. Estimating the frequency of bisexuality in the United States depends on how it is defined (i.e., in terms of behavior, attrac- tion, or self-identity) and ranges from 0.7% to 12.9% in men and from 0.3% to 5.9% in women [98]. Some individuals who have sex with both women and men choose not to identify themselves as bisexual. Others acknowledge the orientation but do not necessarily involve themselves with more than one gender. The distinction between identity and behavior is an important one. To gain a better understanding of the unique needs of the bisexual population, healthcare providers should consider the individual’s sexual behavior, not simply his or
her sexual identity. The National Gay and Lesbian Task Force has published recommendations for creating a friendlier “bi- culture,” particularly for the provision of HIV/STI prevention services [98]. Transgender Health Issues A report released by the Movement Advancement Project finds that transgender people are among the most vulnerable communities in America. Transgender women and transgen- der people of color are particularly affected, and they face enormous barriers to their safety, health, and well-being [99]. Transgender health issues include many of the same concerns as for lesbians, gays, and bisexuals, but even less research is available that has studied the effects of stigma, violence, and social and economic marginalization. Very few surveys ask about transgender status. Only one national study (the National Transgender Discrimination Survey) has focused exclusively on transgender people in the United States [99]. Problems related to stigma may be worse for transgender youth than for LGBQ persons. These youth strive to remain invis- ible and appear indistinguishable from their nontransgender peers in order to avoid harassment and abuse. However, this results in isolation and prevents them from seeking appropriate mental health or medical care until a crisis has arisen [76; 78; 100]. The same issues may be applied to transgender adults as well, including being stigmatized by prominent gay and lesbian movements and organizations [43]. Prejudice and lack of knowledge create significant barriers to medical and social services and care for transgender indi- viduals of all ages. They also contribute to this population’s underutilization of health and social services [101]. While the Affordable Care Act has decreased the number of transgender people without health insurance, transgender people continue to report low insurance rates and high rates of negative health outcomes [102]. According to the Movement Advancement Project, 44% of the LGBTQ population lives in states that do not have LGBT-inclusive insurance protections [103]. Transgender individuals must educate healthcare professionals about transgenderism and related concerns before adequate care can be offered [99; 101]. Some transgender organizations have been advancing toward this goal by working with public health, medical, and mental health researchers [43]. Cancer Breast cancer is one of the most researched topics in lesbian health [8]. Lesbians have a richer concentration of risk factors for breast cancer than any other subset of women in the world [30]. Obesity, alcohol consumption, smoking, and nulliparity contribute to the risk of developing breast cancer, and avoid- ance of a healthcare system that has been discriminatory of lesbians in the past may result in delayed cancer detection and treatment. Lack of health insurance for unmarried partners has created access barriers to quality health care, including screen- ing and prevention [36; 104]. While few differences between the diagnosis and treatment of lesbian and heterosexual women have been found, lesbian women have demonstrated a puzzling
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