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
Epidemiology The most accurate and current information about LGBTQ demographics is based on independent polling and survey organizations. The most recent large-scale survey was a 2021 Gallup report based on interviews with a random sample of approximately 15,000 U.S. adults, which showed that the proportion of American adults identifying as LGBTQ increased to 5.6% from 4.5% in 2017. Millennials (born 1981-1996) and Generation Z (born 1997-2002) are more likely to identify as bisexual compared to lesbian, gay, transgender, or other. 12 As the general population ages, the number of older LGBTQ adults will increase as well. By 2030, there will be an estimated 2 million to 6 million LGBTQ adults ≥65 of age in the United States (vs. an estimated 1 million to 2.8 million in 2000), approximately 120,000 of whom are projected to be living in nursing homes. 13 These individuals will have distinct healthcare needs and face well-documented health-related disparities including disability, poor mental health, smoking, and increased alcohol consumption. In addition, older lesbians have a higher risk of developing metabolic syndromes and cardiovascular disease (CVD). Older transgender adults are at significantly higher risk of poor physical health, disability, depression, and perceived stress compared with cis-gender patients. 13,14 Risk Identification To identify risk, healthcare providers need to see, talk to, and examine patients. This point sounds obvious, but there are many barriers that may prevent this examination and communication from occurring. One of the most common barriers in caring for LGBTQ people is the lack of provider training and experience in caring for sexual minority persons. 15,16 This lack of training may cause a fear of missing or doing something wrong or result in inadvertently doing or saying something offensive. 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.
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.
Terms to Avoid These terms may have been used in the past but are now considered outdated and may be offensive. In addition, while patients may use these terms, when in doubt, the provider should ask the patient which terms they prefer. Unacceptable Acceptable Berdache (to describe gender non-conforming indigenous people) Two-spirit Gender reassignment surgery Gender assignment surgery Homosexual Gay or lesbian Intersex/hermaphrodite Disorders of sex development Sex change Gender affirmation surgery Sexual preference Sexual orientation Transgendered/a transgender Transgender
4
Powered by FlippingBook