Course overview The purpose of this course is to help improve care and health outcomes of the LGBTQ population by recognizing the existing disparities and increased health risks present in this population.
We will examine system and provider/client barriers to equality in healthcare.
INTRODUCTION
Healthcare providers are trained to identify patient populations who experience health disparities and to educate patients about their individual risks. The World Health Organization (WHO) defines risk factors as “any attribute, characteristic, or exposure that increases the likelihood of developing a disease or injury” (WHO, 2009). 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, healthcare professionals educate patients about ways to modify behavior to decrease disease risk and 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. The purpose of this course is to discuss the disparities in healthcare and increased health risks that exist in the LGBTQ population; identify system, provider, and client barriers; as well as ways to provide improved care. The author would like to emphasize there is no single definition of the LGBTQ community. Instead, just as any other group or community, the LGBTQ community is made up of a group of individuals from a variety of racial/ethnic backgrounds, cultures, incomes, religions, and many other characteristics, resulting in unique diverse groups of individuals (Kates et al., 2018). Stigma is a commonly shared experience among the groups. To date, the available data has mainly focused on lesbian, gay, and bisexual individuals with limited information on transgendered individuals. Findings are also varied among different sources, primarily because of differing methodologies for data collection (Kates et al., 2018). Sexual orientation (SO)
questions are included in 11 federal surveys and, of these, seven also have an inquiry regarding gender identity (GI; Holzberg et al., 2018). Gender identity questions were added to the National Health Interview Survey (NHIS), a principal source of US population health, beginning in 2013 (Kates et al., 2018), and in the National Survey on Drug Use Abuse and Health (NSDUH) in 2015. It is important for healthcare providers to understand the differences between gender identity, sexual orientation, and sex assigned at birth and how these factors are important. Sex assigned at birth helps to determine health risk factors and the need for screening, particularly if there are remaining natal organs (i.e., breasts, ovaries, testes). Gender identity refers to the way an individual feels about themselves, for example, as a male, female, transgender, or non-binary. Sexual orientation identifies who the individual is attracted to romantically or physically. These feelings cannot be identified by appearance and should be gathered directly from each individual in their own words. The 2020 census was the first census that included a question specifically about same-sex relationships. Optional answers included opposite OR same-sex husband/wife/spouse and opposite OR same-sex unmarried partner (Wang, 2018). Use of census data assist in determining federal funding to states. In 2015, $175 million in funding for Housing Opportunities for Persons with Aids, $312 billion for Medicaid, and $71 billion in money for food stamps was received through census data (Lang, 2020). LGBTQQ people are among those most likely to rely on these programs and under representation may affect financial assistance (Lang, 2020). Unfortunately, a single question is unable to reflect this diverse population.
RISK IDENTIFICATION
To identify risk, healthcare providers need to see, talk to, and examine patients. This sounds extremely obvious, but there are many barriers that may prevent this from occurring. One of the most addressed in caring for LGBTQ people is the lack of provider training and experience in caring for sexual minority persons (Aisner et al., 2019; Dorsen & van Devanter, 2016). 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 (Dorsen & van Devanter, 2016; Sekoni et al., 2017), 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 (McNair & Hegarty, 2010). In both cases, providers may potentially miss important information. In examining disparities in healthcare, we must 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 (Mead et al., 2017). While these examples are mainly interpersonal/relational, there are also system/institutional barriers. Smith & Turell (2017) identified several themes in their study, including substandard care, lack of determinants for quality care, and 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 (Kates et al., 2018). Forty-five percent of the LGBTQQ population live in states that do not have LGBTQ-inclusive insurance protection (MAP, 2021). Evidence-based practice! Despite the Patient Protection and Affordable Care Act, millions of Americans remain without insurance coverage. Studies show access to healthcare impacts one’s overall physical, social, and mental health status, and quality of life. Access to healthcare means “the timely use of personal health services to achieve the best outcomes” (Office of Disease Prevention and Health Promotion [ODPHP], n.d.a).
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Book Code: SWTX1524
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