Discussion This office provided a section in the waiting room for literature relating to local resources and information for LGBTQQ individuals. The intake form included preferred gender and pronoun, which was reinforced by the receptionist, and instead of asking only for marital status, included additional options. In the exam room there was a statement signed by employees that showed their support for all individuals (nondiscrimination policy). Finally, the use of a sexual history form to be reviewed with a provider serves as a starting point for a discussion related to sexual practices and assists with risk identification. There are additional methods including displaying sexual minority couples, displaying a rainbow flag or sticker, providing a gender-neutral toilet facility, and listing your office on the Gay and Lesbian Medical Association (GLMA) directory.
He grabbed a brochure and had a seat to wait for his appointment. In about 10 minutes, he heard someone call his name and he stood to walk in the back. After obtaining height and weight, he was led to an exam room. The nurse introduced herself and Sam noticed a framed print on the wall titled “We Promise.” The nurse saw him looking and explained the office felt very strongly that each person deserved respect and privacy for who they were and what they believed and that everyone signed it. She asked a few questions and then handed him a form, saying they have all adult patients complete it and the nurse practitioner would go over it with him. He turned it over and saw it was a sexual history form. Question What are some methods the office used to provide a welcoming environment for LGBTQ people?
HEALTH RISKS FOR LGBTQ PATIENTS
LGBTQ patients have the same risk factors as any patient, but they also have risk factors and healthcare disparities that require special consideration. Healthy People 2020 targeted health disparities for elimination among LGBTQ people (ODPHP, 2020b). Research showed that negative health outcomes of LGBTQ individuals are often related to stigma, discrimination, and denial of human rights (ODPHP, 2020b). Elimination of disparities and improving LGBTQ health are important in contributing to increased longevity, decreased expenditure for healthcare, reduced disease transmission, and increased physical and mental wellness (ODPHP, 2020b). Equality in healthcare has not yet been achieved, but what has been accomplished is an increase in sexual orientation and gender identification data collection (Gonzales & Henning- Smith, 2017). This information will assist in identifying disparity, increasing recognition of the need to obtain unbiased social and sexual histories, and increasing provider education related to sexual minorities and social determinants of health to increase the potential for culturally competent care (ODPHP, 2020b). Social stressors contribute to increased rates of mental health issues, suicide, substance abuse, obesity, and victimization in this population. Chronic stress resulting from stress in the social environment as a result of stigma, discrimination, and prejudice has been referred to as minority stress and is a topic of interest in sexual minority individuals (Baptiste-Roberts et al., 2017). The minority stress model focuses on mental health but there is some evidence that mental health also affects physical health. Meyer (2003) identifies the processes of minority stress, as related to LGBTQ, as having distal to proximal factors. These range from external objective stressors to expecting such events to take place and the vigilance this entails and internalizing negative attitudes. Individual response to stressors varies as do stress- relieving factors. Many minority groups respond with group solidarity, which serves to support morale and protect individuals from adverse stressors (Meyer, 2003). When a person does not have access to group level resources it can lead to increased stress and alienation. Mental health issues are prevalent among LGBTQQ people of all ages. Much of the risk for mental health conditions is thought to result from discrimination, bullying, violence, and loss of support. LGB identified youth were more than eight times more likely to have attempted suicide if their family rejected them than LGB peers with low or no level of family rejection (Veltman & La Rose, 2019). LGB individuals have a two-to-six-time higher lifetime risk of suicide and/or depression (Herman et al., 2019). A 2015 US study on transgender individuals found that 81.7% contemplated suicide and 40.4% had attempted suicide at some point (Herman et al., 2019). In addition to risk factors common to the non-transgender public, elevated risks of suicidal thoughts and attempts were more likely among transgender people who report heavy substance use, poor general health, have a disability, or experienced recent homelessness or an arrest (Herman et al., 2019).
Stress and mental health issues can increase the use of tobacco, alcohol, and other substances to relieve stress. In 2016, the Centers for Disease Control and Prevention (CDC) reported that 20.5% of LGB adults smoked compared to 15.3% of heterosexual adults (CDC, n.d.). This means that about one in five LGB adults is a smoker. Limited information exists on transgender tobacco use; however, it is reported to be higher than among the general population (CDC, n.d.). Although actual substance abuse rates are unknown, the Substance Abuse and Mental Health Services Administration (SAMHSA) reports rates of 20% to 30% vs. 9% for the general population (Redding, 2014). In 2019, 7.6 million LGB adults > 18 had a mental health or substance use disorder. That is a 20.5% increase from 2018 (SAMHSA, 2020). Although cardiovascular deaths have declined since 2010, in the US there remains significant differences based on race, sex, and income (American Heart Association, 2020; Caceres et al., 2020). Caceres and colleagues (2017) found that sexual minority persons experienced a higher prevalence of elevated cardiovascular (CVD) risk because of largely modifiable conditions than their heterosexual peers. For women these included tobacco, alcohol, and illicit drug use, mental health issues, and elevated body mass index. For men the risks were because of tobacco use, illicit drug use, and poor mental health (Caceres et al., 2017). Repeat exposure to interpersonal stress (discrimination, family rejection, expectation of stigma), general stress (financial, life adversity, childhood trauma) and the potential for additional physical stress from hormone or antiretroviral treatments combined with risks of tobacco, illicit drugs, excess alcohol, and elevated BMI are believed to increase CVD risk. These findings were based on subjective data rather than physical markers and show the need for further research. According to Caceres and colleagues (2020), cardiovascular health research in sexual minorities has not been prioritized because of other health concerns such as HIV/AIDS and substance use. In 2018, there were 37,968 new diagnoses of HIV in the US and its territories, with 69% being among gay and bisexual men (CDC, 2020b). A 2019 systematic review found 14% of transgender women have HIV; racial and ethnic breakdown is 44% African American, 26% Hispanic/Latino, and 7% of White transgender women (CDC, 2019). Sixty-four percent of new cases are among men who have sex with men (MSM), ages 13 to 34, with higher representation in African American and Hispanic/Latino groups. Use of pre-exposure prophylaxis is lower among these two racial/ethnic groups than among White MSM (CDC, 2020b). Sexually transmitted infections (STI) are also more prevalent among MSM, in particular more than 8 in 10 new cases of gonorrhea and primary and secondary syphilis, 10% of new hepatitis A, and 20% of new hepatitis B cases are found in this group (Kates et al., 2018).
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