LGBT: An Evolving Health Disparity
Staci Grothues
University of Massachusetts Amherst
Running head: LGBT: AN EVOLVING HEALTH DISPARITY 1
LGBT: AN EVOLVING HEALTH DISPARITY 9
LGBT: An Evolving Health Disparity
Introduction
There are many barriers to achieving health equality among varying populations. Factors such as socioeconomics can lead to avoidable differences in the health status and health treatment of certain groups and subgroups. These health disparities cause afflictions that lead to unnecessary declines in overall well-being (Center for Disease Control and Prevention [CDC], 2019). Those who consider themselves as lesbian, gay, bisexual, and transgender (LGBT) have long been persecuted and are exposed to extreme injustices. A discriminatory culture has led to unequal treatment of this population resulting in serious health consequences. Although the general view and rights of the LGBT community have evolved greatly over the last several decades, there is still more to be done. Policy change is necessary to decrease the overall disparity and the healthcare community needs to lead the charge for righting the wrongs of the past by providing culturally competent and equal care to this suffering population.
It should be noted that as more is understood about gender identity and sexual orientation, which are not mutually exclusive, more terminology emerges for multiple subgroups. Although LGBT is not all inclusive of those who experience health disparities as part of a stigmatized group related to sexism, it has been the longest standing identifier and as such provides the most researched literature to maintain validity in this paper.
The Disparity and its Determinants
There are many factors that can play a role in health disparities. For the LGBT community, socioeconomic determinants seem to play a vital role. Social discrimination and phobias are not new for this population and have led to a global stigma. This group is often faced with violence and victimization leading to undue physical harm and psychological stress. They have even been denied civil and even basic human rights throughout the years (“HIM’s Role in Eliminating LGBT Health Disparities,” 2017).
The Minority Stress Model
The minority stress model shows how experienced stigmas, negative prejudices, and other social disparities lead to a significant stress response that can increase the likelihood of developing physiological conditions manifested from psychological stress. Societal contexts of being LGBT contribute to a variety of external and internal stressors such as experienced discrimination, internalized homonegativity and stigma consciousness. General and environmental circumstances contribute to these stressors as well, along with others which can be experienced by anyone such as ending relationships, unemployment, or poor health. The cumulative effect of these stressors can lead to declines in mental and sexual health and drug use (Dentato, 2012).
Disparity Within Disparity
The LGBT community is one who is very susceptible to compounded health disparities. Being a part of multiple groups who are discriminated against leads to disproportionate inequalities. LGBT are a population who can experience unjust treatment solely based on their sexual orientation or preferences, as well as gender, race, financial and health status (Daniel & Butkus, 2015). Of the multiple disparities this group may face, the most critical may be the elderly and those afflicted with HIV.
Elderly. Elderly LGBT are thought to be within an “at risk” population by the Institute of Medicine in 2012 due the nature of being underserved. As age advances, a person suffers from greater health risks and disease processes. LGBT elderly have an even higher risk and present with poorer general health than either group alone (Emlet, 2016). This group is also associated with an increase in substance abuse, mental disorders, financial distress, and disability all contributing to poor health outcomes. Because many in this subgroup were raised in a time when homosexuality was neither accepted nor understood (and even criminalized), there is a greater sense of shame. Some have lived in lifelong concealment and social isolation (Foglia & Fredriksen-Goldsen, 2014). The lack of social support is in itself a health consequence, but the indignity that is felt can lead to hesitation to seek medical care or inappropriate treatment. Many in this group are unlikely to have consistent care or follow up with chronic conditions (“HIM’s Role in Eliminating LGBT Health Disparities,” 2017). There is a greater number of LGBT elderly living below the poverty threshold than those in either group exclusively, and those living with HIV are further put at risk for financial and economic distress (Emlet, 2016).
To have any impact of change, the problem must first be addressed and understood.
Advancements in the LGBT elderly movement have been evolving since the Stonewall uprising in 1969. Organizations were created to advocate for the group and give a voice to be heard as a platform for policy change. The first federally funded approach began as a research project called Caring and Aging with Pride that sought to shed light on the struggles and distresses of this specific population (Foglia & Fredriksen-Goldsten, 2014). Services and Advocacy for GLTB Elders (SAGE) is one of the country’s largest organizations in support of research, development and advocacy for LGBT elderly, and perhaps the most significant impact has been the opening of their office in Washington D.C. in 2010 “which provided a dedicated voice to lobby for concrete federal changes” (Espinoza, 2016, p. 88). Although there is more work to be done, there is a roadmap to reduce the disparities of the LGBT elderly by an expanding national infrastructure that is determined to do so by addressing inequalities related to social security, Medicaid and Medicare (Espinoza, 2016).
HIV. 40,324 people were newly diagnosed with Human Immunodeficiency Virus (HIV) in 2016 alone. Homosexual and bisexual men 13 years and older account for 82% of diagnoses. This staggering number has only been increasing over the last decade. Some socioeconomic factors that may account for this high prevalence include higher rates of unemployment, lower income and education levels, incarceration, and limited access to healthcare (CDC, 2019). Even as recently as 20 years ago, there are HIV patient reports of being treated as though they had the plague by healthcare providers who took extreme measures or refused to touch them. This prejudicated treatment by those who are supposed to be the most trusted profession has lasting psychological implications (Rubin, 2015).
The HIV/AIDS epidemic has a substantial financial burden, both to the individual and the country as a whole, with an estimated lifetime cost of $367,134. There has been progress through more reliable HIV testing and the development of medications that are safer and more effective in prevention and treatment, allowing for people living with HIV to reach undetectable viral loads (CDC, 2019). However, there remains a need to increase federal funding in support of public health programs to educate and treat this caustic disease. One out of six persons are unaware that they have HIV leading to further spread of the disease. Detection and diagnosis through education is vital (CDC, 2019).
The magnitude of this disease has led to the nation’s awareness of actions needed. President Trump’s plan, discussed in his 2019 State of the Union address, is an ambitious road map in which he wishes to reduce new HIV diagnoses by 75% within the first five years and 90% within ten. The actions focus on geographical locations in which HIV is most prevalent and rapidly spreading, to diagnose, treat, protect and respond by identifying these areas and then allocating resources and funding (U.S. Department of Health and Human Services, 2019).
The CDC also has a plan in place described in their 2019 HIV Prevention Progress Report, which supports efforts on federal and state levels to accomplish national goals of eliminating new infections. The report describes 21 prevention strategies across different population subgroups and geographical locations. For each strategy, there is an outline which includes the goal, the importance of that goal, the action plan to reach it and progress measurements. As of now, each strategy is within 10% of meeting its 2020 target goal (CDC, 2019).
Hallmarks Through the Years
Although there is still much stigma associated with being LGBT, the nation has been progressively making efforts to equalize this population both on a social and political level. Being homosexual was a criminal offense in the 1960s, until Illinois was the first state to decriminalize it. Around this time, many gay rights organizations emerged, and activists began to speak out in advocacy for LGBT to raise awareness around the nation. Once thought to be a mental disorder, the American Psychiatric Association (APA) removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) in 1973, and in 1974 the first openly LGBT person was elected to public office (CDC, 2019).
Same Sex Marriage and Benefits
It has been since 1970, when the first gay couple were declined a marriage license application escalating their case to the state Supreme Court, that same-sex marriage has been an ongoing ticket item for policy makers. At this time, there was no gender specification in marriage law which led some states, like Maryland, to officially ban same-sex marriage. A significant health related issue developed around this time concerning partnerships; since same-sex couples were not legitimately recognized, a same-sex partner could not have legalized health proxy of their loved one and therefore were unable to make health-related decisions. On the same note, other health related benefits such as health insurance were not provided for same-sex partners as they were for heterosexual couples. In 1984 after five years of lobbying, Berkley, CA was the first city to enact a domestic partnership ordinance allowing dental coverage for domestic partners, restricted to city employees. However, by 1992, large corporations all over the nation began offering domestic partnership benefits, some providing full medical coverage (Cable News Network [CNN], 2019).
In 1996, President Bill Clinton signed the Defense of Marriage Act (DOMA). This federal law specifies that a marriage must be between a male and female, setting back over 1000 state laws with eligibility criteria for benefits and privileges that were already set into action. The next few years were filled with independent states taking their stand on the issue, some making a constitutional ban on same-sex marriage. In 2000, Vermont was the first state to legalize same-sex marriage, and as of 2015 the U.S. Supreme Court ruled in favor of legalized same-sex marriage nationwide. As of now there are 37 states which have legalized gay marriage; however, there are still over a dozen who continue to have statutory provisions, upholding the DOMA and prohibiting same-sex marriage (CNN, 2019).
Conversion Therapy
There are still some who believe LGBT to be a choice; something that can be changed or reversed. Conversion therapy was a common practice to attempt to change someone’s sexual identity or orientation by means of castration, electric shock therapy or institutionalization. Less extreme forms are also practiced in ways of aversion treatments to make one feel shame or physical pain when aroused by the same sex. It wasn’t until 2009 that the APA came out stating that conversion therapy is not only ineffective, but poses considerable harm, especially to children. They also concluded that research indicates there is no therapy effective to change someone’s sexual orientation or gender identity (American Psychological Association [APA], 2016). Yet, to this day there are only 15 states and Washington D.C. who have protection laws in place against conversion therapies for youth (Human Rights Campaign, 2019). The APA lists an abundant amount of negative side effects consisting of depression, shame, hostility, stress, substance-abuse and even suicidality, but over 30 states do not have any laws to protect youth from receiving this type of treatment (APA, 2016).
Discrimination
Although the LGBT community has been thought to have made significant progress in social reform over the last few decades, they are still subject to discriminatory injustices that negatively impact their well-being. There are 28 states in the U.S. who do not offer any type of protection against discriminatory treatment based on sexual orientation or gender identity. This primarily and substantially affects employment and housing for LGBT. Some states offer partial protection, not explicitly banning discrimination against gender identity, or protection for housing or employment, but not public accommodations (Freedom for all Americans, 2018). This means it is perfectly legal to victimize LGBT people by not employing or not accepting leasing agreements solely based on their sexual orientation or gender identity in more than half the country. Perhaps this is why a large number of LGBT fall below the poverty line and struggle financially, further escalating health disparity.
Health Related Consequences
As seen through out this paper, there are many factors that relate to the unequal resources provided to the LGBT community that have disproportionate negative health consequences. Discomfort and mistrust across the healthcare environments account for much of the health concerns in this population. Foglia and Fredriksen-Goldsten (2014) suggest that healthcare provider nonconscious biases are a main contributor to this health disparity that must be acknowledged. Due to the fear of being marginalized, LGBTs are less likely to seek preventative care (Rubin, 2015), leading to undetected health issues and increasing the risk of poor health outcomes later in life (Stall et al., 2016). Rubin (2016) states that although there is equal risk for developing cervical cancers, lesbians are 10 times less likely to receive screenings than heterosexual women. Perhaps this is lack of provider knowledge. There are some providers who still adhere to the “don’t ask, don’t tell” policy, in which they prefer to remain unaware of the patients’ gender identity or sexual orientation. This is a blatant representation of healthcare ignorance and attributes to much of the health disparity. Although, the medical culture seemingly abides as well by not allowing for patients to identify themselves on medical forms. Rubin (2016) suggests that by not allowing for gender and sexual preference identification on medical intake forms, a culture of nondisclosure is created from the moment they walk in the door. As the patient-provider relationship becomes damaged, the patient’s mistrust increases and thereby inevitably decreases complete and appropriate healthcare treatments and resources (“HIM’s Role in Eliminating LGBT Health Disparity,” 2017).
Reducing Disparity
To eliminate disparity, the affected group must first be seen as worthy and deserving of equal and fair treatment on a global scale. Although being LGBT has become more accepted over the last decade, there remains a stigma and prejudices against them. This must be stopped. Stop the victimization, the violence and the shaming. The general public needs to be better educated on the struggles that are experienced by LGBT and understand that it is not a choice. There must be a shift in thinking to create a culture change in which LGBT are not discriminated against. This change needs to start from the top. There are several ways in which the federal government can help close the gap of disparity among this population.
First there must be mandated civil equality for the well-being of this group. It was just within the last year that the U.S. Supreme Court ruled in favor of same-sex marriage; however, some states still do not recognize it as such and even deny privileges and benefits (CNN, 2019). The allowance to marry whomever one chooses should be a standard enforced across all states, including the extension of health benefits to domestic partners.
Disparities can be greatly reduced by identifying the unique needs of each group. More resources need to be allocated to detecting and exploring the disparity antecedents. Increased training and support for junior researchers is needed to continue to reassess the issues leading to inequalities (Hswen et al., 2018). There must also be a change in standards for data collection of gender identity and sexual orientation both in national census reports, as well as medical environments (Maragh-Bass et al., 2017). A person needs to be allowed to designate freely how they identify and their sexual orientation to properly treat. Electronic Medical Record systems need to be updated to allow for these types of designations.
Health Providers’ Role
Policy change becomes necessary to formally mitigate the health disparities of the LGBT community; however, health providers have ample opportunity to reduce the risk. The first step becomes personal acknowledgment of nonconscious biases. A provider must first be aware of implicit stereotypes to overcome unequal treatments. A comprehensive exam must be performed without assumptions and should always include obtainment of a sexual history, gender identity, and preferred names and pronouns (Yeung, Luk, Chen, Ginsberg, & Katz, 2019). Assure the patient that the reason for this information obtainment is to promote appropriate health-related measures and is not to be used as a source of judgement (Maragh-Bass et al., 2017). Understanding and utilizing LGBT terminology appropriately enhances an environment of trust and strengthens the patient-provider relationship, projecting a patient-centered focus (Yeung et al., 2019). Although the LGBT population may require specialized resources and treatment, they still must be addressed as an individual with individualized needs (Maragh-Bass et al., 2017).
To further improve provider care, education must be instituted in medical curriculum to allow for appropriate treatment of this specialized group. As of now, there is no formal requirement of LGBT education instituted in medical curriculum and the federal government only requires two hours’ worth of LGBT education for medical license renewal (Yeung et al., 2019).
Conclusion
There have been overwhelming advancements in the last several decades for people who identify as LGBT; however, injustices and inequalities still remain leading to serious disparities of health for this population. Social and economic factors create less opportunity for the LGBT population to receive fair and equal healthcare and many are afflicted with compounding disparity identities. Equalization must begin on a national platform to transform discriminatory thinking and biases. Health care providers have a duty to advocate for this group and maintain an environment of acceptance and trust. The recognition of this group has led to national efforts to reduce this health disparity with lofty goals within the coming years. If this focus remains, the LGBT health disparity just might have a possibility of being something of the past.
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