01 May LGBT Rights: Quality of Care
Health Inequities and LGBT Rights
What health inequities are facing LGBT Americans today?
Health inequalities, or health differences, refer to differences in illness, injury, mortality or disability experienced by one group compared to another. For example, women are more likely than men to experience a chronic condition, and older people are likely to experience more illnesses than younger people. Comparisons of health differences are usually made based on race, ethnicity, gender, age, sexual orientation, or other group, and these differences are unavoidable by virtue of the group’s genetic factors or other characteristics. Health differences are not to be confused with health disparities. While health differences are associated with varying outcomes based on a group’s characteristics, health disparities refer to differences rooted in social injustice, rendering a particular group to certain disadvantages such as economic disadvantage or restricted access to health care based on discrimination. Health 2020 defines health disparity as “…a particular type of health difference…closely linked with economic, social or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion….sexual orientation or gender identity…or other characteristics historically linked to discrimination or exclusion” (Braveman, 2014). Compared to the sexual majority, or those who identify themselves as being heterosexual, LGBT individuals are subject to higher risks for substance abuse, sexually transmitted diseases (STDs), cancer, cardiovascular diseases, anxiety, depression and suicide, yet they receive poorer quality of care from providers who remain unaware or insensitive to the needs of the LGBT community (Hafeez, Zeshan, Tahir, Jahan & Naveed, 2017). National health surveys have documented additional health disparities such as increased rates of obesity, physical limitations, HIV infection and disability among this marginalized population (Fredriksen-Goldsen et al., 2014). LGBT rights are further compromised by unequal access to health insurance coverage (Ponce, Cochran, Pizer & Mays, 2010).
What factors affect quality of care for LGBT individuals?
LGBT individuals face unique barriers in health care. Whether they hold back their sexual identity or disclose their orientation, they are subject to poorer quality of care either way. Research shows that when a patient disclosed his or her sexual identity to a health care provider, the provider’s attitude and the patient’s self-disclosure adversely affected the quality of patient care in a clinical setting (Hafeez et al., 2017). When individuals belonging to a sexual minority refrain from self-disclosure out of fear, they are treated as heterosexual and consequently receive services that do not meet their unique needs. This results in subpar quality of care and client dissatisfaction (Alencar Albuquerque et al., 2016), which is a fundamental denial of LGBT rights to adequate healthcare.
Providers’ lack of awareness about LGBT-specific health issues may be attributed to inadequate training on the specific needs and challenges facing the LGBT community (Hafeez et al., 2017). According to data from the 2010 Census, over 10,000 same-sex couples resided in Minnesota where only 28 LGBT-friendly general providers were identified in the Rainbow Health Initiative (RHI) Directory in 2017. The primary care clinic setting used for this quality improvement initiative had limited LGBT cultural competencies, as evidenced by the types of questions found in the admission intake form, lack of orientation and follow-up staff trainings, and lack of any visual representation that would indicate the clinic’s competencies and awareness about the LGBT population (Felsenstein, 2018). For example, the admission intake form did not ask any questions that would allow a patient to self-identify as a member of the LGBT community only one clinician chart had a question about sexual orientation, but none of the questions asked about a patient’s gender identity.
The lack of providers’ sensitivity to the needs of the LGBT community does not necessarily reflect individual negative attitudes and personal prejudices. A study reveals that many medical students are open to learning more about the LGBT community, but LGBT-focused content is scant in their curricula, education and training, which renders them feeling uncomfortable about the training they received. The lack of training and knowledge trickles down to the provider’s discomfort with addressing sexual health concerns in LGBT patients (Wittenberg & Gerber, 2009).
LGBT Cultural Considerations
LGBT cultural considerations refer to taking existing cultural values, issues, and stereotypes into consideration when working with clients or patients. In the context of substance abuse treatment, this means creating a safe place for individuals to self-identify as members of the LGBT community without fear of risking the loss of support from staff members, peers, or health providers based on sexual orientation and gender identity. Providers would be mindful of their own cultural stereotypes as they assist clients who identify as lesbian, gay, bisexual, transgender or questioning. It’s also important to consider the client’s family and cultural group’s views on sexuality and substance abuse and to assess where the client stands within his or her own social context.
The importance of understanding a client’s culture is underscored in a case study about Hoshi, a Japanese native who received substance abuse treatment for his drinking in the United States (CSAT, 2014). The treatment program required that clients contact their family members about being in treatment; for Hoshi, this made him feel uncomfortable, but after some prodding from the staff members, he notified his family in Japan about his decision to go to an addiction treatment center. This proved to be an unwise and culturally inappropriate move on the provider’s end; Hoshi experienced shaming from his family and was disowned for publicly disclosing the private details of his drinking problem to the staff members. Culturally competent counselors and behavioral health service providers are in a better position to help clients with substance use and mental health disorders when they understand how their own world views and those of their clients affect client response to treatment and treatment outcomes (CSAT, 2014).
1 Alencar Albuquerque, G., de Lima Garcia, C., da Silva Quirino, G., Alves, M. J., Belém, J. M., dos Santos Figueiredo, F. W., … Adami, F. (2016). Access to health services by lesbian, gay, bisexual, and transgender persons: systematic literature review. BMC international health and human rights, 16, 2. doi:10.1186/s12914-015-0072-9
2 Braveman P. (2014). What are health disparities and health equity? We need to be clear. Public health reports (Washington, D.C. : 1974), 129 Suppl 2(Suppl 2), 5–8. doi:10.1177/00333549141291S203
3 Center for Substance Abuse Treatment (CSAT). (2014). Improving Cultural Competence. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 59.) 1, Introduction to Cultural Competence. Available from: https://www.ncbi.nlm.nih.gov/
4 Felsenstein D. R. (2018). Enhancing Lesbian, Gay, Bisexual, and Transgender Cultural Competence in a Midwestern Primary Care Clinic Setting. Journal for nurses in professional development, 34(3), 142–150. doi:10.1097/NND.0000000000000450
5 Fredriksen-Goldsen, K. I., Simoni, J. M., Kim, H. J., Lehavot, K., Walters, K. L., Yang, J., … Muraco, A. (2014). The health equity promotion model: Reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities. The American journal of orthopsychiatry, 84(6), 653–663. doi:10.1037/ort0000030
6 Hafeez, H., Zeshan, M., Tahir, M. A., Jahan, N., & Naveed, S. (2017). Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review. Cureus, 9(4), e1184. doi:10.7759/cureus.1184
7 Ponce, N. A., Cochran, S. D., Pizer, J. C., & Mays, V. M. (2010). The effects of unequal access to health insurance for same-sex couples in California. Health affairs (Project Hope), 29(8), 1539–1548. doi:10.1377/hlthaff.2009.0583
8 Wittenberg, A. & Gerber, J. (2009). Recommendations for improving sexual health curricula in medical schools: results from a two-arm study collecting data from patients and medical students. The journal of sexual medicine, 6(2):362-8. doi: 10.1111/j.1743-6109.2008.01046.x.