By Sarah Tran
After almost three years of training in a federally qualified health center, I had the privilege of working with the undocumented, unresourced, and underserved populations in one of the largest cities in America. However, I have only served a handful of LGBT patients. One would think in a city as wonderfully diverse as my hometown of Houston, where 4.4 percent1 identify themselves as lesbian, gay, or bisexual, including our beloved mayor, that if I’ve seen 1,000 patients, at least 40 of these visits might have been opportunities where I could and should focus on the different aspects of care for this specialized population. Sadly, it is more likely that up until late last year, whether for acute visits or follow-up of chronic conditions, I missed the chance to offer culturally competent care as a physician. Consider it a part of learning and growing, but without knowledge and training, it is incredibly difficult to ask the questions you don’t know need to be asked.
After meeting with a lesbian couple, both of whom did not realize they needed the same preventive health maintenance as other women, e.g. pap smears, I began reading more about different health risks LGBT individuals face, and I emailed my attending asking her to mentor me. She echoed the same sentiments as Healthy People 2020—that understanding LGBT health begins with understanding the history of oppression that this community has faced. For instance, because bars and clubs used to be the only place LGBT individuals could meet and feel safe, alcohol abuse remains a prevalent ongoing problem.2
In December of 2010, the U.S. Department of Health and Human Services launched Healthy People 2020, a set of nationwide goals to improve the health of all Americans in the next 10 years. Highlighted in these objectives was a focus on eliminating health disparities among the LGBT population linked to “societal stigma, discrimination, and denial of their civil and human rights.” This report noted that “discrimination against LGBT persons has been associated with high rates of psychiatric disorders, substance abuse, and suicide.”2 Five years in, halfway to the date we hoped to reach this goal, how far have we come? How far do we have to go? Where do we as physicians begin?
On a national level, the passage of the Patient Protection and Affordable Care Act (PPACA) has led to increased protection against discrimination based on sexual orientation. The Marketplace even offers specifically laid-out provisions for same-sex married couples. For instance, insurance companies that offer health coverage to opposite-sex couples must provide the same coverage for same-sex couples. This is irrespective of the state in which the couple lives or in which the insurance company is located.3 Even so, in Texas an estimated five million people remain uninsured, half of whom might have been eligible for coverage had Texas accepted the Medicaid expansion as reported by U.S. Health and Human Services Secretary Kathleen Sebelius. Another resource, the Kaiser Family Foundation, places this number closer to one million individuals.4
On a state level, Rep. Sarah Davis became the first GOP lawmaker to back same-sex marriage by not signing a letter issued by House Republicans. One simple act made huge waves in this community, garnering her support as the first Republican to be endorsed by Equality Texas. A recent University of Texas/Texas Tribune poll showed 42 percent of registered voters in Texas say yes to marriage equality, 47 percent say no, and 11 percent are undecided.5 Whichever side one lands on in this culture war should not be translated into the practice of medicine. As a primary care physician, I had been trained for years to look at the overall picture, before realizing I had missed an important piece in building a relationship with my patients. I did not understand the different doors of discussion I closed by unintentionally using gender-specific pronouns when asking medical questions. I failed to realize that those who were not up to date with preventive health screenings may not realize they needed the same maintenance as everyone else. So, where do we start?
A great first source for physicians is GLMA’s (Gay and Lesbian Medical Association) Guidelines for Care of LGBT Patients.6 This resource broaches subjects on how to create a welcoming environment, ways to maintain confidentiality, processes for staff and sensitivity training, and specific health issues to discuss with LGBT patients. For example, exploring the degree to which a patient is “out” in the community correlates with high-risk sexual practices. Understanding the societal stresses that contribute to the prevalence of substance abuse (e.g. 50 percent more tobacco use in gay men than heterosexual men, 200 percent more in lesbian women than in heterosexual women) can provide an opportunity for healthy lifestyle changes. Furthermore, it is always, always essential to ask violence-screening questions. GLMA even has a Provider Directory for patients to search for LGBT-friendly doctors. So for the doctors out there, the first initiative to better serving our LGBT population may be as simple as signing up to be on the list. For Texas, the CDC presently only has one clinic listed as an LGBT Health Clinic (Legacy Community Health Services).7 Did you know in Texas Health and Safety Code sec. 85.007(b) that education programs for those under 18 years of age must “state that homosexual conduct is not an acceptable lifestyle and is a criminal offense under Section 21.06, Penal Code”? Are you aware that affirmative defense (Romeo and Juliet Law) does not apply to LGBT persons? We have to use our power as citizens to speak. “For the ones amendments do not stand up for. “For the ones who are forgotten. For the ones who are told to speak only when you are spoken to and then are never spoken to. Speak every time you stand, so you do not forget yourself.” – Anis Mojgani
Last and never least, for those who are a part of the LGBT community, there are some things I hope I can talk with you about as a physician. Unless it is dangerous to your wellbeing or the wellbeing of others, my priority is building an open relationship with you and maintaining confidentiality. Your health-maintenance screening is the same as every other person of your sex and age. We want to see you for yearly exams, address concerns, talk about high-risk practices, perform appropriate STD testing, talk to you about prevention care, and offer treatment, counseling, and access to other resources. In 2010, gay and bisexual men accounted for 63 percent of new HIV cases in the U.S.8 I mention this not to stigmatize—this is fact. We have to start addressing these medical issues together and talk about very real exposures and ways to prevent their occurrence. Our goal as physicians is not to just treat the diseases we diagnose—we want to help keep them from occurring in the first place. The only way to do this is for us physicians to realize our lack of knowledge in this area and for you as patients to help guide us in caring for you.
Sarah Tran is a Family Medicine physician completing her training at Houston Methodist Hospital. She is also a contributing editor of You, Me & Charlie – a collaborative of artists and creators sharing music, film, art, and life. She loves stories told in all forms and is physically moved by love, music, social justice…and coffee.
3. https://www.healthcare.gov/married-same-sex-couples-and-the-marketplace/ 4. http://www.texastribune.org/2014/09/16/texas-tops-census-list-highest-uninsured-rate/