Out On The Couch
With the global COVID-19 pandemic continuing into its second year, the conversation around access to healthcare has never been more relevant. For many people, going to a doctor for an annual physical was not feasible before the pandemic, whether due to lack of insurance coverage, financial cost, taking time off from work, transportation issues, or anxiety around healthcare-related trauma. On top of this, the added stress of COVID-19 exposure risk has led many to postpone necessary care. LGBTQIA+ people often face an additional barrier: whether the provider they see will be affirming, supportive–or even safe.
Primary Care as a “Medical Home”
Primary care is founded on a “medical home” model, meaning that patients will return periodically to the same practice, developing a relationship with their provider or medical team to ensure high-quality, comprehensive healthcare (Rosenthal, 2008). This can include physicians, nurses, social workers, and non-medical staff in the office. In an article for the Journal of American Board of Family Medicine, physician Thomas Rosenthal writes that “When people get sick, they use stories to describe their experience,” and goes on to say that “patient-oriented care is bound up in a physician’s ability to accurately perceive the essence of a patient’s story” (2008, p. 428).
This is a fundamental principle of the medical home model, and it speaks to the importance of primary care providers demonstrating expertise in LGBTQIA+-affirmative care. By gaining an understanding of how LGBTQIA+ people live and experience the world, providers build an essential framework for interpreting their stories and addressing their concerns. In this way, LGBTQIA+-affirmative primary care becomes a partnership, with patients and providers allying together to promote good health.
Social Determinants of Health in Primary Care
Furthermore, there has been a push in recent years for primary care practices to focus on the impact of social determinants of health–the factors that impact a patient’s well-being outside of their physical traits. Emerging from the Center for Disease Control and Prevention’s Healthy People 2020 campaign, social determinants of health include elements like poverty, depression, alcohol or drug use, social isolation, and exposure to violence in one’s home or neighborhood (CDC, 2020). To incorporate this into the flow of the office visit, patients may answer a paper or digital questionnaire about their experiences, or may be interviewed by a medical professional. In their medical homes, patients would ideally feel comfortable answering questions about such sensitive topics, as they have a relationship with their team.
However, without expertise in LGBTQIA+-affirming care, this is not always the case. Additionally, there is evidence to suggest that LGBTQIA+ people are more likely to be impacted by one or more of these elements due to the social stigma of being out in their communities (Knight et al., 2014). In a 2014 study of LGBTQIA+ youth in primary care, researchers examined the impact of “a set of social conditions that influence [the] health-related outcomes [of LGBTQIA+ people], including heteronormative and cisnormative assumptons, stigma, and social exclusion” (Knight et al., p. 662). In addition, queer and trans people comprise a large percentage of the gig economy and part-time workforce. As such, they are less likely to have employer-sponsored health insurance coverage, and are less likely to be able to afford out-of-pocket insurance costs (National LGBTQ Workers Center, 2018). This means that members of the LGBTQIA+ population may not make it to the doctor’s office at all when they are sick. As our understanding of health changes, primary care must be responsive to it.
With so many barriers to accessing healthcare, skipping appointments or going long times in between them is a reality for many LGBTQIA+ patients. Particularly during a global pandemic, this has become commonplace, and even necessary, for many people. But foregoing essential healthcare can have significant and long-lasting impacts on patients’ physical and mental health. A 2019 study in BMC Medicine concluded that missed appointments comprise a significant risk factor for increased comorbidities and overall mortality (McQueenie et al.). This means that patients who skip necessary appointments are likely to only get sicker. LGBTQIA+ people are at unique risk for various health problems as well, including higher rates of depression and substance abuse, as opposed to the general population (Ng & McNamara, 2016).
The need for affirmative care surfaces in the long-term treatment of HIV, for which LGBTQIA+ people–particularly gay men and transgender women of color–face a disproportionate risk (Feldman et al., 2014). HIV is a chronic illness that is often managed by a patient’s primary care provider. With daily medication and regular follow-up, patients can live healthy lives. However, this depends greatly on a patient’s retention in care, i.e. their ability to stay connected to their provider and maintain adherence to their medication regimen. When we factor in the influences previously mentioned, this becomes an increasingly challenging task.
Trans-Affirming Medical and Mental Healthcare
As the patients’ medical homes, primary care providers serve as liaisons to other specialties (Rosenthal, 2008). We know about the negative impact of postponing necessary health maintenance, but to make matters worse, LGBTQIA+ people without primary care providers are cut off from necessary specialist care. For transgender and gender non-conforming people, medical transition may be inaccessible without documentation of treatment by a primary care provider. While some clinics have adopted an informed-consent model for cross-gender hormone therapy, the majority of gender-affirming surgeons require that patients have a working relationship with not only a primary care provider, but a mental healthcare provider as well.
Depression and anxiety are 1.5 times higher in lesbian, bisexual, and gay adults than in the general population (Ng & McNamara, 2016). In a 2017 study of over 400 transgender adults in primary care, foregoing or postponing medical care due to fear of discrimination was associated with poor mental health, including increased incidence of depression and suicide attempts (Seelman et al). This suggests that the impression of discriminatory or stigmatizing healthcare practices is out there, and is acting as a barrier to care for many transgender patients before they even get in the door. When trans people are denied medical transition care, whether due to lack of access to healthcare services or to medical gatekeeping, the impact on their mental health can be devastating. In a population already at disproportionate risk of poor mental health and increased substance abuse, this is not a risk we can afford to take.
By developing a continuous relationship with their patients, primary care providers can foster trust with them to address health inequities. Many patients feel uncomfortable discussing their sexual and reproductive health with providers, and providers who are not trained in LGBTQIA+-affirming care may fumble or avoid these conversations altogether. Assumptions around patients’ sexual behaviors can lead to missed opportunities for STI screening and reproductive health counseling. For example, providers may believe that women who identify as lesbian or bisexual do not need the HPV vaccine or routine Pap smears, and may forego inquiring further about sexual behavior or partners. A 2018 qualitative study included interviews with 39 assigned-female-at-birth patients about their experiences with reproductive healthcare, revealing discrepancies in treatment but indicating similar needs between cisgender, heterosexual patients and LGBTQIA+ patients (Wingo et al.). This suggests that reproductive healthcare providers must be both well-versed in LGBTQIA+-affirming practices and also practice from what Ng & McNamara (2016) refer to as an anatomical inventory, or “screen what you have” model.
The authors suggest that providers “screening for breast, cervical, and prostate cancer…should consider an individual patient’s surgical history and hormonal status” (2016, p. 535). This means that, for example, transgender men or gender non-conforming people who have had a mastectomy may not need breast cancer screening. By “screening what you have,” physicians can individualize care to the needs of a specific patient, and further avoid making gendered assumptions or using exclusionary language like “women’s health screenings.”
The Imperative of Becoming an Affirmative Healthcare Provider
Bearing this in mind, there are a number of practices that primary care offices can adopt to create LGBTQIA+-affirming environments and retain their patients in care. For employees at every level, this can include practical or administrative changes, like changing documentation and medical records to reflect a patient’s sexual orientation or gender identity, or designating gender-neutral restrooms in an office setting (Ng & McNamara, 2016). For medical providers, adopting screening for mental health and substance use disorders is critical when working with LGBTQIA+ patients, as well as shifting cis- and heteronormative assumptions around patients’ responses (Ng & McNamara, 2016; Knight et al., 2014). Increasing education of all staff around LGBTQIA+-affirming care, social determinants of health, and their intersections can improve patients’ experiences in primary care and prevent negative health outcomes.
One final note to consider is that in many studies, recommendations are made for improving primary care practices for providers who are “interested” in LGBTQIA+ populations. This view is outdated and simply no longer reflects the reality of the patients coming into our offices. According to the Williams Institute at UCLA Law School, an estimated 4.5 percent of all Americans identify as LGBTQ+ (2019). These data are several years old, and do not include the responses of adults in Generation Z, who are predicted to identify as LGBTQ+ at higher rates. The message here is clear: whether or not providers have a special “interest” in working with LGBTQIA+ patients, those patients are here in our practices. To serve these community members and promote better health overall, our care must reflect an understanding of their unique needs and experiences, and affirm their LGBTQIA+ identities.
Affirmative Organizational Development Consulting
The Affirmative Couch offers affirmative organizational development consulting for mental and medical healthcare clinics who want to create a safe, welcoming environment for all patients who walk through their doors.
Our consulting team joins your clinic and gathers information to identify all the ways in which you can improve your services for LGBTQIA+ community members. We utilize the community narration approach to begin exploring the mission and values of your organization, and the gaps in service delivery to these communities. Our tailored needs assessment will review our findings from these interactions, offer next steps, and provide the foundation for your ongoing training with The Affirmative Couch.
Through this empowered approach, you will have all the information and support you need to make systemic change in your paperwork, administrative procedures, staff training, and organizational culture. We are here to answer every question in a non-judgmental, non-shaming way to help you become a more affirmative provider.
If you want to learn more, schedule a call with us to discuss your needs!
Centers for Disease Control and Prevention (2020, August 19). About Social Determinants of Health (SDOH). https://www.cdc.gov/socialdeterminants/about.html
Feldman, J., Romine, R. S., & Bockting, W. O. (2014). HIV risk behaviors in the U.S. transgender population: prevalence and predictors in a large internet sample. Journal of homosexuality, 61(11), 1558–1588. https://doi.org/10.1080/00918369.2014.944048
Knight, R. E., Shoveller, J. A., Carson, A. M., & Contreras-Whitney, J. G. (2014). Examining clinicians’ experiences providing sexual health services for LGBTQ youth: considering social and structural determinants of health in clinical practice. Health Education Research, 29(4), 662-670.
Movement Advancement Project & The National LGBTQ Workers Center. (2018). LGBT People in the workplace: Demographics, Experiences and pathways to equity. [Infographic]. lgbtmap.org. https://www.lgbtmap.org/file/LGBT-Workers-3-Pager-FINAL.pdf
Ng & McNamara (2016). Best practices in LGBT care: a guide for primary care physicians. Cleveland Clinic journal of medicine, 83(7), 531.
Rosenthal, T. C. (2008). The medical home: growing evidence to support a new approach to primary care. The Journal of the American Board of Family Medicine, 21(5), 427-440.
Seelman, K. L., Colón-Diaz, M. J., LeCroix, R. H., Xavier-Brier, M., & Kattari, L. (2017). Transgender noninclusive healthcare and delaying care because of fear: connections to general health and mental health among transgender adults. Transgender health, 2(1), 17-28.
The Williams Institute, UCLA School of Law. (January 2019). LGBT Demographic Data Interactive. https://williamsinstitute.law.ucla.edu/visualization/lgbt-stats/?topic=LGBT#density
Wingo, E., Ingraham, N., & Roberts, S. (2018). Reproductive Health Care Priorities and Barriers to Effective Care for LGBTQ People Assigned Female at Birth: A Qualitative Study. Women’s health issues : official publication of the Jacobs Institute of Women’s Health, 28(4), 350–357. https://linkinghub.elsevier.com/retrieve/pii/S1049386717305996