LGBT Healthcare in Post Affordable Health Care Act America

By Kiana Green

April 8, 2018

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There has been an ongoing health epidemic that has plagued the LGBT (lesbian, gay, bisexual, transgender, etc.) community since the 1980s. The spread of the AIDS/HIV epidemic and other health issues within the community were more understandable during that era considering the fight for LGBT issues were still within its beginning stages. Homosexuality was classified as a mental disorder until 1973 so most research and literature were based on the "causes" of homosexuality rather than studying the health issues that affected this community (Boehmer 2002). Even though more studies were being conducted around the 1990s, many of them were not very inclusive of the many different aspects of the LGBT community (regarding individual health needs within the spectrum) so many individuals within the community were neglected when strides in healthcare were made. It has been a little over forty years since the beginning of the LGBT gay rights movement and although there has been a lot of progress in LGBT rights (such as the passing of the Affordable Care Act that includes LGBT focused rights), inadequate health care seems to be an issue that is still a difficult one to solve. The point of this research is to discover a few of the main causes of health care disparities that are still affecting the LGBT community and how to solve them. In order to adequately accommodate the LGBT community's health care needs, there needs to be an improvement in inclusivity in hospital environments, an implementation of LGBT health needs in medical school curriculum, and a change to the way policymakers create and implement their LGBT policies and laws.

In 2010 Barack Obama signed the Affordable Care Act into law. According to the Family Equality Council, the law prohibits discrimination based on sex (which includes sexual orientation and gender identity) and health status, including HIV status and being a person who identifies as transgender ("The Affordable Care…" 2018). Before the Affordable Care Act, fewer families that had parents that were a part of the LGBT community had health insurance compared to the rest of the population. It was harder these families to afford insurance because most employers did not offer coverage for same-sex partners or their children so it was more expensive for parents to have separate insurance plans for their family ("The Affordable Care…" 2018). Now, through the law, families with LGBT parents are able to afford health insurance at the same rate as the general population and are able to receive the same kind of coverage as the general population as well. People that identify as transgender also have increased access to coverage due to the fact that they can no longer be denied access based on their identity or expression ("The Affordable Care…" 2018). The Affordable Care Act laid a basic foundation for LGBT rights in the healthcare system as far as giving them more access to care for the LGBT community, but it does not give hospitals or their states' policymakers a detailed roadmap on how to best execute quality care for LGBT patients. Without any specific directions to lead health care providers towards the goal of improving the quality of health care for LGBT patients, hospitals are left to create their own ideas of inclusivity that usually misses the mark.

Many hospitals and doctors' offices have a plaque or framed poster of their anti-discrimination policy on their walls, but that is the only physical evidence that these settings are inclusive towards LGBT patients. The lack of LGBT ideals in posters and health-related handouts in public hospitals create a negative atmosphere for LGBT individuals. Majority of public hospitals display posters and pamphlets that are heterocentric, meaning that they only display posters and pamphlets centered on heterosexual lifestyles. LGBT individuals that seek medical help within public hospitals deserve the right to receive the same exposure to helpful information displayed in hospitals that heterosexual individuals receive. Displaying LGBT posters and pamphlets will also let LGBT individuals know that they can trust that their clinicians care and are knowledgeable about LGBT health issues before getting past the front desk.

LGBT inclusive medical forms also need to be implemented alongside inclusive posters and handouts. LGBT individuals that are forced to fill out medical forms that only have binary gender and sexual orientation categories that they do not identify with are more likely to have their mental health and self-esteem which can be isolating for them (McWayne et al., 2010). There needs to be a revision to medical documents that displays LGBT identities with options that do not just regard them as "other". The stress of having to classify themselves as an "other" or not having forms that give them an opportunity to self-identify properly can cause LGBT individuals to cease seeking medical attention before even meeting their health care provider. Having inclusive medical forms will also ensure that LGBT patients will receive better care because health care providers will be able to better identify LGBT patients' situations and needs.

Hospitals need to add more family bathrooms to their offices in order to make LGB individuals (especially Transgender patients) more comfortable in the office (Unger 2017). There has been a lot of discussions around allowing Transgender individuals to legally use bathrooms that they identify within the United States in the past few years and implementing family bathrooms will help to quell any speculation on whether or not a certain individual should be allowed to use the bathroom within a hospital setting. Individuals that identify as non-gender conforming will also benefit from having bathrooms as having to choose between bathrooms that they do not identify with at all can be very stressful for them as well.

In addition to making forms, posters, and bathrooms more inclusive, hospitals should implement staff diversity training that teaches employees how to interact with LGBT patients (Unger 2017). Better training for prospective and current medical professionals in LGBT health needs will help to create a better inclusive environment for LGBT individuals because these professionals will know how to best attend to their LGBT patients. Individuals who are a part of the LGBT community are more likely to continue to seek care in offices where they do not have to explain their gender identity and sexual orientation. LGBT patients will also continue to seek care if they feel that there are plans put into place that ensures their rights are being protected before they enter the examination room. Former President Barack Obama issued a memorandum in 2010 that instructed hospital administrators and staff to develop a protocol to ensure that individuals are not discriminated against in a medical setting on the basis of sexual orientation or gender identity (McWayne et al., 2010). The story that compelled Obama to issue the memorandum was centered on a couple, Janice Langbehn and Lisa Pond. Lisa and Janice were on vacation when Lisa collapsed and had to be taken to the hospital. Janice was barred from going into the room to be by Lisa’s side and was not allowed to have any information about Lisa’s condition. Janice stated that the nurse told her that she was in an “anti-gay city and state” so Janice was not allowed to enter Lisa’s room. The nurse also told Janice that if she wanted to have any information on Lisa’s condition, Janice would need to have health care proxies (which states that Janice is allowed medical information and can make medical choices for Lisa if Lisa is unable to make them for herself). Janice had the health care proxies faxed to the hospital, but it was not until Lisa’s sister arrived at the hospital that Janice was allowed to know any information. Lisa died without Janice being by her side and that prompted Obama to commission the memorandum so that no other LGBT couple would have to endure that situation. This memorandum was a huge step forward for LGBT medical rights and made LGBT individuals and their families feel much safer in hospital situations.

Although it is helpful to have diversity training for clinicians that are currently practicing medicine, it is also very important to create a more inclusive curriculum for prospective medical professionals regarding LGBT sexual orientation and gender identity. According to Cecile Unger in her "Care of the Transgender Patient: A Survey of Gynecologists' current knowledge and Practice", Unger states that in her 2015 survey that was conducted based on OB Gyns' current knowledge and practice regarding LGBT care, only one-third of respondents indicated they were comfortable caring for transgender patients, one-third were only knowledgeable about steps to transition, and less than half were familiar with recommendations for the routine health maintenance and screening of patients such as pap smears and mammograms for transgender patients. This survey was sent to nine medical institutes across the country and only 141 out of the 352 providers that received the survey actually responded to it. Unger's survey displays two things: 1) Healthcare providers lack the education needed to adequately treat LGBT needs. And 2) Not many healthcare providers want to address their views and knowledge on LGBT care. Referring back to the introduction in which I stated that homosexuality was considered a mental disorder until 1973, the fact that medical students circa 1973 and in the recent years afterward would still have the mentality that they should handle LGBT health-related issues a product of a mental disorder is understandable. Medical professionals and institutes had to suddenly omit relating mental illness to homosexuality from their curriculum. But it has been 45 years since the classification change and there has not been a change in the curriculum to ensure that health care providers are educated on LGBT health issues. Unger's survey found that transgender patients who had to teach their clinicians about their transgenderism were four times more likely to postpone or not seek medical care compared to transgender patients that postponed or did not seek medical care due to discrimination. Having a curriculum that includes LGBT health issues and needs will help to create a more open relationship between practitioners and their LGBT patients (McWayne et al., 2010) and can also encourage LGBT individuals to seek health care more often.

The second finding of Unger's study, the fact that majority of the providers did not respond to the survey, shows that there are a lot of health care providers that are not willing to address their roles in LGBT health disparities and discrimination. It is no surprise that there is a large number of health professionals that are not comfortable with tending to LGB especially Trans patients. Within the last 20 years, there has been a struggle between health care professionals’ moral/religious rights and women's/LGBT health needs. George W. Bush first implemented policies during his presidency to protect healthcare workers' religious liberty (Shugerman 2018). The American Medical Association were against these policies due to the fact that they were too broad and allowed workers to refuse services such as birth control, blood transfusions, or treatment for gay men with AIDs (Shugerman 2018). These policies were terminated because they further instigated discrimination in the health care system toward LGBT patients in the name of religious freedom. President Trump is currently in the process of trying to reinstate these policies as of January 2018 which would be a step backward for women's and LGBT rights and will further the divide between these patients and their healthcare providers. These policies and the lack of effort put forward by health care professionals to bridge the gap of understanding between their patients sends the message that health care providers are unwilling to take care of their LGBT patients’ needs under the guise of moral and religious reasons. Health care professionals must understand that their religious and nonmedical moral reasons for denying care such as blood transfusions and treatment for gay men and those infected by AIDS/HIV are professionally unethical, discriminatory, and dangerous for these patients and society.

Denying individuals that are gay the right to donate blood and plasma based on their sexual orientation is also detrimental to society. When disasters occur (whether they are natural or man-made) people in need of blood donations deserve the opportunity to receive help from eligible individuals who are willing to donate. Across the nation, medical centers are prohibited from allowing gay men or individuals who have come into contact with gay men from donating blood within the last 12 months from their last sexual encounter. According to the American Red Cross website (underneath their LGBTQ+ tab), only in recent years did the FDA decide to change their regulations on deferring gay men from donating blood from a lifetime deferral to a 12-month deferral from the time of their sexual encounter. The issue that remains with this decision is that the American Red Cross states that "At present, there are insufficient scientific data available to determine whether it is safe to rely only on individual behavioral risks factors when determining donation eligibility" (American Red Cross 2018). The ARC's statement shows that there is no real basis for the FDA's decision to defer gay men from donating. This point is further proven to the follow-up question that potential transgender donors might ask which is: "I am a trans man, and I have been eligible to donate because my assigned sex at birth was female. However, I have had sex with another man. Can I donate?" (American Red Cross 2018). The ARC's answer to this question is that transgender males are still unable to donate until 12 months of having sex with another male. The implementation of these types of rules without much research to justify them is an act of discrimination based off of historical stigma associated with gay men and AIDs/HIV. Blood and plasma donation centers conduct screening tests for infectious diseases before they send off a donor's blood and plasma so the pre-screening questions that relate to sexual orientation are unnecessary and not proven to be helpful when determining a donor's eligibility. Although the decision to change the deferment from lifetime to 12 months is progressive, it is still heavily influenced by biases towards the gay community that was seen in the original decision to bar gay men from donating at all. Policy makers, like the FDA, need to create anti-discrimination policies and laws that are based on adequate amounts of research and are less vague towards the issues that they are trying to solve. This will help to improve the quality of the policies and laws that are supposed to benefit the LGBT community and the rest of society.

Additionally, policymakers must also work harder at including the voices of the LGBT community and its advocates. It is true that not all policies and laws are impacted by the same factors. LGBT anti-discrimination laws are impacted by political and social factors and the result of the policies depend on who the majority social and political groups are in the state (liberal or conservative). There is a discrepancy of anti-discrimination laws between states and even within states due to the ever-changing political climate that is in the United States. In Taylor's (et al., 2012) exploration of what determines the creation of anti-discrimination laws and policies made for the LGBT community, they found that liberal states and Democratic legislatures are more likely to adopt laws and policies compared to more conservative states and legislatures.

During 2015 and 2016, Indiana considered passing an LGBT-rights bill that would prohibit discrimination in housing, education, public accommodations, and employment based on sexual orientation and gender identity but has exceptions for religious organizations and some vendors who work in the wedding industry ("Republicans…" 2015). The debate that surrounded the bill is if the rights of people within the LGBT community should be protected like they are for people based on race and religion. The bill was proposed after a poll conducted by Angie's List Inc. CEO and LGBT-rights advocate, Bill Oesterle, found that most Indiana voters support adding sexual orientation and gender identity to Indiana's civil rights law ("Republicans…"2015).  This is an important study considering that according to the Pew Research Center, 42% of registered voters in Indiana vote Republican, 37% vote Democrat, and 20% have no affiliation (Pew Research Center 2014). With Indiana being a red state (majority conservative voters), it is unlikely that LGBT protection laws would be created or even passed and it was proven so when Republican Senators assembled and decided to not give further discussion on the bill or pass it on the basis that there was not "enough Republican support" for it (Wang et al., 2016). Even though a majority of Indiana's voters believe that LGBT individuals should be protected under civil rights laws, the majority political party still impacts whether or not a policy or law reflecting those beliefs will be passed. Indiana's legislature is a perfect example of how difficult it is to progress with LGBT rights when there are no voices within the room that speak for the LGBT community. There were no LGBT individuals or advocates in the room to fight for the bill to at least have a proper discussion so it was highly unlikely to be passed.

There need to be more LGBT voices within medical boardrooms and legislature in order for LGBT anti-discrimination laws and policies to be taken more seriously in environments that have a tendency to oppose them.  Ensuring LGBT individuals and advocates are a part of the process will reduce the number of loopholes within healthcare and anti-discrimination policies and laws and will also ensure that no group is left out of the discussion. In Davis and Berlinger's "Moral Progress in the Public Safety Net: Access for Transgender and LGB Patients", Davis and Berlinger discuss the negative impact that the Affordable Health Care Act has on the transgender community. According to their article, Transgender patients are at a higher risk of discrimination when seeking health care and the Affordable Care Act does not include the health needs of this particular group.

Furthermore, policymakers also need to focus on how their anti-discrimination laws and healthcare policies affect the hospitals that are supposed to adopt them and find ways to help financially support hospitals so they can uphold these laws and policies. Davis and Berlinger also talk about the negative impact the Affordable Care Act has on public hospitals. They discuss how Medicare and Medicaid policies have limited the number of patients that need to stay more than two nights of care in public hospitals (which specifically affects transgender patients). Transgender patients sometimes have the need to stay in hospitals for more than two days when they have complications from transitioning, but cannot have that need met due to Medicare's policies for public hospitals. If hospitals fail to comply, they will be audited by Medicare auditors and lose more funding. Public hospitals are also suffering due to the reduction of payments they receive if they are considered a "disproportionate-share hospital", the fear of losing even more funding is making it harder for medical professionals to help low income or "difficult" (transgender) patients when they already do not have the funds to support them. Policy makers need to reform their policies in order to take into consideration the financial status of public hospitals that are caring for LGBT patients that have needs that go beyond what the ACA covers and what the hospitals can afford.

After considering some of the biggest factors that contribute to LGBT health care disparities it is simple to see why tackling the issue can seem very daunting to members of the community and would just be simpler for them to cease seeking care. But living in a first world country, no member of any group (be it a part of the LGBT community, lower socioeconomic class, or ethnic minority) should be discouraged from seeking health care. It is up to the medical professionals, the general population, and policymakers to work together to improve the quality of health care for the LGBT population. It can be achieved by reflecting LGBT issues and ideals in hospital environments, properly educating current and prospective medical professionals on LGBT health needs, and making sure that there are LGBT and public hospital medical professional representation present during policymaking.

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