“I’m going to a drag show tonight.”
My third-year resident asked what I was doing with my day off, and my reply, the gayest of weekend plans, gave her pause.
I felt the same awkward beat in our otherwise amiable conversation, saw the same uneasy shift in her seat, just the day before when I told her about a date I had been on. I’m not exactly inconspicuous about my sexuality in the first place, so I wasn’t prepared for her to be surprised that I’m beyond-a-shadow-of-a-doubt-gay. I had felt uncomfortable for making her uncomfortable, and wasn’t exactly sure why. I wondered if I was allowing some sort of personal insecurity or professional courtesy insinuate discord in a completely innocuous conversational pause. So I could have said “I’m going out” or to a bar, or something similarly vague, but I wanted to test the waters. I wanted to confirm a suspicion that it wasn’t just me, and it wasn’t just once.
I have spent the last 11 months as a student in North Carolina’s largest not-for-profit hospital system, and in all that time, have heard very few LGBT physicians speak openly about their lives. Even in conversations overheard in communal spaces — about Tinder dates and husbands, the antics of beloved children, office politics, hectic schedules and Blue Apron dinners — the lives of LGBT people are rarely discussed. When they are, it is in hushed tones and whispers. Physicians in particular seem reticent even to say the word “gay,” and I can only imagine why. For some, it is likely out of fear of offending coworkers or patients — for saying the wrong thing in front of the wrong person. For others, whom I hope are in the minority, maybe it is out of some actual disdain for LGBT people. For most, however, I suspect it is simply because they are not accustomed to thinking about LGBT people, and so personal, real, non-political discussions about us seem foreign and uncomfortable, an ill-fitting glove on a surgeon’s busy hand.
Even the other residents, many just a few years older than myself, seem to get a bit squirrely when the topic of conversation involves the LGBT community. They shy away from discussing the topic, and for many, their few interactions with the LGBT community are not enough to remind them of our existence. What then is the motivation for these future leaders of health care to learn about the health of our community? How can they be expected to empathize, to relate, to communicate on a deeply personal level with us, their patients?
The interpersonal ease needed to establish trust between patient and provider might come easily to some, but it is only the first barrier. As physicians and physicians-in-training, we ask patients to disclose, often through uncomfortable social and sexual histories which may go beyond the limits of our own experiences. Then, we critique them, offering suggestions for risk reduction based on our medical expertise. In order to do this effectively, we must know about communities to which many of us are not members. A heterosexual, white, female physician should be able to stratify STI and HIV risk beyond the level of “gay versus not gay,” and tell a bisexual man of color about his statistically higher risk of HIV infection compared to that of his white or Hispanic peers. To do so, she must also know that HIV is on the rise in many male sexual minority communities, and that even protected sex is not 100 percent safe because diseases such as syphilis and herpes may be transmissible even with the use of a condom. She should also know that putting patients on pre-exposure prophylaxis (PrEP) medications can decrease the risk of sexually transmitted HIV infections by over 90 percent in high risk individuals, which includes approximately one in every four men who has sex with men — but in 2015, only one in every three primary care doctors and nurses even knew about PrEP.
Our hypothetical physician must evaluate her patient’s need for PrEP, but she also can’t forget to have discussions about tobacco, alcohol and drug abuse and screen for depression, each of which is significantly more common in LGBT patients. If her patient happens to be transgender, she must broach the idea of STI and cancer screening in organs that the patient may feel very negatively about, or be trying to forget. Perhaps her patient would like to affirm their gender identity with hormones or surgery; what then? Not only does she have to be confident and tactful when talking about these sensitive subjects with her patients, her knowledge about them has to be up-to-date and community-specific.
Transgender people have needs that are not shared by their LGB peers, which providers may be particularly unlikely to recognize. According to the National Transgender Discrimination Survey, 50 percent of respondents reported having to teach their doctors about trans* health, which includes an enormous number of health care disparities. For example, the rate of attempted suicide in the community is egregiously high at 41 percent, and the prevalence of HIV is four times higher than the national prevalence. Even more upsetting, though, are the social inequities suffered by trans* patients. 55 percent of trans respondents to the NTDS reported losing their jobs simply because they are trans*, and 16 percent had to resort to illegal trade of sex or drugs in order to survive. Kids are not impervious to these disparities, either: the rate of bullying of trans* kids in schools is nightmarishly high (78 percent), with nearly one-third having been physically, and one in 10 sexually, assaulted.
Health care providers, however, are only one component of the disparity perpetual motion machine that is a health care system designed for profit. After all, lesbian, gay and bisexual people are all less likely to have insurance than straight people (even following implementation of the ACA), or even a usual place to go for medical care. Bisexual and lesbian women in particular are less likely to obtain medical services, including preventative screening, due specifically to cost. Trans* people too are significantly underinsured and have worse health outcomes than even their LGB peers; yet, 19 percent of trans* people have been refused medical care in the past simply for being transgender.
Although a national problem, health disparities within the LGBT community are even greater in the South. Never a state to discriminate discriminately, Tennessee recently passed SB1556, a bill that allows therapists and counselors to refuse service to all variety of LGBT patients when treating them is contrary to any physician’s “sincerely held” beliefs. In Mississippi, HB1523 allows universities, government employees, contractors and private businesses, which includes nearly all of the state’s health care providers, to similarly discriminate against LGBT people on the basis of religious beliefs. Here in North Carolina — ground zero for state-sanctioned LGBT discrimination — HB-2 requires that transmen and transwomen use the public restroom congruent with the gender assigned to them at birth. It also eliminates expanded LGBT anti-discrimination policies that previously existed in some cities, removes all local authority to increase minimum wage and benefits for public contractors and abolishes state-level legal recourse for employment discrimination. Other states too have tried, and failed, to pass the same type of bigoted legislation, including Georgia, Kentucky, Indiana, South Dakota and West Virginia.
Justice in health care alone cannot solve all of these problems, but it is one of the most important interventions for the elimination of disparities affecting the LGBT community. It is imperative that we all become advocates for LGBT health equity, beginning with the adequate training of health care providers. Ask your colleagues if they have any training in LGBT health, refer friends, residents and attendings to LGBT Health Education for free CME, and use the HRC Healthcare Equality Index to determine how LGBT-inclusive your medical center is. Implement the guidelines proposed by national organizations like the Joint Commission, The Fenway Institute, or Gay and Lesbian Medical Association to improve patient care and the environment for learners and employees. The antidote to division and disparity is unity; educate yourself, find a way to make and difference, and get involved.