LGBT patients: Reluctant and underserved
■ Lesbian, gay, bisexual and transgender patients sometimes postpone care because of discrimination concerns. Sometimes health professionals chase them away unknowingly. Here are ways to combat that.
Some patients of family physician Robert J. Winn, MD, travel more than 500 miles for routine care at the Philadelphia health center where he works. Most are transgender. Others are lesbian, gay and bisexual.
They live in East Coast towns that stretch from upstate New York to southern Virginia. And all are looking for the same thing -- a physician who understands them.
"It's ridiculous to get health care from 500 miles away," but they don't have anywhere else to go, said Dr. Winn, medical director of the Mazzoni Center, an LGBT health care and wellness facility. He also teaches in the Dept. of Family and Community Medicine at Jefferson Medical College of Thomas Jefferson University in Philadelphia.
An estimated 8.8 million Americans (3.8% of the population) say they are lesbian, gay, bisexual or transgender. Experts say the actual figure probably is higher, but data on this population are limited, and there are many LGBT people who do not report their sexual identity for fear of discrimination.
In general, LGBT people have an increased risk of developing cancer and contracting sexually transmitted diseases, including HIV, experts say. They also are more likely to drink alcohol, smoke, use drugs, be overweight, attempt suicide and engage in other risky behaviors than heterosexual counterparts, according to physicians who specialize in treating LGBT individuals. Yet they remain medically underserved, data show.
Twenty-eight percent of transgender and gender nonconforming people postponed medical care when they were sick or injured due to concerns about discrimination, said a 2010 survey of about 7,000 people by the National Center for Transgender Equality and the National Gay and Lesbian Task Force. Gender nonconforming individuals are defined as people who do not fit stereotypes about how they should look or act based on the sex they were at birth.
More than one in five LGBT adults withheld information about their sexual practices from their doctor or other health care professional, said a 2004 survey by Witeck-Combs Communications/Harris Interactive.
Physicians specializing in LGBT care say discrimination by doctors and staff often is unintentional. Experts recommend educating health professionals about LGBT issues and making medical practices more welcoming to all patients.
For example, experts encourage doctors to place LGBT literature in waiting rooms and to post nondiscrimination statements that include gender identity and sexual orientation.
Experts note, however, that there are some instances in which health professionals knowingly are biased against LGBT individuals. Some of Dr. Winn's patients told him about being scolded by physicians for identifying themselves as LGBT and doctors offering them information "about how to not be gay."
"It's 2011. It's hard to believe that's even out there. But it is," said Dr. Winn, who is bisexual and married to a woman.
Physicians who do not believe they can provide unbiased or appropriate care for LGBT patients are encouraged to refer them to other doctors. But primary care physicians should be able to care for this population, said Joe Freund, MD, a family physician in Des Moines, Iowa, who specializes in treating LGBT patients. "It's just an awareness issue," said Dr. Freund, who is gay. "We don't need to make huge, major changes. People are just afraid of things they don't know."
Identifying LGBT patients
An estimated 3% to 6% of patients seen by doctors identify themselves as LGBT. Although they represent a small portion of patients, these individuals are an important population because of their increased health risks and tendency to avoid or delay preventive health care, experts say.
Nearly 40% of lesbian, gay and bisexual people put off medical treatment because they are concerned about the cost of health care, and nearly 40% said they do so because of a lack of adequate health insurance, according to a 2005 Harris Interactive survey of more than 2,000 adults (patients could give more than one answer). One in five LGB individuals delayed care due to a bad experience with a health professional, and 15% did so because of concerns about discrimination.
Of the health care-related bias that LGB patients reported, 16% of incidents occurred in the office of a physician or another health professional. Other common places of discrimination included public health departments and clinics (15%) and hospitals (14%).
Physicians say such bias often involves inappropriate comments by health care staff about a patient's sexual orientation or gender identity and refusal to treat individuals because of their LGBT status. Complicating matters, some physicians do not think they have LGBT patients and do not take steps to make such individuals feel welcome.
Austin, Texas, family physician Terrance Hines, MD, uses an intake form that allows new patients to write their gender in a blank space. The form also allows patients to note who lives with them, rather than offering standard choices of "alone, spouse, children and parents."
Doctors need to make sure patients feel comfortable at a visit, said Dr. Hines, a gay physician who is vice chair of the American Medical Association's GLBT Advisory Committee. One way to accomplish that is providing open-ended questions on new patient intake forms, said Magda Houlberg, MD, a Chicago geriatrician, internist and HIV specialist.
"Many LGBT people look at [medical] forms and documents to get an idea if it is a safe place for them to be," said Dr. Houlberg, who is a lesbian. "If a form gives them no option [to identify themselves as LGBT], it gives the notion that people here are not aware" of LGBT issues.
Just as important, experts say, is that physicians ask patients about their sexual behavior when they take a sexual history during an office visit. Dr. Freund asks patients, "Do you have sex with men, women or both?" He said this question opens the door for LGBT patients to express their sexual orientation.
"Every practice has LGBT patients. It's just that we don't recognize them because we either aren't looking for them or aren't open to them," said Dr. Freund, who works at Planned Parenthood of the Heartland Family Practice Center in Des Moines.
The consequences of not identifying this population are missed opportunities for preventive care that probably lead to increased rates of morbidity and mortality among LGBT patients, said Dr. Houlberg, chief medical officer at Howard Brown Health Center in Chicago. The center specializes in treating LGBT adults and youths.
There are limited studies on the health disparities of the LGBT community. But that is expected to change after a March Institute of Medicine report urged researchers to engage LGBT people in health studies to identify and better understand health problems that affect them.
Until that occurs, Dr. Houlberg said LGBT people will remain an invisible population involved in what she calls a silent epidemic. "Not only can we not address the health disparities, we can't prove them, either."
Taking steps in the right direction
Some reports have shown that LGBT people are 40% to 70% more likely to smoke cigarettes than heterosexuals. They also are more likely to have higher rates of alcohol use and substance abuse, said the Dept. of Health and Human Services.
Additionally, each group within the LGBT population has distinct health risks that primary care physicians should know, Dr. Winn said.
Gay men often are more sexually active than heterosexual counterparts and have a greater risk of contracting sexually transmitted diseases, he said. For these patients, doctors are encouraged to focus on discussing safe sex. Gay and bisexual men should be screened regularly for STDs.
Dr. Winn also said physicians should be aware that gay men have higher rates of bulimia and depression than heterosexuals.
He recommends that doctors speak with lesbian patients about birth control options, because some lesbians have sex with men. He also encourages physicians to be aware of this group's slightly increased risk of breast cancer because many do not get pregnant. The hormonal changes that occur during pregnancy might reduce a woman's chances of developing the disease, according to the National Cancer Institute.
Transgender people are among the most at risk in the LGBT population, and many are victims of violence, Dr. Houlberg said. For preventive care of this population, Dr. Winn recommends that physicians follow screening guidelines for the body parts the patient has. For example, if a person who was born a man has breasts due to hormone treatment, doctors should follow mammography guidelines.
Physicians who specialize in LGBT care say primary care doctors should seek out educational courses on LGBT issues and how to best serve this population. They urge physicians to pass the information to their staff.
AMA policy promotes educating medical students about LGBT health issues. The Association opposes discriminating against physicians, medical students and patients because of their gender identity and supports educating doctors about LGBT research.
Experts say progress is being made on the federal level to address health issues that impact LGBT individuals. Among the efforts is a National HIV/AIDS strategy, introduced in 2010, that aims to lower the number of new HIV cases in the United States by 25% within the next five years. And Healthy People 2020, for the first time, set a goal of improving the health, safety and well-being of LGBT people.
Dr. Freund of Planned Parenthood said such actions show that the public realizes there are health disparities among LGBT people. "These are little, bitty baby steps" for the LGBT community. "But this is like the hope shining."