LGBT Health Care: You deserve equal, respectful and knowledgeable care
In
a 2009 survey of LGBT people conducted by Lambda Legal, more than half the
respondents had experienced health care discrimination. Of nearly 5,000
respondents, more than half had experienced health care discrimination. Bias
included patients being refused needed care and health professionals refusing to
touch them.
Currently, there is no federal law that directly says a healthcare provider
cannot discriminate against someone because they are LGBT. However, the
Affordable Care Act (or Obamacare) bans discrimination on the basis of sex,
which courts and government agencies are increasingly coming to see as including
gender identity and sexual orientation. You can even submit a complaint to the
Department of Health and Human Services if you feel you�ve been discriminated
against in this way.
Some states and local jurisdictions have even stronger protections for LGBT
people seeking healthcare. Many states have an Office of Civil Rights or Office
of Human Rights that can take on discriminatory healthcare providers. Connecting
to a local LGBT community center or a lawyer can help you learn about all the
options where you live.
Additionally, the Joint Commission � which accredits healthcare providers �
prohibits hospitals or other accredited providers from discriminating based on
LGBT status. If the provider does not have a public nondiscrimination policy, we
urge you to file a complaint with the Commission.
You deserve to receive the best possible care, and your healthcare providers
have a duty to provide it, especially in an emergency. Although a doctor does
not have to accept new patients in a non-emergency, and every individual you
encounter may not always be perfectly polite, there are many laws and
regulations that might prevent a provider from being able to turn you away for
being LGBT.
As a high school student in the 1960s, Susan DiPronio had an early encounter
with a doctor, and it wasn't pretty. She'd become so upset during class
regarding a youthful crush on another girl that the school called her mother to
come get Susan, and to bring her back after a doctor pronounced her "cured."
During a session, DiPronio was open with the psychiatrist: "I told him why I was
so upset and about my gay feelings, and he discounted them," she says.
DiPronio's mother advised her to "tell him what he needs to hear" so she could
get a clean bill of health and resume classes. DiPronio, who identifies as
lesbian and genderqueer, says she rarely went to see doctors as a young adult,
"because it didn't make sense to me to not be who I was." But when diagnosed
with breast cancer about 13 years ago � with a strong family history, her risk
was high � she had no choice.
Since then, large strides have been made in the awareness and health care of
lesbian, gay, bisexual and transgender patients, although serious gaps exist.
Still, many Americans lack access to LGBT-focused health care. You deserve
respectful, competent and equal care, regardless of your sexual identity. That
means feeling included when you walk into a facility and free to be open about
every aspect of your physical, sexual and mental health with informed, accepting
providers.
Partners Permitted
Living Beyond Breast Cancer, an advocacy and support organization, recently
published a guide tailored to LGB patients seeking quality breast cancer care.
(Transgender patients may have unique health issues, the guide notes, related to
hormone and other treatments.) Sensitive issues are explored, like the pros and
cons of coming out to doctors and nurse, along with a slew of resources and
tips for finding LGBT-friendly providers � whose waiting rooms may display LGBT-friendly
health brochures and posters, or signs or stickers with rainbows or the phrase
"safe space" to show patients they're welcome. Partners must be welcomed too,
says Jean Sachs, CEO of Living Beyond Breast Cancer.
"When you're diagnosed with breast cancer, there are a lot of decisions that you
have to make pretty quickly," she says. "It's a time where you really want to be
surrounded by people you trust."
DiPronio, now a job coach in Philadelphia, recalls a cancer-center experience:
"At the time I was diagnosed, I had a partner, and they were very welcoming to
her," she says. But when a bad reaction to chemo put DiPronio in the intensive
care unit, system rules kicked in. "They made my partner leave the room because
she wasn't immediate family,"
DiPronio says. Distraught, she contacted her oncologist in the middle of the
night. The next morning as she recovered, she found her partner at her side.
A federal mandate requires hospitals to tell patients about the right to have
visitors of their choice, and makes it illegal to discriminate against visitors
based on gender identity.
Wary? No Wonder
Cultural competence for LGBT patients starts with the people sitting at the
health facility's front desk, says Dr. Jesse Joad, president-elect of GLMA:
Health Professionals Advancing LGBT Equality. "When somebody has a spouse and
the spouse is the same sex, that should be a seamless part of the intake that
they're doing. Calling people by their chosen name, calling them by their chosen
pronoun."
Past encounters can harm future health. Lesbians are less likely to get
screening mammograms, although they have more risk factors for breast cancer,
such as higher rates of obesity and smoking, and less likelihood of having been
pregnant, says Joad, who is also a professor of pediatrics and associate dean
for diversity and faculty life emirata at University of California�Davis School
of Medicine. "They're not going to see the health care system because of how
they may be treated," Joad says. GLMA's online provider directory helps you
locate LGBT-friendly health professionals where you live.
Transgender Gap
In the 2009 survey, transgender or gender-nonconforming respondents were most
likely to report health care bias. Transgender patients are likely have the
hardest time finding appropriate care as well. "Most physicians don't know how
to take care of transgender patients," Joad says. "There are specific things to
do with transition that do take some medical knowledge. Certainly it's not
taught in medical school."
Part of the solution lies in preparing new medical students to take care of LGBT
patients. "They're just really ready, willing and hungry to do it," Joad says.
Young and LGBTQ
In June, the Youth Pride Clinic at Children's National Health Center opened its
doors in the District of Columbia for adolescent and young adult patients who
are LGBTQ (the "Q" is for "Questioning"). Adolescence is a time for development,
and sorting out your sexuality is a developmental process � such as coming to
terms with the fact that you may be lesbian, gay, bisexual or transgender, says
Dr. Lawrence D'Angelo, director of the new clinic and division chief of
adolescent and young adult medicine for Children's National Health System.
Health providers can help "with great patience," he says. "Because we don't want
to assume that a person is going to continue the developmental process and feel
the same way about themselves and about their sexuality in two or three years
that they feel currently."
In most states, young people age 13 and older can receive confidential care for
sexually transmitted diseases, pregnancy and sexual and psychological issues,
D'Angelo notes. "I would make sure they're asking their provider, 'Is my care
around sensitive issues confidential?'" he says. "If the answer comes back, 'No,
I have to talk to your parents,' it's time to look for another provider or a
different place to get care."
You may want your parents to be aware of what you're going through, or you may
feel they're not ready to handle it or you're not ready to tell them. D'Angelo
says at his clinic, providers make the offer to speak with parents, which the
patients can accept or not.
Straight Talk for LGBT Patients
About one-and-a-half years ago, Children's National put together cultural
competency training for staff at all levels, D'Angelo says. "One of the things
we try to teach our providers is don't presume. Make sure that your questioning
is open-ended. Make sure you give people the idea that you expect that people
are going to have differences in terms of sexual orientation."
An example of open-ended questioning, he says, is "'Are you having sexual
contact with other individuals that involves the exchange of body fluids?' If
the answer comes back 'Yes,' we say, 'How many partners have you had in the past
six months? How many partners have you had in the past year?' And then, 'Are
your partners men, women or both?'" Some non-LGBT patients might be offended �
and that's a learning opportunity, D'Angelo says. "My immediate answer is, 'This
is a practice that doesn't judge people. This is a practice that's open to
everyone. This is a practice that wants people to feel comfortable, regardless
of who they are. And if you're straight, we want you to feel comfortable with
who you are.'"
Musts to Discuss
The next time you visit your health care provider, bring along a top 10 list of
issues you should discuss together. Created by GLMA, each list targets a
specific sexual orientation and addresses higher health risks faced by LGBT
people.
For lesbians, items to ask about include gynecological cancer and regular pelvic
exams. Gay men should discuss safe sex with providers, along with the need for
immediate treatment after HIV exposure to prevent the virus from spreading
throughout the body. Bisexual patients are advised to remind providers about
current partners, which may affect the screening tests they offer. Transgender
patients should ask about hormone treatments, heart health and other concerns.
Psychological well-being is an important topic for LGBT patients, who are at
higher risk for a number of mental health issues, including substance abuse and
suicide.
Patient Power
When it comes to health care, DiPronio says, "I'm always looking for someone
who's open to listening to me. I have a few doctors who have not been so
welcoming, and I've just moved on. I don't want to ever have to go back in the
closet." She continues, "I'm also at the point where, for many years, I've been
a champion for my own health care. I'm not going to stop or not say, 'I'm
queer,' or not say, 'I want the best care possible.' I'm very aggressive when it
comes to my health care, my friends' health care and that of the people I love."
An "advance directive," also known as a healthcare power of attorney, is a legal
document that names who can make medical decisions for you in case of an
emergency. For example, if you need to undertake surgery and will be unconscious
during and after, the advance directive will say who gets to talk to your
doctors and make choices that arise while you are incapacitated.
Advance directives are especially important for LGBT people because otherwise
healthcare providers might be reluctant to recognize our partners, spouses,
children, families of choice, or friends as the "right" decision-maker.
Additionally, many LGBT people do not want their legal next-of-kin (usually a
parent, sibling, or adult child) to be their decision-maker because that person
may be estranged from them or may not respect their orientation or gender
identity.
Federal regulations require hospitals, nursing homes, and home health aides to
give you information about how to create an advance directive under state law
(this regulation is cited as 42 CFR � 489.102). You can also learn more about
creating an advance directive online, but because they vary by state law, it is
best to have a healthcare provider or better yet an attorney assist you. If you
are transgender or gender-nonconforming, this guide explains how you can tailor
an advance directive to include gender identity-related protections.
You can name anyone you want to be your healthcare power of attorney (meaning
the one who makes decisions for you). You do not have to be married or
"biological" family. You should name someone who you trust to be a good advocate
and who knows you well.
Often, an advance directive also includes a "living will" � a document that says
what kind of care you would like to receive if you were ever in a terminal
condition. For example, you can state whether you would want to be kept alive
using a feeding tube and assistive devices, or would prefer to be kept
comfortable and allowed to pass away naturally.
These documents are especially important for LGBT people because providers may
second-guess what our decision-maker has to say (for example, a provider might
not trust a same-sex spouse to make this choice because of an anti-gay bias).
