In Focus: LGBTQ Health and Healthcare
Many external factors affect a person’s physical, emotional, and mental health, including lower incomes, lack of paid sick leave, and discrimination in accessing healthcare because of class, race, sexual orientation, gender identity, and/or gender expression. Proximity to environmental or climate risks can also affect health. In addition, LGBTQ people and youth experience health disparities because of lack of support at home, school, or other social spaces.
In other words, the key to LGBTQ health is not a theoretical difference in biology or behavior between LGBTQ people and cisgender, straight people, but in the many challenges and stigmas that make LGBTQ people vulnerable to illness. The National Institute on Minority Health and Health Disparities has identified the LGBTQ community as a “health disparity population” in need of increased National Institutes of Health research.
Data on LGBTQ health is lacking. One of the major impediments to understanding the reality of LGBTQ health is a lack of data collection. Many national LGBTQ organizations have made data collection one of their top priorities, which became even more critical during the COVID-19 pandemic, when data about the impact on LGBTQ people was not collected until months after it began. Data that does exist shows deep disparities for LGBTQ people, and significant gaps in understanding between LGBTQ patients and providers — including the mistaken belief by providers that most patients will not discuss sexual orientation or gender identity if asked. This lack of data will have ongoing and compounding effects on LGBTQ people, including the study and impact of other diseases and epidemics such as cancer rates.
Medical professionals are not always allies and receive little training. While blatant discrimination may be illegal, the healthcare industry is still affected by societal homophobia, biphobia, and transphobia, negatively affecting the quality of healthcare that LGBTQ people receive. According to a December 2021 statement from GLMA: Health Professionals Advancing LGBTQ Equality, more than half of all medical schools lack any LGBTQ-focused health training beyond treating HIV. A 2018 report from the Kaiser Family Foundation noted that more than half of lesbian, gay, and bisexual people reported that they have faced cases of providers denying care, using harsh language, or blaming the patient’s sexual orientation or gender identity as the cause for an illness.Up to 39% of transgender people have faced some type of harassment or discrimination when seeking routine healthcare, including being denied care outright or encountering violence in healthcare settings. There are currently just over 200 LGBTQ-specific healthcare centers in the United States, but not all of them provide services like mental health or have pharmacies. Thirteen states have no LGBTQ-specific healthcare centers at all. LGBTQ people who live in rural areas or in those 13 states have little to no access to LGBTQ-specific care.
Anti-LGBTQ activists are targeting healthcare access. In May 2021, President Joe Biden restored federal protections for LGBTQ people seeking healthcare. While protections have been restored at the federal level, some states are still targeting and limiting LGBTQ healthcare. In 2021, for example, Arkansas and Ohio passed laws allowing providers to deny care to LGBTQ people based on religious objection. And two states, Arkansas and Tennessee, passed laws in 2021 banning or limiting gender affirming care for transgender youth. Other states proposed bills that penalize parents who provide gender affirming care for their trans children, as well as bills that punish school employees who keep a student’s transgender identity from their parent. In total, these state bans could affect up to 45,000 transgender youth.
Gay and bisexual men face many more health disparities than just HIV. Stigma and discrimination can lead to a host of mood and substance abuse disorders in gay and bisexual men, including depression, anxiety, PTSD, and alcoholism. Gay and bisexual men also report higher levels of eating disorders, including anorexia and bulimia, than their straight counterparts. Gay and bisexual men also smoke at a higher rate than their straight counterparts, putting them at risk for a variety of cancers and other health conditions. Tobacco companies have a history of targeting ads to gay men.
Gay and bisexual men in the U.S., especially gay and bisexual men of color, face disproportionate rates of HIV. See HIV and the LGBTQ community for more.
Gay and bi men are also still subject to a discriminatory deferral period when donating blood or plasma. It is now a three-month waiting period instead of a year-long or lifetime ban, thanks to advocacy efforts from medical organizations as well as LGBTQ organizations, including GLAAD. GLAAD continues to call on the FDA to remove the deferral period altogether in favor of risk-based screening, noting that basing any policy on sexual orientation alone is unscientific and discriminatory. In June 2021, the UK’s National Health Service announced that gay and bisexual men in England, Scotland, and Wales can now donate blood, plasma, and platelets. As NPR reported, “Donor eligibility will be based on each person’s individual circumstances surrounding health, travel, and sexual behaviors regardless of gender. Potential donors will no longer be asked if they are a man who has had sex with another man, rather they will be asked about recent sexual activity.”
Lesbian and bisexual women face barriers to comprehensive healthcare. Research indicates that lesbian and bisexual cisgender women may have a higher risk of developing breast and reproductive cancers than straight women, as they can have increased risk factors such as higher estrogen exposure from not having children or having children later in life, as well as higher rates of obesity and alcohol use. As with gay men, lesbian and bi women smoke at higher rates than the general population, putting them at higher risk for many cancers. Queer women who receive cancer care receive much less post-cancer care leading to a worse quality of life after cancer therapy.
Some doctors and medical record intake forms default to assumptions that patients are all straight. Contraception, pregnancy, fertility, and hormone replacement therapy are all forms of healthcare that queer, lesbian, and bisexual cisgender women should discuss with their care team. Providers should also seek information about sexual health and practice from lesbian and bisexual patients —they are at risk for STI transmission at rates similar to straight women. The infections most likely to be passed between female partners — herpes, genital warts, and HPV — are not always comprehensively tested at public health clinics that offer STI tests. Some sexual health challenges specific to lesbian and bisexual women seem to fly under the radar: studies have shown, for example, that bacterial vaginosis rates can be twice as high among lesbians than their straight counterparts.
Transgender people face systemic barriers to access. Transgender people are more likely to experience systemic inequalities that hurt health, including living in poverty, not having health insurance, facing workplace discrimination, and experiencing physical and sexual assault.
The American Medical Association has stated that treatment for gender dysphoria is medically necessary care which can involve changing the body to align with a person’s gender identity (their internal sense of their own gender). However, until very recently, private insurance companies treated transition-related medical care as if it were cosmetic — regularly inserting “transgender exclusion clauses” into health insurance plans. This can make access to care difficult, if not impossible, for most transgender people. In 2016, the Department of Health and Human Services issued a rule stating that under the Affordable Care Act of 2010, people are protected from discrimination based on gender identity and sex stereotyping in healthcare settings that have a connection to federal funds, which includes the vast majority of health insurance companies. This was a huge step forward in improving access to healthcare for the transgender community. However, not all procedures associated with medical transition are covered by this ruling, and any policy that does not receive federal funds may still discriminate. Furthermore, even if a transgender person has a health insurance policy which will cover medical transition, it can still be quite difficult to find healthcare providers who are knowledgeable about transgender health care.
According to the Center for American Progress, one in three trans people has been denied access to medical care because of their gender identity, while one in three transgender people has opted to forego healthcare because they fear being mistreated.
Transgender women face multiple health disparities, particularly trans women of color. Even if transgender women find affirming healthcare providers, they often face denial of coverage for some gender affirming procedures. According to the 2015 U.S. Trans Survey, 54% of transgender women have been denied coverage by their insurance for gender affirming surgeries. Additionally, a 2021 CDC report found that “4 in 10 transgender women surveyed in seven major U.S. cities have HIV.” The report also revealed that nearly two-thirds of African American/Black transgender women and more than one-third of Latinx transgender women surveyed have HIV. The study also found that “nearly two-thirds of the women surveyed lived at or below the poverty level, and 42% had experienced homelessness in the past 12 months.”
When reporting on transgender men, it is important to highlight that they are one of the least-studied demographics in the LGBTQ community. Transgender men are much more likely than cisgender men to face mental health issues, including depression, anxiety, eating disorders and suicidal ideations. According to one study, one of the main predictors of mental health in transgender men was social isolation. Many transgender men bind their chest as part of their social transition and may face significant barriers to accessing chest reconstruction surgery that would make binding unnecessary. Gay transgender men are also at risk for HIV, and yet there are almost no prevention materials that target this population with information about PrEP or PEP.
Gender affirming care for transgender youth is critical. Every major medical association supports gender affirming care as safe, effective, and proven to save young people’s lives. In 2018, the American Academy of Pediatrics published a policy statement and guide “to help pediatricians and parents navigate health concerns of gender-diverse youth while advocating for ways to eliminate discrimination and stigma.” Gender affirming care for minors includes social transition for children who have yet to go through puberty, including using the correct pronouns, names and titles (e.g. “daughter” or “son”), as well as allowing authentic gender expression (hair, clothes, shoes, etc.). Puberty blockers can be prescribed as a child reaches puberty, to pause the unwanted physical effects of a puberty incongruent with one’s gender identity. Research shows that access to puberty blockers during adolescence is associated with a significant decrease in suicidal ideation in transgender young adults. Doctors have used these medications safely for decades for cisgender children who experience precocious puberty. The Journal of Adolescent Health found that gender-affirming hormone therapy resulted in lower rates of depression, suicidal thoughts, and suicide attempts among older transgender and nonbinary teens, but access to hormone therapy can be limited by insurance or by a lack of providers who know how to administer it.
In spite of the expertise of pediatricians, psychiatrists, and psychologists who understand how to support trans youth, anti-trans activists continue to attack trans youth and their families and attempt to prevent them from accessing gender affirming care. Anti-trans activists have proposed bills banning care for trans youth and bills criminalizing private healthcare discussions and decisions for the young person, their family and their healthcare provider. Efforts to restrict gender affirming care risk harming mental health by directly prohibiting medical care that many trans youth rely on. This anti-trans activism also increases minority stress resulting from negative public attention and harmful rhetoric used to debate a trans person’s existence and equal access in society. The American Medical Association notes: “Proponents of [disturbing bills to ban care] falsely assert that transgender care for minors is extreme or experimental. In fact, clinical guidelines established by professional medical organizations for the care of minors promote supportive interventions based on the current evidence and that enable young people to explore and live as the gender that they choose. Every major medical association in the United States, including the AMA, recognizes the medical necessity of transition-related care for improving the physical and mental health of transgender people.”
More research is needed on healthcare for nonbinary people. Nonbinary people interact with a medical establishment that has long divided people into two binary genders. Health insurance, medical records, and accessing procedures specific to body parts that are considered “gendered” are incredibly complicated for nonbinary people. However, one of the best ways for healthcare providers to respect nonbinary people is to use the correct name and pronouns for them. Creating a place on intake forms for gender identity in addition to sex assigned at birth, and a place for the patient to indicate what name and pronouns they use, helps create a more trans and nonbinary inclusive environment. Using correct pronouns has also been proven to help transgender and nonbinary people feel respected and reduce suicide risk.
Healthcare providers can also use language that recognizes that people of all genders may need to access certain services. For example, Planned Parenthood uses gender-inclusive language to ensure that everyone feels welcome to access their service, including phrases like “people with a cervix”, and terms like “external condoms” and “internal condoms,” rather than “male condoms” and “female condoms.”
Intimate partner violence affects LGBTQ people too. Studies show that intimate partner violence is as high or higher in LGBTQ couples than straight couples. Bisexual women are especially at risk of experiencing intimate partner violence, with 61% of bisexual women reporting it compared to 44% of lesbian women and 35% of straight women. Though there are limited studies of trans people and intimate partner violence, available literature shows that transgender people are 1.7 times more likely to experience it than cisgender people. Intimate partner violence not only puts people in physical danger, but also contributes to poor mental and emotional health and puts people at risk for housing insecurity and homelessness.
Homelessness impacts health, and LGBTQ youth are more likely to be homeless. Regardless of gender or sexual orientation, housing is the number one factor in determining overall health. People who are without housing or are housing insecure have poorer health outcomes than people with housing. They are also at more risk of abusing drugs and experiencing depression. Approximately 40% of the homeless youth population is LGBTQ. Youth who are LGBTQ have a 120% higher risk of being homeless or housing insecure than straight, cisgender youth, because of rejection by family members.
E-cigarette use and menthol cigarette use is a bigger issue for the LGBTQ population. Not only do LGBTQ people smoke cigarettes at higher rates than the general population but menthol cigarette use is higher as well. Approximately one quarter of lesbian, gay, and bisexual youth are becoming addicted to nicotine via e-cigarettes.
Sex education is usually not LGBTQ-inclusive. Only six states and Washington, DC require sex education in schools to be LGBTQ-inclusive, and only 18 require it to be medically accurate. This presents a potential for STI transmission among LGBTQ young people and a massive gap in health education for LGBTQ and questioning youth, most of whom will never encounter vital information about their own sexual health. Increasing LGBTQ inclusion in school-based sex education would close this gap, and would also introduce wider understanding of LGBTQ identities and relationships among the population in general. However, there are currently more states with laws that restrict or ban teaching about LGBTQ people in schools — regardless of subject matter — than there are laws that mandate inclusive sex education. These “Don’t Say Gay” laws help contribute to an overall invisibility and ignorance of LGBTQ issues, especially health.
Abortion is an LGBTQ issue. Many lesbians, bisexual and queer women, nonbinary and intersex people, and transgender men can and do get pregnant—and can and do seek abortion services. The Supreme Court overturned Roe v. Wade in its ruling in Dobbs v. Jackson, igniting a series of state bans on abortion around the country, a wave of activism, and a heightened area of media coverage. Inclusive language is a necessary part of thorough and accurate coverage of abortion, whether specifically covered as an LGBTQ issue or not. Read more in GLAAD’s Media Guide on Abortion.
Monkeypox (MPV): A person’s sexual orientation or gender identity does not put them at higher risk of infection; close contact to an infected person puts them at greater risk of infection. Reporting and messaging about any virus should focus on facts, not who people are. GLAAD urges public health officials and the media to elevate information that informs all communities to prevent and control the spread of viruses, and continue to work closely with vulnerable communities to inform and protect them without stigma. Read more in GLAAD’s Media Factsheet on Monkeypox (MPV).
Organizations:
Please reach out to the below organizations — or GLAAD (press@glaad.org) — to learn more and connect with spokespeople:
GLMA: Health Professionals Advancing LGBTQ Equality
National LGBTQIA+ Health Education Center
World Professional Association for Transgender Health (WPATH)
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