Drivers and Solutions for the LGBTQ+ Community and Reducing Disparities

The LGBTQ+ population experiences health care disparities. In fact, statistics show that people who identify as lesbian, gay, bisexual, transgender, queer, nonbinary, or intersex routinely engage less frequently with the health care system than others do. As a result, the LGBTQ+ community may not routinely visit health care providers for cancer screenings and vaccines, among other interventions.

A 2021 Gallup Poll found that at least 7% of US adults identify as LGBTQ+, with the numbers trending sharply upward in younger age groups; roughly 10% of millennials (born between 1981 and 1996) and 21% of members of Generation Z (born between 1997 and 2003) are LGBTQ+.¹ Nationally, 1.3 million adults identify as transgender, including 46,500 people in Ohio alone.²

Despite the growing population of LGBTQ+ community members, there often remains an adversarial relationship with health care providers. According to speaker Ty Stimpert, BSBA, manager of the LGBTQ+ Community Outreach and Patient Navigation Program at Cleveland Clinic Taussig Cancer Center, a 2010 Lambda Legal survey found that 56% of lesbian, gay, and bisexual individuals and 70% of transgender and gender-nonconforming people reported at least 1 of the following on the part of a provider: withheld medical care, refused to touch them, used harsh or abusive language, was physically rough, or blamed the patient for their health condition (such as having HIV infection).³

Other cultural and economic forces further marginalize the LGBTQ+ community. “Our community is more likely to be part of a racial or an ethnic minority in addition to LGBTQ+, more likely to live in poverty, and generally less likely to have social support when compared [with] cisgender and heterosexual peers, which means the intersectionality of these identities, unfortunately, will lead to more disparities in health care and in cancer [care],” Stimpert said.

According to symposium speaker NFN Scout, PhD, MA, executive director of the National LGBT Cancer Network in Providence, Rhoad Island; and vice president of Social Justice in Beverly Hills, California; whereas 24% of the general population identify as members of racial and ethnic minority groups, 42% of the LGBTQ+ community do so.

Scout noted that the well-known Black transgender activist and journalist Monica Roberts recently passed away. She had not seen a medical provider in many years, which Scout said was upsetting given Roberts’ high profile, influence, and education: “[She] actually [was] one of the more privileged trans people, which is why it’s even more frustrating and sad to realize that she was not seeing any doctor [whom]soever.”

Scout explained that as a Black transgender woman, Roberts faced a host of challenges, some of which prevented her from accessing and receiving the care that she needed. The Harvard Civil Rights-Civil Liberties Law Review has cited racism, homophobia, biphobia, transphobia, violence, poverty, unemployment, homelessness, and suicidal ideation as obstacles that Black trans people experience at disproportionate levels, adding that Black trans women are more likely than their male counterparts to be murdered.⁴ In short, being Black, female, and trans frequently means navigating multiple barriers in the health care system.

According to Scout, discrimination has only worsened with time, increasing the amount of antitrans legislation that is introduced every year in various US states. In 2018, 41 antitrans bills were filed; in 2022, almost 240 had been introduced in state legislatures as of October.⁵ The discrimination takes such a huge toll that about 40% of trans people will attempt suicide at some point, Scout said.⁶

Stimpert noted that the harm to people in the LGBTQ+ community extends to their physical well-being. Sexual and gender minorities bear a disproportionate cancer burden, according to the American Society of Clinical Oncology, because of patient-provider communication gaps, outright discrimination, and a higher percentage of individuals in this community living underinsured and below the poverty line.⁷

With its specialized LGBTQ+ health care clinic, the Cleveland Center has taken an important step toward providing an inclusive way for people in this community to access care, specifically cancer screenings. Stimpert noted that when people don’t have a regular doctor or when they feel overlooked by health care campaigns, they often skip vital screenings and preventive tools, such as human papillomavirus vaccines. “Of course, if we do not feel welcome and/or have had negative experiences with health care, maybe even trauma-inducing experiences, then we’re not going to want to deal with health care,” Stimpert said. “Health care utilization will be affected by this, and that contributes to about 30% of LGBTQ+ adults actually not having a medical home or a primary care provider.” By comparison, about 1 in 10 heterosexual adults have no primary care provider.

To rectify this discrepancy, the Cleveland Clinic undertook an initiative to ensure that its electronic medical records (EMRs) include sexual orientation and gender identity data, allowing for more transparency when it comes to funding and research opportunities. Recognizing that many LGBTQ+ people skip vital cancer screenings such as mammograms and colonoscopies, patient navigation teams work to help overcome barriers such as fear, lack of transportation, and financial problems, noted Stampert. Patients can specifically seek a doctor who is LGBTQ+ friendly, has additional training, understands foundational elements of LGBTQ+ care, and documents this care accurately in the EMR.

With outreach as its goal, the hospital system partnered with organizations focused on the LGBTQ+ community to host targeted events, such as mammogram clinics designed for trans and gender-nonconforming people, according to Stimpert. It also hosts an annual health and wellness day, which provides health services and screenings at no cost, including mammograms, prostate cancer screenings, cancer risk assessments, smoking-cessation help, lung function testing, nutritional counseling, hepatitis vaccines, and testing for HIV and other sexually transmitted infections. “Over the last 2 years at this event, we’ve screened [more than] 150 people, and about [one]-third of participants were uninsured,” Stimpert said.

Scout said that as critical as it is to be more accessible to LGBTQ+ patients, these providers and other staffers need recognition, too. “LGBTQ[+] employees in your organization…bring specific population disparity expertise to the table,” he said. “You’re actually paying us and giving us time to bring that expertise to benefit your actual business model for the organization.”

If health care organizations invest time and money in recruiting and attracting providers who resemble the LGBTQ+ community members they serve, Scout noted, they can go a long way toward making patients comfortable engaging in health care. Referencing Roberts, the late transgender activist, Scout wondered what might have been if she had been able to make an appointment with a doctor who also was a Black trans woman, asking, “[What if she] had the opportunity to talk to anybody who even just seemed a little bit more like her, [someone who had] proven…that they really wanted to be welcoming to people like her?”

REFERENCES

1. Jones JM. LGBT identification in U.S. ticks up to 7.1%. Gallup. February 17, 2022. Accessed December 21, 2022. https://news.gallup.com/poll/389792/lgbt-identification-ticks-up.aspx
2. Herman JL, Flores AR, O’Neill KK. How many adults and youth identify as transgender in the United States? UCLA School of Law Williams Institute.June 2022. Accessed December 21, 2022. https://williamsinstitute.law.ucla.edu/wp-content/uploads/Trans-Pop-Update-Jun-2022.pdf
3. Lambda Legal releases health care discrimination survey results; more than half of LGBT and HIV positive respondents report discrimination. Lambda Legal. February 4, 2010. Accessed December 21, 2022. https://www.lambdalegal.org/news/ny_20100204_lambda-releases-health
4. Forestiere A. America’s war on Black trans women. Harvard Civil Rights. September 23, 2020. Accessed December 21, 2022. https://harvardcrcl.org/americas-war-on-black-trans-women/
5. Lavietes M, Ramos E. Nearly 240 anti-LGBTQ bills filed in 2022 so far, most of them targeting trans people. NBC News. March 20, 2022. Accessed December 21, 2022. https://www.nbcnews.com/nbc-out/out-politics-and-policy/nearly-240-anti-lgbtq-bills-filed-2022-far-targeting-trans-people-rcna20418
6. Austin A, Craig SL, D’Souza S, McInroy LB. Suicidality among transgender youth: elucidating the role of interpersonal risk factors. J Interpers Violence. 2022;37(5-6):NP2696-NP2718. doi:10.1177/0886260520915554
7. Griggs J, Maingi S, Blinder V, et al. American Society of Clinical Oncology position statement: strategies for reducing cancer health disparities among sexual and gender minority populations. J Clin Oncol. 2017;35(19):2203-2208. doi:10.1200/JCO.2016.72.0441

NFN SCOUT, PHD, MA

Executive Director

National LGBT Cancer Network

Providence, RI

TYLER STIMPERT, BSBA

Community Outreach and Patient Navigation Program Manager

Cleveland Clinic Taussig Cancer Institute

Cleveland, OH