
On the Margins
Insensitivity, or worse, discrimination, takes a significant toll on the health of LGBTQ individuals
Twelve years. That’s the average number of years of life prematurely taken from LGBTQ individuals who live in communities that harbor strong prejudices against members of sexual and gender minorities. The stress of living in an environment marked by stigma and structural discrimination can result in early deaths from suicide, from an increased risk of cardiovascular disease, and from a cascade of other life-shortening health conditions.
These findings were highlighted in a 2016 statement by Eliseo J. Pérez-Stable, director of the National Institute on Minority Health and Health Disparities, announcing that the National Institutes of Health was designating “sexual and gender minorities” as a disparities population. This designation served as a notification that the NIH recognized the health inequities affecting the LGBTQ community—and the need to address them.
The problems start early in life. Across the nation, lesbian, gay, bisexual, and transgender youth have an elevated risk of bullying, suicide, and substance use disorder and lack access to culturally sensitive and clinically specific LGBT health care, according to a 2017 review of the literature published in the Cureus Journal of Medical Science.
In adulthood, lesbians have a higher risk of obesity and breast cancer, and gay men face an increased risk of prostate, testicular, anal, and colon cancer.
“There’s no biological reason that minority people should be in worse health,” says Alex Keuroghlian, an HMS assistant professor of psychiatry, part-time, at Massachusetts General Hospital, and an active participant in efforts to build LGBTQ health equity in Boston, across the United States, and around the globe.
“It’s the result of various social determinants of health, of stigma, and of medical practice not being oriented toward including sexual and gender minority people. It’s a human-made problem,” he adds.
The daunting task of addressing the problem is magnified by the limited data available for researchers to analyze, use to assess clinical outcomes, or drive clinical improvements. Until the past few years, none of the major national health surveys collected sexual orientation or gender identity data, and health systems haven’t had intake forms or electronic records that track sexual or gender minority patients.
“All people are unique and need to be treated in a person-centered, tailored way. The key for physicians is getting to know your patients as people.”
This challenge was highlighted in the landmark 2011 report from the National Academy Press, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a foundation for better understanding: “Lesbian, gay, bisexual, and transgender individuals have unique health experiences and needs, but as a nation, we do not know exactly what these experiences and needs are.”
Now, with growing societal acceptance and legal rights for LGBTQ people, along with an increasing awareness of the health disparities that the community faces, physicians, researchers, medical educators, advocates, and members of the community itself are working together to make sure that LGBTQ people have equitable health care and the opportunity to live healthier lives.
A sense of the breadth of research occurring in the field can be found in a quick sampling of the more than three dozen papers, perspectives, and reviews authored or co-authored by Keuroghlian, who also directs the MGH Psychiatry Gender Identity Program and the education and training programs at The Fenway Institute in Boston. In just two years, he has had publications in NEJM, JAMA, and Lancet that address the damage caused by “conversion therapy,” ways to improve clinicians’ communication with LGBTQ patients, and the importance of capturing sexual orientation and gender identity data to improve health care. The work also gives a sense of how the knowledge base needs to be expanded and shared in order to provide more equitable, and more informed, health care to LGBTQ patients.
Teach, then teach some more
At HMS, Keuroghlian leads education efforts and curriculum development projects that help train health care providers and support staff at the School and at two of its affiliated hospitals: Mass General and McLean. He also is course director for the School’s fourth-year elective clerkship Care for Patients with Diverse Sexual Orientations and Gender Identities.

“When I talk with people about equity for members of the LGBTQ community, they sometimes say ‘I respect everyone, I treat everyone the same,’ ” Keuroghlian says. “What we’re trying to help them understand is that all people are unique and need to be treated in a person-centered, tailored way. The key for physicians is getting to know your patients as people.”
More inclusive intake forms and electronic health record formats would be a step in that direction, according to a paper that Keuroghlian’s team authored in 2018 and published in the Journal of the American Medical Informatics Association. These improved forms would contain space in which physicians could enter data about a person’s sexual orientation and gender identity, their pronouns, and the name they go by. That paper, a guideline of best practices for the collection of patients’ sexual and gender identity information, includes tips on finding ways to work around limitations in existing EHRs to collect this vital information.