Medicine and LGBTQ health policies

HMS students, physician weigh in on health care sector role

A stethoscope rests on a table covered with  rainbow-colored cloth.
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Recent executive, legislative, and judicial actions in the United States are expected to have a significant impact on the health and well-being of members of sexual and gender community groups. A perspective piece published in the New England Journal of Medicine  on July 23 argues that these developments require the health care sector to do more to protect these individuals’ rights.

The commentary was written by Michael Liu and Sahil Sandhu, both second-year students at Harvard Medical School, and Alex Keuroghlian, HMS associate professor of psychiatry at Massachusetts General Hospital and a leader in efforts to advance LGBTQ health equity.

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According to the U.S. Centers for Disease Control and Prevention, LGBTQ people currently face a number of grave health disparities, including elevated rates of cardiovascular disease, obesity, cancer, and sexually transmitted infections, including HIV, human papillomavirus, syphilis, and hepatitis C.

These groups also have substantially higher rates of certain mental health problems, including depression, anxiety, and substance use disorders and are more likely to attempt suicide.

A string of newly enacted and proposed federal and state policies across the U.S., however, threaten to make the situation worse, the authors stated in their commentary, writing, “As policymakers endanger health and access to care among sexual and gender minority communities, we believe the health care sector should rededicate itself to supporting health equity for these populations.”

The authors cited recent executive action by Texas Gov. Greg Abbott allowing authorities to investigate for child abuse those parents who seek gender-affirming care for their children, as well as a new Florida law that prohibits reading and talking about sexual orientation and gender identity in elementary school classrooms.

The writers also included other proposed laws and judicial decisions that restrict care that has been shown to significantly reduce suicidality and poor mental health among these at-risk groups, and which also contribute to an atmosphere that stigmatizes sexual and gender minority individuals, they said. 

These policies can reduce access to care and create stressors that contribute to overall poor health outcomes among LGBTQ people, the authors wrote.

“Public policies that cast sexual and gender minority people as outsiders, whose identities should not be discussed and whose health care is criminalized, are doubly damaging for the health of sexual and gender minority people,” Liu said in an interview.

“First, in some cases [the policies] directly limit access to lifesaving, evidence-based health care. Second, they exacerbate minority stressors such as employment discrimination, peer violence, and internalized oppression that are associated with belonging to marginalized groups and known to worsen physical and mental health,” Liu added.

Triple Aim framework

To address the repercussions of these policies, the authors suggested using the Triple Aim framework for improving health care by simultaneously working to improve individual patient care experiences, promoting a focus on population health, and making overall health care spending more equitable and sustainable.

To address the health needs of LGBTQ populations, the first goal of the Triple Aim approach would be to improve the kinds of experiences that sexual and gender minority people have within the health care system, an area with significant room for improvement, the authors said.

Many of the challenges related to achieving the second goal—improved population health for sexual and gender minority people—are related to pervasive social stigma that must be addressed at both the societal and individual levels before gains can be made, the authors wrote.

“It’s critical for health care providers and policymakers to understand that simply acknowledging a person’s right to be who they are, or to love who they love, can have profound direct and indirect consequences on health,” Sandhu said in an interview. “That can play out either on the national political stage or in one-on-one interactions between a patient and a health care provider.”

The third goal would be to improve the equity of health care expenditures between LGBTQ and non-LGBTQ people. Because sexual orientation and gender identity are not routinely captured in either public or private health care claims databases, however, there currently is not enough information available to compare spending between groups or to suggest ways to improve existing inequities.   

“What kind of services do LGBTQ people need that they aren’t getting? Where can our resources do the most good for the people who need help? To answer these questions, we need data,” Keuroghlian said in an interview. “Then we need to educate doctors, nurses, and all professionals in the health care sector so that they can help support health care systems that work for everyone.”

The authors outlined a series of steps that could improve data collection, including using regulatory requirements and financial incentives, increasing research to improve understanding of the health and well-being needs of LGBTQ people, and training and workforce development to share and implement best practices in all clinical settings. 

Finally, the authors said, physicians and professional organizations should advocate for federal policies that protect the fundamental rights of LGBTQ people and build health care systems and practices that are welcoming, inclusive, and effective for all people.

“Working at the intersection of care delivery, medical education, and research teaches us how powerful those three tools can be when we use them synergistically to improve health care,” said Keuroghlian. “We have both the capacity and the responsibility to save lives and improve the health and well-being of sexual and gender minority people, especially at a moment like this when public policies are being enacted that we know put lives at risk,” he said.