Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority people (LGBTQ+), are at greater risk of dying by suicide, of cardiovascular disease, and of a cascading list of other health problems, compared with the rest of the population. To help stop this suffering and eliminate disparities, the U.S. Centers for Disease Control and Prevention and National Institutes of Health have called for more research and better care to address the health needs of LGBTQ+ people.
Three recent studies led by Harvard Medical School students working with researchers and clinicians from HMS and its affiliated hospitals provide new evidence about the specific drivers of these disparities and point the way to new solutions to overcome these challenges.
These studies demonstrate that the convergence of political and social environment, structural inequities, and implicit and explicit bias within the medical system erode LGBTQ+ health and well-being.
And all of these findings, the HMS researchers noted, point to the importance of tackling LGBTQ+ health disparities on multiple fronts — through research, education, and outreach.
“Research like this is crucial for building an evidence base that can allow doctors, policymakers, and sexual and gender minority people to work together to design better health care systems and to improve the health and well-being of everyone in our communities,” said Alex Keuroghlian, HMS associate professor of psychiatry at Massachusetts General Hospital and senior author of two of the studies.
But it’s just as important to augment disparities research with education and community-based efforts to pave the way for inclusive health care that respects and welcomes all patients, notes Keuroghlian, who is also the principal investigator of the National LGBTQIA+ Health Education Center.
Such evidence-based approaches to LGBTQ+ health are especially important in the face of politicized efforts to limit care for sexual and gender minority people, argues Keuroghlian in a recently authored editorial piece in Science, the first published in the journal to discuss the health of transgender and gender diverse people. These political efforts include limitations or outright bans on some forms of gender-affirming care for transgender people in 25 states in the U.S. and in countries around the world.
The teaching and practice of gender-affirming care are aligned with recommendations and guidance by the American Medical Association, American Psychological Association, and World Health Organization. The WHO defines gender-affirming care as “any single or combination of a number of social, psychological, behavioral or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual’s gender identity.”
The impact of a hostile political environment on mental health
A recent study in JAMA Internal Medicine led by HMS MD student Michael Liu and Keuroghlian found significant increases in poor health outcomes for transgender and gender diverse adults compared to cisgender adults from 2014 to 2022, a time marked by escalating attacks on transgender health care and access to public accommodations in many states in the U.S. The worsening health disparities were especially apparent in self-reported mental distress and depression.
While they did not collect any direct evidence linking these policy changes to increasing disparities, the researchers said that they are an obvious source of stress, which has been shown to be a major driver of health disparities in multiple studies.
“Our findings certainly suggest that this hostile environment is eroding the health of an already very vulnerable population,” Liu said.
For example, the percentage of transgender and gender diverse adults experiencing frequent mental distress more than doubled from 18.8 percent in 2014 to 38.9 percent in 2022, while rates among cisgender adults increased from 11.2 percent to 15.5 percent. The number of people reporting frequent mental distress increased five times faster per year among transgender and gender diverse people than among cisgender people.
Unease at the doctor’s office
Liu and Keuroghlian were also among the authors of a study published in the Annals of Family Medicine that found that many LQBTQ people don’t feel comfortable or welcome in their own doctor’s offices. One in five sexual minority adults and more than one in three gender minority adults reported avoiding or delaying necessary care because the provider was of a different background, such as a transgender patient who did not feel comfortable seeing cisgender providers, the analysis showed.
Importantly, people who had experienced discrimination while receiving medical care in the past were far more likely to avoid seeking future care from providers who did not share their sexual orientation or gender identity, the study found.
Taken together, the researchers said, these findings highlight the importance of several mutually reinforcing approaches deployed in parallel: recruitment and retention of a health care workforce with diverse sexual orientations and gender identities; ensuring all members of the health care workforce are trained to deliver affirming and evidence-based care for sexual and gender minority patient populations; and policies that explicitly prohibit discrimination against sexual and gender minorities in health care settings.
“We have an obligation to create health care spaces free from discrimination, and concerted efforts are needed to ensure all members of the health care workforce are capable and willing to provide affirming and culturally responsive care to sexual and gender minority patients,” Liu said. “It’s the right thing to do, and it’s also good medicine.”
The researchers note that most similar prior studies have focused on racial discordance, measuring the impact on health and patient experience based on differences in patient and provider racial backgrounds. Understanding that this phenomenon also extends to LGBTQ+ adults is critical for informing policies and practices to improve the care and health outcomes of LGBTQ+ people. The previous research shows that patients who avoid care due to identity mismatches with their clinicians also often report having worse overall patient experiences and less of the necessary care they need.
When the wait is too long or care never comes
A 2023 study led by Lindsay Overhage, a fourth-year student in the Health Policy PhD program at the Harvard Kenneth C. Griffin Graduate School of Arts and Sciences and an MD student at HMS and colleagues from the Department of Health Care Policy in the Blavatnik Institute at HMS found a dramatic increase in teen mental health emergency department visits in the second year of the COVID-19 pandemic. This strained emergency departments and inpatient psychiatric units and left many children and teens waiting multiple days to be admitted to the hospital, a phenomenon known as boarding.
“The experience of boarding – of being stuck in one room in an emergency department 24-7, under one-on-one supervision, for days or weeks at a time with little definitive mental health treatment and not knowing how long you’ll be stuck there – it’s detrimental to kids’ well-being,” said Overhage.
While it does ensure that a teen in crisis is physically safe, boarding takes a toll of its own that extends beyond the patient.
“Families and clinicians have repeatedly likened it to incarceration in prior qualitative studies,” said Overhage, who recently published a follow-up study in JAMA Pediatrics that took a closer look at the cases of the nearly 5,000 youths who spent three or more days awaiting admission for psychiatric care in Massachusetts emergency departments. The analysis sought to identify whether there were racial or gender disparities in wait times or in the chance of being sent home without being admitted.
Researchers found that transgender and nonbinary youth were less likely to receive an inpatient admission when compared with cisgender females, the group with the shortest wait times and who were most likely to be admitted. On average, transgender and nonbinary youth boarded in the emergency department for about two days longer than their cisgender female peers.
Black youth were also less likely to be admitted for inpatient treatment than their white counterparts with similar clinical presentations, the study showed.
Some of the inequity for transgender and nonbinary youth may be related to structural factors, Overhage noted. For example, most psychiatric units are built with mostly double rooms but have policies that require transgender or nonbinary youth to have a room to themselves. Thus, when a medical unit nears capacity, there may be no empty room available for a gender-diverse patient.
“The resulting disparities are unacceptable. Fixing these inequities will likely require collaboration between hospital administrators, staff, patients, and families to identify effective policy changes,” Overhage said.
A path to better health
At HMS and its affiliate hospitals, numerous projects are underway in research, medical education, and clinical care working to improve the health of the LGBTQ+ community.
One such project is the Massachusetts General Hospital Psychiatry Gender Identity Program, which provides culturally responsive mental health care across the lifespan.
The program delivers mental health services within a safe, welcoming, inclusive, and affirming environment, and it is a training site for HMS students in the senior course, Caring for Patients with Diverse Sexual Orientations, Gender Identities, and Sex Development: A Clinical and Scholarly Elective.
The four-week elective trains medical students to provide care for patients with diverse sexual orientations, gender identities, and sex development.
All medical and dental students at HMS and the Harvard School of Dental Medicine learn about care for sexually and gender diverse patients in several required preclinical courses, including Introduction to the Profession and Practice of Medicine.
The past informing the future
In addition to looking toward the future, researchers are turning back in search of lessons from the past.
Over the last year, the New England Journal of Medicine has published a series of independently edited perspective pieces analyzing the history of injustice in medicine through the lens of publications in the journal. The two most recent installments are “A Legacy of Cruelty to Sexual and Gender Minority Groups” and “Malicious Midwives, Fruitful Vines, and Bearded Women — Sex, Gender, and Medical Expertise in the Journal.” On Nov. 20, the authors will discuss their findings at the third in a series of symposia hosted by the HMS Office for Diversity, Inclusion, and Community Partnership.
Moving forward, Keuroghlian emphasized that the voices, priorities, and needs of LGBTQ+ people must guide sexual and gender minority health research, education, training, and policy efforts.
“There is great power working in community with the people who need our help,” Keuroghlian said. “As clinicians and health researchers, we have a responsibility to use our privilege, experience, and expertise to help counter disinformation, shape the public discourse, and work with policymakers to advance health equity for all people.”
