SEXUAL MINORITY
HEALTH & HEALTHCARE
January 20, 2016
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Lynn Hunt, MD
Clinical Professor of Pediatrics, UC Irvine
Chair, Section on LGBT Health and Wellness
American Academy of Pediatrics
Learning Objectives
• Review terminology and definitions for various
sexual minority populations
• Develop an understanding of LGBTQI health
disparities and their causes
• Speak with a diverse group of individuals from
LGBTIQ communities; have your questions
answered in a safe and respectful environment
• Review your own unconscious assumptions or
biases
• Think about ways to improve the climate for
LGBTQI people in your own environment.
Terms and Definitions:
LGBTQQIAA …& other initials
Lesbian, Gay, Bisexual, Transgender,
Intersex, Queer/Questioning
Asexual/Agender
• LGBTIQA shorthand way to describe sexual
and gender minorities
• Diversity within each group
• 3 main concepts
• Sexual orientation
• Gender identity
• Intersex
Terms and Definitions
• Sex: biological markers associated with
males and females – anatomy, chromosomes
• Gender: refers to attitudes, feelings, and
behaviors that a culture associates with either
males or females
Terms and Definitions
• Sexual Orientation: refers to an individual’s
enduring pattern of physical, romantic, emotional
and/or spiritual attraction toward other persons.
• Gender Identity: A person’s internal, deeply felt
sense of knowledge of being male, female, something
else or in between.
Terms and Definitions
• Intersex: refers to a person whose body is not
typically male or female, or whose anatomy is
not concordant with genetic sex.
Terms and Definitions
• Gender Expression: Outward expression of
maleness or femaleness or other.
Characteristics and behaviors such as
appearance, dress and speech patterns, that
are perceived as masculine or feminine.
Terms and Definitions
Gender variant/non-conforming
• Refers to people whose gender expression
is different from what society expects for a
male or female
Terms and Definitions
Gender expansive/creative
Terms and Definitions:
Sexual Orientation
• Lesbian, Gay, Bisexual: besides describing
sexual orientation, are sexual identities.
• Often associated with mainstream western
culture. These labels may not be used by other
ethnic/racial minorities or younger people.
Terms and Definitions:
Gender Identity
Transgender
• Umbrella term that can describe a broad range of
people who experience or express their gender
differently from what people expect (gender nonconforming).
• Commonly used to describe people who
experience and live in a gender different from the
sex assigned to them at birth.
Transgender
• FTM / Transmen
assigned female at birth and transition to
a male gender identity
• MTF / Transwomen
assigned male at birth and transition to a
female gender identity.
•
Cisgenger
a person who is not transgender
Terms and Definitions
Intersex
• Also called DSD: “Differences of Sex
Development”
• May be apparent in the newborn period,
puberty, or later
• Very much of an umbrella term for dozens of
conditions
Terms and Definitions:
Q can be for Questioning
• An individual that is exploring or becoming
more aware of their gender identity or sexual
orientation
Q can be for Queer
• Traditionally a pejorative term, queer has been
appropriated by some GLBT people to describe
themselves.
• Some value the term for its defiance and
because it can be inclusive of the entire LGBT
community.
Terms and Definitions
A is for Agenger/Asexual
• Gender neutral, genderless
• Low or absent interest in sexual relationships
A is for Ally
• A person who respects sexual diversity, acts to
challenge homophobic or transphobic remarks
and behaviors, and explores and understands
these forms of bias within oneself.
• Can be straight or cisgender or not
Sexual Humanity:
NON-Binary
• Human beings express their sexual orientation
and gender identity in a variety of ways considered a spectrum.
• Intersex conditions illustrate that sex is also on a
spectrum
• Sexual orientation or gender identity are in not
predicted by chromosomes, anatomy or
hormonal status.
• Sexual orientation and gender identity are not
rigidly static – often fluid.
SEX
Genetic:
XY
Anatomic:
Male
Many Variations
Female
GENDER
Identity:
Man
Gender Queer, Agender, Trans*
Woman
Expression/Role: Masculine
XXY XY X
Androgenous
XX
Feminine
SEXUALITY
Attraction:
Same Sex
Both
Opposite Sex
Behavior:
Same Sex
Both, None
Opposite Sex
Identity (label):
Lesbian, Gayl
Bisexual, Pansexual, Queer
Straight
How many people
are we talking about?
Epidemiology
• Measurement challenges (IOM 2011 report)
• Self-identity?
• Behavior?
• Stigmatized - Hidden (in plain sight)
Gallup October 2012
"Do you, personally, identify as lesbian, gay,
bisexual, or transgender?“ (June – Sept)
• 3.5% said yes
• 4.5% declined to answer
• 6.5% Youth (18-29)
• 8.3% Young women (18-29)
• Racial minorities more likely to answer “yes”
• Black
40% more
• Asian
35% more
• Hispanic 25% more
DSD incidence
• Depends on how you measure:
• ANY variation from “typical”
• “Medically significant” / Socially significant
• Age at which conditions become apparent
• Multiple diagnoses; variable presentations
• Range from 1/100 to 1/20,000 for different
conditions
• “About as common as being born a natural
redhead”
3-5% is a lot of people!
Population of Oregon and
Washington combined
Population Asian Americans
Discrimination Is Legal in Many States
• In June 2015 thousands of LGBT people
across the US gained the freedom to
marry….
• But in July
52% of LGBT were at risk for being
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fired from their job
kicked out of their home
denied access to doctor’s offices or
restaurants
Employment and Housing
Public Accommodation
School Anti-bullying Laws
Conversion Therapy
The State of Transgender California
Transgender Law Center 2009
• 5 years since passage of anti-discrimination law
• Respondents twice as likely to have college
degree as general population
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70% reported workplace discrimination
Twice as likely to be living in poverty
20% had been homeless
30% avoided needed healthcare
LGBTQ Health Disparities
• Discrimination/Stigma
Associated health risks
• Access
• Quality
Disparities & Antecedents
• Most LGBTQ youth are resilient and develop
into healthy adults
• As a group increased risk for depression,
suicide attempts, smoking, substance use,
homelessness, and risky sexual behavior.
• Important to understand the key mediators of
adverse health outcomes
Health Disparities - Stigma
• No health risk conferred by being LGBT per se
• Findings are similar to research with other
minority populations
• Daily stressors caused by stigma and
discrimination can lead to adverse mental and
physical health outcomes
Health Disparities - Stigma
• Internalized stigma can cause self-harm and
unhealthy risk-taking behaviors
• Those who are victimized or perceive
discrimination are more vulnerable
• Reported disparities
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Depression
Smoking
Substance use
Suicide attempts
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HIV/STIs
Type and presentation of cancers
Overweight or eating disorders
Diabetes and other chronic
conditions
Bullying
• LGBT youth (or kids thought to be gay) are 3
times more likely to be bullied
• In the last year LGBT students:
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74% verbally harassed
49% experienced electronic harassment
36% physically harassed
16% physically assaulted
Impact of Discrimination
LGBT students who experienced LGBT-related
discrimination at school were:
• More than three times as likely to have
missed school in the past month as those
who had not
• Had lower GPAs than their peers (3.0 vs. 3.3)
• Had lower self-esteem and higher levels of
depression.
Homelessness
• LGBTQ youth are significantly overrepresented
among homeless youth.
• 40 percent of homeless or at-risk youths
identify as gay or transgender
Top 3 reasons for homelessness
among LGBTQ Youth
Violence
• Experiences of violence and victimization are
frequent for LGBT individuals, with long-lasting
effects on the individual and the community.
Healthy People 2020
• 22% of all hate crimes (vs 5% population)
• LGBT homicides 2014
• 80% transgender women
• 55% percent people of color
• 35% gay/bi men
Suicide Risk
• LGB youth 3-4 times more
likely to attempt suicide than
their heterosexual peers.
• 41% of transgender
respondents reported
attempting suicide (vs. 1.6%
of the general population)
Importance of Acceptance:
Resilience
Higher rates of family rejection during adolescence
impact health of young adults
• 8 ½ times more likely to have attempted suicide
• 9 times more likely to report high levels of depression
• 3 ½ times more likely to use illegal drugs
• 3 ½ times more likely to have engaged in unprotected
sex compared with peers from families with no or low
levels of family rejection
Ryan, Pediatrics 2009
LGBT Health Disparities
85
80
Heterosexual
LGB
Trans
75
70
65
60
Excellent or Very Good Health
Well-Being Index Scores
Gallup-Healthways Well-Being Index 2014
64
Non-LGBT
63
LGBT
62
61
60
59
58
57
56
55
54
National adults
Men
Women
Access to Care
• Less likely to feel welcome or comfortable in
healthcare setting
• Lower income after controlling for education
• Historical lack of federal marriage benefits
• Trans care has been specifically excluded from
insurance coverage
Insurance Status
Quality of Care
Healthcare Disparities:
Quality
•National survey of lesbians found that less than
half (47%) reported that a healthcare provider
had ever inquired about their sexuality
•Only 28% or trans* were out to all of their
medical providers
•Missed opportunities to support patients
•Missed opportunities for risk assessment and
counseling regarding risk reduction
Quality of Care
2009 Patient Survey of
Provider Behaviors
30
25
20
15
10
5
0
LGB
Trans
Refused
Needed Care
Harsh
Language
Physically
Rough
Faces of Discrimination in
Healthcare
Faces of Discrimination in
Healthcare
How Can Healthcare Be More
Welcoming?
LGBT-Friendly Hospitals
Joint Commission 2010
• May not refuse care
• Must prohibit discrimination, regardless of local
law
• Recognize same-sex partners as the patient’s
family
• Intake forms (or electronic record) should be
inclusive of LGBT patients and families
• Hospitals should use a transgender patient’s
preferred name even if not the legal name
Human Rights Campaign
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Annual online survey
Healthcare organizations rate themselves on a number
of measures regarding equitable, inclusive care
LGBT Americans can find healthcare organizations with
a demonstrated commitment to their care.
HEI 2014 Participants
Efforts to improve LGBT health include:
• Appropriately inquiring about and being
supportive of a patient’s sexual orientation to
enhance the patient-provider interaction and
regular use of care.
Welcoming Healthcare
Professionals
• Aware of assumptions or biases
• Avoid the assume that everyone is heterosexual
or cis-gender. Open to differences.
• Use gender neutral language when taking a social
or sexual history
• Ask open ended questions
• Who lives at home with you?
• Are you in a relationship?
What Else?
• Use language patient requests
• chosen name
• preferred pronoun
• labels for patient or partner
Other LGBT-Friendly Ideas
• Visual symbols to signal welcoming environment
• Post anti-discrimination policies
Resources
• The LGBT Center OC – local LGBTQ resource center
in Santa Ana
• GLMA (health professionals for equality in
healthcare) – provider directory that any
interested health professional can join
• The Trevor Project – crisis intervention and suicide
prevention services
• Fenway Institute – online education
• Human Rights Campaign – large civil rights
organization
Thank You!
What Would You Do?
• You are volunteering in a hospital or clinic.
You overhear health providers making fun of
the appearance and demeanor of recent who
patient who may be transgender.
• How would you feel?
• How would you respond?