Healthcare and the LGBT community

"LGBT health" redirects here. For the academic journal, see LGBT Health (journal).

LGBT topics in medicine are those that relate to lesbian, gay, bisexual and transgender people's health issues and access to health services. According to the US Gay and Lesbian Medical Association (GLMA), besides HIV/AIDS, issues related to LGBT health include breast and cervical cancer, hepatitis, mental health, substance abuse, tobacco use, depression, access to care for transgender persons, issues surrounding marriage and family recognition, conversion therapy, and refusal clause legislation, and laws that are intended to "immunize health care professionals from liability for discriminating against persons of whom they disapprove."[1]

Studies show that LGBT people experience health issues and barriers related to their sexual orientation and/or gender identity or expression. Many avoid or delay care or receive inappropriate or inferior care because of perceived or real homophobia or transphobia, and discrimination by health care providers and institutions;[2] in other words, negative personal experience, the assumption or expectation of negative experience based on knowing of history of such experience in other LGBT people, or both.[3]

It is often pointed that the reason of this is heterosexism in medical care and research:[3][4]

"Heterosexism can be purposeful (decreased funding or support of research projects that focus on sexual orientation) or unconscious (demographic questions on intake forms that ask the respondent to rate herself or himself as married, divorced, or single). These forms of discrimination limit medical research and negatively impact the health care of LGB individuals. This disparity is particularly extreme for lesbians (compared to homosexual men) because they have a double minority status, and experience oppression for being both female and homosexual."[5]

Especially with lesbian patients they may be discriminated in three ways:

  1. homophobic attitudes
  2. heterosexist judgements and behaviour
  3. general sexism – focusing primarily on male health concerns and services; assigning subordinate to that of men health roles for women, as for service providers and service recipients[3]

Issues affecting LGBT people generally

Research from the UK indicates that there appears to be limited evidence available from which to draw general conclusions about lesbian, gay, bisexual and transgender health because epidemiological studies have not incorporated sexuality as a factor in data collection.[6] Review of research that has been undertaken suggests that there are no differences in terms of major health problems between LGBT people and the general population, although LGBT people generally appear to experience poorer health, with no information on common and major diseases, cancers or long-term health.[6] Mental health appears worse among LGBT people than among the general population, with depression, anxiety and suicide ideation being 2–3 times higher than the general population.[6][7] There appear to be higher rates of eating disorder and self-harm, but similar levels of obesity and domestic violence to the general population; lack of exercise and smoking appear more significant and drug use higher, while alcohol consumption is similar to the general population.[6] Polycystic ovaries and infertility were identified as being more common amongst lesbians than heterosexual women.[6] The research indicates noticeable barriers between LGB patients and health professionals, and the reasons suggested are homophobia, assumptions of heterosexuality, lack of knowledge, misunderstanding and over-caution; institutional barriers were identified as well, due to assumed heterosexuality, inappropriate referrals, lack of patient confidentiality, discontinuity of care, absence of LGBT-specific healthcare, lack of relevant psycho-sexual training.[6][7]

Research points to issues encountered from an early age, such as LGBT people being targeted for bullying, assault, and discrimination, as contributing significantly to depression, suicide and other mental health issues in adulthood.[8][9][10] Social research suggests that LGBT experience discriminatory practices in accessing healthcare.[11][12][13]

Causes of LGBT health disparities

Some causes of lack of access to healthcare among LGBT people are: perceived or real discrimination, inequality in the workplace and health insurance sectors,[14] and lack of competent care due to negligible LGBT health training in medical schools.[15] Healthcare professionals that have little to no knowledge about the LGBT community can result in a lack of or a decline in the type of healthcare these families receive. "Fundamentally, the distinctive healthcare needs of lesbian women go unnoticed, are deemed unimportant or are simply ignored" (DeBold, 2007; Weisz, 2009). This citation is from the article Marginalised mothers: Lesbian women negotiating heteronormative healthcare services, which talks about how heteronormative rhetorics affect the way lesbian couples are viewed. Views like these lead to the belief that health care training can exclude the topic related to the healthcare of LGBT and make certain members of the LGBT community feel as though they can be exempt from healthcare without any bodily consequences.[16]

Issues affecting lesbians

Breast cancer

According to Katherine A. O’Hanlan, lesbians "have the richest concentration of risk factors for breast cancer [of any] subset of women in the world." Additionally, many lesbians do not get routine mammograms, do breast self-exams, or have clinical breast exams.[17]

Depression and anxiety

Depression and anxiety are thought to affect lesbians at a higher rate than in the general population, for similar reasons.[17]

Domestic violence

For more details on this topic, see Domestic violence in lesbian relationships.

Domestic violence is reported to occur in about 11 percent of lesbian homes. While this rate is about half the rate of 20 percent reported by heterosexual women, lesbians often have fewer resources available for shelter and counselling.[17]

Physical fitness

Research shows that on average lesbians have a higher body mass index than heterosexual women.[17]

Obesity

Lesbian and bisexual women are more likely to be overweight or obese.[18]

Substance abuse

Lesbians often have high rates of substance use, including recreational drugs, alcohol and tobacco. Studies have shown that lesbian and bisexual women are 200% more likely to smoke tobacco than other women.[2]

Heterosexism

Lesbians who tell their health care providers they are sexually active report being pressured to obtain birth control, since the provider often equates female sexual activity with the possibility of pregnancy.[19]

Issues affecting gay men

Human papilloma virus

Human papilloma virus, which causes anal and genital warts, plays a role in the increased rates of anal cancers in gay men, and some health professionals now recommend routine screening with anal pap smears to detect early cancers.[20] Men have higher prevalence of oral HPV than women. Oral HPV infection is associated with HPV-positive oropharyngeal cancer.

Depression, anxiety, and suicide

Studies by Cochran et al. (2003) and Mills et al. (2004), among others, suggest that depression and anxiety appear to affect gay men at a higher rate than in the general population.[20][21]

According to GLMA, "the problem may be more severe for those men who remain in the closet or who do not have adequate social supports. Adolescents and young adults may be at particularly high risk of suicide because of these concerns. Culturally sensitive mental health services targeted specifically at gay men may be more effective in the prevention, early detection, and treatment of these conditions."[20] Researchers at the University of California at San Francisco found that major risk factors for depression in gay and bisexual men included a recent experience of anti-gay violence or threats, not identifying as gay, or feeling alienated from the gay community.[21]

Results from a survey by Stonewall Scotland published in early 2012 found that 3% of gay men had attempted suicide within the past year.[22]

Eating disorders and body image

Gay men are more likely than straight men to suffer from eating disorders such as bulimia or anorexia nervosa.[23] The cause of this correlation remains poorly understood, but is hypothesized to be related to the ideals of body image prevalent in the LGBT community.[24] Obesity, on the other hand, affects relatively fewer gay and bisexual men than straight men[25]

Hepatitis

Men who have sex with men are at an increased risk of sexually transmitted infection with hepatitis, and immunization for Hepatitis A and Hepatitis B is recommended for all men who have sex with men. Safer sex is currently the only means of prevention for the Hepatitis C.[20]

Sexually transmitted infections

The first name proposed for what is now known as AIDS was gay-related immune deficiency, or GRID.[26] This name was proposed in 1982, after public health scientists noticed clusters of Kaposi's sarcoma and Pneumocystis pneumonia among gay males in California and New York City.[27]

Men who have sex with men are more likely to acquire HIV in the modern West, Japan,[28] India,[29] and Taiwan,[30] as well as other developed countries than among the general population,[31] in the United States, 60 times more likely than the general population.[32] An estimated 62% of adult and adolescent American males living with HIV/AIDS got it through sexual contact with other men.[33] HIV-related stigma is consistently and significantly associated with poorer physical and mental health in PLHIV (people living with HIV).[34]

The US Center for Disease Control recommends annual screening for syphilis, gonorrhea, HIV and chlamydia for men who have sex with men.[2]

Black gay men have a greater risk of HIV and other STIs than white gay men.[35] However, their reported rates of unprotected anal intercourse are similar to those of men who have sex with men (MSM) of other ethnicities.[36]

Substance abuse

David McDowell of Columbia University, who has studied substance abuse in gay men, wrote that club drugs are particularly popular at gay bars and circuit parties.[37] Studies have found different results on the frequency of tobacco use among gay and bisexual men compared to that of heterosexual men, with one study finding a 50% higher rate among sexual minority men,[2] and another encountering no differences across sexual orientations.[38]

Issues affecting bisexual people

Typically, bisexual individuals and their health and well-being are not studied independently of lesbian and gay individuals. Thus, there is limited research on the health issues that affect bisexual individuals. However, the research that has been done has found striking disparities between bisexuals and heterosexuals, and even between bisexuals and homosexuals.

It is important to consider that the majority of bisexual individuals are well-adjusted and healthy, despite having higher instances of health issues than the heterosexual population.[39]

Body image and eating disorders

Youth who reported having sex with both males and females are at the greatest risk for disordered eating, unhealthy weight control practices compared to youth who only have same- or other-gender sex.[40] Bisexual women are twice as likely as lesbians to have an eating disorder and, if they are out, to be twice as likely as heterosexual women to have an eating disorder.[41]

Mental health and suicide

Further information: Suicide among LGBT youth

Bisexual females are higher on suicidal intent, mental health difficulties and mental health treatment than bisexual males.[42] In a survey by Stonewall Scotland, 7% of bisexual men had attempted suicide in the past year.[22] Bisexual women are twice as likely as heterosexual women to report suicidal ideation if they have disclosed their sexual orientation to a majority of individuals in their lives; those who are not disclosed are three times more likely.[41] Bisexual individuals have a higher prevalence of suicidal ideation and attempts than heterosexual individuals, and more self-injurious behavior than gay men and lesbians.[43] A 2011 survey found that 44 per cent of bisexual middle and high school students had thought about suicide in the past month.[44]

Substance abuse

Female adolescents who report relationships with same- and other-sex partners have higher rates of alcohol abuse and substance abuse.[45] This includes higher rates of marijuana and other illicit drug use.[46][47][48] Behaviorally and self-identified bisexual women are significantly more likely to smoke cigarettes and have been drug users as adolescents than heterosexual women.[49]

Cancer

Bisexual women are more likely to be nulliparous, overweight and obese, have higher smoking rates and alcohol drinking than heterosexual women, all risk factors for breast cancer.[50] Bisexual men practicing receptive anal intercourse are at higher risk for anal cancer caused by the human papillomavirus (HPV).[51]

HIV/AIDS and sexual health

Most research on HIV/AIDS focuses on gay and bisexual men than lesbians and bisexual women. Evidence for risky sexual behavior in bisexually behaving men has been conflicted. Bisexually active men have been shown to be just as likely as gay or heterosexual men to use condoms.[52] Men who have sex with men and women are less likely than homosexually behaving men to be HIV-positive or engage in unprotected receptive anal sex, but more likely than heterosexually behaving men to be HIV-positive.[53] Although there are no confirmed cases of HIV transmitted from female to female, women who have sex with both men and women have higher rates of HIV than homosexual or heterosexual women.[54]

In a 2011 nationwide study in the United States, 46.1% of bisexual women reported having experienced rape, compared to 13.1% of lesbians and 17.4% of heterosexual women,[55] a risk factor for HIV.

Issues affecting transgender people

Access to health care

Transgender individuals are often reluctant to seek medical care or are denied access by providers due to transphobia/homophobia or a lack of knowledge or experience with transgender health. Additionally, in some jurisdictions health care related to transgender issues, especially sex reassignment therapy, is not covered by medical insurance.[56] However, Principle 17 of The Yogyakarta Principles affirms that "States shall (g) facilitate access by those seeking body modifications related to gender reassignment to competent, non-discriminatory treatment, care and support.[57] The WPATH's Standards of Care also provide a set of non-binding clinical guidelines for health practitioners who are treating transgender patients.[58]

In 2011, the National Gay and Lesbian Task Force and the National Center for Transgender Equality published the National Transgender Discrimination Survey.[59] Survey results shed light on the discrimination transgender and gender non-conforming people are facing in all aspects of their daily lives, including in medical and health care settings. The survey reported that 19% of respondents had been refused healthcare by a doctor or other provider because they identify as transgender or gender non-conforming and transgender people of color were more likely to have been refused healthcare.[60] 36% of American Indian and 27% of multi-racial respondents reported being refused healthcare, compared to 17% of white respondents. In addition, the survey found that 28% of respondents said they had been verbally harassed in a healthcare setting and 2% of respondents reported being physically attacked in a doctor's office. Transgender people particularly vulnerable to being assaulted in a doctor's office were those who identify as African-Americans (6%), those who engaged in sex work, drug sales or other underground work (6%), those who transitioned before they were 18 (5%), and those who identified as undocumented or non-citizens (4%).

Access to transgender health care is a global issue. In 2004 Venkatesan Chakrapani reported that hijras 'face discrimination in various ways' in the Indian health-care system, and sexual reassignment surgery is unavailable in government hospitals in India.[61] In a report on hijra social exclusion in Bangladesh by Sharful Islam Khan et al., it was said that health facilities sensitive to hijra culture are virtually non-existent in Bangladesh.[62]

In the UK the NHS is legally required to provide treatment for gender dysphoria.

Insurance coverage

Although they are not the only uninsured population in the United States, transgender people are less likely than cisgender people to have access to health insurance and if they do, their insurance plan may not cover medically necessary services.[63] The National Transgender Discrimination Survey reported that 19% of survey respondents stated that they had no health insurance compared to 15% of the general population. They were also less likely to be insured by an employer. Undocumented non-citizens had particularly high rates of non-coverage (36%) as well as African-Americans (31%), compared to white respondents (17%).

While a majority of U.S. insurance policies expressly exclude coverage for transgender care, regulations are shifting to expand coverage of transgender and gender non-conforming health care.[63] A number of private insurance carriers cover transgender-related health care under the rubric of "transgender services", "medical and surgical treatment of gender identity disorder", and "gender reassignment surgery".[64] Nine states (California, Colorado, Connecticut, Illinois, Massachusetts, New York, Oregon, Vermont, and Washington) and the District of Colombia require that most private insurance plans cover medically necessary health care for transgender patients.[65]

Depending on where they live, some transgender people are able to access gender-specific health care through public health insurance programs. Medicaid does not have a federal policy on transgender health care and leaves the regulation of the coverage of gender-confirming health care up to each state.[66] While Medicaid does not fund sex reassignment surgery in forty states,[67] several, like New York[68] and Oregon,[69] now require Medicaid to cover (most) transgender care.

Cancer

Cancers related to hormone use include breast cancer and liver cancer. In addition, transmen who have not had removal of the uterus, ovaries, or breasts remain at risk to develop cancer of these organs, while trans women remain at risk for prostate cancer.[56]

Mental health

According to transgender advocate Rebecca A. Allison, trans people are "particularly prone" to depression and anxiety: "In addition to loss of family and friends, they face job stress and the risk of unemployment. Trans people who have not transitioned and remain in their birth gender are very prone to depression and anxiety. Suicide is a risk, both prior to transition and afterward. One of the most important aspects of the transgender therapy relationship is management of depression and/or anxiety."[56] Depression is significantly correlated with experienced discrimination.[70] In a study of San Francisco trans women, 62% reported depression.[71] In a 2003 study of 1093 trans men and trans women, there was a prevalence of 44.1% for clinical depression and 33.2% for anxiety.[72]

Suicide attempts are common in transgender people. In some transgender populations the majority have attempted suicide at least once. 41% of the respondents of the National Transgender Discrimination Survey reported having attempted suicide. This statistic was even higher for certain demographics – for example, 56% of American Indian and Alaskan Native transgender respondents had attempted suicide. In contrast, 1.6% of the American population has attempted suicide.[73] In the sample all minority ethnic groups (Asian, Latino, black, American Indian and mixed race) had higher prevalence of suicide attempts than white people. Number of suicide attempts was also correlated with life challenges - 64% of those surveyed who had been sexually assaulted had attempted suicide. 76% who had been assaulted by teachers or other school staff had made an attempt.

In 2012 the Scottish Transgender Alliance conducted the Trans Mental Health Study. 74% of the respondents who had transitioned reported improved mental health after transitioning. 53% had self-harmed at some point, and 11% currently self-harmed. 55% had been diagnosed with or had a current diagnosis of depression. An additional 33% believed that they currently had depression, or had done in the past, but had not been diagnosed. 5% had a current or past eating disorder diagnosis. 19% believed that they had suffered from an eating disorder or currently had one, but had not been diagnosed. 84% of the sample had experienced suicide ideation and 48% had made a suicide attempt. 3% had attempted suicide more than 10 times. 63% of respondents who transitioned thought about and attempted suicide less after transitioning. Other studies have found similar results.[73]

Trans women appear to be at greater risk than trans men and the general population of dying of suicide.[74] However, trans men are more likely to attempt suicide than trans women.[75]

Personality disorders are common in transgender people.[76]

Gender identity disorder is currently classed as a psychiatric condition by the DSM IV-TR.[77] The upcoming DSM-5 removes GID and replaces it with 'gender dysphoria', which is not classified by some authorities as a mental illness.[78] Until the 1970s, psychotherapy was the primary treatment for GID. However, today the treatment protocol involves biomedical interventions, with psychotherapy on its own being unusual. There has been controversy about the inclusion of transsexuality in the DSM, one claim being that Gender Identity Disorder of Childhood was introduced to the DSM-III in 1980 as a 'backdoor-maneuver' to replace homosexuality, which was removed from the DSM-II in 1973.[79]

Hormones

Transgender individuals frequently take hormones to achieve feminizing or masculinizing effects. Side effects of hormone use include increased risk of blood clotting, high or low blood pressure, elevated blood sugar, water retention, dehydration, electrolyte disturbances, liver damage, increased risk for heart attack and stroke.[56] Use of unprescribed hormones is common, but little is known about the associated risks.[80] One potential hazard is HIV transmission from needle sharing.[81] Cross-sex hormones may reduce fertility.[82]

Injectable silicone

Some trans women use injectable silicone, sometimes administered by lay persons, to achieve their desired physique. This is most frequently injected into the hip and buttocks. It is associated with considerable medical complications, including morbidity.[83] Such silicone may migrate, causing disfigurement years later. Non-medical grade silicone may contain contaminants, and may be injected using a shared needle.[56] In New York City silicone injection occurs frequently enough to be called 'epidemic', with a NYC survey of trans women finding that 18% were receiving silicone injections from 'black market' providers.[83]

Sexually transmitted infections

Trans people (especially trans women – trans men have actually been found to have a lower rate of HIV than the general US population[60]) are frequently forced into sex work to make a living, and are subsequently at increased risk for STIs including HIV. According to the National Transgender Discrimination Survey, 2.64% of American transgender people are HIV positive, and transgender sex workers are over 37 times more likely than members of the general American population to be HIV positive. HIV is also more common in trans people of color. For example, in a study by the National Institute of Health more than 56% of African-American trans women were HIV-positive compared to 27% of trans women in general.[84] This has been connected to how trans people of color are more likely to be sex workers.[73]

A 2012 meta analysis of studies assessing rates of HIV infection among transgender women in 15 countries found that trans women are 49 times more likely to have HIV than the general population.[85] HIV positive trans persons are likely to be unaware of their status. In one study, 73% of HIV-positive trans women were unaware of their status.[86]

Latin American trans women have a HIV prevalence of 35%,[87] but most Latin American countries do not recognize transgender people as a population. Therefore, there are no laws catering to their health needs.

Transgender people have higher levels of interaction with the police than the general population. 7% of transgender Americans have been held in prison cell simply due to their gender identity/expression. This rate is 41% for transgender African-Americans.[60] 16% of respondents had been sexually assaulted in prison, a risk factor for HIV. 20% of trans women are sexually assaulted in prison, compared to 6% of trans men. Trans women of color are more likely to be assaulted whilst in prison. 38% of black trans women report having been sexually assaulted in prison compared to 12% of white trans women.

In a San Francisco study, 68% of trans women and 55% of trans men reported having been raped, a risk factor for HIV.[88]

Substance abuse

Trans people are more likely than the general population to use substances. For example, studies have shown that trans men are 50% more likely, and trans women 200% more likely to smoke cigarettes than other populations. It has been suggested that tobacco use is high among transgender people because many use it to maintain weight loss.[89] In one study of trangender people, the majority had a history of non-injection drug use with the rates being 90% for marijuana, 66% for cocaine, 24% for heroin, and 48% for crack.[90] It has been suggested that transgender people who are more accepted by their families are less likely to develop substance abuse issues.[91]

In the Trans Mental Health Study 2012, 24% of participants had used drugs within the past year. The most commonly used drug was cannabis. 19% currently smoked.[73] A study published in 2013 found that among a sample of transgender adults, 26.5% had abused prescription drugs, most commonly analgesics.[92]

Health of LGBT people of color

In a review of research, Balmsam, Molina, et al., found that "LGBT issues were addressed in 3,777 articles dedicated to public health; of these, 85% omitted information on race/ethnicity of 9 participants".[93] However, studies that have noted race have found significant health disparities between white LGBT people and LGBT people of color. LGBT health research has also been criticized for lack of diversity in that, for example, a study may call for lesbians, but many black and minority ethnic groups do not use the term lesbian or gay to describe themselves.[94]

See also

References

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