Pride and Equity: 6 Questions About Inclusive Health Care for the LGBTQ+ Community | Deloitte US has been saved
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By Malik Eljallad, manager, Deloitte Consulting, LLP
June is Pride month, a month that recognizes and celebrates the impact lesbian, gay, bisexual, transgender, and queer (LGBTQ+) individuals have had on history and society. In addition to being involved in LGBTQ+ recruitment and retention initiatives at Deloitte, I also work with the Deloitte Health Equity Institute, which provides funding for organizations that are working to make health care more accessible and more equitable for everyone.
Earlier in my career, I worked with Mo Connolly, M.D., a pediatrician with Henry Ford Health and the medical director of a community center in Detroit that serves LGBTQ+ young people who are experiencing homelessness. Mo and I recently had a conversation about improving health equity. We were joined by Alex Keuroghlian, M.D., MPH, a psychiatrist and director of education and training programs at The Fenway Institute at Fenway Health, a federally qualified health center in Boston. Fenway, one of the first federally qualified health centers in the US, is the largest provider of transgender health services and HIV care in New England. Dr. Keuroghlian is also director of Massachusetts General Hospital’s Psychiatry Gender Identity Program and Associate Professor of Psychiatry at Harvard Medical School. Fenway provides education in all 50 states, Washington, D.C., and Puerto Rico to help health care organizations gain a better understanding of LGBTQ+ patients and their unique health needs. Here is an excerpt from our conversation:
Malik: It’s not uncommon for a physician to tell an LGBTQ+ patient to find a specialist who works with that population. Sometimes physicians aren’t familiar with certain drugs, such as pre-exposure prophylaxis (PrEP), which can prevent HIV. Some patients might be afraid to speak up and ask for a prescription, or to discuss their gender identity. Why is it important to make LGBTQ+ patients feel comfortable seeking care?
Mo: Some of the young people I work with don’t want to see a medical provider. It can be intimidating. The goal of our center is to provide a space that feels safe. We try to celebrate the fact that the patient had the courage to walk through the door to seek care, despite all of the negative and potentially traumatizing experiences they might have experienced in the past. Just walking through the door to seek services is an act of courage, and we try to show them that we are happy they are here.
Alex: Even as a practicing physician and associate professor in a leadership position, I still feel anxious and uncomfortable every time I go to the doctor because of my LGBTQ+ identity. Imagine how a young person feels. Think about the courage it takes just to show up and seek health care services. The environment in which care is delivered needs to be inclusive and affirming. That can range from the physical environment, like the posters and pamphlets in the waiting room, to non-discrimination policies that should include gender identity, gender expression, and sexual orientation.
Malik: Is it the responsibility of an LGBTQ+ patient to educate clinicians and staff about their identity?
Mo: It shouldn't be, but that is often the case, particularly when someone is seeking care in a health care setting where this type of education is limited. Leaders should make sure that staff is attuned to people's identities. The name a patient uses, for example, might not match the name on their ID, or the patient might not use he/she pronouns. These seemingly tiny things can accumulate and make a patient uncomfortable when they seek care. There are ways to make the experience better and more equitable.
Alex: Understanding LGBTQ+ communities is not part of standard training at most medical schools and nursing schools. A study done more than a decade ago found that medical students in the US and Canada receive an average of five hours total education on this topic. That hasn’t improved much. This means clinicians are graduating without the readiness, cultural responsiveness, or technical skills to serve LGBTQ+ patients. As a result, they often don’t start learning until they have an LGBTQ+ patient in front of them. Our education center works with clinicians who are already practicing. We help them unlearn certain biases they might have picked up during their medical education. In 2018, Harvard Medical School launched the Sexual and Gender Minority Health Equity Initiative. This incorporates LGBTQ+ health into the core curriculum to help ensure that every graduate is confident and competent providing care for LGBTQ+ people. This type of education should be standard for everybody. We have a lot of work to do and there is a lot of opportunity for improvement.
Malik: A new report from the National Academies of Sciences, Engineering, and Medicine recommends standardized language be used in survey questions that ask about a respondent’s sex, gender identity, and sexual orientation. Why is it important that health care providers understand a patient’s sexual orientation and gender identity?
Mo: It’s a way of conveying to the patient that their sexual orientation or gender identity is a normal part of being human. It is an opportunity to normalize and destigmatize the situation for the patient. Some of the patients I see are transgender or non-binary. In other health care settings, they might be misgendered or information about their pronouns might be met with confusion by staff. In some cases, these patients have faced outright disrespect. This is a real challenge.
Alex: In order to provide effective and equitable care, we need to know the patient’s sexual orientation and gender identity. That information is important, but it needs to be collected in a sensitive and effective way to ensure the patient can receive personally tailored and culturally responsive care that is similar to the standard of care provided to the general population. Collecting that information signals to patients that we're interested in their experience and that we're not making assumptions about their sexual orientation or gender identity, or the pronouns they use. However, sometimes staff don’t know how to ask these questions in a sensitive and effective way. They might be afraid of offending patients by asking such personal questions, but several studies have shown that the vast majority of patients are comfortable answering these questions. Staff should be trained to ask these questions in a way that puts the patient at ease.
Malik: What sort of an impact did COVID-19 have on your LGBTQ+ patients?
Mo: It gave us an opportunity to expand our reach. The space where we operate our clinic is a community center for LGBTQ+ young people, many of whom are affected by homelessness or have some instability in their homelife. We did initial video intakes with transgender and non-binary people who might live four or five hours away. I don’t think we would have thought about offering virtual health without COVID pushing us in that direction. As a result, some people gained access to a level of care that maybe wasn't available in their communities.
Alex: The pandemic increased isolation and made it difficult for LGBTQ+ communities to come together in person. Fenway Health shifted to an almost completely virtual-care model, whereby clinicians trained in gender-affirming care met with patients virtually. During the first six months of the pandemic, Fenway provided virtual care to nearly as many transgender and gender diverse patients as we saw in-person during all 12 months of 2019. Patients didn’t have to risk being harassed on their way to the health center, and many patients now want to continue with virtual care. But some of the rules regarding virtual care across state lines have since tightened up, which has made it difficult to provide gender-affirming care to many of the people who need it.
Malik: The physical environment where a patient lives, their access to healthy food, employment, education, and social connections can all have an impact on health. Do these drivers of health (also known as social determinants) have a more profound impact on LGBTQ+ people?
Mo: A lot of young people I see live at the intersection of racism and homophobia or transphobia. Even though we are focused on providing care to LGBTQ+ patients, we have to make sure we are providing care while looking through an anti-racist/anti-bias lens. You can't achieve health equity by focusing on one aspect of someone's identity. It's incredibly important to consider the patient’s lived experiences.
Alex: I couldn't have said it better. LGBTQ+ young people are often estranged from their families. They might experience a wide range of discrimination in school, their jobs, and in finding a place to live. We sometimes see young people who have run away or been kicked out of their home. Some don’t complete school because of the harassment and mistreatment that they experienced there. A lot of minoritized groups are protected by federal anti-discrimination laws. But that’s not true for the LGBTQ+ community. It’s important to understand discrimination intersectionally: A Black trans person is impacted more significantly by social determinants than a white trans person.
Malik: Do you collect information about the drivers of health when working with patients?
Mo: Yes. That might be the most important thing we can do to help ensure people achieve their version of health. I can prescribe all the medications in the world, but if a patient doesn’t have a safe place to stay, or isn’t eating well, those medications aren’t going to be as effective. A lot of the time, we talk to patients about health issues that don’t show up in a blood test. What is their social environment like? Do they have the layers of support they need to be healthy?
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