The Importance of LGBTQ+ Inclusive Healthcare: Overcoming Challenges and Finding Solutions

Members of the LGBTQ+ population are significantly more likely to suffer from depression, premature cognitive decline, substance abuse, and physical health concerns. At the same time, they are more likely to experience difficulty accessing quality healthcare. [1] LGBTQ+ individuals are more likely to experience discrimination and marginalization during their whole lives. They are also more likely to have a lack of resources and inadequate social support. [2]

There are many challenges for LGBTQ+ healthcare from both the perspective of the provider and the patient. Many healthcare providers don’t feel that they are well informed on the healthcare needs specific to the LGBTQ+ population. In addition, many healthcare providers have implicit bias towards the LGBTQ+ population, which can impact their comfort with caring for this unique population. [3,4]

This article will discuss many of the challenges and resources for caring for the unique needs of the LGBTQ+ population.

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Understanding LGBTQ+ Inclusive Healthcare

LGBTQ+ patients are much less likely to seek healthcare because of their LGBTQ+ identity and a fear of discrimination from healthcare providers. [5] LGBTQ+ inclusive healthcare promotes a safe space within the healthcare environment, which promotes equitable care for the LGBTQ+ patient population. LGBTQ+ inclusive healthcare can improve health outcomes because patients are less likely to delay seeking healthcare and are less likely to have thoughts of self-harm or suicide. [6,7]

Transgender men and women have reported lower levels of satisfaction with their care.[8] Gender-affirming care and inclusive healthcare has the potential to improve healthcare outcomes and patient satisfaction. [9]

Around 3.8% of Americans identify as LGBT. Studies have shown that [1,10-11]:

• LGBTQ+ Americans have an increased risk of poverty than their counterparts (21.6% vs 19.5%)
• LGBTQ+ youth are more likely to report suicidal ideation (30% vs 6%)
• LGBTQ+ youth are more likely to have self-harm behaviors (21% vs 6%)
• 34% of LGBTQ+ teens are bullied in school
• 18% of LGBTQ+ teens report being forced to have sex
• 23% of LGBTQ+ teens were victims of sexual violence
• 18% of LGBTQ+ teens have been victims of physical violence
• LGBTQ+ patients are also more likely to contract sexually transmitted diseases including HIV

With these significant health discrepancies, it is vitally important to improve gender inclusiveness in healthcare to improve healthcare equity and access.

Challenges in LGBTQ+ Healthcare

There are many challenges that the LGBTQ+ population faces when accessing healthcare. One of the most common challenges is implicit bias in the healthcare system. Some of the types of bias that the LGBTQ+ population describes in their experiences with the healthcare system include [12,13]:

• Feeling like their care is transactional
• Feeling of power imbalance
• Verbal or non-verbal cues that make patients uncomfortable, awkward, or inappropriate
• Institutional bias
• Feeling that the healthcare system is unwelcoming or difficult
• Bigotry
• Feelings of being treated unfairly
• Experiencing worsening healthcare conditions after being dismissed by a provider
• Refusal by a healthcare provider to give them care based on gender transition or gender identity
• Being misgendered or called the wrong name by a healthcare provider
• Refusal to recognize their family 

The bias that the LGBTQ+ population experiences undermines their trust in the healthcare system and leads to poorer health outcomes. LGBTQ+ adults have higher rates of ongoing conditions, increased rates of disability or chronic disease, and higher rates of ongoing medical conditions than their non-LBGTQ+ counterparts. [14] 

Research shows that implicit bias is very common in healthcare providers. There is a lack of cultural competency among healthcare providers when treating LGBTQ+ patients. [15] More than 15% of healthcare providers sampled in one study disagreed that more LGBTQ+ education was necessary, 18% did not value the importance of asking about sexual orientations, and 20% didn’t feel comfortable treating LGBTQ+ patients. [15] Many programs provide little education on LGBTQ+ healthcare concerns. The average LGBTQ+ healthcare education throughout medical school is around 5 hours. Some of the areas that healthcare providers were most deficient in included [15]:

• Health screenings such as breast cancer and anal cancer
• Gender reassignment surgery availability
• Rates of domestic violence
• Rates of obesity
• Rates of depression and anxiety

Healthcare systems are not the only place where the LGBTQ+ population faces barriers. Legal and policy barriers have also been a concern for the LGBTQ+ population. Gaps in insurance coverage for gender-affirming treatment has also been a barrier to care. [16] The Defense of Marriage Act allowed for legalization of same-sex marriage nationwide and the Affordable Care Act both serve to improve equity for LGBTQ+ patients.

Mental health is a significant concern for the LGBTQ+ population because the rate of depression and suicide are much higher than the non-LGBTQ+ population. [10] Just like many other areas of healthcare, mental health access is a significant concern. In LGBTQ+ youth, a remarkable 84% of people wanted mental health care while 50% of those were not able to access it. [17] Some of their concerns included:

• Fear of talking about their mental health
• Not wanting to seek permission from a parent or caregiver
• Inability to afford care
• Fear of being outed
• Previous negative experience

Solutions for LGBTQ+ Healthcare

Training LGBTQ+ literate healthcare providers is important for improving LGBTQ+ access to healthcare. Although healthcare organizations have committed to improving healthcare equity, addressing the implicit biases and knowledge gaps in healthcare providers must be addressed in order to improve equity. [18] One initiative involved forming interprofessional teams of healthcare trainees. This study used small-group case-based learning to improve attitude and confidence in addressing LGBTQ+ healthcare concerns. Their results demonstrated the effectiveness of case-based approaches for enhancing the cultural competency awareness amongst the healthcare programs. [19]

In addition to training healthcare providers in LGBTQ+ competencies, it is also important the healthcare environment be welcoming and inclusive. Some of the strategies for creating an inclusive healthcare environment include [20]:

• Non-discrimination policies for the healthcare organization
• Aligning restroom policies with gender identity including posting them to prevent harassment
• Include family and support system per patient’s preferences
• Include LGBTQ+ symbols in materials and include these materials in the waiting areas
• Use gender-neutral language

Partnerships with local LGBTQ+ community organizations can also help improve LGBTQ+ access to healthcare. Not only do these types of programs help raise healthcare awareness in the LGBTQ+ population and improve patient trust in the healthcare provider, they also serve as a way to learn the population's needs and find opportunities to advocate for changes on a policy level. [21]

The National Council on Family Relations has a list of resources for LGBTQ+ individuals and their families. These include places where LGBTQ+ patients can find support, counseling, and education. [22] Another option for LGBTQ patients is the Human Rights Campaign. Connecting patients with resources can help foster an improved relationship between the LGBTQ+ community and healthcare organizations.

Best Practices for Practitioners

The American Medical Association lists some best practices for creating an LGBTQ+ environment. Some of these best practices include [23]: 

• Display brochures and educational materials about LGBTQ health concerns
• Post a nondiscrimination statement in a visible location
• Display information from LGBTQ+-friendly nonprofit organizations
• Customize patient intake forms with LGBTQ+ friendly (inclusive) language

Healthcare providers should look for ongoing education for LGBTQ+ healthcare concerns. There are many resources for LGBTQ+ healthcare education. The National LGBTQIA+ Health Education Center offers a library of materials, including CME, for healthcare providers looking to grow their knowledge on LGBTQ+ issues. [24]

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Take Aways

• LGBTQ+ patients face significant barriers to healthcare, resulting in worse health outcomes
• LGBTQ+ patients are significantly more likely to suffer from depression, suicidal ideation, and self-harming behaviors
• Healthcare providers frequently have implicit bias and lack adequate training in LGBTQ+ concerns
• Promoting gender-inclusive healthcare can improve LGBTQ+ access to healthcare

The LGBTQ+ population continues to be an underserved population with inadequate access to healthcare resources even though this has improved slightly in recent years. Being proactive about improving knowledge of LGBTQ+ health concerns and creating a welcoming environment for LGBTQ+ patients is one way empower patients and help them be their own best advocates.