March 2018

Mandi Pratt-Chapman, MA, is Associate Center Director for Patient-Centered Initiatives and Health Equity, GW Cancer Center

Commentary Overview

* Lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) people have unique health needs that health care professionals are usually not trained to address, and Washington, DC, has the nation's largest per capita LGBTQI population.

* GW Cancer Center's Institute for Patient-Centered Initiatives and Health Equity provides training and technical assistance to health care providers and health care systems nationally.

* The Together-Equitable-Accessible-Meaningful education program, a six-month training program, provides technical assistance to health care systems seeking to improve health equity.

* A new preventive medicine course on sexual and gender minority health will be offered to third- and fourth-year medical students.
About AACI Commentary

As part of AACI's efforts to feature the work and views of its member centers, AACI publishes AACI Commentary, a quarterly editorial series. Written by cancer center leaders, each edition focuses on a major issue of common interest to AACI cancer centers.



What's Love Got to Do with It? Providing Access to Equitable Health Care for LGBTQI Patients in the Nation's Capital

BY MANDI PRATT-CHAPMAN, MA

Washington, DC has the largest per capita population of lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) persons in the nation. One in ten residents self-identify as a sexual or gender minority—and those are the people who feel safe enough to do so. There are over 9 million sexual and gender minority people in the U.S., not counting an additional 1.7 million intersex people, many of whom underwent genital “normalization” surgeries to help them fit predominant social expectations to be "male" or "female." Approximately 1.4 million people are transgender, some of whom identify as male or female and others as non-binary (neither male nor female).

Chances are that you have met many of these people as a clinician or researcher even if you are not aware of it. Yet, we as a community know very little about how to improve health and cancer care for these patients, because we rarely collect information about sexual orientation or gender identity and almost never report this information to contribute to generalizable knowledge. An extremely broad search of literature reporting any aspect of cancer prevention, risk, or care focused on any sexual or gender minority subgroup in the last 10 years yields only 268 articles. This number drops sharply if the search is narrowed to a particular group or aspect of care. For example, there are only seven cancer studies in PubMed relevant to intersex individuals published in the last five years.

LGBTQI people have unique needs that health care professionals are usually not trained to address. The Institute of Medicine, the Joint Commission, the National Institutes of Health and the Patient-Centered Outcomes Research Institute have all said that sexual and gender minority health disparities must be addressed through research, education and training. In 2014, the Association of American Medical Colleges (AAMC) established core competencies for LGBTQI medical care to guide physicians.

At the GW Cancer Center (GWCC), in Washington, DC, the Institute for Patient-Centered Initiatives and Health Equity provides training and technical assistance to health care providers and health care systems nationally.  Recent research has shown that there is still much work to be done to address anti-LGBTQI bias across all health care disciplines. To begin to address this challenge, GWCC created the Together-Equitable-Accessible-Meaningful (TEAM) education program, a six-month hybrid (online and live) training program, offering technical assistance to 24 health care systems seeking to improve health equity in their clinical service setting. The training enrolled 91 health care clinicians, administrators and other professionals and equipped them with strategies to improve patient-provider communication and practice culturally- sensitive care. At the core of the training is intersectionality--the concept that individuals identify with more than one group (race/ethnicity, sexual orientation or gender identity, income, etc.), and that those who identify with multiple minority groups may be at elevated risk for poor health outcomes.  After completing the training, 97.7 percent of trainees indicated they were motivated to make changes in their own practice to improve equitable, patient-centered care.

Researchers and academic membership organizations are also calling for richer educational opportunities for students. A 2011 study noted that 67 percent of medical students and 70 percent of deans rated LGBTQI content as “fair,” or worse—a problem when more than 80 percent of medical students in another study reported anti-LGBTQI bias. At GW, a new preventive medicine course on sexual and gender minority health will be offered to third- and fourth-year medical students to fill some of these gaps. A larger, interprofessional initiative is underway to ensure that health professional students of all disciplines are better equipped to address the health care needs of sexual and gender minorities.

LGBTQI patients may be at greater risk for financial and housing instability, highlighting the need for adequate social support staffing to address non-medical patient needs. One in four LGBTQI people live below the poverty line with transgender individuals experiencing the most homelessness. Such extreme circumstances can lead to fateful decisions. For instance, in a recent community listening session, a transgender woman stated that she “had girls trying to catch HIV in order to get an apartment,” presumably to qualify for special housing assistance programs for HIV+ residents. As health care professionals and researchers, we strive to prevent cancer and improve treatments and quality of life for those diagnosed. However, if a person does not know where they will be sleeping at night, they are unlikely to prioritize cancer prevention, screening or treatment.

In addition, LGBTQI people experience more behavioral risks (e.g., smoking, alcohol abuse), which puts them at increased risk for cancer. This is unsurprising, since bars traditionally have been rare safe spaces for the gay community. Tobacco companies--most famously R.J. Reynold’s Project SCUM campaign--have targeted marketing to gay and homeless consumers. Riskier health behaviors are also a maladaptive coping mechanism in response to chronic social stigma and poor social support.

Sexual and gender minorities also encounter unusual barriers to care including lower rates of health insurance coverage, largely due to an employer-based health insurance system that did not always provide coverage to unmarried partners. This has changed in recent years for two major reasons: First, the 2010 Affordable Care Act provided new options beyond employer-based health insurance, allowing people previously uninsured to obtain coverage through the marketplace; second, in 2015, the Supreme Court upheld the right for same sex couples to marry, ushering in spousal benefits for health insurance coverage for couples who wished to marry. Employers are also increasingly recognizing unmarried partners as eligible for benefits.

Even if an LGBTQI person has financial and housing stability and health insurance coverage, they face other barriers when seeking health care. The health care system can be extremely intimidating, starting from intake and registration forms that do not acknowledge a person’s lived reality and growing from there: awkward front desk interactions, providers who are not trained to address LGBTQI health needs or in some places, blatant denial of care. 

The GW Cancer Center invites you to join us in creating more welcoming clinical and research environments for the many people who identify as lesbian, gay, bisexual, transgender, queer or intersex. Clinical care that misses the opportunity to consider the full life experience of a patient, and research that fails to ask or report important information about sexual and gender minorities perpetuates a lack of data to inform health care for many Americans who deserve better.

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