Somewhere over the rainbow: Inclusive healthcare environments for LGBTQIA+ patients

The June observation of Pride Month brings fresh awareness of the significant disparities faced by LGBTQIA+ individuals, even though many healthcare leaders work to promote equality and equity as being fundamental to the well-being of all patients. 

Scope of the problem 

An April 2024 survey conducted by the Kaiser Family Foundation (KFF) revealed that LGBTQIA+ Americans are twice as likely to report experiencing discrimination in healthcare compared to non-LGBTQIA+ individuals. This survey also found that one-third of LGBTQIA+ adults report being treated unfairly or with disrespect by healthcare providers.  
 
LGBTQIA+ adults were also twice as likely than non-LGBTQIA+ adults to report experiencing healthcare providers making assumptions about them, blaming them for health issues, disregarding their requests or questions or refusing to prescribe necessary pain medication. Additional findings from the KFF report showed that: 

• 24% of LGBTQIA+ adults report worsened health due to negative experiences 
• 9% of non-LGBTQIA+ adults report worsened health due to negative experiences 
• 60% of LGBTQIA+ adults anticipate insults from healthcare providers 
• 60% of LGBTQIA+ adults feel the need to be careful about their appearance to receive fair treatment 
• LGBTQIA+ patients are more likely to rate mental health as "fair" or "poor” 
  • Nearly 70% reporting "fair" or "poor" mental health went without needed services at least once in the past three years 
• Discrimination exacerbates mental health issues  
  • LGBTQIA+ adults facing frequent discrimination twice as likely to feel anxious (65% vs. 34%), lonely (42% vs. 15%), or depressed (38% vs. 21%) 

"Some of the barriers are about access and some are about willingness to engage with the healthcare system," says Dr. Renee Crichlow, vice chair of health equity for the Department of Family Medicine at Boston University Medical School. 

Limited access to services 

A 2018 survey by Human Rights Watch revealed that patients had limited or no access to LGBTQIA+-friendly healthcare providers in their area. As the director of a community center in rural Michigan stated, “I do not know of any trans-affirming healthcare providers in the area. And I’ve talked to many trans people in the area.”  

A pediatrician in Alabama pointed out that religious refusals are “dangerous in a predominantly rural state, [where] health disparities are massive to begin with. Huge, huge, huge swathes of our state not only have no pediatricians but have as few as two or three physicians per county.”  

Interviewees recounted LGBT individuals traveling significant distances for support, such as driving two hours from Tennessee to attend a weekend support group for gender-expansive youth in Birmingham, traveling two hours from Arkansas or Mississippi for therapy or to see a trans-affirming doctor in Memphis, crossing Michigan to find a friendly nurse practitioner or medical practice, or driving from East Tennessee to North Carolina for regular hormone injections. 

The Committee on Economic, Social and Cultural Rights has highlighted that the right to health can be undermined both through direct discrimination and through indirect discrimination. Indirect discrimination occurs when laws, while appearing neutral, disproportionately impact minority groups in practice. 

Initiatives for LGBTQIA+ health equity 

Some of these barriers have been addressed by federal and institutional initiatives to expand legal protections for LGBTQIA+ patients.  

In spring 2024, the Biden administration reinstated and broadened language in Section 1557 of the Affordable Care Act to prohibit discrimination based on sexual orientation and gender identity.  

Additionally, institutions like UC San Diego Health have been recognized for their efforts in promoting LGBTQIA+ healthcare equality. Some of their efforts have included: 

• Ensuring all patients, visitors and team members feel welcome and have equal access to healthcare 
• Providing expertise in care for patients with or at risk for HIV, including pre-exposure prophylaxis for HIV prevention 
• Offering the full spectrum of gender-affirming care services for individuals 18 and older (the only hospital system in San Diego to do so) 
• Adopting the University of California’s Gender Recognition and Lived Name Policy, allowing individuals to choose how they are identified in health records and systems 
• Identifying LGBTQIA+-friendly providers on the "Find a Provider" page 
• Scoring high in the Healthcare Equality Index for policies, training, patient services, employee benefits and community engagement 

Their recognition as a high performer for LGBTQIA+ healthcare equality exemplifies how healthcare institutions can lead by example in creating an inclusive environment. 

The importance of emotional safety in healthcare 

Creating safe spaces within healthcare settings is crucial for providing equitable care to LGBTQIA+ patients. Safe spaces ensure that LGBTQIA+ individuals feel respected and understood. Successful implementation involves visible representation of LGBTQIA+-friendly symbols, staff training on cultural competence and explicit policies protecting against discrimination.  

Medical group managers can implement intentional strategies to recognize and overcome implicit biases, such as: 

Leadership engagement:

• Active involvement from board and senior management; appoint a senior management "champion" for LGBTQIA+ inclusion
• Schedule all-staff LGBTQIA+ health training; form an LGBTQIA+ inclusion task force with regular meetings
• Conduct organization-wide surveys to assess gaps.

Non-discrimination policies:

• Include sexual orientation, gender identity and gender expression in policies
• Post patient non-discrimination policy in multiple locations
• Provide electronic notifications at patient intake
• Establish protocols for reporting and responding to discrimination.

Restroom policies:

• Develop and enforce policies for restroom use aligned with gender identity
• Post policies visibly to prevent harassment.

Family and support person policies:

• Define policies to include chosen family and friends as caregivers
• Allow patients to name visitors and support persons without declaring relationships.

Physical and virtual environment:

• Include LGBTQIA+ symbols and diverse images in materials
• Develop health education materials for LGBTQIA+ people, and provide brochures and resources from local LGBTQIA+ organizations
• Include LGBTQIA+ issues in waiting area materials, and post articles and hang posters during Pride month.
• Offer gender-inclusive restrooms and enhance privacy in facilities.

Partnerships with LGBTQIA+ community:

• Engage with local LGBTQIA+ organizations and individuals
• Host community events in collaboration with LGBTQIA+ groups
• Recognize LGBTQIA+ awareness days (e.g., National Coming Out Day, Transgender Day of Remembrance, LGBT Health Week)
• Organize participation in annual Pride parades
• Invite diverse LGBTQIA+ people to join governing and advisory boards
• Assess community needs through focus groups, surveys and discussions with stakeholders.

MGMA Resources 

• “Know thy patient: Providing a welcoming environment and better care for LGBTQIA+ patients” (MGMA Insight article) 
• “Leadership strategies for confronting our implicit biases” (MGMA podcast) 

Addressing healthcare disparities and ensuring fair treatment for LGBTQIA+ patients should be both a professional obligation and an opportunity to improve patient care. By adopting inclusive practices and advocating for equitable policies, providers can help create a healthcare environment where all patients receive the respect and high-quality care they deserve. 

References 

• “LGBTQ Americans twice as likely to experience discrimination in health care: poll” (The Hill) 
• “LGBT Adults’ Experiences with Discrimination and Health Care” (KFF) 
• “1 in 3 LGBTQ adults say they’ve been treated unfairly by a health care provider” (NBC News) 
• “Biden Restores LGBTQ Healthcare Protections” (The Advocate) 
•  “UC San Diego Health Recognized as High Performer for LGBTQ Healthcare Equality” (UC San Diego Health) 
• “Safe spaces in health care matter for LGBTQ patients” (ABC News) 
• “The Right to Health” [PDF] (OHCHR) 
• “’You Don’t Want Second Best’: Anti-LGBT Discrimination in U.S. Health Care” (Human Rights Watch) 
• "Ten Strategies for Creating Inclusive Health Care Environments for LGBTQIA+ People" (2021) (National LGBTQIA+ Health Education Center)