High Stakes for the Health of Sexual and Gender Minority Patients of Color
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As clinicians, educators, and researchers, our ability to provide the best possible care to our patients who are sexual and gender minority (SGM) people of color is increasingly challenged. Relative to the general population, SGM patients often have worse health outcomes, and among SGM patients, racial and ethnic minorities are particularly vulnerable. Healthcare policies proposed by the current administration, along with an increasingly hostile and dangerous social climate, have the potential to seriously harm SGM patients of color. In this paper, we discuss these key policy issues impacting the health of SGM patients of color. We then suggest questions for clinicians to consider to help them decide which advocacy activities are right for them, recommending self-examination, skills development, and political action. We end by outlining concrete, actionable steps to advocate for SGM patients of color in patient care, healthcare organizations, medical education, research, and public policy.
As clinicians, educators, and researchers, we promise to heal, cure, and otherwise improve the health of individuals with the utmost respect for human life. Since the 2016 U.S. presidential election, our pledge has taken on new meaning, as we grapple with the impact of unprecedented legislative challenges and a changing social climate on the health of some of the most vulnerable patient populations. Sexual and gender minority (SGM) patients, including those who are lesbian, gay, bisexual, transgender, or queer (LGBTQ), continually face discrimination and violence across healthcare, employment, housing, and education settings.1 Relative to the general population, SGM individuals are often sicker and poorer, while facing tremendous barriers in accessing quality medical care and services.1 , 2 SGM individuals who also identify as racial/ethnic minorities may be even more vulnerable, because the barriers, discrimination, and violence they face as SGM intersect with and are often compounded by those unique to immigration and/or racial and ethnic minority status.3 , 4 Under President Trump’s administration, SGM who are also racial/ethnic minorities face new threats to their health and safety due to attacks on protective health and social legislation and the enactment of deleterious policies.5 Health disparities will worsen without our timely, concerted, and committed advocacy efforts.
Here, we discuss harmful proposed health policies that would negatively affect SGM patients of color.6 We explain the health impact of discriminatory policies that create an increasingly hostile and dangerous environment for sexual and gender minorities, racial/ethnic minorities, and individuals who share both sets of identities. We provide concrete, actionable advocacy steps for clinicians, educators, and researchers, outlining a set of questions to consider as they decide which advocacy activities are right for them. We end by discussing specific advocacy actions for patient care, healthcare organization transformation, medical education, and public policy that can enhance the health of SGM patients of color during this critical and challenging time.
Attacks on New Healthcare Gains and Legal Protections for SGM Individuals
Under the Affordable Care Act (ACA), the proportion of uninsured adult Americans decreased from 20% to 12% between 2010 and 2016.7 The ACA has clear flaws that need addressing, such as stabilization of the health exchange marketplaces, but attempts to repeal the ACA would reverse gains, increase the number of uninsured, and cost lives.8 , 9 For example, the proposed American Health Care Act (AHCA) would have increased the number of uninsured to 24 million by 2026, due largely to states discontinuing their expansion of Medicaid eligibility.6
The ACA’s Section 1557 is a federal civil rights law that bans discrimination based on sex, which the Department of Health and Human Services (HHS) interpreted to include discrimination based on gender identity (i.e., citing gender identity as a basis for denying coverage for healthcare services related to gender transition) for health programs or activities that receive federal financial assistance.10 , 11 Prior to the ACA, being transgender was considered by many private insurance carriers to be a pre-existing condition.10 Since the ACA, the Nondiscrimination in Health Programs and Activities rule proposed by the HHS specifically prohibits medically indicated sex-specific healthcare (e.g., cervical cancer screening in female at birth) from being denied or limited based on current gender identity (e.g., individual’s identification as a transgender man).11 Repealing these protective measures under the ACA would compromise healthcare for thousands of SGM individuals.
Public policy affects the health of SGM patients not only via healthcare access, but also through attacks on civil liberties.12 Threats to remove legal protection for marriage equality, for example, would decrease access to state and federal healthcare, increase taxes, and diminish social security and veterans’ benefits to same-sex partnerships.12 Some Cabinet members have supported legislation opposing same-sex marriage, workplace discrimination protection for SGM people, and inclusion of sexual orientation and gender identity in hate crime legislation.13 , 14 The Texas House Bill 3859 would allow foster care providers to refuse to place children with non-Christians and same-sex couples.15
Attacks on New Healthcare Gains and Legal Protections for SGM Patients of Color
SGM patients who are racial/ethnic minorities are at particularly high risk for worsening health disparities if protections are repealed. The personal experiences of people with multiple intersecting social identities (e.g., Asian-American, lesbian, undocumented status) are shaped by interlocking systems of social inequality (e.g., racism, heterosexism, xenophobia).16 Thus, SGM patients of color frequently have worse health outcomes than either white SGM or heterosexual patients of color. For example, LGB Latinos/Hispanics have especially high rates of alcohol abuse,17 cigarette smoking, sexually transmitted infections, and mental health problems.18 Prior to the ACA, LGBTQ racial/ethnic minorities showed lower rates of insurance coverage, less regular healthcare access, and greater reliance on emergency services relative to LGBTQ whites.19 Since passage of the ACA, uninsured rates have declined across racial, ethnic, age, and income groups.20 Uninsured rates dropped from 21% to 13% between 2013 and 2016 among African Americans, and from 36% to 19% among Latinos during the same period.21 Removing healthcare protections is regressive for SGM patients of color and would widen health disparities of the most vulnerable who depend on Medicaid and the ACA.5
Anti-immigration policies under the Trump presidency undermine the health of SGM patients of color who may avoid seeking healthcare and public assistance due to fear of deportation.22 – 25 Among those who seek care, some may hesitate to give personal information such as their sexual orientation or gender identity to healthcare and social service providers.23 – 25 A lack of legal documentation status adversely affects health. Undocumented transgender Latinas are at higher risk for HIV infection due to worse healthcare access, housing, and employment.26
SGM patients of color are targets of an increasingly dangerous and hostile environment. At least eight transgender women of color have been murdered since the beginning of 2017.27 , 28 Following President Trump’s election, reports soared of random incidents of harassment and intimidation directed at SGM people, people of color, and immigrants.29
What Clinicians, Educators, and Researchers Can Do to Advocate for SGM Patients of Color
Advice to Clinicians Considering Advocacy to Improve the Health of Sexual and Gender Minority (SGM) Patients of Color
Examples of Clinician Actions
Prioritize specific issues based on personal meaning, importance, and opportunity to impact.
Choose domain(s) of action: Patient Care, Healthcare Organization, Training and Mentoring, Policy.
Recognize that your and your colleagues’ clinical, teaching, and research expertise are powerful tools for political action and changing organizational and public policy.
Develop skills in writing, speaking, teaching, mentoring, organizing, and advocating. Learn about health disparities, and understand the legislative process and specific policy issues.
Understand models of social determinants of equity, such as that of Camara Phyllis Jones, and intervention points:
• Decision-making structures (who, what, when, where)
• Written policies
• Unwritten practices and norms
• Values driving decisions
Use your experience as a clinician and specific patient examples to tell the story of why SGM patients of color need health insurance coverage and access to high-quality, culturally competent care and services.
Develop leadership skills in coalition building. Leverage political capital of coalitions to move policymakers at the local, state, and national levels.
Develop leadership, management, and implementation skills to transform clinics and organizations to deliver high-quality, culturally competent care.
Learn how to train students, physicians, educators, and researchers in advocacy skills.
Political Action 34
• Vote, call, and/or meet legislators.
• Sign petitions and position statements.
• Write commentaries.
• Give talks.
• Communicate through social media.
Take collective action.
• Participate in organizational advocacy, partnerships, and coalitions, both with organizations already committed to health equity and with influential organizations that should expand their advocacy for health equity.
• Organize coalitions of organizations interested in expanding health insurance coverage and high-quality, culturally competent care to SGM people of color.
• March, demonstrate, and rally (e.g., Pride Parade, White Coats for Black Lives, March for Science).
Volunteer for community- and statewide advisory boards working on healthcare reform and/or health disparity issues.
Track policy changes regarding discrimination, health disparities, and health policy via sources such as Health Affairs Blog (http://healthaffairs.org/blog/) and Kaiser Family Foundation (http://kff.org/). Read conservative, moderate, and liberal news and commentary sources.
Actionable Items to Improve the Health of Sexual and Gender Minority (SGM) Patients of Color for Patient Care, Healthcare Organization, Training and Mentoring, and Policy
Examples of Advocacy Actions
Encourage patients to participate actively in healthcare decisions.
Allow patients to self-identify in terms of their race, ethnicity, gender, and sexual orientation.
Realize that SGM patients of color may have experiences different from white SGM and heterosexual racial/ethnic minority patients, and that great diversity exists among these patients.
Have honest dialogues. Get to know people who are SGM people of color. Support patients by listening to their stories.
Review mental health status and needs for social services (e.g., income assistance, food and nutrition, housing, social support).
Provide or refer to services for hormone therapy and gender transition services when appropriate for transgender patients.
Realize that patients’ lack of trust in medical systems often stems from injustice to their communities (e.g., Tuskegee syphilis experimentation, governmental delay in addressing HIV at start of AIDS epidemic).
Be aware that fear of deportation or prosecution for undocumented status may lead to delayed care, decreased adherence, or poor retention in care.
Be aware of risks for depression, anxiety, violence, and sexual assault, and develop skills in diagnosis, communication, and initial treatment or referral.
Institute private, confidential check-in areas and train staff to call patients by their preferred names and pronouns.
Health Information Technology
Create fields in electronic health records for capturing information on disaggregated race/ethnicity, sexual orientation, sex assigned at birth, and current gender identity.
Institute screening for trauma, physical and sexual violence, drug and alcohol use, mental health status, and social service needs (income assistance, food and nutrition, housing, social support).
Organizational Structure and Culture
Commit to building a culture of diversity and inclusion by completing one of the national benchmarking surveys to assess competence in caring for diverse populations.
Provide materials in different languages and dialects; provide easy access to medical interpreters.
Offer patient support groups that would facilitate peer-to-peer support/mentoring regarding the discrimination and bias that SGM people of color face.
Create inclusive environments specific to SGM people of color by displaying visible signage and symbols that affirm SGM people of color and support diversity issues.
Reward clinicians and staff who provide outstanding care to diverse patients.
Participate in and provide training in culturally appropriate care.
Mentor SGM students and early career colleagues of color. Support students and colleagues by listening to their stories.
Act as a role model in the care of SGM patients of color. Individualize care and take opportunities to teach about patients’ clinical, cultural, and communication issues.
Equitable Healthcare Policy
Advocate for equitable healthcare policies, such as:
• Universal access to affordable health insurance
• Medicaid expansion
• Essential health benefits including mental health, substance abuse treatment, and adolescent services
• Coverage for pre-existing conditions such as HIV
• Non-discrimination Section 1557 of the Affordable Care Act. Prohibit discrimination on basis of gender identity. Advocate for insurance coverage of transgender care (e.g., gender-affirming hormone therapy and surgery, gender-at-birth cancer screening).
• Funding for safety-net organizations
• Incentivizing the reduction of health disparities with equity accountability measures in payment programs
Support policies ensuring the rights and well-being of SGM people of color, such as:
• Minimum wage
• Workplace discrimination protection
• Inclusion of sexual orientation and gender identity in hate crime legislation
• Adoption policies and laws
• Immigration reform
• Gender-confirming bathroom access
Research Evidence and Policy
Advocate for data collection by race, ethnicity, gender identity, and sexual orientation.
Protest state and federal efforts to eliminate the collection of health data by race, ethnicity, gender identity, and sexual orientation.
Support or defend research funding for SGM people of color.
Organize academic conferences and special panels to disseminate evidence and to build research networks.
Participate in drafting calls for research proposals or serve as reviewers on these calls for research that aim to eliminate disparities among SGM patients of color.
Develop, test, and disseminate effective interventions and treatment practices for SGM patients of color.
Advocacy to Improve the Health of SGM Patients of Color
Advocacy may initially seem like an alien or intimidating concept to the clinician.42 However, our experience shows that virtually all clinicians believe it is their responsibility to advocate for their individual patients. Many clinicians eventually recognize how much they can improve the health of their patients through advocacy at the organizational and policy levels.34 Clinicians have a unique understanding of how policies impact patients, and are respected for their knowledge and experience.34
We recommend a process of self-examination in which you prioritize specific advocacy issues based on their personal meaning and importance, and your opportunity to impact them (Table 1).34 Decide which domain or domains of action are right for you in patient care, your healthcare organization or professional society, training and mentoring, or public policy. We can all benefit from developing advocacy skills in writing, speaking, teaching, mentoring, and political organizing. Learn the legislative process and specific policy issues. Understand the social determinants of equity and where you can intervene. Develop leadership skills and leverage your experience as a clinician to change policy. Voice your opinions and learn how to take collective action with organizations and coalitions. Stay current about policy issues, and understand thoughtful views and ideas across the political spectrum.
Even the most experienced clinicians can often improve their ability to deliver culturally competent, high-quality healthcare for SGM patients of color (Table 2). Show your willingness to listen to their stories, allow them to self-identify, and encourage them to participate in healthcare decision making.36 Realize that patients’ lack of trust stems from actual negative experiences and a legacy of discrimination.23 , 25 , 43 Similarly, providers should be aware that great diversity exists among SGM patients of color. For example, Asian-American and Pacific Islander sexual and gender minorities represent a group that varies tremendously in income, employment, education, English proficiency, and health status. Review mental health status and needs for social services, and be aware of SGM-specific services.
Clinics can transform their culture and structure to provide culturally competent care to SGM patients of color.31 For patients with limited English proficiency, clinics must provide access to medical interpreters and materials in various languages and dialects. Clinics can train clinicians and staff to call patients by their preferred names and pronouns. Electronic health systems can be programmed to collect patient data on race, ethnicity, sex assigned at birth, sexual orientation, and gender identity; use these data to inform clinic practice, identify health disparities, and guide quality improvement efforts.31 Institute screening and offer referrals for SGM patients of color who suffer from trauma, physical and sexual violence, and drug and alcohol abuse. Organize peer support groups.44
Training and Mentoring
SGM patients of color have frequently reported negative attitudes among healthcare workers and lack of skills in SGM health.23 Medical educators can act as role models, individualizing care for SGM patients of color and taking opportunities to teach students about clinical, cultural, and communication issues.34 , 35
Realize that your clinical, research, and teaching expertise are powerful tools for changing institutional practices and public policy toward equitable healthcare.34 Clinicians can build or join coalitions, or raise awareness to improve upon the ACA and keep protections for SGM patients of color to ensure that the number of uninsured will not rise.34
Clinicians can protest legislation that would harm the health of SGM patients of color by restricting access to healthcare, such as repealing Section 1557 of the ACA or withholding funding from Planned Parenthood clinics that provide essential preventive and primary care to many low-income and racial/ethnic minority patients.45
E-mail your legislators and support policies that ensure the civil rights of SGM and racial/ethnic minority adults and children. Protest the removal of gender-matching bathroom access that undermines health and safety.46 Gender-matching bathroom access could be especially important for SGM students of color, who experience harassment, school-based victimization such as being threatened or injured with a weapon,47 and physical and sexual assault from peers and even teachers.1 Protest anti-immigration policies that pose barriers to healthcare access among SGM and racial/ethnic minority patients.25
Advocate for research funding for SGM and racial/ethnic minority health. Support data collection disaggregated by SGM and racial/ethnic minority status.30 Be vigilant for efforts to eliminate data sources on the diversity of SGM patients of color, such as the removal of sexual orientation and gender identity categories from proposed versions of the U.S. Census Bureau, the American Community Survey, and two Department of Health and Human Services surveys on the health of older adults.48
The stakes are higher than ever for closing the healthcare gap for our SGM patients of color. Our core role and great privilege is to care and advocate for our individual patients. However, proposed policy changes pose dangerous threats to the most vulnerable and already underserved patients, and we can do much within and beyond the walls of our clinics and academic institutions to support our patients. Many impactful actions along the spectrum of advocacy may be right for you. The more skills and experience one develops in advocacy, the more comfortable one feels and the better one gets at it. Our obligation to our patients includes advocating for them when their health and well-being are threatened. Policies that would harm the health of vulnerable people and create hostile environments are a concern for everyone, not just SGM patients of color.
We would like to thank Alison El Ayadi, the K-Scholars Program, Daryl A. Mangosing, and our many colleagues from UCSF for their comments on versions of this manuscript, and our many colleagues at the University of Chicago for their review of earlier versions of the tables.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
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