Where We Stand
Section: Prescribing Guidelines
Policy: Support for Gender-Affirming and LGBTQ+ Health Care
Appendix U

Support for Gender-Affirming and LGBTQ+ Health Care

Lesbian, gay, bisexual, transgender, queer, and other sex, sexual, and/or gender minority (LGBTQ+) people experience significant health disparities compared to their cisgender and heterosexual peers. Cardiovascular disease, certain cancers, mental health disorders, substance use, and sexually transmitted infections occur in higher rates in the LGBTQ+ population (Barger et al., 2020; IOM, 2011; Gonzalez, Gallego, & Bockting, 2017; Kidd et al., 2020; Nagata, Ganson, & Austin, 2020; Price-Feeney, Green, & Dorison, 2020; Rath et al., 2013; Russell & Fish, 2016; Scannapieco, Painter, & Blau, 2018). LGBTQ+ people are more likely to experience poverty and have more physical and mental health conditions (Choi & Meyer, 2016).

Beyond health disparities, there are also differences in access to care, resources, and social support. Poverty, stigma, depression, homelessness, and social isolation are more common in the LGBTQ+ community (Valenti et al., 2020). Older LGBTQ+ adults may also feel the need to hide their identity in healthcare or long-term care settings and may not have legal relationships with their partners because of past discrimination or stigma. LGBTQ+ older adults are more likely to experience social isolation and loneliness, and to worry about having adequate support from family and friends (Fasullo et al., 2022; Freedman & Nicolle, 2020; Preston, 2022). They are also more likely to rely on long-term care facilities (Fasullo et al., 2022).

Over half of LGBTQ+ individuals have faced bias or discrimination as part of their interactions with the healthcare system (Hurd, 2015; Preston, 2022). Fear of discrimination, harassment, or poor treatment in healthcare settings, lead many LGBTQ+ people to delay seeking care (Casey et al., 2019; Grant et al., 2011; Macapagal, Bhatia, & Greene, 2016; Mizra & Rooney, 2018). Studies have shown that 18.4% of LGBTQ+ individuals and 30.8% of transgender individuals who have experienced discrimination or harassment in healthcare settings, avoid future care because of concerns about a repeat of their negative experiences (Jaffee, Shires, & Stroumsa, 2016; Mizra & Rooney, 2018).

Healthcare forms and policies are based on heteronormative assumptions. LGBTQ+ adults may find that their partners are not allowed to visit because of hospital policies or that the forms do not reflect their legal name and gender (Adams, 2022; Hurd, 2015). Additionally, LGBTQ+ individuals may want to involve “chosen family” and friends in their care, instead of legal or biological relatives (Hurd, 2015), which runs counter to the current medical ethics recommendations (Dickson et al., 2020; Wahlert & Fiester, 2012). Guidance about how to navigate the medical-legal system, so that partners and friends can play an active role in decision making, as necessary, is especially important for LGBTQ+ individuals.

Transgender, non-binary, and gender diverse individuals face significant and pervasive discrimination in employment, housing, and healthcare (Medina & Mahowald, 2023). They also experience significant physical health, mental health, and social disparities exacerbated by structural stigma and ongoing legal attacks (Medina & Mahowald, 2023; National Academies Press, 2020). Transgender, non-binary, and gender diverse individuals face high rates of violence, including fatal violence, and hate crimes (Human Rights Campaign Foundation, 2022).

Studies suggest that gender-affirming care supports the well-being of transgender and gender-diverse youth, reduces suicidality, and improves psychological functioning (De Vries et al., 2014; Tordoff et al., 2022). The recent legislation and bans on gender-affirming care have been shown to increase symptoms of depression, anxiety, suicidal ideation, and gender dysphoria; and decrease youths’ sense of safety (Abreu et al., 2022). Youth also reported increased stigma and a lack of access to medical care as a result of the gender-affirming care bans (Abreu et al., 2022). Parents of transgender and gender-diverse youth want legislators and policymakers to decriminalize gender affirming care, decrease discrimination and violence against transgender individuals, educate themselves on transgender health-care issues, and recognize that transgender youth health is not a political issue (Abreu et al., 2022).

Physicians, Physician Assistants, and other healthcare professionals need to acknowledge and address the ongoing discrimination that LGBTQ+ people face in healthcare settings. Health professionals need to be prepared to provide competent and high-quality care to LGBTQ+ people. They need to be aware of how health and social disparities, and structural barriers affect the delivery and receipt of care for LGBTQ+ people to actively address these disparities and barriers.

In order to develop policies for the Oregon Medical Association, a workgroup of the Justice, Equity and Diversity Committee reviewed and considered existing policies from the American Medical Association, American Academy of Pediatrics, and the GLMA: Health Professionals Advancing LGBTQ Equality. In addition to examining these policies, the workgroup also reviewed other policies, statements, studies, and resources from state and national medical associations and organizations advocating for LGBTQ+ health.

These recommendations will become OMA policy and allow OMA to advocate, influence, and educate to advance and improve LGBTQ+ healthcare in the state, furthering the OMA’s goals of advocating for an equitable and accessible healthcare environment.

References

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Casey LS, Reisner SL, Findling MG, et al. Discrimination in the United States: Experiences of lesbian,gay, bisexual, transgender, and queer Americans. Health Serv Res. 2019;54(Suppl 2):1454–1466.

Choi, S. K., & Meyer, I. H. (2016). LGBT aging: A review of research findings, needs, and policy implications. eScholarship. University of California.

De Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014 Oct;134(4):696-704.

Dickson, L., Bunting, S., Nanna, A., Taylor, M., Hein, L., & Spencer, M. (2020). Appointment of a healthcare power of attorney among older lesbian, gay, bisexual, transgender, and queer (LGBTQ) adults in the Southern United States. The American Journal of Hospice & Palliative Care, 38(11), 1291–1298. https://doi.org/10.1177/1049909120979787

Fasullo, K., McIntosh, E., Buchholz, S. W., Ruppar, T., & Ailey, S. (2022). LGBTQ older adults in long-term care settings: An integrative review to inform best practices. Clinical Gerontologist, 45(5), 1087–1102.

Freedman, A., & Nicolle, J. (2020). Social isolation and loneliness: The new geriatric giants: Approach for primary care. Canadian family physician Medecin de famille canadien, 66(3), 176–182.

Grant J, Mottet L, Tanis J, Harrison J, Herman J, Keisling M. Injustice at every turn: A report of the national transgender discrimination survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011.

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Macapagal K, Bhatia R, Greene GJ. Differences in healthcare access, use, and experiences within a community sample of racially diverse lesbian, gay, bisexual, transgender, and questioning emerging adults. LGBT Health. 2016;3(6):434–442.

Mizra S, Rooney C. Discrimination prevents LGBTQ people from accessing health care. Washington: Center for American Progress; 2018.

Nagata JM, Ganson KT, Austin SB. Emerging trends in eating disorders among sexual and gender minorities. Curr Opin Psychiatry. 2020;33(6):562–567.

National Academies of Sciences, Engineering, and Medicine. Understanding the well-being of LGBTQI+ populations. Washington DC, National Academies Press, 2020.

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Scannapieco M, Painter KR, Blau G. A comparison of LGBTQ youth and heterosexual youth in the child welfare system: Mental health and substance abuse occurrence and outcomes. Child Youth Serv Rev. 2018;91:39–46.

Tordoff DM, Wanta JW, Collin A, Stepney C, Inwards-Breland DJ, Ahrens K. Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA network open. 2022 Feb 1;5(2):e220978-.

Valenti, K., Jen, S., Parajuli, J., Arbogast, A., Jacobsen, A., & Kunkel, S. (2020). Experiences of palliative and end-of-life care among older LGBTQ women: A review of current literature. Journal of Palliative Medicine, 23(11), 1532–1539. https://doi.org/10.1089/JPM.2019. 0639

Wahlert, L., & Fiester, A. (2012). Mediation and surrogate decision-making for LGBTQ families in the absence of an advance directive: comment on “Ethical challenges in end-of-life care for GLBTI individuals” by Colleen Cartwright. Journal of Bioethical Inquiry, 9(3), 365–367. https://doi.org/10.1007/S11673-012-9387-6