Gaps in medical school curricula can lead to subpar care for LGBT Americans. Here’s how doctors can fill in those gaps.
By Stephanie Auteri
(Photo: Alex Proimos/Flickr)
When we receive poor or lackluster health care, it can be difficult to avoid taking it personally — especially if you’re a woman and you’ve read all the stories about gender bias and delayed diagnoses, with doctors seemingly always in a rush to hand out a quick fix and get to the next patient on their list.
But is bias at the root of this treatment? Is it ill intent? Callousness? Exhaustion? It can often seem so when you don’t feel heard or respected by your doctor. It can undoubtedly feel even more so when your sexual orientation or gender identity is not aligned with the mainstream of the culture.
This sense of marginalization only deepens when you start to dig into the statistics about health care among lesbian, gay, bisexual, transgender, queer, or intersex (LGBTQI) populations. In 2014, a Gallup poll revealed that Americans who identify as LGBT are more likely than non-LGBT Americans to report that they lack health insurance. And when you explore the reasons behind this, you find signs of an industry that can feel hostile to anyone who is not heterosexual, or to anyone who does not self-identify based upon the sexual organ inside their underpants.
Sure, there may be negative bias at play but, in many cases, the real culprit seems to be an insufficient level of knowledge when it comes to LGBTQI patients.
Research from 2010, for example, shows that obtaining health insurance is simply more difficult for LGBTQI individuals. For one thing, while many employers offer health coverage for employees’ spouses, they don’t extend the same benefits to same-sex partners. Beyond that, most employee health policies flat out refuse to cover surgery and hormone treatment for transgender patients, despite a 2008 American Medical Association resolution calling for such coverage.
Beyond issues of health coverage, research also shows that many LGBTQI individuals delay or avoid medical treatment for fear of encountering bias in health-care settings. There are others who seek treatment, but who are turned away despite laws that prohibit discrimination on the basis of sexual orientation and gender identity. Others report receiving less than stellar treatment from their health-care providers. They speculate that medical practitioners perhaps feel uncomfortable working with someone whose sexuality or gender identity is unfamiliar to them. And sure, there may be negative bias at play but, in many cases, the real culprit seems to be an insufficient level of knowledge when it comes to LGBTQI patients — which in turn points to insufficient education on how best to manage the health-care needs of LGBTQI populations.
To counter this gap in quality of health care, we have resources such as the Health Care Equality Index. This particular online database rates health-care facilities based upon how well they do in terms of patient equality, particularly in terms of LGBT patients. The four core criteria they use when grading these facilities are: 1.) patient non-discrimination, 2.) equal visitation rights, 3.) employment non-discrimination, and 4.) training in LGBT patient-centered care.
That last criterion will hopefully become more commonplace very soon, especially with the passing of bills such as Washington, D.C.’s LGBTQ Cultural Competency Continuing Education Amendment Act of 2015. Just this past December, the D.C. Council Committee on Health and Human Services voted unanimously to approve this new bill, which requires health-care professionals to receive continuing education on how best to treat LGBTQ populations. More specifically, this bill — which passed in February — will require medical professionals licensed in D.C. to take two credits of cultural competency training related to patients who identify as LGBTQI.
The initial version of the bill notes that, according to a 2009 survey, more than half of LGBT respondents had been refused care. More than half of LGBT respondents had had a health-care professional refuse to touch them. More than half of LGBT respondents had been blamed for their health status. The list went on from there.
Which is why such legislation is crucial, especially considering the present limitations of medical school curricula, where many important topics are given short shrift in favor of those that are considered more traditionally essential. Still other medical matters are neglected because of insufficient research. As we’ve seen again and again, cultural competency with LGBTQI populations tends to come toward the bottom of most curricular priority lists. The Gay and Lesbian Medical Association (GLMA; the organization has since re-branded as Health Professionals Advancing LGBT Equality) put together a document, last updated in 2013, containing policy and position statements on health care for LGBTQI individuals from a number of professional health-care organizations. It’s an amazing document, stunning in its comprehensiveness and encouraging in its show of progressive solidarity. But the fact that this document is so necessary — and the fact that these 11 organizations have had to take a stand on something that should be a standard part of health-care practitioners’ education — is also frustrating.
One 2011 survey of medical school deans in the United States and Canada, published in the Journal of the American Medical Association, found that students get only five hours of LGBT-related training over the course of four years of medical school. And those five hours typically don’t include time for students to practice history-taking techniques or behavioral questions related to mental health, sexually transmitted infections, and substance abuse — an essential aspect of health care that provides patients with a close first impression of their health-care provider, and that provides doctors with the information they need to develop the best possible health-care plan going forward.
Because of this great hole in doctors’ training, various organizations have begun releasing recommended guidelines for medical school curricula, and in-depth resources on how to care for varied populations. The American Academy of Family Physicians, for example, has published curriculum guidelines for family medicine residents, including an outline of the attitudes, knowledge, and skills that family physicians should achieve during their residency training in order to provide high-quality care to their LGBT patients.
Then again, medical schools can’t cover everything, doctors can’t be experts at all ailments, and LGBTQI health concerns aren’t the only area lacking in curriculum hours and solid research. Over the course of my writing about health care, I have found similar deficiencies in the ways medical professionals are taught to handle sexual health, women’s health, chronic pain, and more. Which is why continuing education is such an important aspect of health-care practitioners’ professional development.
Hopefully, legislation such as D.C.’s will lead to stronger continuing education requirements outside the capital as well. And cultural competence programs are already available via a number of organizations.
Fenway Health, for example, a Boston-based community health center dedicated to the LGBT community, people living with HIV/AIDS, and the broader population, offers — in addition to its many health-care services — educational programs, resources, and consultation to health-care organizations that are looking to improve the quality and cost-effectiveness of health care for LGBT people. Meanwhile, GLMA offers a cultural competence webinar series on Quality Healthcare for Lesbian, Gay, Bisexual & Transgender People. This four-part webinar explores the health concerns of LGBT people, including the influences behind how this population seeks out and receives care, and the impact those influences have on their health.
National non-profit organization HealthHIV provides, among other things, education and training on a number of topics, including LGBT health. Subtopics include sexual orientation and gender identity, cultural competency, health disparities across racial and ethnic communities, and LGBT-friendly health systems. They also have several additional modules in development that address specific populations, starting with cultural competency in the transgender community, and modules on various stigmas, such as those associated with HIV and STDs.
“The National Coalition for LGBT Health is very pleased with the D.C. Act and testified in support of its passage,” says Brian Hujdich, executive director of HealthHIV, which leads the Coalition, a group that promotes LGBT health through advocacy, education, and research. “It is a significant development and one that needs to be enacted in other states as well. It will have significant impact but is only the beginning in advancing culturally competent LGBT health care.”
Of course, when it comes to professional development, time will always be a barrier. Finding room in one’s schedule for continuing education may not always be an option. Which is why health-care professionals must also seek out other ways in which to better serve their LGBTQI patients, such as working within multidisciplinary teams or with colleagues who have strengths where they are weak, or by building up strong referral networks.
But in an ideal world, health-care professionals will always make the time to further their professional development, even if it’s outside the bounds of traditional continuing education. If not through courses, health-care professionals can always deepen their knowledge by attending professional conferences, or by keeping on top of the latest industry news and research.
“Many healthcare professionals still are not fully accepting of LGBT individuals; do not fully appreciate their particular health challenges; and are not comfortable talking to them about their sex lives,” write the authors of the D.C. Act. These last two items, at least, can be fixed with stronger education policies.