Despite recent advances in LGBTQIA rights, progress has not precluded on-going experiences of discrimination, stigmatization, and exclusion among the LGBTQIA community. These negative experiences have contributed to disparities between the LGBTQIA and general population in several areas including income, employment, housing, and health.

In 2012, 8.3 million American, or 3.5% of the population identified as LGBT; today, that number has risen to 10 million Americans, or 4.1% of the population (Gallup, 2017). While this trend may be, in part, attributable to true growth in the number of people who are LGBT, it is largely symptomatic of a societal shift that has allowed LGBT individuals to feel enough security to come out in greater numbers. The increasing visibility of the LGBTQIA population is significant; it signifies growing acceptance and understanding, which have also been reflected in political and social gains. However, despite recent advances in LGBTQIA rights, progress has not precluded on-going experiences of discrimination, stigmatization, and exclusion among the LGBTQIA community. These negative experiences have contributed to disparities between the LGBTQIA and general population in several areas including income, employment, housing, and health.

Pittsburgh, Pennsylvania is home to a vibrant LGBTQIA community that, while facing these same adversities, is supported by a diverse set of organizations. The Delta Foundation of Pittsburgh, Trans YOUniting, and the Central Outreach Wellness Center are among these organizations that collaborate to create a social support system with the purpose of advocating for and fulfilling the basic needs of the population, chiefly their health needs. According to Dr. Stacey Lane of the Central Wellness Outreach Center, LGBTQIA individuals often lack access to culturally competent and informed health care, resulting in physical and mental health disparities. In this paper, we identify critical health needs of the LGBTQIA population and address misconceptions regarding their prevalence in and significance to the community. Subsequently, we provide recommendation for the health care sector and individual providers to improve their responsiveness to the LGBTQIA community and their capacity to provide quality, culturally competent care.

 The incidence of HIV has been declining over the last decade in the United States.

 HIV/AIDS is not a disease of the past, but a current morbidity that, as of 2015, affects an estimated 1.1 million people aged thirteen and older in the United States (Centers for Disease Control and Prevention, 2015a). However, the annual number and rate of HIV infection has been declining over the last decade. In 2008, there were an estimated 45,700 new HIV infections in the United States (CDC, 2015a). In 2014, this number declined to 37,600, indicating an 18% decrease in HIV incidence over the six -year period (CDC, 2015a). Despite the over-all trend, some groups have experienced increases or stability in their HIV incidence and infection rates. Variations among groups are caused by differences in age, race/ethnicity, and transmission category. The Intersectionality of characteristics can also compound disadvantage- leading to heightened infection risks among certain subgroups.

Transmission category:

Gay and bisexual men, or men who have sex with men (MSM), represent the population most affected by HIV. In 2015, MSM accounted for 82% (26,375) of HIV diagnoses among males and 67% of all diagnoses (CDC, 2017b). The gay and bisexual male population diverges from the general decline in HIV incidence. From 2005-2014, the rate of HIV infection decreased by 19% for the total population, yet increased by 6% among all gay and bisexual men (Center for Disease Control and Prevention, 2017c). This trend has since stabilized: between 2010-2014, the diagnosis of HIV in MSM has increased only by 1% (CDC, 2017c). In 2015, 26, 375 MSM were diagnosed with HIV (CDC, 2015a).

The Intersectionality of characteristics translates into variations in HIV infection among subgroups within the MSM population. Within the both the MSM and general population, HIV incidence differs by age and race/ethnicity.

Age:

From 2010 to 2014, the rate of HIV infection has been declining for all persons aged 13–19 and 30–years and older and remained stable for all persons between the ages of 20-24 years (Center for Disease Control and Prevention, 2017b). During this same period, the rates for 25-29 year-olds, the group that experiences the highest infection rate (33.4), increased (CDC, 2017b). Young people are disproportionally impacted by HIV diagnoses. In 2015, persons ages 13-24 represented 16% of the US population but accounted for 22% of all new HIV diagnoses (CDC, 2017b).

Young gay and bisexual men account for the greatest subgroup diagnosed within their age category. Young gay and bisexual men accounted for 84% of all new HIV diagnoses in people aged 13-24 in 2015, with young black/african American men demonstrating the most severe risk. Among gay and bisexual men in 2015, the 20-24 and 25-29 age categories experience the highest number of infections across all racial categories (excluding Caucasian men) (CDC, 2017b).

Race/ethnicity

Variations in incidence are most dramatic when rates are compared across racial/ethnic categories. In both the general and gay and bisexual populations, HIV disproportionately affects Blacks/African Americans. In 2015, Blacks/African Americans (not of Latin American descent) made up only 12% of the US population but had 45% of all new HIV diagnoses. Hispanic/Latinos (of any race) are also strongly impacted: in 2015 they made up 18% of the US population but had 24% of all new HIV diagnoses (CDC, 2017b).

Among gay and bisexual men, between 2005 and 2014, the rate of diagnosis for Caucasian males dropped by 18% and the rate for Hispanic and Latino and Black/African Americans rose by 24% and 22% respectively (CDC, 2017b). During this time, the rate for Black/African American men ages 13-24 increased by 87% (CDC, 2017b). Diagnosis rates have leveled off since 2010, but African American and Latino men continue to be disproportionally diagnosed (CDC, 2017b). In 2015, Black/African American MSM represented the subgroup with the highest number of new HIV infections (CDC, 2017b)

Pre-exposure prophylaxis (or PrEP) is contributing the creation of a HIV/AIDS-free generation.

Truvada, a combination of two HIV medicines (tenofovir and emtricitabine), is the only medication approved by the FDA for daily PrEP use (Center for Disease Control and Prevention, 2017a). PrEP works by blocking pathways in the blood that the HIV virus uses to establish infections (CDC, 2017a). Daily PrEP use can reduce an individual’s risk of contracting HIV through sex by more than 90% (92%-99%) and from injection drug use by more than 70% (CDC, 2017b). PrEP is considered one of the most significant advances in the fight against the AIDS epidemic and has the potential to accomplish “getting to zero,” or the complete elimination of HIV transmission (Freyer, 2016).

Despite the potential of PrEP to advance a HIV/AIDS free generation, its permeation into high-risk communities is limited. The CDC estimates that approximately 1.2 million people should be using PrEP (Freyer, 2016). Yet, despite having been approved for PrEP five years ago, only 1/10 of the individuals who could benefit from using Truvada are taking the drug (Freyer, 2016). Furthermore, the segments of the LGBTQ+ population with the highest rate of infection and thus the greatest need for PrEP, including Black and Hispanic men under the age of 30, are those least likely to take Truvada (Freyer, 2016). Barriers to access, information, and understanding prevent portions of the LGBTQ+ community from using PrEP and thereby challenge its ability to promote meaningful change. Obstacles preventing PrEP among the LGBTQ+ community include:

Cost:

PrEP can cost upwards of $1,500 for a month’s supply (Scaccia, 2016). While the Affordable Care Act’s Medicaid expansion covers the cost of PrEP, many states refused to adopt the expansion. For low-income citizens of these states, PrEP can be unaffordable and out-of-reach (Scaccia, 2016) PrEP use is also associated with additional costs that can limit the ability of low-income individuals to access the drug. People who take PrEP are advised to visit a doctor every three months to monitor potentially adverse side effects and get tested for STIs (Johns Hopkins Bloomberg School of Public Health, 2016). The cost of transportation, especially in poor urban and rural areas, can make routine doctors visits nearly impossible (Johns Hopkins Bloomberg School of Public Health, 2016). Barriers surrounding cost limit PrEP use among poor individuals and contribute to income-based health disparities.

Health care providers and stigma

The significant proportion of health care providers is unaware of the existence and benefits of PrEP. A 2015 survey found that only 34% of primary care doctors and nurses had ever heard of PrEP (Center for Disease Control and Prevention, 2015b). Even among providers who do know about PrEP, their commitment to discussing its benefits and prescribing it to their patients is unreliable. Findings show that many providers fail to discuss PrEP with their patients, including high-risk patients (Johns Hopkins Bloomberg School of Public Health, 2016).

The stigma surrounding sex, sexuality, gender identity, and HIV may further intensify the challenges LGBTQ+ individuals face in health care settings. Provider bias can create stigmatizing environments that LGBTQ+ individuals chose to avoid after experiencing judgment surrounding their sexual preferences and life style choices (Scaccia, 2016). Transgender people, due to the discrimination and judgment they experience in medial settings, are less likely than other group to seek out PrEP (Scaccia, 2016).

Racial Disparities

Black and Latino gay and bisexual men are disproportionately represented in the HIV/AIDS epidemic and are considered to be the populations most at-risk of HIV infection during their lifetime (Johns Hopkins Bloomberg School of Public Health, 2016). Despite their risk, these groups are far less likely to use PrEP than other subgroups of gay and bisexual men (Johns Hopkins Bloomberg School of Public Health, 2016). According to Shannon Weber, founder of Please PrEP Me, an online directory of clinics in California that provide PrEP, “This is not reflective of the HIV epidemic at all. It is reflective about access, and where and how people are getting that information” (Scaccia, 2016). Gilead Sciences, the biopharmaceutical company that makes Truvada, reported that in 2015 white MSM demonstrated the greatest increases in PrEP use, compared to black men whose PrEP use has dropped since 2012 (Scaccia, 2016). While over-all PrEP use is steadily rising, it is not going to the high-risk communities with the greatest need.

PrEP has contributed the rise of other Sexually Transmitted Diseases

PrEP does not protect against the transmission of other Sexually Transmitted Diseases (STD). Subsequently, STDs are on the rise in the United States among gay and bisexual men. The CDC’s 2015 STD Surveillance Report found that the total combined cases of chlamydia, gonorrhea, and syphilis reached its highest levels ever (Moylan, 2016). Nearly 1.5 million cases of chlamydia (a 6% increase from 2014), nearly 400,000 cases of gonorrhea (a 13% increase from 2014), and approximately 24,00 cases of primary and secondary Syphilis (a 19% increase from 2014) were reported (Center for Disease Control and Prevention, 2016b). Primary and Secondary syphilis has been rising at an alarming rate, with men accounting for 90% of cases and MSM accounting for 82% of male cases where the sexual partner is known (CDC, 2016b).

A decline in condom usage is a contributing factor to the rise of STDs within the MSM community. The CDC’s National HIV Behavioral Surveillance (NHBS) found that total MSM condom use declined by 20% between 2005 and 2011 (Paz-Bailey et al., 2016). In 2014, 44.5% of HIV positive MSM, 40.5% of HIV negative MSM, and 38.5% of MSM with unknown status reported having condom-less anal sex at their last sexual encounter (Paz-Bailey et al., 2016). But, are new prevention and treatment strategies, such as PrEP, causally linked or simply correlated to recent declines in condom use? The CDC determined that the rise of HIV treatment and prevention methods do not explain the trend of unsafe sexual behaviors. (Moylan, 2016). As it notes, PrEP use by MSM is still relatively uncommon and the use of condoms was declining before PrEP became a FDA approved prevention option in 2012 (Moylan, 2016).

As the transgender community has become increasingly visible, they have experienced greater acceptance and improved conditions.

A 2011 report from the University of California School of Law’s Williams Institute found that .3% of the US population, or roughly 700,000 adults are transgendered. Five years later, that estimate doubled to 1.4 million adults, or .6% of the US population (Hoffman, 2016). The increased visibility of the trans community has led to greater understanding and efforts to improve trans representation and protection in policy (Hoffman, 2016). However, the trans community continues to be plagued by unrelenting discrimination and mistreatment. The 2015 U.S. Transgender Survey (USTS) is the largest survey examining the experiences of transgender people in the United States and includes 27,715 respondents from all fifty states, the District of Columbia, American Samoa, Guam, Puerto Rico, and U.S. military bases overseas (James et al., 2016). The USTS reports disturbing disparities between the transgender survey respondents and the general U.S. population in areas of employment status, income, familial support, and health (James et al., 2016).

Employment

Passing, or “being perceived by others as a particular identity/ gender or cis-gender regardless of how the individual in question identifies” is often an essential qualification for transgender people in the job market (Trans Student Educational Resource, 2017). Transgender individuals who are not passable often face discriminatory hiring practices that, in some cities and states, are legally permissible. The unemployment rate among respondents in the USTS was three times higher than the U.S. unemployment rate (15% vs 5%), with American Indian, multiracial, Latino/a, and Black respondents experiencing even higher rates of unemployment (James et al., 2016). Furthermore, (16%) respondents who have ever been employed reported losing a job because of their gender identity or expression in their lifetime and 30% of respondents who had a job in the past year reported being fired, denied a promotion, or experiencing some other form of mistreatment related to their gender identity or expression (James et al., 2016).

Experiences of mistreatment and discrimination in the primary labor market force a high number of transgender individuals to resort to sex work and other jobs in the underground economy. 12% of USTS respondents have done sex work in exchange for income—and 9% did so in the past year, with higher rates among women of color (James et al., 2016). According to Dr. Lane, while the only position transgender people can get is often in a low-wage non-professional field, they can make a lot of money in fetish-based sex work. Essentially, they can either get paid minimum wage doing a job in which their sexual identity is devalued, or make more money in sex work, where their gender identity is valued. Consequentially, transgender individual who engage in sex work are increasingly vulnerable to violence, HIV and other STDs and mental health issues, such as depression.

Family Support

Among the respondents who came out as transgender to their families, 60% reported that their families were generally supportive, 18% reported that their families were unsupportive, and 22% said that their families were neither supportive nor unsupportive (James et al., 2016) Respondents with unsupportive families were much more likely to experience a variety of negative experiences: 45% of these respondents experienced homelessness, 54% had attempted suicide, and 50% were experiencing serious psychological distress at the time of the survey (James et al., 2016).

Deena Stanley works with transgender youth who have ben kicked out of their homes because of their gender identity and expression. She says that most transgender youth, including children as young as 12, who live on the streets are forced to perform sex work to survive. She explains that homelessness is most pervasive among trans women of color. 30% of USTS reported experiencing homelessness at some point in their lifetime due to family rejection and other forms of discrimination (James et al., 2016). Transgender women of color, including American Indian (59%), Black (51%), multiracial (51%), and Middle Eastern (49%) women, experience the highest rates of homelessness among the transgender community (James et al., 2016).

Racial Disparities

According to the USTS report, “transgender people of color experience deeper and broader patterns of discrimination than white respondents and the U.S. population” (James et al., 2016). In addition to homelessness, Transgender people of color (POC) face higher rates of poverty, unemployment, and health disparities. While respondents in the USTS sample were, on average, more than twice as likely as the U.S. population to be living in poverty, people of color, including Latino/a (43%), American Indian (41%), multiracial (40%), and Black (38%) respondents, were up to three times as likely as the U.S. population (14%) to be living in poverty. The unemployment rate among transgender POC (20%) was four times higher than the U.S. unemployment rate (5%). Finally, Transgender POC face substantial health disparities compared to the U.S. population and other transgender subgroups, as reflected in rates of HIV infection. While the HIV rate was .3% in the U.S. population and 1.4% among all respondents, it increased to 6.7% for black respondents and a staggering 19% among black transgender women (James et al., 2016).

Implications for Health

The multiple forms of discrimination and micro-aggressions transgender people face on a daily basis have dramatic consequences on their health and well-being. Barriers preventing transgender people from accessing quality health care exacerbate the severity of health outcomes. Transgender people experience high rates of unemployment and poverty. Consequently, cost, coupled with a difficulty in obtaining health insurance, is a major factor preventing the transgender community from receiving routine and transition care (James et al., 2016).

LGBTQIA in use mental health services more than straight ppl- an indication of equal access

Several large population-based public health studies have found that sexual minorities, including men and women with same-sex partners, are associated with higher use rates of mental health services than heterosexual groups (Tracy, 2016). The high rates of mental health treatment cannot be attributed to ease of service accessibility, but rather a high incidence of adverse mental health outcomes among the LGBT community. The LGB population utilizes mental health services more frequently than heterosexual groups because they suffer from higher rates of mental health issues, including mood, anxiety, and substance abuse disorders (Medley et al., 2016). The prevalence of depression among gay men, for example, is three times higher than the general adult population (Lee, Oliffe, Kelly, & Ferlatte, 2017). Research has also demonstrated that LGBT youth and adults are significantly more likely than heterosexuals to attempt to commit suicide. The rate of suicide attempts is four times greater for LGB youth and two times greater for questioning youth compared to their heterosexual counterparts (Lee et al., 2017). 40% of transgender adults reported having attempted suicide, compared to 2% of the general population, with 92% of then reporting having attempted suicide before the age of 25 (Maza & Krehely, 2010).

Mental health disparities facing the LGBT population stem from a lack of informed health care and minority stress associated with habitual experiences of violence, discrimination, the internalization of homo- and transphobia, and rejection (National LGBT Health Education Center, 2016). A 2009 study substantiates this link through its findings that the stress associated with family rejection is a significant risk factor of mental illness. Compared to counterparts with supportive families, LGBTQ youth who have experienced strong family rejection are eight times more likely to have tried to commit suicide, six times more likely to report high level of depression, three times more likely to use illegal drugs, and three times more likely to have risky sex (Center for Disease Control and Prevention, 2016a). The risk of minority stress as a prelude to mental health issues is even more substantial for racial and ethnic LGBTQ minorities, who face multiple layers of oppression as they contend with the intersection of racism and homophobia (National Alliance on Mental Illness, 2017).

Symptomatic of the multiplicity of mental health risk factors they face, LGBTQ individuals also experience a greater prevalence of comorbid disorders than heterosexual persons. One study found that 20% of gay and bisexual men and 24% of lesbian/bisexual women had two or more mental health disorders in the year prior to the interview (Cochran, Sullivan, & Mays, 2003). These comorbidity rates were three to nearly four times greater than those observed among heterosexuals (Cochran, Sullivan, & Mays, 2003). Substance abuse is a common comorbid disorder in the LGBTQ population as individuals try to cope with minority stress (National LGBT Health Education Center, 2016). The 2015 National Survey on Drug Use and Health found that sexual minorities were more likely than their sexual majority peers to have both substance abuse and mental health issues (Medley et al., 2016). The survey concluded that sexual minorities were more likely to have used illicit drugs in the past year (2014) and to be currently abusing alcohol (Maza & Krehely, 2010).

Accessing mental health services is the first step in treatment and recovery for individuals suffering from mental health issues. While high service use rates among the LGBTQIA populations suggests accessibility, nation-wide shortages of mental health professionals, in conjunction with other barriers, prevents greater usage. According to a 2009 study, 18% of counties in the United States had an unmet need for psychologists and other non-prescribing mental health professionals and 96% of counties had an unmet need for psychiatrists and other prescribing professionals, indicating a “widespread prescriber shortage and poor distribution of no prescribers” (Thomas, Ellis, Konrad, Holzer, & Morrissey, 2009).

While the number of mental health professionals is low to begin with, LGBTQIA individuals face even an even greater challenge finding LGBTQ-friendly providers and programs that specialize in LGBTQIA services, particularly in rural areas (National Alliance on Mental Illness, 2017). According to the 2008 National Survey of Substance Abuse Treatment Services, 777 of 13,688 (6%) of surveyed facilities offered specialized mental health and substance abuse programs for LGBT clients (: Substance Abuse and Mental Health Services Administration, 2010). The consequence of this shortage of essential mental health experts is unmistakable. On average, the higher the number of psychiatrists, psychologists, and social workers per capita in a state, the lower the suicide (Russell, 2010).

In the absence of experts, the non-mental health care sector provides significant portions of mental health treatment services. As Dr. Lane commented, “I practice a lot more mental health care than I thought I would as an internal medicine doctor and an infectious disease doctor.” An increasing number of individuals turn to their primary care physician to receive help for mental illness, but are confronted by structural barriers that undermine the adequacy of care (Maza & Krehely, 2010). Barriers include, 1) a lack of LGBT-specific training for health care providers, 2) a lack of financial incentives and time for primary care providers to treat mental health concerns for LGBT individuals, and 3) a general lack of information about LGBT health needs (Maza & Krehely, 2010). Primary care appointments last an average of 13 minutes, during which the physicians are required to monitoring and identify multiple physical problems (Russell, 2010). Without a fundamental knowledge of LGBTQ risk factors, primary care providers can miss indicators of mental illness, especially those that primarily present with physical symptoms.

Recommendations for Health Care providers

How can we raise awareness of and increase access to PrEP among the populations with the highest risk of HIV?

PrEP use is recommended by the CDC for an estimated 1.2 million high risk individuals in the U.S., including 1 in 4 sexually active gay and bisexual men, 1 in 5 people who inject drugs, and 1 in 200 sexually active heterosexual adults (CDC, 2015b). To ensure the adequate dissemination and appropriate use of PrEP among these populations, the CDC suggests that it is the responsibility of health care providers to: 1) Test patients for HIV as a regular part of medical care. Discuss HIV risks and continued use of prevention methods, including condom use, with all patients, 2) Counsel patients who can benefit from PrEP on how to take it every day and help them apply for insurance or other programs to pay for PrEP and 3) Schedule appointments for patients using PrEP every 3 months for follow-up, including HIV testing and prescription refills (CDC, 2015b). However, physicians must first become increasingly knowledgeable about PrEP and comfortable prescribing it to their patients. While only 1/3 of doctors know about PrEP, familiarity is predominantly limited to specialists, with few primary care physicians knowing about and/or understanding the its benefits (Freyer, 2016). According to Julia Reitman from the Johns Hopkins Bloomberg School of Public Health

“This [PrEP] is a new safe and effective tool in our toolbox to prevent HIV. “But it does us no good if no one is using it” (Johns Hopkins Bloomberg School of Public Health, 2016).

Educating both doctors and patients is crucial to expanding PrEP use. State and local health departments and community organizations are uniquely able to raise awareness about PrEP use, train health care providers, and educate people about risky sexual and drug use behaviors and ways to reduce their risk (CDC, 2015b). Dr. Lane at the Central Wellness Outreach Center takes an active role in educating local care providers and high-risk members of the LGBTQIA community about PrEP through targeted awareness campaigns. These include advertising PrEP at local gay bars and on Grindr and Scruff, apps used by MSM for anonymous sex, and holding community meetings to discuss PrEP and its benefits.

Among the LGBTQIA population, Dr. Lane has found that individuals frequently underestimate their risk levels and their need to be on PrEP. She acknowledges that it is the role of health care professionals to address this misunderstanding and implement strategies to educate the LGBTQIA community. The Central Wellness Outreach Center, for example, hosts outreach events where they provide HIV, STD, and PrEP testing. A PrEP test is a CDC verified Risk Reduction Tool that measures individuals’ HIV risk levels based on personal, relationship, partner, social, cultural, network, and community factors. To highlight the success of outreach initiatives, she cited an event held by the Central Outreach Wellness Center at the 2016 Pittsburgh Pride festival where, by providing free testing, they had a 70% conversion rate of gay men who began taking PrEP.

Dr. Lane also advocates for health care providers to work with patients to remove barriers preventing them from using PrEP, such as costs and privacy concerns. She explains that among low-income patients health often comes secondary to needs like food, shelter, and even cell phones. To remove barriers of cost, the Central Outreach Wellness Center takes all insurances and they take no insurance. “Studies show that gay men are more likely to take it [PrEP] if it is free and delivered…so we do all we can do to make PrEP free and show up on ppl’s door step.” For patients who want to keep their PrEP use private from their spouses, family, or roommates, the Center allows them to send their PrEP to the office instead of their home. According to Dr. Lane, the Center goes the extra mile for patients because removing barriers preventing people from taking PrEP is imperative.

How can we create systemic change in the medical community that will improve its understanding of and relationships to the LGBTQIA population?

Stigmas surrounding sex, sexuality, gender identity, and HIV can impact doctor-patients interactions, where biases affect the quality of care and create stigmatizing and discriminatory environments. LGBTQIA individuals learn to avoid such environments, thereby preventing them from getting tested for HIV and other STI’s and receiving PrEP and other essential health services. Dr. Lane explains that, when treating patients, she needs to know their risk levels- who they have sex with and how they have sex. To obtain this information, she must be able to have open and honest conversations with patients. Dr. Lane believes that medical professionals need to learn how to have important conversations with LGBTQIA patients about sex, sexuality, and gender identity. They have to become comfortable with asking patients about their sexuality and sexual practices in order to comprehensively evaluate risks and provide care accordingly.

To improve interactions and care, medical professionals should focus on creating trusting, non-judgmental environments in which LGBTQIA patients feel safe and accepted. Eliminating stigmas in the medical field requires systemic changes in the medical education curriculum that prepares providers to address the health risks and needs of the LGBTQIA population and emphasizes culturally competent care. Culturally competent care occurs when health care services are responsive to the cultural attitudes, beliefs, and behaviors of racial, ethnic, and other minority group (Development Services Group, Inc., 2016). Culturally competent training is key to eliminate health disparities should be reflected in medical school curricula (Development Services Group, Inc., 2016).

The majority of medical schools in the United States fail to realize the standard set by the Association of American Medical Colleges (AAMC), which recommends that “medical school curricula ensure that students master the knowledge, skills, and attitudes necessary to provide excellent, comprehensive care for [LGBT] patients” by including “comprehensive content addressing the specific healthcare needs of [LGBT] patients” and “training in communication skills with patients and colleagues regarding issues of sexual orientation and gender identity” (Obedin-Maliver et al., 2011). Dr. Kristen L. Eckstrand is a psychiatry resident at the University of Pittsburgh and formerly served as co-director of Vanderbilt University medical school’s Program for LGBTI Health and chair of the Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development for the AAMC. Dr. Eckstrand calls attention to superficiality of LGBTQIA-related content that is currently included in curricula, as it focuses heavily on sexually transmitted infections and avoids critical topics such as mental health risks, suicide, coming out, and chronic diseases (Beck, 2014). According to Dr. Eckstrand, They teach students to ask, “Do you have sex with men, women, or both?” But once students get that answer, they don’t always know what to do with it” (Beck, 2014).

Two studies published by the Stanford University School of Medicine present the most comprehensive research on the state of LGBTQIA content in medical school curricula. Their 2011 study surveyed deans of 132 medical schools in Canada and the United States and determined that the median reported time dedicated to teaching LGBT-related content in the entire curriculum was 5 hours, with 33.3% of deans reporting 0 hours during clinical years (Obedin-Maliver et al., 2011). Deans were also asked to indicate the presence or absence of 16 LGBT-related topics in their required or elective curricula. 62.9% reported teaching at least half of the 16 topics while only 8.3% reported teaching all 16 topics. When evaluating the quality of their schools’ coverage of LGBT-related content overall, 43.9% of respondents said “fair” while 24.2% answered “very good” or “good” and 25.8% answered “very poor” or “poor” (Obedin-Maliver et al., 2011).

The follow-up 2015 study surveyed 4,262 medical students from 170 schools to evaluate their self-assessed level of preparedness and comfort across the 16 LGBT-related health topics LGBT health issues. 35.0% rated their over-all curriculum, as “fair,” 32.3% rated it as “poor” or “very poor,” and 31.2% said that it was “good” or “very good.” When asked if they felt more comfortable addressing LGBT health issues as a result of their medical school training, 46.3% reported felling “more comfortable”, while 45.6% reported feeling “no change.” While the majority of medical students felt prepared to care for sexual health in LGBT populations, they also felt unprepared to provide patient care in areas related to LGBT primary care, transgender healthcare, and healthcare for intersex individuals (White et al., 2015). These finding support Dr. Eckstrand’s assertion that, while medical schools teach students the basics of sexual health, “things that create disproportionate burdens for the LGBT community are not being taught in medical schools” (Beck, 2014).

Overall, the students included in the 2015 study reported that their medical school did “not provide the breadth and depth of coverage they need to be fully prepared and comfortable to care for LGBT patients” (White et al., 2015). To supplement their education, the respondents emphasized the need for greater clinical experience working with LGBTQIA patients (White et al., 2015). Opportunities for clinical interactions with LGBT patients would improve their comfort and preparedness and allow them to learn how to translate classroom experience into practice (White et al., 2015). In support of a more comprehensive medical school curriculum, Stanford University Medical School also recommends the development of a standardized list of required LGBT curricular topics for all medical schools and of LGBT-related curricular materials that schools could use to expand their curricula (White et al., 2015). Such materials have been created by the AAMC who, in 2014, released comprehensive online resources devoted to teaching all aspects of LGBTQ health care (Summer, 2017). The ultimate goal is to ensure that LGBTQIA health care is expansively embedded in all medical school curriculums so that physicians can become better prepared to recognize and meet the diverse health needs of the community (Summer, 2017).

How can we increase access to mental health services for the LGBTQIA community?

Mental health care is imperative to promoting wellness in the LGBTQIA population. Yet, health care professionals tend to fixate on sexual health issues and neglect mental health risks and outcomes. As Dr. Lane explains, you can treat a patient with PrEP, but they may still be depressed or addicted to crystal meth. The health community needs to focus greater attention on the mental health needs of the LGBTQIA population and make efforts to understand underlying social determinants of health.

Any initiative to improve LGBTQIA community mental health requires significant investments in expanding and improving the clinical infrastructure. According to Dr. Lane, “We have a mental health shortage in Pittsburgh and nationally.” She adds that, “organizations that do offer services are overwhelmed and have long waitlists to get in to see them.” Strategies to grow the population of mental health professionals should be intentional in their efforts increase the number of LGBT medical professionals in the health care workforce. According to the Center for American Progress, “Developing an LGBT-inclusive workforce would help patients feel more comfortable discussing mental health issues related to their sexual orientation or gender identity, and allow them to more readily access necessary treatment” (Maza & Krehely, 2010). To overcome provider shortages, the Center for American Progress also suggests expanding the use of telecommunication tools that can deliver mental health services to LGBTQIA individuals in rural and other underserved regions (Maza & Krehely, 2010).

In the absence of an abundant mental health care workforce, the medical community can improve the capacity of primary care physicians to provide mental health services to the LGBTQIA population. This requires the support of a system in which primary care physicians receive an appropriate financial incentive for them to spend the time and resources necessary to fully evaluate both the physical and mental health of patients (Russell, 2010). Furthermore, “rigorous, LGBT-supportive cultural competency training programs” for primary care providers will equip them with the skills to better diagnose and treat mental health issues and create trusting provider-patient relationships (Maza & Krehely, 2010). According to (GLMA, 2006), “The training should cover the use of appropriate language amid identifying and confronting any internalized discriminatory beliefs about gay men and their health issues…. Learning to identify and confront internalized discriminatory beliefs is important because some health providers may have inaccurate perceptions about gay patients due to their lack of awareness of LGBT issues.”

Conclusion

As the visibility of the LGBTQIA population grows, so should our focus on perpetuating an informed and culturally competent health care system that adequately assesses and responds to their health care needs. Pursuant of this goal, Dr. Lane recommends instituting strategies to raise awareness of and increase access to PrEP, expanding and improving mental health services for the LGBTQIA community, and implementing more substantive LGBTQIA-related content in the curricula of medical schools. Dr. Lane also defends the need for more specialized clinics like the Central Outreach Wellness Center. Similar to the Center, these clinics should offer inclusive, supportive, and culturally competent care to the LGBTQIA population and offer harm reduction and recovery-based services. Such clinics must focus on holistic medicine that addresses the wide range of mental and physical health issues affecting this community while also prioritizing accessibility.

References

Beck, J. (2014, November 15). What Doctors Don’t Know about LGBT Health. The    Atlantic, Retrieved from http://www.theatlantic.com

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