Addressing LGBTQ Health Disparities Through Strengthened Primary Care
By Kelsey Kolbe, Global Health Corps
Primary healthcare providers occupy a position of privilege and responsibility in society, one that is distinct from other types of service roles. Most significantly, because of asymmetric access to medical knowledge, people rely on primary care providers when they are at their most vulnerable. Whether it is in a moment of crisis or at a regular check-up, people disclose intimately personal information about their health and bodies, trusting providers to respond with respect and compassion. As most people will require medical expertise or intervention at some point in their lives, providers possess a large sphere of influence in their communities.
However, while the experience of illness and injury may be universal, not allcommunities experience the same quality of and access to healthcare. The LGBTQ community is one such group that has particular significance to me. I came out as queer in my last year of college. Prior to that, I was so firmly in the closet that I was unwilling to admit, even to myself, that this was a part of my identity. When I came out, I felt like I could finally breathe, could finally see the world in full color. But it was also one of the most difficult things I’ve ever done. I struggled to overcome feelings of shame and disappointment in myself, fear that I was disappointing others by being different or less than what they had hoped for me. The challenges of coming out were exacerbated by the fact that I was living in Oklahoma, where queer and gender non-conforming people face more overt discrimination and prejudice than might be experienced in more progressive areas (although to be sure, homophobia and transphobia are alive and well in those areas as well). Coming out was an ongoing process, involving daily, moment-to-moment decisions around whether it felt safe to hold my girlfriend’s hand, to wear a tie, to describe myself as queer — in other words, to be too visibly out.
Despite these challenges, I also became part of a community of friends and mentors and peers who would come to embody chosen family for me. I was welcomed with open arms by people who knew what it felt like to be where I was and who wanted to make my journey out of the closet easier, or at least less lonely. To me, queerness is about placing the way you relate to others at the core of your identity; it is about claiming humans who are also “other” and embracing and affirming that otherness to each other. I think inherent in that definition is also a sense of responsibility for other people, a recognition that many LGBTQ people, because of their gender identity or presentation or sexual orientation or family structure, face significant challenges to self-actualizing and leading lives of their own choosing.
Healthcare providers and institutions have made great strides to be more inclusive of and knowledgeable about queer and transgender people. Yet LGBTQ people still face significant health disparities in the U.S., including higher rates of depression and suicide, of hate-motivated and gender-based violence, of obesity and diabetes and cardiovascular complications, and of substance abuse and addiction. These disparities are caused by many factors, including social stigma, minority stress, and institutionalized discrimination. But a primary cause of these health disparities is also a general attitude of distrust toward doctors and other primary care providers that inhibits people from seeking care when they need it.
While not all queer and transgender people have had negative experiences in a healthcare setting, many of us have or at least know someone close to us who has. These experiences contribute to the general belief that providers do not have the knowledge or desire to effectively care for LGBTQ people, and will not treat these patients with decency and respect. I think that sense of distrust is founded in real experiences of violence and trauma in healthcare settings. But I believe, too, that there are many providers and hospitals and medical schools that value inclusivity and that are actively seeking to improve care for LGBTQ populations.
So, how can primary care provision be improved to address existing disparities in LGBTQ communities?
First, primary care providers need to be trained in and learn to cultivate emotional intelligence. It is a skill that is underrated but utterly crucial to the provision of empathetic, effective care, and it is especially important in mitigating the distrust felt by many LGBTQ people in interacting with the healthcare system. Technical proficiency and competency are necessary traits in primary care providers — we expect them to have a specific set of skills related to the management of human health and illness, after all — but these skills are moot if a patient does not feel heard or understood and subsequently does not adhere to medical recommendations.
In coming out, I very often felt vulnerable, afraid, and anxious. Those feelings were made easier to bear by the unrestrained willingness of people in my life to give me undivided attention, to sit and listen, to affirm my sense of self, and to share their courage. I know what it feels like to be truly heard, an experience that positively and profoundly shaped my coming out process. Primary care providers regularly meet patients in moments of vulnerability and discomfort. When they encourage conversation and truly listen to patients’ experiences and concerns, providers can make recommendations for care that better reflect their patients’ desires. Unsurprisingly, patients are then more likely to follow recommendations and care plans. Emotional intelligence can be taught and incorporated into medical training to an extent — but I think this also touches on the fact that we need more women serving as primary care providers.
“Primary care providers regularly meet patients in moments of vulnerability and discomfort. When they encourage conversation and truly listen to patients’ experiences and concerns, providers can make recommendations for care that better reflect their patients’ desires. Unsurprisingly, patients are then more likely to follow recommendations and care plans.”
Second, we need primary care providers who have the cultural competency and humility to engage patients more effectively, especially in marginalized communities. Frequently, problems arise when a provider simply lacks the knowledge or language to ask the right questions. In conversations related to sexual orientation, sexual practices, and gender identity, this can result in the alienation of the patient through insensitive or invasive questions. Perhaps more often, a provider may avoid broaching the subject at all. I have been asked by a doctor if I’ve dated men “yet”; another insisted on recording in my medical records that I was not sexually active because my partners were not men. I did not return to those providers. I think this exemplifies the idea that a provider can be technically competent and yet still inflict harm by failing to account for differences in identity and experience.
“…we need primary care providers who have the cultural competency and humility to engage patients more effectively, especially in marginalized communities. Frequently, problems arise when a provider simply lacks the knowledge or language to ask the right questions.”
And finally, we need primary care providers who identify as LGBTQ themselves. It makes a difference to receive care from someone who looks like you or who experiences the world in the same way that you do. Minority providers are more likely to encourage affinity with patients who share their identity, and are more likely to serve populations that are traditionally underserved in medicine. Expanding the number of providers who identify as LGBTQ would serve two purposes: first, it would increase the collective knowledge in the medical community about queer and transgender-specific health needs, and second, it would inspire greater trust among LGBTQ communities in accessing healthcare. It could reduce disparities by making these populations more likely to seek care when they need it.
“Primary care providers serve a crucial role in delivering inclusive and affirming care to people in their communities, allowing them to access healthcare in a way that respects their identities and recognizes universal dignity and worth.”
The problem of mitigating disparities in LGBTQ health and healthcare is complex and especially challenging in a political environment that devalues queer and transgender lives and experiences. It will take time and collective, intentional effort to make improvements. Primary care providers serve a crucial role in this effort. By delivering inclusive, affirming, and culturally competent care to people, they allow LGBTQ patients to access healthcare in a way that respects their identities and recognizes universal dignity and worth.
Kelsey Kolbe is a 2017–2018 Global Health Corps (GHC) fellow at 1000 Days.
This piece originally appeared in AMPLIFY, which features new voices and ideas from Global Health Corps.
