HEALTH, HEALTH CARE, AND HEALTH CLINICS

LGBT communities are highly diverse in terms of sex, gender, age, race, ethnicity, religion, class, nationality, and citizenship, and all of these factors affect health and health care. Moreover, despite common concerns about health, these four communities also have different health needs and agendas.

LGBT persons have many of the same health needs and concerns that all other members of society have, but they also have additional needs. For example, while many youth experiment with alcohol or drugs and need education to prevent (or treat) addictions and related health problems, sexual minority youth tend to use drugs more frequently. If this is because being LGBT places these youth under extraordinary social pressures or encourages them to join social networks where drugs are more available and attractive to use, distinct types of health education are needed. To take another example, many menopausal women must decide about the risks and benefits of taking estrogen, but many male-to-female transgender women of any age worry about the risks of not taking estrogen. Successful LGBT health policy requires attention to these and many other distinctive aspects of LGBT health.

LGBT Health Issues

An increasing body of research suggests that health disparities exist between LGBT people and their non-LGBT counterparts. However, most of this evidence comes from small descriptive studies. More evidence needs to be gathered about the general health of transgender people, partially because that group is so internally diverse.

Two publications synthesize much of the existing literature and research on LGBT health. LGBT Health: Findings and Concerns and Healthy People 2010: Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health provide evidence of what is known and what is unknown. The former was written by members of the Center for Lesbian, Gay, Bisexual, and Transgender Health at Columbia University. Members of the Gay and Lesbian Medical Association, in collaboration with other LGBT individuals and organizations, developed the Companion Document. The group responsible for the Companion Document then evolved into the National Coalition for LGBT Health.

Healthy People 2010 proposes a national agenda for promoting the health of all people in the United States. Its goals are to increase the quality and quantity of healthy life and to eliminate health disparities between groups—specifically racial and ethnic majority and minority groups. The Companion Document demonstrates that sexual and gender minority groups must also be considered a priority.

Among their various health issues, lesbians report being most concerned about cancer and want greater access to cancer screening. Lesbians desire improved cancer screening in part because of their understanding that they may be at increased risk for breast cancer due to such factors as lack of pregnancy, obesity, and use of alcohol. Lesbians may also be at increased risk of developing cervical cancer, primarily because of the false belief, common among lesbians and health care providers alike, that lesbians do not need Pap smears. If lesbians are not screened regularly, the disease may be diagnosed later, with less likelihood of effective treatment.

Gay men have been at high risk for HIV and other sexually transmitted diseases, and the risk seems to be rising. Persons with HIV are also at greater risk for opportunistic infections, and gay men appear to be at higher risk for anal cancer.

Bisexual men and women have higher rates of sexually transmitted infections (STIs) than lesbians, gay men, or heterosexuals. This is probably because they have higher average numbers of sexual partners, but studies also suggest that bisexuals do not perceive themselves to be at higher risk for STIs.

Health care issues for transgender persons include obtaining hormones and surgeries. Female to male transsexuals may minimize their risk of developing cancers of the breast, cervix, or ovary if they have those organs removed, but there are also various risks associated with taking androgen hormones.

Many LGBT people share various mental health problems related to the stresses of living in a society in which heterosexism is the norm and discrimination and violence are all too common. Transgender persons often must be diagnosed as having Gender Identity Disorder to receive care, which, some have argued, may lead them to strategically feign symptoms in order to be considered eligible for surgery. LGBT people with serious mental illnesses may experience discrimination both from society in general and from within LGBT communities. There is now a growing LGBT mental health care consumer/survivor movement in the United States working to build acceptance and affirmation of LGBT people with psychiatric illnesses.

Although the evidence is conflicting, there is a common perception that lesbians and gay men are more likely to use alcohol and drugs and to smoke cigarettes than heterosexual people are. Evidence suggests that use is higher in younger people and decreases with age. Many LGBT people are also in recovery from addictions.

Intimate partner violence is also a problem among LGBT people. Rates appear to be similar to those for heterosexual or bisexual couples, but abused lesbians and gay men may be less likely to seek help than heterosexual women.

Members of all LGBT groups confront issues related to parenting. They may have children from former marriages or relationships or they may want to have children in their current life situations. Although issues related to the bearing of children differ among diverse LGBT groups, fostering and adoption issues may be similar. Both state regulations and individual health care providers can make parenting difficult for LGBT people. Lesbians may not have access to sperm banks, and same-sex partners may not be able to adopt children. Any nonheterosexual parents may rightly fear the loss of their children through custody battles.

Aging is also a significant health issue for LGBT people. Older LGBT people, for example, worry about being alone in an environment, such as a nursing home, that pays no attention to minority sexualities and genders.

Barriers to Health Care

What LGBT people have most in common in the area of health is the difficulty of accessing quality health care. Barriers to health care result from homophobia, transphobia, and heterosexism in society, the hostility and ignorance of health care providers, and the attitudes and behaviors of LGBT people themselves.

Perhaps the most common barrier to adequate health care for LGBT people is the assumption by health care providers that all people are heterosexual. For example, the assumption that a woman without a male partner is not sexually active can have dangerous consequences. Health care providers may also treat clients in a homophobic or transphobic manner, using harsh or rude language and behavior, avoiding LGBT clients, or manifesting hostility in interactions.

Another problem among health care providers is the lack of knowledge most have about providing care to LGBT people. This is because professional education for doctors, nurses, psychologists, and social workers has been extremely limited with respect to LGBT health. In addition, conventional medical science requires research or best evidence as the basis for care. Because there has been very little non-homophobic or transphobic research on LGBT health, providers do not have sufficient evidence and can thus feel inadequately prepared to deal with sexual and gender minority clients.

Barriers to quality health care originating within LGBT persons themselves relate primarily to fear. Many LGBT people are afraid to disclose their identity as LGBT to health care providers, because they expect negative and homophobic responses that will severely affect the kind of health care they receive.

Disclosure by LGBT people has been increasing, however, though there is evidence that men disclose more readily than women do. There are three types of disclosure: Planned, or active, disclosure is when an individual consciously decides, prior to a health care visit, to "come out" to the provider. This allows the person to plan for possible reactions from the provider. Passive disclosure is when a LGBT person assumes, on the basis of their health history or personal characteristics, that the provider knows she or he is a member of a sexual or gender minority. In this case the LGBT person does nothing to affirm or deny that presumed assumption. Finally, there is unplanned disclosure. In this case the individual either actively decides not to disclose or has not even considered the possibility, but something occurs during the health care interaction that causes the individual to believe that disclosure is necessary. Unplanned disclosure can cause a person to feel very unsafe.

Another major barrier to access for LGBT people is financial. Individuals may lack health care insurance or other health coverage because they are not covered under a partner's policy or they may be employed in jobs that do not provide coverage, or they may be unemployed.

Interactions between health care providers and LGBT people affect care-seeking behaviors. Negative expectations can result from an individual's bad experience and may cause a person to never seek health care again. Hearing that someone else has had a bad experience can also prevent an individual from seeking needed health care.

The AIDS crisis has both helped and hindered access to care for LGBT people. When health care providers could not avoid the large numbers of gay men who needed care or were dying, attitudes and knowledge did improve. However, with that came what has been called "AIDS stigma," in which health care providers assume that all gay men, and often lesbians too, are HIV-positive. Even as that attitude has modified, LGBT people often continue to be treated as groups always at risk.

Health Alternatives

One response to lack of access to and poor interactions with health care providers has been to seek care outside of the mainstream health care system. One source of alternative care is providers of what is known as complementary and alternative medicine (CAM). CAM providers, such as massage therapists, acupuncturists, herbalists, and naturopaths, are believed to be more holistic in their approaches and more open to diverse clients. Consequently, reportedly large numbers of sexual and gender minorities seek care from these kinds of providers.

But an even more important result of lack of access to care is the creation by LGBT people of their own health care clinics and support groups as a safe alternative to mainstream health care. Beginning in the 1970s, LGBT people, both health care providers and activists from outside the medical profession, opened clinics to meet needs that were not being met in the mainstream health care delivery system. In so doing, they put themselves at the center of care, rather than at the margins of mainstream health care systems.

LGBT health services or clinics opened in several major cities in the 1970s. One principal service they offered was confidential screening (with or without treatment) for STIs, especially for gay men. Howard Brown Health Center, in Chicago, began in 1971 with that mission, as did the Whitman-Walker Clinic in Washington, D.C., in 1978. These and other centers are thriving today as providers of care to persons with HIV/AIDS. The Fenway Community Health Center, in Boston, opened in 1971 as a grassroots neighborhood health clinic. It is now a model for providing comprehensive health services to LGBT people.

In the lesbian community, a whole network of lesbian (or women's) clinics and support groups developed in the 1970s. Lyon-Martin Women's Health Services, in San Francisco, opened in 1979 as a free-standing clinic, specifically to meet the needs of lesbians who were not accessing mainstream health care because of fears of discrimination. An all-volunteer, all-woman staff provided care. The clinic has expanded to provide a variety of primary care and other services for all women, but especially lesbians, women of color, poor women, and transgender women.

Following the onset of the HIV epidemic, the need for alternative clinics was even greater, since gay men were being diagnosed with HIV at incredibly high rates, and mainstream health care was very homophobic. Existing clinics expanded their services to include HIV treatment, and new clinics opened. In addition, the HIV epidemic motivated LGBT people to pioneer important sex education and safer sex programs and campaigns for sexual and gender minorities and others.

More recently, LGBT people have recognized the need to work together to improve their health and the delivery of health care. In 1996–1997 the Mary-Helen Mautner Project for Lesbians with Cancer in Washington, D.C., with funding from the Centers for Disease Control and Prevention, developed a curriculum for educating health care professionals about providing culturally competent care to lesbians. The curriculum is to be implemented nationwide. In Chicago, the first city in the United States to mandate cultural competency training for city health workers, the Lesbian Community Cancer Project collaborated with the Chicago Department of Public Health's Office of Lesbian and Gay Health to train staff at all Chicago Public Health Clinics.

Finally, in October 2000, the National Coalition of LGBT Health was founded to work for the improvement of LGBT health and health care. More than forty-five agencies and organizations have committed to working together. Their first national conference was held in August 2002 with more than 300 persons in attendance. At the dawn of a new millennium, the future appears promising.

Bibliography

Claes, Jacalyn A., and Wayne Moore. "Issues Confronting Lesbian and Gay Elders: The Challenge for Health and Human Services Providers." Journal of Health and Human Services Administration 23 (2000): 181–202.

Dean, Laura, et al. "Lesbian, Gay, Bisexual, and Transgender Health: Findings and Concerns." Journal of the Gay and Lesbian Medical Association 4 (2000): 101–151.

Eliason, Michele J., and Robert Schope. "Does 'Don't Ask Don't Tell' Apply to Health Care: Lesbian, Gay, and Bisexual People's Disclosure to Health Care Providers." Journal of the Gay and Lesbian Medical Association 5 (2001): 125–134.

Gay and Lesbian Medical Association. "Healthy People 2010: Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health." Available from http://www.lgbthealth.net.

Klitzman, Robert L., and Jason D. Greenberg. "Patterns of Communication between Gay and Lesbian Patients and Their Health Care Providers." Journal of Homosexuality 42(2002): 65–75.

Meyer, Ilan H. "Why Lesbian, Gay, Bisexual, and Transgender Public Health?" American Journal of Public Health 91(2001): 856–859.

Oriel, Kathleen A. "Medical Care of Transsexual Patients." Journal of the Gay and Lesbian Medical Association 4(2000): 185–194.

Ponticelli, Christy M., ed. Gateways to Improving Lesbian Health and Health Care: Opening Doors . New York: Haworth, 1998.

Schilder, Arn J., et al. "'Being Dealt With as a Whole Person': Care Seeking and Adherence: The Benefits of Culturally Competent Care." Social Science and Medicine 52 (2001): 1643–1659.

Solarz, Andrea L., ed. Lesbian Health: Current Assessment and Directions for the Future. Washington, D.C.: National Academy Press, 1999.

Stevens, Patricia E., and Sarah Morgan. "Health of LGBT Youth." Journal of Child and Family Nursing 2 (1999): 237–249.

Linda A. Bernhard

see alsoaids and people with aids; aids service organizations; alcohol and drugs; gyms, fitness clubs, and health clubs; health and health care law and policy; medicine, medicalization, and the medical model; psychology, psychiatry, psychoanalysis, and sexology; psychotherapy, counseling, and recovery programs; sexually transmitted diseases.