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Report calls for much more research on LGBT health issues; Q&A with U of M participant

Numerous serious health disparities were identified for this group, including poorer access to health insurance, a higher incidence of mental-health problems and an increased risk of sexually transmitted diseases.

The federal government needs to fund much more research on lesbian, gay, bisexual and transgender (LGBT) health issues, a major new report from the Institute of Medicine (IOM) has recommended.

Published last week, the report’s panel of experts examined studies conducted on LGBT health topics in recent decades. They identified several dozen serious health disparities for this population, including poorer access to health insurance, a higher incidence of mental-health problems and an increased risk of sexually transmitted diseases.

They also found that the research on LGBT health issues is significantly lacking.

The report is being called “groundbreaking” and “historic” by LGBT health activists. On Friday, the Obama administration mentioned the report as it announced a series of initiatives that it says will begin to close the health disparity gap experienced by individuals in the LGBT community.

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Late last week, I spoke about the IOM report with Walter Bockting, one of its authors and an associate professor and coordinator of the transgender health-services program at the University of Minnesota.

MinnPost: Did you and the other members of the panel uncover anything that surprised any of you?

Walter Bockting
Walter Bockting

Walter Bockting: When the committee initially convened, some of us, myself included, said, “Well, yes, we do have research on this and on that.” But when we actually went to the scientific literature and examined it and looked for empirical research — research [with] original data from surveys and so on — I had to acknowledge that, indeed, I was surprised that we know even less than I thought we do. … Most of what we know about LGBT health, I would say, is about HIV. The other areas of the health of this population we know very little about.

MP: The report discussed health disparities by age group. LGBT youth, for example, are at greater risk of depression, attempted suicide and substance abuse than their non-LGBT peers.

WB: Yes. In the report we make the case, which came out of the research that we reviewed, that social stigma plays a very important role [in that increased risk]. The fact that people realize that they’re different and are maybe stigmatized for their difference seems to [increase their vulnerability] for such health issues as substance use and depression and suicide.

MP: Are we making any progress on that?

WB: I think we are, but I think we need research to really identify what factors will foster that kind of progress. What are some of the protective factors and what are effective interventions that can help ameliorate the effects of stigma on the health of this population?

MP: And that’s where the report found a lack of research.

WB: Right.

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MP: The report also emphasizes the barriers to accessing quality health care that members of the LGTB encounter. What are some of those barriers?

WB: I think it’s hard for many LGBT people to find culturally competent and informed providers. I think providers nowadays may know a little bit more about gay men and lesbian women, but [LGBT patients] may still receive questions from their provider that if the provider had taken into account their particular identity and sexuality would not have been asked — questions about HIV risk for lesbian women, for example. 

[LGBT health care] is a topic that is typically not covered in medical-school training, especially when it comes to the transgender population. At the University of Minnesota we are sort of an exception. Our university is a leader in that area. But I think at most medical schools it is not being covered. So even if the providers are very willing to work with this population, they are oftentimes not trained and don’t have the know-how to competently respond to the transgender person’s specific health concerns.

MP: Did you find any evidence that providers don’t want to treat this population?

WB: No. But we did find quite a bit of qualitative research that illustrates the negative experiences that some people in the LGBT community — again, particularly in the transgender community — have with providers.

MP: How does that poor quality manifest itself?

WB: The providers do not have the know-how. [Transgender patients] find themselves educating the provider, and that takes up most of the consultation time, rather than being able to get their health concerns addressed. 

MP: The report also found that some in the LGBT community express fear of discrimination in health care. Did you find actual discrimination or only the fear of it?

WB: I think those are really two aspects of stigma. [There is] so-called felt stigma, which is the perception [and] the anticipation that people have of rejection or of ignorance. And then there are the actual experiences of discrimination, which we call enacted stigma, when people really receive harassment or denial of services.

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MP: Did you find that negative health-care experiences are common for the LGBT community?

WB: For some of the subgroups in the LGBT community there is more evidence than in others. Again, for the transgender community, which is the one I’m the most familiar with and thus was my main role in terms of contributing to this report, there’s a lot of qualitative research that illustrates people’s negative experiences.

But that discrimination extends outside of the health field. Transgender people, as well as other LGBT people, may experience stigma and discrimination in their daily lives.

MP: The report also found that elderly members of the LGBT community rely more on friends and other caretakers than family for their health-care needs, in part because they are less likely to have children.

WB: Correct. 

MP: How does that affect their health in old age?

WB: The research for this is really limited, but some struggle to have a solid support system that can be there for them. That is an important role that families usually play. For others, we find that they are resilient. They have established a family of choice and have people other than their biological relatives who will support them. But the research is very limited on that, and we need to understand those caregiver and care issues better, especially as we have an aging population.

MP: The report is national in scope, but how do you think Minnesota fares on these issues?

WB: Minnesota was one of the very first states in the nation to have a human rights act that provides protection to LGBT people against discrimination. I think that shows that Minnesota has been a good place to live as an LGBT person. … [The University of Minnesota] also has one of the very few training programs where health providers can develop a special competency in the area of transgender health. But this is something that the report doesn’t really speak to, although the report recommends that [the National Institutes of Health] foster efforts to make researchers more aware and to provide training to current and future researchers so they can address and be sensitive to LGBT health issues in their research.

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MP: What are the major health concerns that you’d like to see more research done on? Is there anything specific?

WB: We were asked to identify gaps [in LGBT health care]. And what we found is that it’s hard for us to begin to name gaps because there is no foundation of research in which to identify gaps. There is so much that we don’t know. The report recommends that a comprehensive agenda be developed.

MP: So we don’t even know where to focus resources to help this community?

WB: Well, several priority areas of research were mentioned: demographic research, research of social influences, health-care inequities, intervention research, and then some transgender-specific health needs. Based on the limited data that was available to us, we were also able to identify certain areas of specific concern. Those are depression and mental-health issues and higher rates of that among subgroups of this population. …

What the cause of that is we don’t exactly know. … We need research to see what the relationship is between the stigma and discrimination that people may experience and their mental health. Substance use is another area, and sexually transmitted infections. And HIV remains another important area.

MP: What would you like the general public to take away from this report?

WB: Many of us who have been active in this field, myself included, are just really pleased that we have been able to conduct this assessment and that this information is [now] published. When people who are active in the health field read it, I think they will find a lot of areas in which they can consider conducting research. I think the report will also give anyone, including the larger public, an education about where we’re at with LGTB health. It provides a nice context in which to think about the special vulnerabilities among this population.

The report also shows some of the resilience among this population — how they have addressed the HIV/AIDS epidemic over the years, for example. … I think the report also provides an education for anyone who is concerned with this population or who has LGBT relatives and friends. They will be able to gather a deeper appreciation, I think, of the context of health for this population.

MP: Are you concerned about all the talk about federal and state budget cuts? Is that going to affect the health of the LGBT community?

WB: I don’t know. That wasn’t what this report concerned itself with. It just recommends a direction to go in, and hopefully the resources will be available to carry out the recommendations.

(This interview has been condensed.)