Sean Philpott: Stonewalling on Health Care

Jan 24, 2013

While being sworn in for a second term earlier this week, Barack Obama made history by being the first president to refer to the LGBT (lesbian, gay, bisexual and transgender) community in an inaugural speech. In what that some pundits are calling ‘Lincoln’s third inaugural address,’ the President laid out a civil rights agenda that placed the fight over gay rights on equal footing as battles against racial, ethnic, religious and gender discrimination.

Gay rights groups were obviously pleased, and now expect the Obama Administration to be more active in their support for marriage equality. Conservative groups were clearly displeased, and anti-gay organizations like the National Organization for Marriage and the Family Research Council quickly released public statements condemning the President’s remarks. The head of the National Organization for Marriage, Brian Brown, went so far as to claim that “gay and lesbian people are already treated equally under the law. They have the same civil rights as anyone else.”

What is sorely overlooked in this debate, however, is the issue of equal access to health care. The HIV/AIDS epidemic, for example, has had a disproportionate impact on gay and bisexual men in the US. Gay and bisexual men, particularly men of color, still account for nearly two-thirds of all new HIV infections. The impact of HIV/AIDS has been even greater in the transgender community, with almost a third of all transgender women (someone who was born male but whose gender identity is female) testing positive for the virus.

But the problem that the LGBT community faces goes much deeper than HIV/AIDS. Recent studies show that the community as a whole is underserved medically. In a companion document to the 2010 Healthy People report – a statement of national health objectives produced every ten years by the US Centers for Disease Control and Prevention – the Gay and Lesbian Medical Association cataloged a long list of health disparities.

Lesbian women, for instance, are more likely to be overweight or obese than straight women. They are also less likely to get preventive services for cancer, such as routine mammograms to detect breast cancer or regular Pap smears to look for cervical cancer.

As already mentioned, gay men and transgendered individuals are at higher risk for HIV and other sexually transmitted diseases. In addition, they also are more likely to smoke and to abuse alcohol or other substances. They also have higher rates of untreated mental illness, and are more likely to commit suicide.

These problems are particularly acute among LGBT youth, who are far more likely to be homeless or to be the victims of domestic violence and bullying than their straight counterparts.

These health disparities exist primarily because of social stigma and legal discrimination. Current laws and policies can make it more difficult for LGBT individuals to get insurance. Despite recent gains, for example, many private companies and public institutions still do not offer health insurance to same-sex spouses or domestic partners. Even if they do, the cost is often prohibitive. While federal and state governments do not tax health benefits for spouses, they usually tax benefits for domestic partners because they do not legally recognize same-sex relationships. These benefits may even be subject to double taxation; employees must not only pay their partner’s insurance premium with after-tax dollars, they must pay taxes on the values of the benefit because it counts as income.

Even if they have health insurance, LGBT individuals are less likely to seek medical care. This is due in part to the fact that many doctors and nurses lack any formal training in LGBT health. In a recent review of the curriculum offered by 132 medical schools, nearly half provided no training on LGBT issues. Of those schools that did offer training, on average they spent a meager five hours on LGBT health issues over the course of four years.

This lack of training not only perpetuates stereotyping and discrimination in the clinic – a 2007 survey of nearly 1,000 physicians in California found that nearly 20% were uncomfortable or unwilling to provide care to gay and lesbian patients – it also exacerbates existing health disparities. Doctors unfamiliar with the special needs of LGBT patients simply cannot provide an adequate level of care and treatment. Moreover, gay and lesbian patients are unlikely to seek or follow medical advice if they feel that the doctor is ignorant or judgmental.

In his inauguration speech, Obama claimed that the promise of equality laid out in the Declaration of Independence would never be fulfilled unless “our gay brothers and sisters are treated like anyone else under the law.” He’s correct. But it’s also important to remember that the Declaration of Independence holds that all men have certain rights, and among these are “Life, Liberty and the pursuit of Happiness.” In order to have both Life and Happiness, however, one must have good health.

Issues of marriage equality aside, the gay rights agenda must address the legal and social barriers that prevent the LGBT community from living a healthy life. We need to change current laws that prohibit or discourage the provision of domestic partner benefits like health insurance, and we need to ensure that all health care professionals are properly trained to recognize LGBT-specific health needs and to provide for them in an appropriate non-discriminatory manner.

A public health researcher and ethicist by training, Dr. Sean Philpott is Director of Research Ethics for the Bioethics program at Union Graduate College-Icahn School of Medicine at Mount Sinai in Schenectady, New York.  He is also Acting Director of Union Graduate College's Center for Bioethics and Clinical Leadership, and Project Director of its Advanced Certificate Program for Research Ethics in Central and Eastern Europe.

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