Ending LGBT Clinical Bias

Lesbian, gay, bisexual and transgender people continue to experience discrimination in health care – underscoring the need for a dramatic shift in attitudes for a long-stigmatized minority and more behavioral health specialists working in primary care clinics.

Not only does providing primary and behavioral health services in a single setting improve patient outcomes, said HRSA public health analyst Kim Patton in a recent webcast, it costs less.

More than 1,100 health professionals listened in June to a panel of experts who said tighter integration of mental health is overdue.

Convened by HRSA's Denver and San Francisco regional offices, speakers addressed the "Behavioral Health Needs of Transgender and Gender Non-Conforming Patients" – who are almost three times more likely to suffer major depression and anxiety disorders from fear of "coming out" and all it entails, said Patton and others.

Three out of four experience workplace discrimination, for example, and more than 90 were murdered in 2015.

Repeated studies have shown that the population suffers higher rates of related substance abuse into late life. Yet, "there is a history of medical professionals … refusing care," said Tricia Smith of the Los Angeles LGBT Center.

Less than one of three affected people is "out" to their providers, and as many as 20 percent of transgender people have been completely denied medical care based on their identity, she said, citing a 2011 report. And an estimated 28 percent have been verbally attacked in a medical setting.

"They are bringing that into the room with them," she said.

Eight of 10 transgender people say they want mental health support. Nearly a third smoke; more than a quarter report substance use; 40 percent attempt suicide – "reactions to the severity of marginalization they are experiencing," Smith said.

Encouragingly, she added, studies indicate transgender children who are supported by their families are significantly more stable and better adjusted than children whose families do not support them. For want of that acceptance, thousands of others suffer.

Section 1557 of the Affordable Care Act mandates that organizations receiving HHS dollars – including health centers -- treat individuals consistent with their gender identity, said Ian Shipp of the Department's Office of Civil Rights. This includes equal access to bathrooms, exam rooms and other facilities, regardless of a patient's birth gender.

Gender identity is "how you relate to yourself and in the world throughout the day," explained social worker Sandra Hall of San Francisco's Lyon-Martin Health Services.

While stereotypes and misconceptions may persist across the broader culture, in certain times and in certain places, federal policy and law are consistent.

"Stigmas create special vulnerabilities for trans-people," explained Smith. "Having them be pushed to the fringes of society leaves them unprotected and especially susceptible to hate-based violence."

And a wealth of data now suggests that having behavioral health counselors and medical staff serving patients together in primary care settings best serves the interests of the nation – in both cost-avoidance and reduction of human suffering and disease.

That means, Hall said, integrating care so one's "medical and mental health needs are assessed within every primary care visit, and mental health professionals are on staff to meet with clients on the same day as their medical appointment."

The next step is educating health care staffs and making the nation's clinics "judgment-free zones," Smith said.