How to take control of your healthcare despite bias and barriers

By Kevin Miller

Finding quality healthcare with culturally competent providers as a member of the LGBTQ community can be difficult. This challenge is made worse by the numerous barriers to care within the community, as LGBTQ individuals are less likely to have health coverage and are more likely to be refused health care services or even harassed by providers than their cisgender, heterosexual peers.

These institutional failings among hospitals and medical programs create a self-perpetuating cycle that harms the LGBTQ community in immeasurable ways. Studies reviewed by the Center for Disease Control have shown individuals that identify as LGBTQ are:

• 8 times more likely to have attempted suicide;
• 6 times more likely to report extreme depression; and,
• 3 times more likely to use illegal drugs or engage in risky sexual behavior.

Some organizations have begun implementing implicit and explicit bias training to help reduce the prevalence of heteronormative attitudes in their providers, but a study from the National Journal of Public Health found that, among heterosexual providers, “Implicit preferences always favored heterosexual people over lesbian and gay people.” Many LGBTQ individuals who have faced past discrimination are more likely to delay or avoid seeking care entirely, causing irreparable harm to their health because the implicit and explicit biases providers hold often manifest in ways that make patients afraid to disclose their sexual history, sexuality orientation, or gender identity.

Some providers will automatically assume an LGBTQ identified patient engages in risky sexual health with numerous partners, demanding they get STI panels even when a patient has not had sexual contact with anyone since their last test. Some opt to chastise their patients about the importance of things like monogamy or condom use, irrespective of a patient’s own history with these things.

While progress is being made, with many states enacting laws addressing health coverage for LGBTQ patients, it is important that LGBTQ patients know how to self-advocate in a medical setting and know what to do if they experience discriminatory treatment from a provider.

Important Concerns to Discuss with a Provider:

Sexually active LGBTQ individuals have several increased health risks that benefit from proactive medical care. Breast cancer, colon cancer, and throat cancer are more prevalent among LGBTQ individuals, along with increased risk of contracting hepatitis, HIV, and HPV.

Some preventative treatments can be received free of cost, or at steep discounts, in many places:

• Pre-Exposure Prophylaxis (PrEP), a daily pill taken to reduce the likelihood of contracting HIV through sexual contact that has seen an increase in popularity in recent years;
• Post-Exposure Prophylaxis (PEP), a limited course of HIV medication taken after a possible exposure in order to prevent contraction of the virus;
• Guardasil, the HPV vaccine is recommended for anyone 26 or younger, and may still be recommended for those over 26 depending on the individual.

For those with health insurance, they can contact their insurer or access their patient portal to see if these options are covered under their plan. For those without insurance, or whose plans do not cover these medications, discounted prescriptions may be available through The Patient Advocacy Foundation or directly through the manufacturer.

These options are covered by most insurance plans; however, many providers do not offer them to heterosexual patients and some providers are unfamiliar with them due to their target demographics.

Even if you do not pursue these preventative treatment options, a competent medical provider should ask if you are interested in learning about them after you disclose your LGBTQ status. If you have concerns about your provider’s competence, pay attention to red flags that may come up in conversation:

• If a provider does not ask about your sexual health and practices after disclosing your LGBTQ status
• If a provider responds to your LGBTQ status by asking too many questions, or suggesting you are lying about your sexual habits
• If a provider insists you undergo an STI panel irrespective of your position on it
• If a provider insists you undergo an STI panel even when you inform them of recent test results
• If a provider speaks about your identity in a dismissive or third-person way, using terms like “homosexuals” or any phrase that sounds too academic for a provider-patient conversation.

Tips for Finding a Competent Provider

When trying to find a healthcare provider to approach with questions or concerns about sexual health, sometimes the best thing to do is be transparent with the staff. A lot of frustration and heartache can be avoided if you call the front desk of the medical center you want to visit and ask them outright if they have providers trained to address LGBTQ sexual health.

Avoid asking things like this:

• Do you accept LGBTQ patients?
• Do your doctors know about LGBTQ health?
• Can Dr. Jane Doe talk to me about LGBTQ sexual health?

Many staff members may say yes to comply with state law, while others may simply not understand how nuanced LGBTQ care is. Instead, be clear and assertive in your questions so they understand you want someone who deeply understands the field.

Instead, word your questions like this:

• Do you have any providers that completed training in LGBTQ-specific care?
• Do you have any providers that have recently earned Continuing Medical Education credits in LGBTQ-related care?
• Do you have any providers that specialize in LGBTQ care?

Groups like OutCare offer comprehensive provider training on LGBTQ issues, alongside continuing education opportunities offered by the American Medical Association, and the National LGBTQIA Health Education Center. With so many opportunities for providers to improve their level of care for LGBTQ patients available, a medical network being unable to provide a single doctor who has taken a competency course can be a warning sign that you should seek care elsewhere, if possible.

Those questions are better suited for leading a staff member to an appropriate provider and can give you a clearer idea of how proactive a facility is when it comes to culturally competent healthcare. If a staff member seems dismissive, rude, or has to scramble to answer a question, it is a red flag that it might not be the right facility for you.

If you have concerns about or are not comfortable calling around, there are online resources like the Gay and Lesbian Medical Association or the World Professional Association for Transgender Health that allow you to seek verified providers that are inclusive and welcoming. These websites are not comprehensive and may be missing information for other, wonderful providers, but they are a great starting point if you do not want to call around.

Unfortunately, not everyone has the luxury of picking from a long list of providers. In situations where you have no choice but to take the provider you are given, sometimes you will be stuck with someone who is dismissive, rude, or not receptive to your needs. When that happens, it is important to be prepared and know how to take control of your appointment.

Interacting with a Provider

Sometimes you end up seeing a provider who is not as welcoming or inclusive as you would like, even when you make a concerted effort to avoid it. This can come in different forms, from a dismissive attitude to outright poor behavior, to a lack of knowledge around LGBTQ+ issues

It can be tempting to avoid disclosing gender identity or sexuality when you feel a provider is not compassionate or accepting, but disclosing these details is incredibly important for receiving comprehensive care. You should not risk sacrificing your health or the quality of your healthcare because a provider is failing to do their job.

If a provider reacts poorly to learning you are a member of the LGBTQ community, there are several options:

• If the appointment is unrelated to your sexual health, tell the provider you plan to keep it that way in unambiguous terms: “I am here to discuss symptom X, not my sexual history.”
• If a provider tries to sell you a line about being required to discuss risk factors or they claim your symptoms could be indicative of an STI you know you do not have, make it clear they are not doing their job. “I am proactive about my sexual health. I came to you because these symptoms have no clear cause, not to be told they are from an STI I do not have.”
• Most importantly, do not be afraid to say “No.” If a provider wants to refer you for tests you know you do not need, or tries to prescribe something you do not want, remember that you are the patient and you get to decide what is done with your body. You can say no.

If you say no and a provider pushes you or makes false claims about things like having to report you to a public health department unless you provide a negative STI test, tell them you will be seeking a second opinion, and then tell them you will be reporting them to their state licensing board, and follow through. Report them to the licensing board and then report them to your health insurance provider.

Healthcare professionals must remain certified with every health insurance provider they work with, at each facility they work at. Their contracts with an insurer can be pulled and they can be denied patients from certain insurance networks if they fail to live up to their obligations. An insurer may find cause to pull a contract for a specific provider at one or two specific medical centers or with the provider at any location if there is reasonable cause.

Finally, any hospital that participates in Medicare and Medicaid programs is federally mandated to have a grievance process in place that allows patients to formally express concerns about a provider without fear of retribution.

Interacting with a Provider on Sexual Health

Sometimes you like a provider, but they are not as progressive as you need when it comes to LGBTQ sexual health. A lot of people are wary when it comes to being the one to raise an issue, and patients' self-diagnosis or doing independent research on medical issues can be a divisive issues for providers.

If you find that your provider is not open-minded to your concerns, the first step is always to express this. Simply telling them that you have concerns rooted in your LGBTQ identity or experience with non-heteronormative sexual activity and would appreciate if they find information you may benefit from can work wonders.

If this does not work, you can tell them that you enjoy the rapport you have but would like recommendations for a provider who is more knowledgeable about LGBTQ issues. Some providers will have this information readily available, and some may even opt to gain a more well-rounded background in LGBTQ care to avoid losing a patient.

Because LGBTQ individuals have unique healthcare needs and are a historically underserved community when it comes to medical treatment, being forthright is important. Your own health and wellbeing are more important than keeping a specific provider, and if you feel harassed, dismissed, or ignored by a medical professional it is important to assert yourself and know when to seek alternative care rather than letting it deter you from regular treatment.

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