LGBTQ Health Disparities

Abstract

LGBTQ populations worldwide experience disparities and inequities in health and in health care. In the United States, the landscape of LGBTQ health disparities and inequities has evolved from the early history of LGBTQ persons in society (before LGBTQ identity categories existed as such) to the present day. In this chapter we will review the historical roots of disparities, identify disparities, and discuss how to provide a better standard of care for LGBTQ patients.

Appendices

Boards-Style Application Questions

Question 1.

A 17-year-old boy comes to the physician for a precollege examination . He has no history of serious illness. He does not smoke cigarettes or drink alcohol, and he is not currently sexually active. Examination shows no abnormalities. During a discussion of sexual activity, the patient acknowledges that he is attracted to another boy and that they have been seeing each other. Though he has been abstinent, he reports that he is thinking about becoming sexually active with the other boy but wants to prevent sexually transmitted diseases. He asks for advice about safer sex. What is the most appropriate recommendation for this patient?

• A. Abstinence from sex

• B. Avoiding oral sex

• C. Avoiding symptomatic partners

• D. Correct and consistent condom use

• E. Limiting his number of sexual partners

Question 2.

During a routine examination, a 25-year-old natal female who self-identifies as male and has not decided to alter his body hormonally or surgically expresses concern about his risk for ovarian cancer because his mother died of the disease. The patient uses he/him/his pronouns. Which of the following terms best describes this individual’s gender identity ?

• A. Gay.

• B. Lesbian.

• C. Transgender.

• D. Transvestite.

• E. Transitioning.

What is the most appropriate course of action?

• A. Annual CT scan of the patient’s abdomen

• B. Obtaining a more detailed family history of cancer

• C. Reassuring him that ovarian cancer is not hereditary

• D. Recommending a diet high in beta-carotene

• E. Recommending prophylactic oophorectomy

Question 3.

A previously healthy 32-year-old man comes to the emergency department with a three-day history of pain and swelling of his right knee . Two weeks ago he injured the knee during a touch football game and had more swelling and bruising than expected. One week ago, he underwent extraction of a molar for severe dental caries. He is sexually active with one male partner and uses condoms consistently. HIV antibody testing was negative three months ago. Temperature is 39.2 ° C (102.6 ° F), pulse is 106 beats/min, and blood pressure is 125/65 mm Hg. Examination of the right knee reveals warmth, erythema, and joint effusion. Flexion and extension of the right knee are severely limited. An x-ray of the knee confirms the joint effusion. What is the most appropriate next step in diagnosis?

• A. Arthrocentesis

• B. Arthroscopic exploration of the knee

• C. Bone scan

• D. MRI of the knee

• E. Venous doppler ultrasonography

Question 4.

An otherwise healthy 27-year-old man is referred to a cardiologist after three episodes of severe palpitations, dull chest discomfort, and a choking sensation. The episodes occur suddenly and are associated with nausea, faintness, trembling, sweating, and tingling of the extremities; he feels as if he is dying. Within a few hours of each episode, physical examination and laboratory tests show no abnormalities. The patient, who works as a welder, is afraid that the episodes will significantly affect his work. During a recent lunchtime conversation, he was outed by a co-worker who saw him leaving a popular gay bar. Since then he has felt that his co-workers have been treating him differently and keeping him at arm’s length. He does not use drugs or alcohol and has no history of interpersonal problems . What is the most likely diagnosis?

• A. Delusional disorder

• B. Generalized anxiety disorder

• C. Hypochondriasis (Illness Anxiety Disorder)

• D. Panic attack

• E. Somatization disorder

What is a good course of action?

• A. Advising him to change jobs and to keep his sexual orientation a secret

• B. Listening to and acknowledging his concerns, discussing possible courses of action, and continuing to monitor the patient

• C. Prescribing anti-anxiety medication and telling him to ignore the situation

• D. Referring him for psychiatric evaluation

• E. Telling him he is just having panic attacks and that they will eventually pass without treatment

Question 5.

Which of the following statements are true?

• A. LGBTQ youth are less likely than heterosexual youth to be homeless.

• B. The burden of HIV falls disproportionately on white men who have sex with men.

• C. Elderly LGBTQ people no longer face social isolation and lack of appropriate services.

• D. Lesbians and bisexual women have higher rates of breast cancer than heterosexual women.

• E. LGBTQ youth and adults are at increased risk for suicidal ideation and attempts, as well as depression.

• F. Lesbians and bisexual women are more likely than their heterosexual counterparts to use preventive health services.

• G. In general, LGBTQ people are more likely than heterosexual ones to have access to adequate and quality health care

• H. LGBTQ youth and adults have lower rates of smoking, alcohol consumption, and substance use than heterosexual ones.

• I. LGBTQ people are frequently the targets of stigma, discrimination, and violence because of their sexual and gender minority status.

Boards-Style Application Questions Answer Key

Question 1.

(D) A common mistake would be to identify this youth as “high risk” based on his sexual identification. The course of action for this youth is the same as for any youth with no risk factors and abstinent, which is correct and consistent condom use. All remaining answers are not supported in evidence-based STI prevention guidelines. Option A has been demonstrated ineffective, and the remaining options do not effectively mitigate risk.

Question 2.

Part 1. (C). Part 2. (B) Transgender is an umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth. In part 1, options A, B, and C are sexual orientations, and E is not an identity term. While many transgender people are prescribed hormones, and some undergo surgery, not all transgender people can or will take those steps, and a transgender identity is not dependent upon physical appearance or medical procedures. As for part 2, the correct course of action for this patient is obtaining a more detailed family history of cancer to assess his level of risk for developing ovarian cancer. A, D, and E would not at this early juncture be indicated for a natal female with a family history of ovarian cancer without better history. Option C is a false statement.

Question 3.

(A) This patient has the same exact risk factors as his heterosexual counterparts. Therefore, an arthrocentesis should be performed to establish a diagnosis and treatment. The patient’s history of trauma two weeks prior with unusually pain and swelling suggest hemarthrosis. However, a significant tooth extraction without the mention of prescribed antibiotic prophylaxis raises the possibility of an infectious process requiring prompt treatment of a joint infection to preserve the joint integrity. Items B, C, D, and E do little to nothing to establish the presence or identity of an infectious agent. This question is a reminder to proceed rationally with differential diagnosis and not fixate on minority characteristics.

Question 4.

Part 1. (D). Part 2. (B) Somewhere between 30 and 60 percent of LGBT people deal with anxiety and depression at some point in their lives. That rate is higher than that of their straight or gender-conforming counterparts. This otherwise healthy individual is clearly suffering from panic attacks brought on by being outed at work. The description of his physical and mental experience is classic for a panic attack. There are no data to support delusional thinking (A), longstanding anxiety symptoms across multiple domains of life (B), excessive attention to the possibility of illness (C), or a broader pattern of fixation on somatic symptoms (E). As for part 2, his perceived fear of being discriminated against by his co-workers and possibly losing his job are real in context with his profession as a welder. Panic attacks can be very frightening and can cause the individual severe anxiety. The sense of losing control, having a heart attack, or even dying are highly distressing. Initial treatment should focus on listening to and acknowledging specific concerns, discussing choices, and continuing to monitor his progress. Reassurance and encouraging insight may be sufficient for this patient given recent onset. Options A, C, and E are dismissive of the underlying cause, and due to his clear history, he does not need referral to a specialist level of care yet (option D).

Question 5.

F, T, T, F, F, F, F, T, F