In 1973, reversing a position it had held for nearly a century, the American Psychiatric Association issued a resolution stating that homosexuality was in fact, not a mental illness or sickness. Nearly five decades later, we are still witnessing the fight for gay and LGBTQ+ individuals to be treated with dignity and equality when it comes to mental health treatment, among other areas.
While progress has been made since 1973, today there are still roadblocks and barriers for LGBTQ+ individuals to receive adequate mental health treatment. In fact, when it comes to healthcare, there may be no greater disparity between need and access to care than for LGBTQ+ mental health services.
The Greater Need for Care
LGBTQ+ individuals face drastically higher rates of psychiatric and behavioral health conditions than cisgender/heterosexual persons. Discrimination, prejudice, denial of civil and human rights, harassment, and family rejection are can be common for those who identify as LGBTQ+, factors which researchers believe correlate strongly with such poor mental health outcomes.
● LGB adults are more than twice as likely as heterosexual adults to experience a mental health condition.
● LGBTQ+ people are at a higher risk than the general population for suicidal thoughts and suicide attempts.
● High school students who identify as lesbian, gay, or bisexual are almost five times as likely to attempt suicide compared to their heterosexual-identifying peers
● 48% of all transgender adults report that they have considered suicide in the past 12 months, compared to 4% of the overall US population.
Unfortunately, despite such a large need for access to mental health services, LGBTQ+ individuals must also contend with high levels of discrimination in the healthcare field.
Barriers to Healthcare
In a landmark 2010 survey on the subject of LGBTQ+ discrimination in healthcare by Lamda Legal, 73 percent of transgender respondents and 29 percent of gay, lesbian and bisexual respondents reported that they believed they would be treated differently by medical personnel because of their LGBTQ+ status.
The reason? Roughly 70 percent of transgender or gender non-conforming patients and 56 percent of lesbian, gay, or bisexual patients surveyed had already experienced some type of discrimination in healthcare, including practitioners refusing to provide needed care, refusing to touch them or using excessive precautions, using harsh or abusive language, blaming them for their health status, or being physically rough or abusive.
In a 2014 survey, nearly 30 percent of transgender individuals reported postponing or avoiding medical care when they were sick or injured because of discrimination and disrespect. More than 30 percent delayed or did not try to get preventive care, and approximately eight percent of LGB individuals and nearly 27 percent of transgender individuals reported being denied needed health care outright.
Despite what appears as progress in the broader cultural sense in America, LGBTQ+ individuals clearly still face significant barriers to receiving equal treatment. If we’re to address the issue of mental health for this population, we have to start by acknowledging their unique barriers and needs. Dismantling these barriers begins with writing legal protections for LGTBQ+ patients. On this front, the last decade has seen some progress.
Building Legal Protections for Equality
Section 1557 of the Affordable Care Act, passed in 2010, was the first federal law to provide protections to LGBTQ+ individuals in health care. Although Sec. 1557 does not contain an explicit prohibition against sexual orientation or gender identity discrimination, it imports the protections against sex discrimination contained in Title IX, which, thus far, have been upheld in lower courts and regulatory agencies as extending to claims of discrimination based on gender identity and sexual orientation.
Additionally, in 2011 the Joint Commission issued a standard requiring accredited facilities to include sexual orientation and gender identity in their non-discrimination policies. Even now, cases are being heard in the Supreme Court to determine the extent to which the Civil Rights Act provides protections for LGBTQ+ persons.
While access to healthcare providers is a start, it is unfortunately not enough to ensure that people get the behavioral health services they need. Laws must exist to ensure that LGBTQ+ individuals do not experience discrimination when seeking behavioral health care. Existing laws currently help protect people with coverage through the ACA, but in the healthcare world at large, protections are still lacking.
In 2019, an organization called the Healthcare Equality Index surveyed more than 680 healthcare providers with a national benchmarking tool that evaluates healthcare facilities’ policies and practices related to the equity and inclusion of LGBTQ+ patients, visitors and employees.
This index is measured by examining four major factors, those being whether or not the hospital has:
1) An LGBTQ+ inclusive patient non-discrimination policy
2) An LGBTQ+ inclusive visitation policy
3) An LGBTQ+ inclusive employment non-discrimination policy
4) Staff training in LGBTQ+ patient-centered care.
In its latest survey, more than 400 of 680 surveyed healthcare facilities wound up achieving top scores in these marks. However, among a select sample of hospitals that declined to participate in the survey, the HEI found that only 67 percent had policies that include both “sexual orientation” and “gender identity,” and only 62 percent were found to have an LGBTQ-inclusive employment non-discrimination policy.
Clearly, more work remains to be done for creating and enforcing legal protections for LGBTQ+ individuals in the healthcare setting.
What Can Healthcare Providers Do Today?
Healthcare networks can better address the mental health needs of LGBTQ+ patients by instituting policy changes and creating a more supportive environment and culture. Overall, networks can start making real changes through the following means:
● Create an LGBTQ+ inclusive patient non-discrimination policy, an LGBTQ-inclusive visitation policy and an LGBTQ+ inclusive employment non-discrimination policy,
● Mandate adequate staff training in LGBTQ+ patient-centered care.
● Integrate and incorporate a broad definition of the family into new and existing policies.
● Develop clear mechanisms for reporting discrimination or disrespectful treatment for LGBTQ+ staff and patients and foster a culture of accountability and transparency.
● Appoint a high-level advisory group to assess LGBTQ+ policies and make recommendations for improvement regularly.
For more information about LGBTQ+ healthcare and advocacy, these organizations are working tirelessly to create resources, procedures and policies to help LGBTQ+ individuals get the healthcare treatment they deserve:
● Center for LGBTQ Evidence-based Applied Research (CLEAR)
● The National Coalition for LGBT Health
● The National LGBT Health Education Center
● Gay and Lesbian Medical Association
● Healthcare Guild
● Healthcare Equality Index
Carol Olson, MD is a physician at District Medical Group and chairman of the department of psychiatry at Valleywise Health.