Advancing Health Care for Lesbian, Gay, Bisexual, and Transgender Patients in Missouri

Sexual and gender minorities (SGM), the new umbrella term used for LGBT, (lesbian, gay, bisexual, queer, other non-heterosexual sexual orientations, transgender and gender variant identities) persons represent three to four percent of the population¹ with one in 37 children living with a gay parent.² SGM patients and parents may feel reluctant to disclose their sexual and gender identities to their providers due to confidentiality concerns, fear of discriminatory reactions and stigmatization, and either personal or known negative experiences due to SGM status within the health care system.^{3, 4} Needless to say, this lack of disclosure limits the provider’s ability to truly know their patients and potentially negatively affects care.

The authors hope to make physicians aware that there is a significant community of LGBT patients and families in Missouri who feel alienated from the health care system, not so much by lack of trust in the competency of their doctors to meet basic health needs, but by fear of being turned away if they are honest about the circumstances of their lives. In this paper the authors review the history of this marginalization and offer physicians effective strategies for reaching out to SGM patients and communities.

Over time, various strategies have been employed to address the needs of SGM patients seeking welcoming providers. Each strategy has advantages and disadvantages.

Local listings maintained at LGBT community centers and organizations have the advantage of including patient-driven recommendations and knowledge of the local community. However, lack of coverage for non-urban areas, concerns about the currency of the list, community access to the list, who maintains it, and any personal biases that might impact entries to the list are all significant disadvantages.

Having practices or health care systems identify LGBT-friendly providers allows for each system to integrate SGM competency into their health care mission. Resources to train frontline staff as well as health care professionals on culturally relevant issues could be integral to this working environment. Disadvantages include inconsistences of documentation of safe providers in that some systems might have a listing whereas other systems might not. This strategy requires an internet presence, and smaller practices, particularly in rural areas, might not use this resource. How LGBT-friendly providers are identified might also vary by system.

A national referral directory provides the huge potential advantage of a national database which would allow patients to find providers throughout the U.S., including in both urban and rural areas and for all manner of specialty care. A disadvantage of this strategy is that the viability of a national directory depends upon providers’ willingness to populate the list. Assuring that providers, as well as patients, even know that such a directory exists as a resource is also a challenge. The most comprehensive directory is administered by GLMA: Health Professionals Advancing LGBT Equality, formerly known as the Gay and Lesbian Medical Association. Their Provider Referral Service (PRS) can be accessed online at www.glma.org and is searchable by specialty, city, state, and ZIP code.

GLMA was founded in 1981 as the American Association of Physicians for Human Rights (AAPHR) and was an offshoot of the Bay Area Physicians for Human Rights (BAPHR), a San Francisco-based physician organization founded to fight discrimination faced by gay and lesbian physicians in the workplace based upon their sexual orientation. AAPHR was founded to take this mission to a national level.

As the original name American Association of Physicians for Human Rights implies, in the 1980s physician members still had valid concerns about the possibility of being fired or losing their practice if their SGM status were publicly known. AAPHR maintained a member directory to alert its members to advances in gay and lesbian, and later LGBT health, as well as to communicate with members about upcoming events like the Annual AAPHR Symposium, the first of which was held in 1982. A Member Directory was printed and mailed to all dues-paying members. However, members had to Opt-In to agree to their contact information being included in the Member Directory, again because of fears of loss of livelihood if their SGM status were known publicly.

Over time, the focus of AAPHR grew to include, not just confronting homophobia faced by physicians, but also discrimination that lesbian and gay patients encountered in the health care environment. As such, AAPHR instituted its first Physician Referral Program (PHP) in 1993. Here, as with the Member Directory, physician members were always required to Opt-In to be included in the PRP. In order for patients to find a physician, they would have to call the AAPHR office during business hours and talk to a staff person about where they lived and what specialty they were seeking. The following year, 1994, AAPHR finally “came out” as an organization and changed its name to the Gay and Lesbian Medical Association.

Eventually, patients were able to obtain referrals by email, which still needed to be handled by a GLMA staff person. Even with little promotion or advertising, the service caught on with LGBT patients. A GLMA Executive Director’s (ED) Report from late 1999 states, “during the last fiscal year, the average number of calls per week increased from 40 to 70. Last year we began to investigate ways to [expand] the program, speed up response time, and minimize the labor-intensive nature of the current operation.”⁵ A December 1999 ED Report notes further progress and addresses GLMA members’ confidentiality concerns: “…the Physician Referral Service… will be online at the beginning of February [2000]. A letter is going to the membership telling of the move and allowing members who do not wish to continue, to remove their names. It will also allow new members to join.”⁶ An ED Report from June 2000 reports that, “after… the new web site was launched [in February], we saw the number [of referral searches] jump to more than 140 per week… In the two weeks ending June 22 [2000], there have been more than 250 physician referral searches per week – more than five times the base number…”⁷

Since that time, GLMA has expanded its scope in terms of both its membership reach and its Provider Referral Service. As there has been more awareness of SGM identities beyond gay and lesbian in the medical community and as GLMA expanded its membership to health care providers beyond physicians, the name “Gay and Lesbian Medical Association” was seen as inadequate to encompass the scope of GLMA’s work and mission. However, since the GLMA name and brand had been established over many years, both in health policy circles and among LGBT-focused advocacy organizations, in 2010 the board decided to change the organization’s designation to “GLMA (pronounced “glamma”): Health Professionals Advancing LGBT Equality.”

The GLMA Provider Referral Service (PRS) has expanded in two ways: As GLMA has broadened its professional membership base beyond MDs and DOs, the PRS also includes non-physicians as of the mid-2000s. By 2008 the PRS had been opened to health care providers who are not members of GLMA yet wished to provide services to SGM patients. Therefore, any health care provider currently wishing to serve SGM clients may be listed in the GLMA PRS.

As of January 2015, there are 2,497 health care providers listed in the GLMA PRS. Forty percent (997) of those providers are listed as MDs or DOs. (However, 765 of the providers in the PRS do not have degrees listed by their names in the directory so the percentage of physicians may be higher.) Just under 10% (245) of the providers on the PRS are GLMA members, and the GLMA PRS gets between 2,800 and 3,200 referral searches per month. GLMA’s mission is “to ensure equality in healthcare for lesbian, gay, bisexual and transgender (LGBT) individuals and health care providers.”⁸ To list oneself as a health care provider in the GLMA PRS does not require special training in LGBT health. It essentially means that you will treat SGM patient with respect and care, that you will seek out referrals when you need them, and that you will educate yourself over time about the particular health care concerns facing persons who identify as LGBT. GLMA encourages any health care provider who has an interest in providing care to SGM patients to add his/her name on this referral list.

To be listed in the PRS, GLMA requires a provider to have a current license in one’s health care profession in the jurisdiction where one practices, but GLMA does not require a level of professional certification for membership. This is because, while the University of Pennsylvania⁹ and a few other academic institutions offer certificate programs in LGBT health, there are no full residency or fellowship programs specific to LGBT health and thus no metrics for certification in this field. This, then, presents a challenge to creating a “safe” Provider Referral Service for SGM persons.

Further, when as a public service, the GMLA PRS was opened to providers who are not GLMA members, the question was raised of how to assure that providers who want to victimize and/or stigmatize vulnerable LGBT patients cannot enter the directory? When the service was only open to GLMA members, the burden of paying $300 or more a year for membership was felt to be a strong disincentive to those who would think of joining the service to cause mischief for SGM clients. Patients accessing the directory are given a caveat emptor message on the cover page that states, “We do not screen providers and therefore cannot make any guarantees.” They are also given contact information for the GLMA office in case they wish to report a problem with a provider. ¹¹

The Out, Proud, and Healthy (OPAH) project at University of Missouri has been working with GLMA to increase provider listings on the GLMA’s PRS. In 2012, there were barely more than 20 providers listed in the GLMA PRS for the entire state of Missouri, with those 20 providers only representing the St. Louis, Kansas City, and Columbia areas. Today, there are 168 providers listed for Missouri including some rural areas of the state. In addition, these Missouri safe providers represent a wide range of professions and over 15 medical specialties such as: therapy and psychiatry, women’s health/OBGYN, family practice, transition counseling, infectious disease, pediatrics, reproduction and fertility, dentistry, hospice, emergency medicine, addiction treatment, dermatology, acupuncture, and surgery. Much of this increase is due to the work of the Out, Proud, and Healthy project which has spent the last two years seeking out SGM patient recommendations for culturally competent providers and systematically contacting those providers to give them information about joining the GLMA PRS.

In 2011 the Institute of Medicine released a report entitled, “The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding.”¹² The 17-member committee that authored the report conducted a review assessing the state of the science on the health status of LGBT populations, identified research gaps and opportunities, and outlined a research agenda that will assist NIH in enhancing its research efforts in this area. In essence they found that work in LGBT health was far behind that in other marginalized populations due to funding priorities that for decades ignored LGBT persons as populations worthy of study.

That same year the Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 20,500 health care organizations and programs in the United States, ¹³ released the report “Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community”¹³ which called upon health care institutions “to create a more welcoming, safe and inclusive environment that contributes to improved health care quality for lesbian, gay, bisexual, and transgender (LGBT) patients and their families.”

Since 2007, the Human Rights Campaign (HRC), a national LGBT civil rights organization, has been using the Healthcare Equality Index (HEI) to rank health care institutions on the basis of patient non-discrimination, equal visitation, employment non-discrimination, and training in LGBT-centered patient care¹⁴ Here in Missouri, through the work of the state-based organizations, PROMO and SAGE, and funded by the Missouri Foundation for Health, the number of health care institutions that have scored 100% on the HEI and been designated “Leaders of LGBT Healthcare” has gone from three in January 2014 to 19 in October 2014.¹⁵

As professional certifying and governmental regulatory organizations make LGBT health a priority, it is imperative that physicians be on the forefront of providing a welcoming space for SGM patients and their families. Furthermore, from a business and marketing standpoint, as more hospitals seek out HEI Leadership designation, it will behoove physicians and other health care providers to proactively solicit LGBT clients in their communities. While it will be essential to include an LGBT-friendly designation on one’s system-wide Physician Profile Page, it will be even more important for physicians to reach beyond the directory of the workplace to attract new patients in the larger community. The GLMA Provider Referral Service, after more than two decades of service to the LGBT community, has a level of credibility among SGM persons nationwide that is unmatched.

Finally, we all went into our health professions to help people. The LGBT community has frequently been marginalized, stigmatized, and victimized, yet the vast majority of their health concerns are the same as anyone else’s. As the increasing searches of the GLMA PRS indicate, these patients are looking for compassionate health care providers. They simply need a place where they can be fully themselves without fear of judgment or mistreatment. Joining the GLMA Provider Referral Service means being a doctor who will say, “I’m glad you’re here. How can I help you?” That is where healing truly begins.

Biography

Jane A. Mcelroy, PhD, (top), and Jenna J. Wintemberg, MPH, (bottom left), are in the Department of Family & Community Medicine at the University of Missouri. Kenneth A. Haller, MD, (bottom right), MSMA member since 2004, is an Associate Professor in the Department of Pediatrics at Saint Louis University.

Contact: mcelroyja@health.missouri.edu