Caring for Our Community: Telehealth Interventions as a Promising Practice for Addressing Population Health Disparities of LGBTQ+ Communities in Health Care Settings

Abstract

While the United States has seen social and policy-based progress in the past two decades, the divisive political climate in the United States toward LGBTQ+ individuals highlights the prevalence of homophobia and transphobia that continues to harm and marginalize these communities. Within the context of health care, LGBTQ+ individuals face discrimination and mistreatment, further perpetuating a community narrative of mistrust in the health care system at large. Despite well-documented evidence of population-specific health needs and risks, LGBTQ+ individuals report less utilization of primary care than their heterosexual and cisgender counterparts. Initial studies of LGBTQ+ individuals’ engagement in telehealth interventions have largely focused within the realm of mental and behavioral health. Utilizing tenants and results seen in previous studies conducted regarding LGBTQ+ individual engagement with mental and behavioral telehealth interventions, this article explores the potential of utilizing telehealth as an interventional tool for addressing LGBTQ+ health disparities and reduced engagement within a primary care setting. Taking into consideration cost, geographic diversity, and implementation concerns, telehealth targeted toward LGBTQ+ individuals in a primary care setting could prove to be an effective method for reaching more LGBTQ+ individuals and providing them with population-specific, culturally-competent care.

Introduction

Within the first two years of the 45^th presidential administration in the United States, policy rollbacks and prevalence of hate speech directed toward marginalized communities have contributed to a fearful environment for many.^1,2 The LGBTQ+ (lesbian, gay, bisexual, transgender, and queer +) communities have been some of the groups heavily affected, with many community members reporting increased emotional distress and anti-LGBTQ+ harassment.^3–5 Prior to the 45^th presidential administration, robust narratives existed that described LGBTQ+ people’s negative interactions with health care environments. One of the most prominent components of reported negative interactions with health care includes the need to “come out” to providers and the related fear of rejection or negative treatment by providers.^6–13 While efforts have been made to create clearer pathways to help patients identify LGBTQ+-competent practitioners, access to said providers still proves a barrier to patients.

Use of telehealth technologies by LGBTQ+-competent providers could reduce barriers to access in geographic regions where availability of culturally competent providers is scarce. Initial reports of telehealth use by LGBTQ+ individuals for behavioral health concerns positions its use in a physical health environment to be a promising practice.^8,14 Through use of telehealth interventions targeting LGBTQ+ patients, providers may be able to reach patient populations that would otherwise not have access to the care they need or avoid pursuing care in fear of mistreatment and neglect.

Review of LGBTQ+ Health Concerns

LGBTQ+ individuals present a unique set of physical and behavioral health concerns. There is well-documented evidence of higher rates of coronary heart disease, asthma, and chronic inflammation among LGBTQ+ individuals in comparison with heterosexual and cisgender individuals.^15–23 Research further parses out health disparities that exist among gay-identifying individuals reporting higher rates of disordered eating, human papillomavirus (HPV), and anal cancer in comparison with their heterosexual counterparts. Lesbian-identifying individuals report higher rates of obesity, breast cancer, and cardiovascular disease in comparison with straight women. In addition to unique health needs of transgender individuals pursuing gender-affirming procedures, transgender individuals in a health care environment provide powerful narratives of neglect and exploitation by providers.^13,24 In addition to subpopulation-specific experiences, a commonality among subpopulations of the LGBTQ+ community are high reports of mental health concerns.

While significant societal progress has been made around LGBTQ+ activism and inclusive public policies, the sociopolitical climate for LGBTQ+ individuals in the United States remains precarious, and varies by geographic region. With a great deal of prejudice still in existence in the United States toward LGBTQ+ individuals, it should come as no surprise that the emotional microcosm that results places a great deal of mental stress on LGBTQ+ individuals. LGBTQ+ individuals report higher rates of depression, suicidal ideation, anxiety, self-harm behavior, and disordered eating.^{9,18–20,22,23} Following an alarming spike in LGBTQ+ suicides in 2010, digital resources such as suicide hotlines targeting LGBTQ+ youth began gaining public attention.^25,26 Within the realm of behavioral health and mental health services, telehealth interventions have proven an effective strategy for outreach to LGBTQ+ individuals.^8,14 However, minimal research has been done on the utility of telehealth services within a physical health setting, specifically for LGBTQ+ individuals.

Telehealth Interventions within Behavioral & Mental Health

Telehealth refers to technologically mediated health services that allow users to interact with various health care providers via computer or smartphone video services.²⁷ By meeting with patients through digitally-mediated technology, providers are able to reduce patient wait time, reduce costs incurred by patients, and reach a wider patient population who may not have access to a physical care environment. The convenience and accessibility of telehealth services are certainly a major draw to this intervention; however, for LGBTQ+ patients, telehealth services could potentially address some of the keystone issues that prevent LGBTQ+ patients from accessing care.

Numerous studies have been conducted regarding LGBTQ+ individuals’ engagement with telehealth interventions as they pertain to mental and behavioral health.^28–30 Overarching trends from these studies elucidate the helpfulness of having interventions that specifically address LGBTQ+ needs, in addition to taking the guesswork out of finding a provider who will understand LGBTQ+-related issues. A particular area of interest has been outreach to LGBTQ+ individuals in rural locations.^31–33 In addition to the increased stigma of being an LGBTQ+-identified person in a rural setting, the problem is compounded with the additional barrier of access to LGBTQ+-friendly health care providers.^34,35 By providing rural LGBTQ+ individuals with access that is anonymous and confidential, patients are able to protect their safety in potentially hostile environments, while also accessing culturally-informed behavioral health interventions.

The bodies of literature that address LGBTQ+ engagement in care with telehealth interventions for behavioral and mental health concerns point to a potentially promising practice in tackling LGBTQ+ health needs in the digital age. However, there has been minimal research as to how digital health interventions can benefit LGBTQ+ individuals outside behavioral and mental health.

LGBTQ+ Engagement in Clinical Care

A digital environment that is created through telehealth services has the potential to address the practitioner-based concerns that patients may have, in addition to mediating the health care delivery and compliance with directives. Access to LGBTQ+-friendly health care providers serves as a barrier for many LGBTQ+ patients. For more than a decade, the Human Rights Campaign (HRC) has conducted a Healthcare Equality Index (HEI) survey of health care facilities that focuses on health care delivery and policies that affirm and advocate for patients with LGBTQ+ identities.³⁶ In a similar vein, GLMA (the Gay and Lesbian Medical Association), provides a directory on their website of health care practitioners who have pledged their commitment to LGBTQ+ health.³⁷ Patients with access to the internet are able to easily search for health care practitioners in their area who are registered with GLMA; although, GLMA specifically cites that they do not individually screen practitioners for competent LGBTQ+ care.³⁸

While the HRC and GLMA have made concerted efforts to identify LGBTQ+-friendly practitioners, the identification of practitioners does not necessarily address issues of geographic access to care. For LGBTQ+ patients who do not have access to urban areas where many LGBTQ+-friendly providers are, patients run the risk of seeking care from a culturally insensitive provider or foregoing care altogether.^8,39,40 For health care organizations, this means treating patients in critical care settings (e.g., emergency department visits, immediate-care clinics, etc.) for conditions that may have been able to be addressed sooner and with less urgency had the patient pursued early care options. Treating patients for preventable conditions in a critical care setting yields more cost to the health care system, in addition to unnecessary allocation of time and personnel to treat conditions that could have been mitigated in a primary care setting.^41,42 These costs are not only passed on to the patient, but are also incurred by the health care organization as a whole. Subsequently, the mere identification of practitioners who can provide LGBTQ+-friendly patient care is not enough; rather, health care delivery methods to ensure that patients are aware of their care options and have access to them are key to addressing LGBTQ+ health disparities.

Considerations for Implementing Telehealth Interventions for LGBTQ+ Patients

For health care practitioners and health care organizations that are interested in improving outreach and care of LGBTQ+ patients, telehealth could offer an opportunity to address many of the barriers to access that LGBTQ+ patients face. With proper consideration, telehealth interventions could offer LGBTQ+ patients culturally competent health care in a way that addresses negative community narratives toward seeking health care in a primary care setting.

Cost

Avoidance in seeking care poses serious concerns for the economic well-being of health care organizations. For health care organizations, treating patients in a critical care setting for a condition that could have been treated in an outpatient setting incurs unnecessary cost.^43,44 As a general tenant of health care delivery, identifying and treating a condition early, not only allows for better targeted treatment but also potentially halts disease progression from becoming more severe and, therefore, necessitating more aggressive treatment. By increasing access to LGBTQ+-friendly providers, health care organizations may begin to mitigate the costs of seeing patients in critical care settings when they could have been treated in an outpatient setting.

Provider Access

As previously mentioned, the HRC compiles an annual index of health care facilities that have met certain criteria to be considered an “LGBTQ Healthcare Equality Leader.³⁶” While some states, such as California, New York, Ohio, and North Carolina, have a robust number of facilities that have been identified as exemplars by the HRC in their 2019 annual report, other states, such as Georgia, South Carolina, Idaho, and Montana, do not have a single facility registered with the HRC. For LGBTQ+ patients, access to LGBTQ+-friendly providers may be scarce in their geographic region, which may have an influence on their engagement in care.^27,45 Telehealth services have the potential to alleviate geographic barriers by allowing patients, especially in rural communities, to access LGBTQ+-friendly providers from the comfort of their own homes.

Advertising and Community Outreach

While telehealth interventions have great potential to alleviate access barriers for LGBTQ+ individuals seeking culturally competent care, one cannot ignore the effect that years of discrimination have had on LGBTQ+ community narratives in seeking care. The horror stories of LGBTQ+ discrimination in health care environments are pervasive and indicate fear and mistrust in the health care system.^6–13 As individual practitioners and health care organizations aim to implement telehealth interventions specifically for LGBTQ+ communities, they must also be aware of the community outreach and engagement that will be necessary to help dispel current community narratives, and begin to build trust between health care providers and LGBTQ+ patients.

Limitations & Future Considerations

While telehealth services have been in existence for nearly a decade, their effect on marginalized communities remains relatively new and unexplored. Subsequently, careful implementation and diligent assessment are necessary to determine their effectiveness. As with the development of any new clinical intervention or treatment method, rigorous pre- and post-assessment metrics should be collected. As previously noted, telehealth interventions specifically for LGBTQ+ patients outside mental and behavioral health have not been researched. As interventions are established, LGBTQ+ health needs must be at the forefront of development rather than retrofitted from existing models.

Moreover, telehealth services should not be viewed as a panacea for LGBTQ+ health disparities. The root causes of health disparities (systemic oppression and subsequent prejudice) are still incredibly prevalent and powerful in affecting the lives of LGBTQ+ individuals. Telehealth interventions may be used as a countermeasure to begin addressing health disparities; however, increased practitioner education and training in cultural competency remain the key to addressing health disparities in a long-term, sustainable fashion.

Conclusion

Different disciplines within the healing arts are showing promise for incorporating care practices that honor the growing diversity of patient populations within the United States. However, there is still a great deal of work that needs to be done to address pervasive population health disparities that are ever present within the United States. Foundational causes of systemic oppression that propel the trajectories of population health disparities are still very much alive and well within the United States. Efforts to educate health care practitioners and provide them with interventional resources necessary to tackle population health disparities are pivotal in changing the way that health care access is gate kept in the United States.

Specifically for LGBTQ+ individuals, systemic barriers instill narratives of fear and subsequent neglect for individuals seeking health services. Until LGBTQ+ individuals can confidently show up authentically in the offices of their health care providers and receive culturally competent, population-specific care, the need for education and interventional countermeasures will exist. Telehealth services offer a promising avenue for targeted outreach to LGBTQ+ individuals to begin changing the community narratives of mistrust and neglect and allow LGBTQ+ individuals to seek care without fear of mistreatment.