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Creating a Welcoming Healthcare Environment for LGBTQ+ Patients and Honoring Our Elders
By: Salvatore Volpe, M.D., FAAP, FACP, FHIMSS, ABP-CI, CHCQM
May 16 is Honor Our LGBT Elders Day. I would like to touch upon some of the topics that healthcare providers should be aware of and provide a list of resources at a statewide and national level.
Nearly three million LGBTQ+ people are age 50 and older in the U.S. This population will grow to nearly seven million by 2030. Of the estimated 800,000 LGBTQ+ adults in New York State, nearly one-third, or 28%, are over the age of 50.1
A 2022 Gallup Poll found that 7.1% of adults in the United States identify as lesbian, gay, bisexual or transgender. The 2022 Behavioral Risk Factor Surveillance System Brief from the New York State Department of Health revealed that 7.9% of all New Yorkers, 5.7% of adults aged 55-64 and 4.5% of adults over the age of 65 openly self-identify as lesbian, gay, bisexual or another sexual orientation. Additionally, 0.5% of all New Yorkers, 0.2% of adults aged 55-64 and 0.3% of adults over the age of 65 identify as transgender. The UCLA Williams Institute found that 5.1% of the population in New York State identifies as LGBT.1
In January 2021, AARP, SAGE and other advocates for LGBTQ+ older adults issued a report revealing that:
23% of LGBTQ+ New Yorkers of all ages cite inadequate insurance coverage as the most significant barrier to healthcare.
One-third of LGBTQ+ adults aged 50 and over live at or below 200% of the federal poverty level, compared to a quarter of non-LGBTQ+ people.
21% of LGBTQ+ adults aged 50 and over have provided care to friends – three-and-a-half times the 6% of non-LGBTQ+ peers.
These results need to be taken with a grain of salt as they only account for those individuals who felt comfortable self-identifying as LGBTQ+. An estimated 40% of LGBTQ older respondents in their 60s and 70s reported that their provider did not know about their sexual orientation.4 Fear of discrimination keeps many individuals from accessing the acute and chronic care that ultimately leads to worse outcomes.3 Examples include: increased rates of disability, poor physical and mental health, alcohol and tobacco use and HIV. Disparities are worse for LGBTQ people of color or transgender people.4
LGBT older people were half as likely to have life partners or significant others; half as likely to have close relatives to call for help; and four times less likely to have children to provide care. Many LGBT older people are also disconnected from their families of origin. Heartbreakingly, almost a quarter of LGBT older people have no one to call in case of an emergency.5
One of our roles as healthcare providers is to create a trusting environment that would permit individuals to share details about their gender identity and sexual orientation. MLMIC recently released a podcast that touches upon this topic. 2
Websites, social media and office locations should have inclusive imagery and text. Ensure that all online and in-office intake forms have been updated to include SOGI (sexual orientation and gender identity options). Include links and printed literature with useful LGBTQ+ health-related sites and organizations.
Consider providing bathrooms that are either unisex or provide access to bathrooms consistent with the person’s gender identity. Your Social Care Network (SCN) can provide introductions to community-based organizations that can provide training with a focus on person-centered care, as well as the LGBTQ community.6
Remember to take a gender-affirming approach when speaking to the patient and referring to the parts of the body that will be examined. Be sensitive to the anxiety that the patient may have and offer to schedule a follow-up if needed, as a trusting relationship is being established.
Patients receiving gender affirming hormone therapy may present along a spectrum of physical characteristics depending on the duration of the therapy. Some findings could include androgenic alopecia, acne, estrogenic, feminine fat redistribution and decreased testicular size. It is important to include an organ survey, which would also include gender affirming procedures.7
Women are at increased risk for breast cancer if they have never been pregnant or taken oral contraceptive pills. Women are at increased risk for cervical cancer if they believe that PAP smears are unnecessary due to having no or limited sex with men.
Pap smears on transgender men have a ten-fold higher incidence of an unsatisfactory result compared to non-transgender women, which is positively correlated with the length of time on testosterone. Testosterone can cause atrophic cervicovaginitis and inflammation.
Transgender women on feminizing hormones may experience an increased risk of cardiovascular events and thrombosis, and there is an increased risk for prostate cancer if not reminded of recommended screenings.
Integration of behavioral health with physical health has been found to improve outcomes in all populations. Suicide most often occurs when stressors and health issues converge to create an experience of hopelessness and despair. For LGBTQ+ people, stigma, prejudice and discrimination can increase the likelihood of stress, depression and other mental health concerns. Conditions like depression, anxiety and substance problems, especially when unaddressed or when people lack access to quality mental health care, can increase the risk for suicide.
In closing, let us remember that the elderly LGBTQ+ have accumulated a lifetime of inadequate access to quality healthcare and that by creating a trusting and welcoming relationship and environment, we can provide them the care that we all deserve.
MLMIC offers an online and in-person CME program to its policyholders entitled: “Addressing the Needs of Your LGBTQ Patients”. Insureds can log onto their portal to complete the program or contact our risk management department here.
MLMIC policyholders can reach out to our legal department for questions regarding treating the LGBTQ+ population or ask any other healthcare law inquiries by calling (877) 426-9555 Monday-Friday, 8 a.m.-6 p.m. or by email here.
Our 24/7 hotline is also available for urgent matters after hours at (877) 426-9555 or by emailing hotline@tmglawny.com.
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If you are not already a MLMIC insured, learn more about us here.
Sources:
1. New York State LGBTQ+ Resource Guide For Older Adults and Aging Services Networks
2. The Verdict: Understanding and Welcoming LGBTQ+ Patients: A Conversation with Salvatore Volpe, M.D. Podcast
3. Health disparities among LGBTQ+ older adults: challenges and resources. A systematic review
4. Disrupting Disparities: Challenges and Solutions for 50+ LGBTQ Illinoisans
5. LGBTQ Older People & COVID-19, Addressing Higer Risk, Social Isolation, and Discrimination
6. https://www.health.ny.gov/health_care/medicaid/redesign/sdh/scn/
7. Neurological care for LGBT+ people
Volpe SG, Ahmad J, Patel RA, Rosendale N. Neurological care for LGBT+ people. Nat Rev Neurol. 2024 May;20(5):288-297. doi: 10.1038/s41582-024-00944-0. Epub 2024 Mar 18. Erratum in: Nat Rev Neurol. 2024 Oct;20(10):637. doi: 10.1038/s41582-024-01015-0. PMID: 38499761
ACP 2015 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health
LGBTQIA+ Health Center – https://www.lgbtqiahealtheducation.org/wp-content/uploads/Providing-Inclusive-Services-and-Care-for-LGBT-People.pdf
National LGBTQIA+ Health Health Education Center: Resources Page
Learning Resources -Organizational Changes
Telehealth for LGBTQIA+ Patients Eligible for CME
AHA Scientific Statement from 2020 – https://www-ahajournals-org.newproxy.downstate.edu/doi/10.1161/CIR.0000000000000914
Creating an LGBTQ-friendly practice, AMA – https://www.ama-assn.org/delivering-care/population-care/creating-lgbtq-friendly-practice
Cultural Competence in the Care of LGBTQ Patients – https://www.ncbi.nlm.nih.gov/books/NBK563176/
