Although our culture -- particularly medical culture -- puts forth the image of a doctor's office as the one place where you will always be treated equally, that doesn't quite match up with reality. Numerous studies have collected reports of discrimination against lesbian, gay, bisexual, and transgender patients in health care settings. These can range from a doctor or nurse refusing to use a transgender patient's preferred name, to a reproductive health center declining to provide treatment to a lesbian couple. Other minority groups have similar experiences.
Even when the examples are less overt, few health care providers willingly accept the idea that they may not be providing equal quality of care to all of their patients. But it is a topic worth exploring, especially since we know that LGBT people experience more health risks and disparities than the general population. LGBT people are more likely to smoke and use drugs and alcohol. They also bear a higher burden of depression and anxiety, and engage more often in self-harming behaviors. Meanwhile, gay men are at least 44 times more likely than the general population to become infected with HIV; transgender women are also highly vulnerable to HIV infection. Lesbians and bisexual women are far less likely to receive screenings for cervical cancer. Transgender people have a high prevalence of attempted suicide and victimization.
There are many reasons for these disparities in health, not least of which is the stigma and discrimination LGBT people commonly face, which can be internalized, interpersonal, or structural. This stigma exacerbates the normal stressors of life.
It has long been thought that health care visits can be stigmatizing for LGBT patients and that health care providers are unwitting contributors, or in some cases intentional perpetrators, of health inequities. "Health Care Providers' Implicit and Explicit Attitudes Toward Lesbian Women and Gay Men," a study published this month in the American Journal of Public Health, explores this issue.
Researchers examined results from 18,983 heterosexual health care providers (2,338 medical doctors, 5,379 nurses, 8,531 mental health care providers, and 2,735 other treatment providers) who voluntarily took Project Implicit's sexuality implicit association test (IAT) between 2006 and 2012. IATs measure the automatic associations of the test taker to variables such as race, sexual orientation, gender, religion, and other areas where bias often exists.
Researchers found that the implicit preferences -- that is, bias that exists on an unconscious level -- of heterosexual providers "always favored heterosexuals over lesbian and gay people" while their explicit preference for heterosexuals over lesbians and gay men were "moderate to strong."
It is important to note that this study measured preferences on a test and did not correlate them with actual patient care. So it is impossible to conclude anything from this study about the delivery of care to lesbians and gay men (associations to bisexual and transgender people were not measured) by heterosexual health care providers. But the results have provocative implications, first among them that implicit bias "about sexual orientation may contribute to health and health care disparities among sexual minority populations," as the study authors write. They also note that research published in the American Journal of Public Health in 2012 correlated implicit racial bias among health care providers with treatment recommendations and recommend further research to "investigate how implicit sexual prejudice affects care."
What this study and others that explore disparities and inequities in health among minority populations demonstrate is that the art and science of providing health care across all disciplines is immeasurably complex. Possible solutions include the routinization of some clinical decisions to mitigate the possibility of bias in treatment recommendations.
Electronic health records help provide quality care as they have reminders built into them that have been demonstrated to help health care providers do the right thing in a range of areas. In tech jargon this is called "decision support." For example, using established, evidence-based guidelines, an EHR would remind a clinician examining a man in his 60s to conduct a prostate exam and recommend a blood cholesterol test. A doctor conducting an annual exam for a woman will be prompted to take a Pap smear to check for cervical cancer, and conduct a breast exam according to evidence-based guidelines.
Efforts are currently underway to routinely collect patient data related to sexual orientation and gender identity as is currently done with a patient's race and ethnicity. These data could be used to build prompts into EHRs with regard to appropriate and sensitive care related to a patient's sexual orientation and gender identity. For example, while EHRs should remind clinicians that everyone between the ages of 15-65 should have an HIV test, men who have sex with men may need to be tested for HIV more frequently in addition to having screenings for STIs based on their history. This data could also be used to evaluate both quality of care provided to LGBT people as well as their satisfaction with care received. Without knowing who is L, G, B, or T, sexual and gender minorities are invisible, and these important markers cannot be explored.
All that said, two other findings from the AJPH study that may not make headlines show that more can -- and must -- be done to mitigate bias. Lesbian and gay health care providers demonstrated implicit and explicit preferences for lesbian and gay people over heterosexual people, and heterosexual female mental health providers "explicitly reported favoring lesbian women and gay men over heterosexual people."
Whatever solutions are put forward, surely none can be more important than training health care providers to continuously look for unaddressed, unconscious biases of any kind. Getting them the data to demonstrate differential quality and satisfaction outcomes will help. Only then can we set a course of providing more sensitive, high quality care to every patient.
HARVEY MAKADON, MD, is Director of the National LGBT Health Education Center at The Fenway Institute and professor of medicine at Harvard Medical School.
