The American College of Physicians (ACP) is the largest organization of internists in the country, with 141,000 members — making it the U.S.’s second largest physician group after the American Medical Association. This week, the ACP issued an extensive position paper detailing how best to serve LGBT people, including a number of political positions about what would best support LGBT people’s health.
LGBT people experience a host of health disparities, the ACP noted, because of challenges that “range from access to health care coverage and culturally competent care to state and federal policies that reinforce social stigma, marginalization, or discrimination.” Not only are they often discouraged from obtaining preventive care, but they also face an “increased rates of anxiety, suicide, and substance or alcohol abuse” because of laws and policies that reject them or treat them unfairly.
To correct these disparities, the ACP took the following nine positions:
1. Add “gender identity” to nondiscrimination and anti-harassment policies.
Though transgender people have found some employment protection under Title VII, discrimination against transgender people is still otherwise legal in most states. The ACP observes that transgender people are particularly vulnerable to discrimination, and thus recommends that medical schools and facilities not rely on state laws to protect this community.
“Employers have the option to include gender identity as part of their company’s nondiscrimination or anti-harassment policies even if their state does not, and many companies have chosen to include comprehensive protections policies,” the statement reads. “To reduce the potential for discrimination, harassment, and physical and emotional harm toward persons who are not covered by current protections, the medical community should include both sexual orientation and gender identity as part of any comprehensive nondiscrimination or anti-harassment policy.”
2. All public and private health benefits should include comprehensive transgender health care services and provide equal service to transgender people.
Transgender people are often denied insurance coverage for treatments like hormones and surgeries, even though their doctors have deemed them medically necessary to treat their gender dysphoria. They can also be denied coverage for some sex-specific procedures (such as mammograms, Pap smears, and prostate exams), though new guidance from the federal government will hopefully end that discrimination. The ACP wants to see transgender people receive all of the care that they need.
The position statement notes that the World Professional Association for Transgender Health (WPATH) has outlined standards for transgender medical care that emphasize affirming transgender people’s experienced gender identity. “Research shows that when transgender persons receive individual, medically appropriate care, they have improved mental health, reduction in suicide rates, and lower health care costs overall because of fewer mental health–related and substance abuse–related costs.” Refusing coverage hurts trans people both in terms of their physical and mental health and can financially burden them, adding to their stress and anxiety.
Providing coverage, conversely, does little to burden businesses. Not only have employers found that covering transition-related procedures added no cost to their plans, but “the inclusion of transgender-related health care services within a health plan may also result in an overall reduction of health care costs over time because patients are less likely to engage in self-destructive behaviors, such alcohol or substance abuse.”
3. The definition of “family” should not be limited according to legal and biological relationships.
“The term ‘family’ as it is seen in society is changing and no longer means married heterosexual parents with children,” the ACP writes. Because the structure of families is becoming more diverse, the ACP recommends that the medical community be more inclusive in its definitions of families and the way it treats them. Doing so could directly impact the health of LGBT people. For example, “if LGBT spouses or partners are not legally considered a family member, they are at risk for reduced access to health care and restrictions on caregiving and decision making; further, they are at increased risk for health disparities, and their children may not be eligible for health coverage.” Additionally, LGBT people and their families are more likely to face financial disparities that can translate to a lack of access for medical care.
To ensure that LGBT people are treated equally in the hospital setting, “family” should be defined expansively to include “any person(s) who plays a significant role in an individual’s life.”
4. Visitation policies should allow patients to decide who can visit them regardless of their sexual orientation, gender identity, or marital status.
One of the most common consequences of marriage inequality (and even civil unions) has been when hospitals deny patients’ partners access to them. Though the Department of Health and Human Services now requires all hospitals to allow patients to choose who may visit, including same-sex spouses, domestic partners, and other visitors, hospital policies are not always clear or consistent. How hospitals consider these policies has a big impact on the patient’s stay: “The absence or limited access of loved ones can cause uncertainty and anxiety for the patient. In contrast, the involvement of family and outside support systems can improve health outcomes, such as management of chronic illness and continuity of care.”
5. Marriage equality is good for the health of LGBT people.
The ACP endorses marriage for same-sex couples, noting that they would experience the same health benefits from the institution that different-sex couples already enjoy. For example, “research suggests that being in a legally recognized same-sex marriage diminishes mental health differentials between LGBT and heterosexual persons.” Additionally, “a comparison study on the utilization of public health services by gay and bisexual men before and after Massachusetts legalized same-sex marriage found a reduction in the number of visits for health problems and mental health services.”
Furthermore, research has shown that marriage bans hurt the overall health of the LGBT community. “A study of LGBT individuals living in states with a same-sex marriage ban found increases in general anxiety, mood disorders, and alcohol abuse. The denial of marriage rights to LGBT persons has also been found to reinforce stigmas of the LGBT population that may undermine health and social factors, which can affect young adults.”
The ACP has not previously expressed support for marriage equality nor signed amicus briefs submitted in same-sex marriage cases by other medical organizations.
6. The LGBT community should be identified and included in data collection and research.
One of the biggest obstacles to eliminating LGBT health disparities is identifying them. So often, doctors either do not ask or do not have a way to catalog patients’ sexual orientation or gender identity. As a result, there is not the plethora of demographic information about LGBT health as there is for, as an example, racial and ethnic minorities, whose identities are already uniformly recorded in patients’ records.
As the ACP notes, though there is already a lot of data about LGBT health disparities, including questions about these identities in patients’ medical records would be a gamechanger both for national research and for individual patient care. “In addition to obtaining information from population surveys, including gender identity and sexual orientation as a component of a patient’s medical record (paper or electronic) may help a physician to better understand an LGBT patient’s needs and provide more comprehensive care.” The ACP also recommends flagging transgender patients’ charts to indicate their preferred name and pronouns.
7. Med schools should recruit and support LGBT students and incorporate LGBT health into their curricula.
Patients need to feel safe coming out in the examination room. “Reported instances of physician bias or denial of care to LGBT patients,” the position paper warns, “may influence patients to withhold information on their sexual orientation, gender identity, or medical conditions that could help the physician have a better understanding of the potential health needs of their patients.” Educating doctors about how to talk about LGBT issues can help them create the safe atmosphere that helps patients share this kind of information.
“To better understand the unique health needs of the LGBT community, physicians and medical professionals must develop a knowledge base in cultural and clinical competency and understand the factors that affect LGBT health; this should begin in the medical school setting and continue during practice,” the ACP asserts. Exposure to LGBT people also makes a big difference, and some still feel that medical schools are not welcoming institutions. In one study, 30 percent of respondents did not reveal their sexual orientation when applying for residency positions for fear of not being accepted. Making medicine more inclusive for LGBT professionals will benefit both other physicians as well as their patients.
8. No LGBT person should be subject to “conversion,” “reorientation,” or “reparative” therapy.
Adding their voice to the consensus of medical professionals who oppose ex-gay and ex-trans therapies, the ACP concludes, “Available research does not support the use of reparative therapy as an effective method in the treatment of LGBT persons. Evidence shows that the practice may actually cause emotional or physical harm to LGBT individuals, particularly adolescents or young persons.”
Not only is such treatment potentially harmful, but it’s also rooted in the very kind of stigma that contributes to LGBT health disparities. The core of such therapies, ACP writes, is “mostly based on religious or moral objections to homosexuality or the belief that a homosexual person can be ‘cured’ of their presumed illness.”
9. Blood donation policies for men who have sex with men should continue to be reviewed.
This week, the Food and Drug Administration issued the draft of a new policy that would still require men to go a full year without having any sexual contact with another man to be eligible to donate blood. The ACP describes lifting the lifetime ban on gay and bi men as “an important first step toward creating equity among those wishing to donate blood,” but urges the FDA to continue reviewing the policy and narrowing it with more specific criteria in the future.
Not all doctors support the ACP’s new position paper. Breitbart.com, for example, found two doctors who oppose the LGBT-inclusive statement. Both of them happened to be the heads of conservative medical organizations that oppose LGBT equality. Jane Orient is head of the Association of American Physicians and Surgeons, which believes that HIV doesn’t cause AIDS but being gay reduces life expectancy, and she told Brietbart, “ACP has supported every advance of cultural Marxism since the mid-1970s at least.”
Likewise, Michelle Cretella is head of the American College of Pediatricians, a fringe social conservative medical organization not to be confused with the mainstream American Academy of Pediatricians. She called the ACP “shameful” for the position paper because “the science is clear: no one is born gay or transgender.” Her organization opposes same-sex parenting and has been classified as a hate group by the Southern Poverty Law Center.
Wayne J. Riley, president of the ACP, is proud of his organization’s work. “It’s incumbent upon us as healthcare professionals, as general internists and internal medicine subspecialists,” he told Medscape, “to provide the LGBT community the best possible culturally competent and relevant healthcare which addresses their needs.”