The US healthcare system ignores LGBTQIA

Preventive health care, like cancer screening, is a critical tool in the early detection of disease. Lack of detection can result in misdiagnosis, delayed treatment, and reduced chances of survival.

But the medical system is ill-equipped to meet the needs of gender-diverse patients.

About 1.64 million people in the US identify as transgender, non-binary, or gender diverse: people whose gender identity differs from the sex they were assigned at birth.

This adds up to 1.3 million or 0.5% of American adults, all of whom are more likely to encounter implicit or unconscious bias when seeking health care compared to their cisgender counterparts, those whose gender identity aligns with their sex. that was assigned to them at the time. birth.

I am a primary care physician in Appalachia as well as a medical educator studying how to improve instruction of future health care providers. I work hard every day to improve the health of the underserved.

Primary care physicians dedicate much of their lives to preventive medicine – the art of stopping disease before it starts. Cancer detection consumes a large part of my life.

Therefore, I am concerned about the barriers to preventive care for transgender patients, including consistent access to appropriate cancer screenings.

The problems with the binary model

Healthcare spaces and providers often focus specifically on “men’s health” or “women’s health”. Intake forms may not have the option to declare a gender identity separate from the sex assigned at birth. Health tests and insurance policies for diseases like cancer tend to remain oriented to a flawed male-female binary.

Gender diverse patients often find themselves teaching their primary care physicians how to provide competent care, because many medical students receive little training on how to provide gender-affirming care.

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The US healthcare system ignores LGBTQIA

As a result, 1 in 3 gender-diverse adults do not seek preventive care, according to a report by the National Center for Transgender Equality, or are not offered these services at all, when they see a health care provider. Even more alarming, 19% of transgender people report that they have been denied care outright.

This may contribute to higher rates of tobacco use, obesity, alcohol use and other cancer risk factors in people of diverse gender.

Cancer Care Challenges

Research to date shows that transgender adults over the age of 45 are being screened for colon cancer at a lower rate than cisgender patients. They are also more likely to be diagnosed at later stages of lung cancer. This can be devastating, because finding lung cancer before it spreads can literally mean the difference between life and death.

The University of California, San Francisco, one of the few places that has protocols for caring for transgender patients, recommends that transgender women over the age of 50 who have been taking a feminizing hormone for five years begin cancer screening. of breast. However, according to a recent Canadian study, only approximately 1 in 3 transgender women who are eligible for breast cancer screening receive mammograms, compared to 2 in 3 eligible cisgender women.

In a 2021 study, researchers found that transgender patients with non-Hodgkin lymphoma, prostate cancer, or bladder cancer had roughly twice the death rate of their cisgender counterparts. Since the researchers were able to firmly identify only 589 transgender people from nearly 11.8 million records, they were unable to accurately compare rates for other types of cancer.

Since 2017, the American Society of Clinical Oncology has recommended including data on sexual and gender minority of patients been in cancer registries and clinical trials. However, in 2022 the society discovered that only half of cancer care providers routinely collect gender identity information. Thus, it is clear that much remains to be learned about the barriers to inclusive cancer care.

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Lack of training both in medical school and in residencies—intensive training periods in which new doctors hone their skills—perpetuates these disparities.

Bias in medical school

Medical education is plagued with biases that reflect society’s stereotypes and prejudices. Additionally, researchers have found that students may unconsciously absorb biases or stereotypes they encounter in their medical education.

And only 26% of doctors who lead family medicine internships, courses in which medical students begin working and interacting with real patients, say they are comfortable teaching transgender healthcare.

Therefore, the Association of American Medical Colleges has called for an emphasis at all levels of training on the health of lesbian, gay, bisexual, transgender, queer or questioning people and other identities, known as LGBTQ+. The association recommends that schools take a “layered” approach that integrates gender-affirming health care education into their curricula. This can include incorporating LGBTQ+ health into initial courses, using practice patients in simulation, and creating opportunities to see patients with lived experience.

However, many medical schools still fail to integrate gender-affirming care throughout the curriculum. Instead, medical schools often add it to the existing curriculum, offering dedicated lectures or small group activities that address LGBTQ+ health. Medical schools in general provide an average of just five hours of instruction on gender-affirming healthcare practices.


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Health insurance obstacles

In 2015, the Centers for Medicare & Medicaid Services clarified that preventive care services are available under the Affordable Care Act, regardless of gender identity.

However, the major organizations that guide providers and insurance coverage regarding breast, cervical, and prostate cancer screening keep using an approach based on the entrenched male-female binary model.

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For example, the US Preventive Services Task Force still gears its recommendations for breast and cervical cancer screening toward cisgender women, with little guidance on how to apply them to transgender patients.

This is partly driven by lack of data on how to best screen transgender patients for cancer.

Insurance coverage and companies also create obstacles. Gender-diverse patients are more likely to be uninsured or underinsured, making it very difficult for them to access preventive health care. A gender identity discrepancy in an electronic medical record may result in a denial of a cancer screening test.

momentum for change

Fortunately, the medical field is recognizing that gender diverse patients have unique health care needs.

Since 2017, the American College of Obstetricians and Gynecologists has published recommendations for health care providers on how to make their practices open and inclusive to all people. Training all staff and creating an open office space without a gender focus is a key recommendation.

Now, more than 20 medical organizations provide similar guidance, hoping to increase inclusion through the health care system.

Another encouraging sign is that some medical schools are integrating gender-affirming care into their courses. The University of Louisville in Kentucky reports that it now offers 50 hours of specific LGBTQ+ topics. And a team of faculty and students at Boston University School of Medicine has developed a tool to help medical schools assess and improve the way they educate students to provide care for sexual and minority minorities. gender.

It is my hope that the next generation of health care providers will be a force for change in their institutions; In my experience, new medical students are more aware of health disparities than their previous generations of educators.

Jenna Sizemore is a Assistant Professor of Medicine, West Virginia University, first published the article in The conversation