Advocating Healthcare Equity for LGBT Patients Through Compassionate and Culturally Competent Care

Each year, the Geiger Gibson Program in Community Health Policy of the George Washington University School of Public Health and Health Services (SPHHS) recognizes young Emerging Leaders in community health. Renato Barucco, Program Manager of the Transgender Program at Community Healthcare Network (Bronx, NY), was among eight honored this year. He sat down with me to share his knowledge and experiences caring for transgender and lesbian, gay, bisexual, and transgender (LGBT) patient populations, an especially under recognized and underserved population. CHN’s Bronx health clinic is located on Westchester Ave in the South Bronx, in a busy industrial area under the elevated subway tracks. From inside the clinic, you can hear the rumble of trains, and feel the vibrations as they pass above from time to time. The center’s small waiting room is filled with patients and their families sitting patiently. One section of the clinic has two small offices attached to a larger meeting room that houses the Transgender Program staff. The clinic’s Transgender Program, which now serves over 250 patients a year, began somewhat accidentally, when the Bronx site was a family planning clinic offering women’s health services. A transgender woman came to the clinic seeking care and while not initially prepared to provide services to a male-bodied person who identified as female, the staff welcomed her with open arms. “If a woman identifies herself in womanhood you should be able to provide services,” Renato explains. After this first patient received treatment she passed the word that the clinic was trans-sensitive and more trans women began coming in for services. Dr. Luis Freddy Molano, then the Center’s director, recognized that there was insufficient care for transgender and LGBT people in the South Bronx and felt that it was the health center’s responsibility to meet this need. This singular incident became the impetus for the CHN’s Transgender Program, which was founded in 2003 and has expanded to include HIV outreach and treatment services for the transgender and LGBT community and also provides primary care, counseling, mental health services, and weekly support groups in the South Bronx and Jamaica, Queens. Mr. Barucco shared the Center’s strategies to create an environment that is inclusive and respectful of all patients regardless of their sexual orientation or gender identity. “A community health center should be able to serve everybody.” His advice to those health centers that don’t necessarily have trans- or LGBT-specific health programs or funding, but want to do a better job at serving and reaching out to these special populations, is to make a top-down commitment to serving all patients regardless of sexual orientation or gender identity and include it in the center’s mission statement and official policies. Community Healthcare Network has included language about gender and sexual orientation in their center’s mission statement and brings up its commitment to Trans and LGBT issues when hiring staff. Every staff person goes through training about LGBT and trans-specific health issues as well as using culturally appropriate language which respects and recognizes patients regardless of their gender identity and sexual orientation. Renato related that there are simple measures community health centers can take to show commitment to patients’ needs, including gender-neutral bathroom signage and medical forms with inclusive language. He pointed out a poster on his office door that pictures a transgender man with a message promoting routine PAP smears. He also noted the importance of not making presumptions when asking the patient’s gender identity and or sexual history. . These seemingly small steps can have a huge impact for patients who are seeking care in a setting that respects them and makes them feel recognized. A psychologist by training in Italy, his home country, Renato explained that through his work at the Center he has learned to not make assumptions about patient’s health priorities based on his own belief system or training as a health provider. As a provider, he explained “your priority is HIV/AIDs but their priority is gender.” He gave some anecdotal examples to explain some of the unique issues and concerns that require a heightened sensitivity to patient needs. Some patients have been known to sell their retroviral medication on the street in order to pay for hormone injections. Others may get unregulated silicone injections, which are associated with a host of health risks and complications including subcutaneous infection and extreme pain and emotional trauma when un-encapsulated silicone migrates in the body. Someone not aware of trans health issues might not understand why an individual would take health risks for seemingly cosmetic concerns, but for a transgender person these hormone treatments or body modifications are life sustaining. Renato’s message echoed themes I heard at a workshop at the recent NACHC Policy and Issues Forum in Washington DC, called “Learning about Health Care for LGBT People and National Strategies on HIV and Hepatitis.” The workshop discussed recommendations to address the health disparities among the LGBT population nationally. According Amanda Castel, an Assistant Professor of Epidemiology and Biostatistics at the George Washington School of Public Health who reported on research from Healthy People 2020 and the IOM Report, The Health of Lesbian, Gay, Bisexual and Transgender people, LGBT patients are underserved and are less likely to receive health services. This disparity is linked to the discrimination and social stigma that non gender conforming patients suffer, individually and collectively. As a result, LGBT individuals experience poorer health outcomes than their heterosexual peers. According to statistics, the LGBT population suffers greater incidences of substance abuse, psychiatric disorders and suicide. They are also at higher risk for cancer and HIV/AIDS. The elderly LGBT population faces particular challenges accessing adequate healthcare and other social services due to institutionalized discrimination. Federal programs like Social Security and Medicare, which are designed to support seniors, exclude LGBT partners and widows from receiving spousal and survivor benefits. Many also experience social isolation in their own communities, which has negative implications on their health. In order to close the healthcare access gap for LGBT patients, the first step is determining who they are. To accurately identify and document gender identity and sexual orientation, it is essential that CHCs educate their staff about cultural competency toward LGBT issues and how to sensitively pose these questions, recognizing that the LGBT community is not homogenous and distinctions are diverse. The best way to gather information is to get to know patients as people and to communicate with respect and compassion. Using gender neutral language, such as asking “do you have a partner” instead spouse, wife or husband, is important, as is creating inclusive spaces for LGBT patients at the health center with gender-neutral restroom signage. Accurately obtaining and documenting clinical information is essential to effectively screen, detect and prevent conditions in the LGBT communities. There are resources available to health centers as they work to address the unique needs of this varied population. The National LGBT Health Education Center offers training, continuing medical education and technical assistance to Federally Qualified Health Centers, look-alikes and other health centers through a partnership with HRSA, with the aim of reducing disparities for LGBT people. The Center’s training addresses the practical and clinical aspects of providing accessible, high quality, and cost effective care to LGBT people. Many community health centers, long at the forefront of serving high-quality, comprehensive care to diverse, underserved populations, are uniquely positioned to serve LGBT communities, and help end the invisibility, discrimination and health disparities they often face. CHN, Boston Healthcare for the Homeless, and many other CHCs are doing just that today, and will hopefully be joined by many more health centers committed to high quality care for all, as our Emerging Leaders pave the way. By Nicole Rodriguez-Robbins

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