Lesbian/Gay/Bisexual TransgenderPublic Health Issues William C. Bufﬁe, M.D. OneVoiceIndiana.org
Key Points• Disparities in outcomes• Reasons: “Minority stress” and unequal access to health care• Economic implications• Role of Family• Role of Stigma
Bias• family, friends, patients• research, Christian Pluralist, author• state medical association advocacy work since 2007 ... American Journal of Public Health article June 2011
Clinical Case• stigma internalized by individual and family• emotional stress manifest by risky behaviors and adverse events• emotional and ﬁnancial costs• avoidable??• inherent to the “gay lifestyle”?
Data• evidence-based• peer-reviewed• validated by expert consensus --> policies and position statements:
• American Medical Association (AMA)• American Academy of Child & Adolescent Psychiatry (AACAP)• American Academy of Family Physicians (AAFP)• American Academy of Pediatrics (AAP)• American Bar Association (ABA)• American College of Obstetrics and Gynecology (ACOG)• American Medical Women’s Association (AMWA)• American Psychiatric Association (APA)• American Psychoanalytic Association• American Psychological Association• North Carolina Psychological Association• American Anthropology Association• Indiana State Medical Association (ISMA)• National Association of Social Workers (NASW)
U.S. Demographics• Estimated that 4-8% of U.S. women and men are LGBTQ (15 million?)• More than 1,000,000 same-sex couples in U.S. are found in every Congressional district and in every county in Indiana• More than 1 million children are being raised by LGBT couples or individuals• Estimated 3.1 million live together in same- sex relationships
Indiana Demographics• Estimated same-sex couples make up 3.8% of the population -- 16,328 couples• 11.5 same-sex couples/1000 households in Indianapolis• 3697 same-sex couples raising children
Health Disparities• Bullying victims/hate crimes • 86% report being verbally or physically abused • 44% physically abused at schools • 58% incidence of sexual assault• Rejection by family or caregivers -- 8-fold increase in teen homelessness (25-30%)• 70% of LGBT foster care children are victims of violence; 78% run away or are removed from unhealthy situations
• 6-fold increase in rates of mental health disorders• 2-3-fold increase in substance abuse• higher incidence of obesity and physical inactivity• 8-fold increase rates of attempted suicide and 3-fold increase in successful suicides • 47% have considered suicide • 36% have attempted suicide
• All contributing to: • higher incidence of HTN and cardiovascular disease • higher incidence of bulimia or anorexia • higher prevalence of risky sexual behavior/increased rates of STIs • syphilis outbreaks, HPV, gonorrhea, chlamydia, HIV/AIDS
• Cirrhosis - hep C&B, alcohol• Cancer • breast - obesity, nulliparous, access • cervical - fewer screenings (72% of heterosexual peers) • anal - MSM • prostate/colon/testicular - access • lymphoma/Kaposi’s sarcoma • hepatocellular
Access/Finances• 40% higher overall mortality if uninsured• Health insurance denied to partners • partnered gay men 42% as likely to have employer-sponsored dependent coverage • lesbians: 28% as likely compared to heterosexual peers • costs pushed into the public domain
• IF domestic partnership beneﬁts available, cost may be prohibitive (i.e. a taxed beneﬁt)• COBRA beneﬁts not guaranteed• FMLA and visitation rights denied• Denial of Social Security beneﬁts to surviving partner and children• No legal standing for surviving partner in cases of accidental or negligent death
• IRA rollovers treated as “a stranger” --> lump sum distribution immediately taxed• Immigration law does not recognize legal standing of family of those married legally elsewhere• Some countries: illegal or capital offense• Lack of job protection outside of Indianapolis
Deﬁning Normal• Power + Prejudice = “isms”• Heterosexism: 2nd class citizens deemed to be outside the spectrum of normal human behavior (despite de-classiﬁed as a “disease” state in the U.S. in 1973 and by the World Health Organization in 1990)• The “other”• Subtle and overt messages to gays and lesbians every day:
• Innocent questions • “girl friend?” • hospital/ofﬁce intake forms “marital” status, “spouse” etc• Role models/advertisements• Bullies/jokes/derogatory terms• Pulpit• Newspaper stories of rejection/hate crimes• Institutionalized stigma (1138 federal statutes invoke “marriage”)
Minority Stress• nonconformity to societal norms• stigma = daily stress and conﬂict -- NOT a singular event; LGBT = invisible minority• fear of rejection by family, friends, church, co- workers, employers -- ALL internalize societal prejudice• For SOME --> cycle of self-doubt, shame, risky behaviors and victimization resulting in adverse outcomes
Institute of Medicine• Report from the Institute of Medicine, March 2011 (committee on LGBT Health Issues and Research Gaps and Opportunities/project approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine/was convened at the request of the National Institutes of Health in 2010)key conclusion:
• “The minority stress model attributes the higher prevalence of anxiety, depression, and substance use found among LGB as compared with heterosexual populations to the additive stress resulting from nonconformity with prevailing sexual orientation and gender norms. The committee’s use of this framework is reﬂected in the discussion of stigma as a common experience for LGBT populations and, in the context of this study, one that affects health.”
Suicides• Zachery Gray Billy Lucas• Jack Reese Asher Brown• Raymond Chase Seth Walsh• Kenneth Weishuhn Jay Corey Jones• Tyler Clementi Cody Barker
Brain Drain• Maureen Fitzpatrick, M.D.• Harvard undergrad, son of IUSOM Drs. Larry Cripe and Mimi Jacob• Medical and bioscience researchers ...
Hate Crimes• Matthew Shepherd, Mollie Olgin, Mary Chapa, Ryan Skipper, Max Pelofske ...• FBI Stats: • 2008 1617 against LGBT • 2009 14 hate crimes/day against LGBT • 16% of national hate crimes directed at LGBT individuals
Bottom Line• Most basic human need is to be valued• LGBT identities are within the spectrum of normal human behavior• Families, when disrupted -> fractured social and ﬁnancial safety nets which are vital to one’s health• Marginalization through stigma and discrimination restrict access to health care and adversely affect outcomes
HIV/AIDS• 1.2 million cases in U.S.• 20% unaware -> epidemiologic nightmare• MSM 44-fold increased risk• Young Blacks MSM additional 2-fold risk• $20,000/year/individual for cost of rx, labs, clinic visits
Indiana StateDepartment of Health• January 1, 2011 – December 31, 2011• New HIV Cases: 385 (50% MSM)• New AIDS Cases: 133 (38% MSM)• Total Persons Living with HIV (without an AIDS diagnosis) as of 12/31/2011: 4638• Total Persons Living with AIDS: 5587
Economics• individual case study: $1,260,000 • teen suicide attempt/hospitalization: 25K • AIDS hospitalization: 35K • HIV dx and rx over 40 years: 800K • Hep C labs, liver bx, clinic, rx: 200K • late cancer dx and rx: 200K
Health Beneﬁts of Legal Marriage• Mortality data show that the married state provides the least stress and the greatest social and material support• Holds true regardless of race, ethnicity, socioeconomic status, religion, education, or sexual orientation• The legal and social validation of nontraditional families and relationships positively affects health outcomes
• The Health and Marriage Equality in Massachusetts survey administered by the Massachusetts Department of Public Health in 2009 (5th year of marriage equality): • 72% more committed to partner • 62% families more accepting and supportive • 69% sense of greater acceptance by one’s community • signiﬁcantly less depression and anxiety • reduction in sense of stigmatization and marginalization
• 30% report that one member of the couple receives health beneﬁts from an employer as a result of being married• 82% more likely to come out to a co-worker• 83% more likely to come out to healthcare providers• nearly all respondents (93%) agreed or somewhat agreed that their children are happier and better off as a result of their marriage
• Gay men post-marriage equality • 13% reduction in healthcare visits • 14% reduction in healthcare costs • 50% reduction in high risk behaviors for HIV and STD’s • signiﬁcant reductions in mental health visits and costs regardless of partnered status in 12 months post- legalization
• Lesbian couples post-marriage equality • marriage -> strong predictor of improved physical, psychological and ﬁnancial well being• Midlife and older men with or without HIV/AIDS • independent of multiple variables being legally married was signiﬁcantly protective of mental health disorders • c/w minority stress model affecting youth • general aging-related stressors -- ﬁnancial, loneliness, health concerns
• Danish mortality study post-marriage equality • progressively declining mortality rates with time • overall mortality rates remain high though at about 33% higher than married heterosexual counterparts
Savings?• billing records -> reduction in HTN, depression, and adjustment disorders• 50% reduction in high risk behaviors for HIV and STD’s• 20% reduction in suicide attempts• 14% reduction in healthcare costs• Indiana: assume a 10% reduction in prevalence HIV/AIDS --> $20 million/yr savings in just HIV dx/rx costs alone
• Costs to the state over a generation: $$$ • other medical expenses • disability or unemployment expense • loss of tax revenue: $$$ • epidemiologic effects of homelessness/rejection?? • each high school drop out costs the nation $260,000 • lifetime cost of one year’s national drop outs: $319 billion
AMA• recognizes that denying civil marriage based on sexual orientation is discriminatory and imposes harmful stigma on gay and lesbian individuals and couples and their families;
AAFP• Support civil marriage for same- gender couples to contribute to overall health and longevity, improved family stability and to beneﬁt children of gay, lesbian, bisexual, transgender (GLBT) families.
AMWA• Stands uniﬁed in a broad policy of nondiscrimination against lesbian, bisexual and gay individuals, urging the following: National legislation to end discrimination by sexual orientation in housing, employment, marriage and tax laws, child custody and adoption laws, to redeﬁne family to encompass the full diversity of all family structures and to ratify marriage for gay, lesbian, and bisexual people.
AAP• Support the right of every child and family to the ﬁnancial, psychologic, and legal security that results from having legally recognized parents who are committed to each other and to the welfare of their children.
ISMA• Recognizes that exclusion from civil unions or marriage contributes to health care disparities affecting same-sex households;• Will work to reduce health care disparities among members of same-sex households, including minor children; and• Will support measures providing same-sex households with the same rights and privileges to health care, health insurance and survivor beneﬁts, as afforded opposite-sex households.
House Joint Resolution 6 (HJR-6): [Indiana’s constitutional ban on non-traditional unions]Only a marriage between one man and one woman shall bevalid or recognized as a marriage in Indiana. A legal statusidentical or substantially similar to that of marriagefor unmarried individuals shall not be valid orrecognized.
HJR-6 Timeline:February 2011: HJR-6 passed House and SenateJan-Apr 2013: HJR-6 can be passed for a 2nd timeNov 2014: HJR-6 can be placed on the state election ballot for public vote
Indiana House of Representatives HJR-6 Votes D: 25 11 R: 1 59 Total: 26 70Red: “Yea” to HJR-6Blue: “Nay” to HJR-6
Indiana Senate HJR-6 Votes D: 10 3 R: 0 37 Total: 10 40Red: “Yea” to HJR-6Blue: “Nay” to HJR-6
Impact of HJR-6?• Health/Minority Stress? • Survey to 34,653 LGB individuals in 2001 and 2002 (Wave 1) on a range of psychological health indicators • Same survey in 2004 and 2005 (Wave 2) after 14 states approved constitutional amendments limiting marriage to opposite-sex unions
• Economic/competitive disadvantage? • Dr. Fitzpatrick ... • Researchers at Lilly, IUMC, ... • State stigmatized as non-inclusive, non- welcoming • Public Health $$ spent??
Revenues• Williams Institute/UCLA School of Law and Lee Badgett, professor of economics, Amherst, senior policy director for public health in Massachusetts • Marriage/tourism • tax revenues
• Massachusetts: an estimated $111 million to the state economy.• New York City: an estimated $259 million in economic impact and $16 million in City revenues.• Washington D.C. : $52.2 million over three years, which would generate increases in local government tax and fee revenues by $5.4 million and create approximately 700 new jobs.• Iowa: $12 to $13 million boost; likely to have added $850,000 to $930,000 in tax revenue to state and local coffers
National Impact• If same-sex marriage rights were granted nationwide, same-sex weddings would generate a net $1 billion each year for the Federal budget over the next 10 years, according to a 2004 report by Congressional Budget Ofﬁce. Thats after taking into account lower income and estate tax revenues as well as increased spending for health-care beneﬁts and Social Security.
What can we do?
Resolved, that we supporters of OneVoiceIndiana: The IndianaCoalition for Lesbian/Gay/Bisexual/Transgender Health andNondiscrimination:(1) afﬁrm, in concurrence with the American Medical Associations June2011 policy H-65.973 Health Care Disparities in Same-Sex Partner Households,that denying civil union or marriage based on sexual orientation, asproposed by HJR-6, is discriminatory and imposes harmful stigma on gayand lesbian individuals and couples and families;(2) recognize that individuals who are LGBT fall within the spectrum ofnormal human experience; and(3) do, therefore, in the interest of optimal public health outcomes and in theeconomic interests of our state oppose legislation, such as HJR-6, that not onlymarginalizes and discriminates against a particular minority group, but alsoeffectively precludes further bipartisan rational discourse relative tomeasures!which!may offer!legal and social validation of non-traditional couplesand their families.
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Lesbian/Gay/Bisexual TransgenderPublic Health Issues William C. Bufﬁe, M.D. OneVoiceIndiana.org
Appendix for healthcare institutions and medical providers
Human Rights Campaign• Healthcare Equality Index (HEI) • 2011: 375 institutions nationally • Only 2 in Indiana -- Ball Memorial and Clarian (now IU Health)• Rating Criteria:
• Patient nondiscrimination policies • includes sexual orientation/gender identity• Visitation policies • equal access for same-sex couples or parents• Cultural competency training and client services• Employment policies and beneﬁts
Welcoming Strategies• intake forms • relationship status - M/S/D/W/Partnered • partner/spouse• social history questionnaires • Gender identity - M/F/transgender • sexual orientation • hit or threatened
• Inclusive (non-heterosexual) language • “signiﬁcant other?” • intentionally non-judgemental, inviting • not a “lifestyle”
• Visual cues demonstrating inclusivity and awareness• Cultural competency training for staff• Non-discrimination policies for patients and staff• Respect (through policies) visitation rights and healthcare decision-making rights• Support legislative efforts that afford equal access to health care
Medical Encounter• History focused on speciﬁc risk factors: • anxiety/depression • sexual history - risky behaviors; safe sex • substance abuse • suicidal ideation • family acceptance • victimization/bullying
• Vaccination status • hepatitis A and B • HPV • HIV?
Education• For patients • www.itgetsbetter.org • www.thetrevorproject.org • Indiana Youth Group • PFLAG• For Physicians:• www.glma.org, www.lgbthealth.net