OneVoice Research 2012


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OneVoice Research 2012

  1. 1. Lesbian/Gay/Bisexual TransgenderPublic Health Issues William C. Buffie, M.D.
  2. 2. Key Points• Disparities in outcomes• Reasons: “Minority stress” and unequal access to health care• Economic implications• Role of Family• Role of Stigma
  3. 3. Bias• family, friends, patients• research, Christian Pluralist, author• state medical association advocacy work since 2007 ... American Journal of Public Health article June 2011
  4. 4. 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”?
  5. 5. Data• evidence-based• peer-reviewed• validated by expert consensus --> policies and position statements:
  6. 6. • 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)
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. • 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
  11. 11. • 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
  12. 12. • 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
  13. 13. WHY?
  14. 14. 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
  15. 15. • 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
  16. 16. • 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
  17. 17. 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:
  18. 18. • 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”)
  19. 19. 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
  20. 20. 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:
  21. 21. • “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.”
  22. 22. Suicides• Zachery Gray Billy Lucas• Jack Reese Asher Brown• Raymond Chase Seth Walsh• Kenneth Weishuhn Jay Corey Jones• Tyler Clementi Cody Barker
  23. 23. Brain Drain• Maureen Fitzpatrick, M.D.• Harvard undergrad, son of IUSOM Drs. Larry Cripe and Mimi Jacob• Medical and bioscience researchers ...
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. • 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
  31. 31. • 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
  32. 32. • 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
  33. 33. • 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
  34. 34. • 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
  35. 35. 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
  36. 36. • 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
  37. 37. 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;
  38. 38. 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.
  39. 39. 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.
  40. 40. 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.
  41. 41. 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.
  42. 42. Current State ofMarriage Equality
  43. 43. • Subject: Critical Decision Unit meeting When: Thursday, November 29, 2012 7:00 AM-8:00 AM. Where: 2nd floor Administrative Conference Room (Administration)
  44. 44. 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.
  45. 45. 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
  46. 46. Indiana House of Representatives HJR-6 Votes D: 25 11 R: 1 59 Total: 26 70Red: “Yea” to HJR-6Blue: “Nay” to HJR-6
  47. 47. Indiana Senate HJR-6 Votes D: 10 3 R: 0 37 Total: 10 40Red: “Yea” to HJR-6Blue: “Nay” to HJR-6
  48. 48. 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
  49. 49. Constitutional No Constitutional Disorder Amendment Amendment Wave 1, % Wave 2, % Change, % AOR Wave 1, % Wave 2, % Change, % AORAny mood disorder 22.7 31.0 36.6 1.67* 22.5 17.2 -23.6 0.69Generalized Anxiety 2.7 9.4 248.2 4.20* 5.6 8.2 48.0 1.54 Disorder Alcohol Disorder 21.7 30.8 41.9 1.80* 16.4 21.2 28.9 1.41Comorbid Disorder 17.6 27.6 36.3 2.00* 13.7 14.9 8.5 1.11 * P<0.05, Significant difference before and after amendment
  50. 50. • Economic/competitive disadvantage? • Dr. Fitzpatrick ... • Researchers at Lilly, IUMC, ... • State stigmatized as non-inclusive, non- welcoming • Public Health $$ spent??
  51. 51. 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
  52. 52. • 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
  53. 53. 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.
  54. 54. What can we do?
  55. 55. 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.
  56. 56. Bibliography(1) Gates GJ. Same-sex couples and the gay, lesbian, bisexual population: new estimates from theAmerican Community Survey. Available at: Published October 2006.Accessed February 14, 2011.(2) Center for Health Promotion. National Survey of Sexual Health and Behavior. Available at: Accessed February 14, 2011.(3) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps andOpportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation forBetter Understanding. The Institute of Medicine. Copyright 2011 by the National Academy of Sciences.(4) Buffie WC. Public Health Implications of Same-Sex Marriage. Am J Public Health. 2011;101(6):986-990.(5) Australian Medical Association. Position Statement on Sexual Diversity and Gender Identity.Kingston, Australian Capital Territory: Australian Medical Association; 2002.(6) Riggle E, Rostosky S. The consequences of marriage policy for same-sex couples’ well-being. In:The Politics of Same-Sex Marriage. Chicago, IL: University of Chicago Press; 2007(7) Levitt H, Ovrebo E, Anderson-Cleveland M, et al. Balancing dangers: GLBT experience in a timeof anti-GLBT legislation. J Couns Psychol. 2009;56(1):67-81.(8) Pawelski JG, Perrin D, Foy J, et al. The effects of marriage, civil union, and domestic partnershiplaws on the health and well-being of children. Pediatrics. 2006;118(1):349-364.(9) Ryan C, Huebner D, Diaz R, Sanchez J. Family rejection as a predictor of negative healthoutcomes in White and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009;123(1):346-352.
  57. 57. (10) Cochran SD, Sullivan JG, Mays V. Prevalence of mental disorders, psychological distress andmental health services use among lesbian, gay and bisexual adults in the United States. J Consult ClinPsychol. 2003;71(1):53-61.(11) Hatzenbuehler ML, McLaughlin K, Keyes K, Hasin D. The impact of institutional discriminationon psychiatric disorders in lesbian, gay, and bisexual populations: a prospective study. Am J PublicHealth. 2010;100(3):452-459.(12) Johnson NJ, Backlund E, Sorlie P, Loveless C. Marital status and mortality: the NationalLongitudinal Mortality Study. Ann Epidemiol. 2000;10(4):224-238.(13) Herdt G, Kertzner R. I do, but I can’t: the impact of marriage denial on the mental health andsexual citizenship of lesbians and gay men in the United States. Sex Res Soc Policy. 2006;3(1):33-49.(14) Centers for Disease Control and Prevention. Marital status and health: United States, 1999-2002. Adv Data. 2004:351. Available at Accessed February14, 2011.(15) Ramos C, Goldberg NG, Badgett MV. The effects of marriage equality in Massachusetts: a surveyof the experiences and impact of marrage on same-sex couples. Available at Accessed April 15, 2012.(16) Wilper AP, Woolhandler S, Lasser K, McCormick D, Bor D, Himmelstein D. Health insuranceand mortality in US adults. Am J Public Health. 2009;99(12):2289-2295.(17) Ponce N, Cochran S, Pizer J, Mays V. The effects of unequal access to health insurance for same-sex couples in California. Health Aff (Millwood). 2010;29(8):1539-1548.
  58. 58. (18) Hatzenbuehler ML, O’Cleirigh C, Grasso C, Mayer K, Safren S, Bradford J. Effect of same-sexmarriage laws on health care use and expenditures in sexual minority men: a quasi-naturalexperiment. Am J Public Health. 2012;102(2):285-291.(19) Badgett MVL. Will providing marriage rights to same-sex couples undermine heterosexualmarriage? Sex Res Soc Policy. 2004;1(3):1-10.(20) Wainright JL, Russell S, Patterson C. Psychological adjustment, school outcomes, and romanticrelationships of adolescents with same-sex parents. Child Dev. 2004;75(6):1886-1898.(21) American Medical Association. H-65.973 Health care disparities in same-sex partner households.Available at 2009. Accessed March 26, 2012.(22) American Bar Association. Resolution 111. Available at 2010. Accessed March 26, 2012.(23) American Medical Women’s Association. Position paper on principals of lesbian health issues.Available at Accessed April 11, 2012.(24) American Psychiatric Association. Support of legal recognition of same-sex civilmarriage: position statement. Arlington (VA): APA; 2005. Available at:http://archive. March 26, 2012.(25) North Carolina Psychological Association. Position statement opposing defenseof marriage amendment. Available at Accessed April 12, 2012.(26) Indiana State Medical Association. Resolution 11-32A. Available at (Click on “Health Care System”). 2011.Accessed April 12, 2012.
  59. 59. (27) Indiana General Assembly. First regular session 117th general assembly (2011). House EnrolledJoint No. 6. Available at 2011.Accessed March 23, 2012.(28) Rothblum, Emily, et al. Journal of Homosexuality(29) U.S. Department of Health and Human Services/Substance Abuse and Mental Health ServicesAdministration/Center for Substance Abuse Prevention: Top Health Issues for LGBT PopulationsInformation and Resource Kit, 2012(30) Hatzenbuehler et al. Am J of Public Health; 2012 Feb; 102 (2): 285-91. Effect of same-sexmarriage laws on health care use and expenditures in sexual minority men: a quasi-natural experiment.(31) Ducharme JK, Kollar MM. J of Homosexuality; 2012 April; 59 (4): 580-91. Does the “MarriageBenefit” extend to same-sex union?: evidence from a sample of married lesbian couples in Massachusetts.(32) Wight RG, et al. AM J of Public Health; 2012 March; 102 (3): 503-10. Stress and mental healthamong midlife and older gay-identified men.(33) Buchmueller T, Carpenter C. Am J of Public Health; 2010, March; 100 (3): 489-95. Disparities inHealth Insurance Coverage, Access, and Outcomes for Individuals in Same-Sex versus Different-SexRelationships, 2000-2007.(34) Ponce N, et al. Health Affairs; 2010 June; 29 (8): 1539-48. The Effects of Unequal Access to HealthInsurance For Same-Sex Couples in California.(35) Buchmueller T, Carpenter C. 2011 July; Draft: The Effect of Requiring Private Employers to ExtendHealth Benefit Eligibility to Same-Sex Partners of Employees: Evidence from California.(36) Amos, Jason. Alliance for Excellent Education: 2008. Dropouts, Diplomas, and Dollars: U.S. HighSchools and the Nation’s Economy.(37) Hatzenbuehler ML. Pediatrics; 2011 May; 127 (5): 896-903. The Social Environment and SuicideAttempts in Lesbian, Gay, and Bisexual Youth.(38) Klausner JD, et al. Journal of Homosexuality; 2006: 51(4): 137-144. Same-sex DomesticPartnerships and Lower Risk behaviors for STD’s, including HIV Infection.
  60. 60. Lesbian/Gay/Bisexual TransgenderPublic Health Issues William C. Buffie, M.D.
  61. 61. Appendix for healthcare institutions and medical providers
  62. 62. Human Rights Campaign• Healthcare Equality Index (HEI) • 2011: 375 institutions nationally • Only 2 in Indiana -- Ball Memorial and Clarian (now IU Health)• Rating Criteria:
  63. 63. • 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
  64. 64. 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
  65. 65. • Inclusive (non-heterosexual) language • “significant other?” • intentionally non-judgemental, inviting • not a “lifestyle”
  66. 66. • 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
  67. 67. Medical Encounter• History focused on specific risk factors: • anxiety/depression • sexual history - risky behaviors; safe sex • substance abuse • suicidal ideation • family acceptance • victimization/bullying
  68. 68. • Vaccination status • hepatitis A and B • HPV • HIV?
  69. 69. Education• For patients • • • Indiana Youth Group • PFLAG• For Physicians:•,