Mental Health

 

NATIONAL HEALTH LINE

LGBTQ Capacity Building in Health Care Systems: A Social Work Imperative

Darrell P. Wheeler and Sarah-Jane Dodd

W orking within a diverse array of health care settings, social workers encounter a variety of client populations, many

of whom we are well prepared to serve. We have specialties in working with children, adolescents, and older adults with mental illnesses, substance use issues, or particular bealth care concerns such as HIV As a profession, we have begun to pay atten- tion to racial and ethnic health disparities that may cut across each of these groups and have actively engaged in efforts of cultural competence. However, we have not, until recently, paid attention to the health disparities and particular health care needs of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) population.

Estimates of the size of the LGBTQ population in the United Sates vary, with Kinsey’s (1948) 10 percent estimate holding almost mythical status. However, a recent estimate generated by Gary Gates at the Williams Institute, who cross-compared a number of different population surveys, put the number of LGB individuals at approximately 3.5 percent of the population and transgender individu- als at 0.3 percent (Gates,2011). Gates noted that this amounts to “9 million LGBT Americans, a figure roughly equivalent to the population of New Jersey” (p. 1). Given this prevalence, it is likely that all social workers will encounter LGBTQ clients on their caseload whether or not they overtly identify their orientation or gender identity.

Throughout history the dominance of a het- eronormative paradigm has resulted in LGBTQ individuals experiencing stigmatization and dis- crimination. This discrimination may manifest as verbal or physical assaults (Kosciw, Greytak, Diaz, & Bartkiewicz, 2010) or as policies that render these individuals’ relationships invisible (such as not being eligible for a life-partner’s social security benefits).

Having been socialized in a cultural environment that is at best beteronormative and at worst ho- mophobic, health care providers frequently make assumptions of heterosexuality in the questions they ask their patients. In turn, patients anticipate that disclosure of sexual orientation will negatively aff< ct the care they receive (James & Platzer, 1999).

The impact of stigmatization of and discrimina- tion against LGBTQ individuals is the potential for uneven care when accessed, or avoidance I of care altogether, resulting in disparities emergi ig within health issues because many unaddress;d social, contextual, psychological, developmental, interpersonal, and environmental factors can pro- duce deleterious outcomes (Mayer et al., 200E)). The extent of these disparities is sufficient cat: se for concern that the U.S. Department of Health and Human Services has elevated sexual orienta- tion from a noted disparity in their Health People 2010 (U.S. Department of Health and Human Services, 2000) objectives to a target group tor concern and improvement in Healthy People 2020 (see http://www.healthypeople.gov/2020/ topicsobjectives2020/default.aspx). Social work- ers have an important role to play in helping to address this charge.

Social work’s values, as articulated by the NASiW Code of Ethics (NASW, 2008), call on us not oAly to honor the dignity and worth of all persons and to promote social justice, but also to more actively “challenge social injustice,” noting that social woik- ers should “pursue social change, particularly w:th and on behalf of vulnerable and oppressed in(h- viduals and groups of people” (p. 5). Social works rs, therefore, have an ethical imperative to increase th îir capacity to provide culturally competent services to clients of all sexual orientations and gender identitî es, shedding assumptions of heterosexuahty and creating

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more inclusive practices. They should also actively engage in the LGBTQ competency training for aU health professionals.

INEQUALITIES, SOCIAL JUSTICE, AND NEGATIVE HEALTH INDICATORS Recently, the Joint Commission for the Accreditation of Health Care Organizations set for a “road map” detailing requirements for the inclusion of LGBTQ foci within health care settings (Joint Commission, 2010). This document highlights the relevance of this inclusion for health care professionals in several areas, including patient—family engagement, patient assessment, and end-of-life care and directives. For social workers and health care professionals, one of the challenges to effectively implementing these recommendations is having a sufficient database from which we can measure successes.

ABSENCE OF DATA The research available suggests that LGBTQ populations suffer disproportionately from a range of conditions and are at disproportionate risk for others, including obesity, depression, anxiety, sub- stance use and abuse, tobacco use, HIV and other sexually transmitted infections, some cancers, and inadequate cancer screenings (Hussey, 2006; Mayer et al,, 2008; MiUett, Flores, Peterson, & Bakeman, 2007). However, the fuU extent of these disparities and potential others is not known because most studies do not ask about sexual orientation or gen- der identity and, therefore, render this population and their particular health care needs invisible.This invisibility was substantiated by Boehmer (2002), whose content analysis of 20 years of MEDLINE articles (English language only) found that only 0.1 percent addressed LGBT issues. So, for example, her search for “breast cancer” found 26,554 articles, yet only six of those considered LGBT individuals as a separate part of their analysis. The widespread neglect of LGBTQ individuals in public health re- search has devastating consequences for the health of the LGBTQ community. Similar to when health care research and drug trials focused on men and generalized the results to women, the exclusion of sexual orientation as a variable of study prevents the identification of lower or higher prevalence rates of particular diseases among LGBTQ individuals. A potentially catastrophic example of omission was evident in a 28-page special issue of Morbidity and Mortality Weekly Report (Centers for Disease Con-

trol and Prevention, 2004; Kadour, 2005). Despite considerable consensus about the potential for gay youths to be at risk for suicide, the special report made no mention of sexual orientation (Kadour, 2005). As Kadour (2005) pointed out, “data are a cornerstone of any public health system, and the lack of data on sexual minorities correlates with the failure of public health to address this group’s needs” (p. 31).

Health disparities have been defined as”a chain of events signified by a difference in: (1) environment, (2) access to, utilization of, and quality of care, (3) health status, or (4) a particular health outcome that deserves scrutiny” (Carter-Pokras & Baquet, 2002, p. 427). Although “disparities,” “inequities,” and “inequalities” are sometimes used interchangeably, there are nuanced differences between the terms. The term “health disparity” is often used within the United States, whereas the terms “health inequity” or “health inequality” are used more frequently overseas (Carter-Pokras & Baquet, 2002). Although disparity and inequality are defined as synonymous, representing differences in access or opportunity, inequity suggests some level of ethical judgment that is unfair or unjust (Carter-Pokras & Baquet, 2002). For this reason, some health disparities or inequalities may be unavoidable and “fair,” perhaps because of biological predisposition, for example; an inequity is seen as unfair and has the potential to be avoided. Therefore, it is LGBTQ health disparities created by inequities that social workers have the potential to address through active intervention and capacity building.

The coupling of health insurance and employ- ment in the United States means that employment discrimination experienced by LGBTQ individuals has a negative impact on their access to health insur- ance. Lack of recognition of LGBTQ families means that even when available to workers, health benefits may not also be extended to same-sex partners or their children. These discriminatory patterns and impacts may hold especially true for transgender or gender-nonconforming individuals.

CAPACITY BUILDING AND CHANGE For professional social workers, these service dilem- mas and gaps point to areas for educational, practice, and policy capacity building. Clients’ needs and contextual changes facing service delivery, monitor- ing, and payment systems require that professional social workers incorporate skills allowing them

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to assist LGBTQ clients and their allies as well as challenge forces that oppose full health care services for people on the basis of their gender identity or sexual orientation.

Social work has an ethical commitment to social justice and advocacy on behalf of vulnerable and disadvantaged populations. Given that commitment, social workers can come together to help eradicate health disparities experienced by LGBTQ people.

Several policy initiatives have the potential to create positive change and reduce the disparities in LGBTQ health markers and risks. Social workers should advocate for changes that

• require the sensitive and appropriate collection of demographic information related to sexual orientation and gender identity. Such data are typically unavailable and, therefore, cannot be used to inform LGBTQ-specific health initiatives (Gates, 2011; Silvestre, 2003).

• promote policies that end workplace dis- crimination, given that in the United States, access to health insurance is largely employer driven.

• promote policies that support same-sex partner access to health insurance for all and removal of the tax burden for those who take advantage of the health benefits.

• require units on working with LGBTQ pa- tients in the training curriculums for all health professionals (medical doctors, registered nurses, occupational therapists, psychothera- pists, social workers, and so forth).

• support funding research that examines health disparities within LGBTQ populations and the LGBTQ cultural competence of health providers so that we can understand both the needs of the population and the specific train- ing needs of those who teach them.

REFERENCES Boehmer, U. (2002). Twenty years of public health research:

Inclusion of lesbian, gay, bisexual, and transgender populations. American Journal of Public Health, 92, 1125-1130.

Carter-Pokras, Q , & Baquet, C. (2002). What is a “health disparity”? Public Health Reports, 117, 426-434.

Centers for Disease Control and Prevention. (2004). Suicide and attempted suicide [Special issue]. Mortality and Morbidity Weekly Report, 53.

Gates, G. (2011). How many people are lesbian,gay, bisexual, and transgender? Los Angeles:The Williams Institute, UCLA School of Law.

Hussey,W. (2006). Slivers of the journey: The use of pho- tovoice and storytelling to examine female to male

transexuals’ experience of health care access. Journal of Homosexuality, 51, 129-158.

James,T, & Platzer, H. (1999). Ethical considerations in qualitative research with vulnerable groups: Exploring lesbians’ and gay men’s experiences of health care—A personal perspective. Nursing Ethics, 6(1), 7 3 – 8 1 .

joint Commission. (2010). Advancing effective communicatio cultural competence, and patient- and family-centered care. A roadmapfor hospitals. Oakbrook Terrace, lL:Autho

Kadour, R. (2005). The power of data, the price of exclu sion. Oay & Lesbian Review, •/2(1),31—33.

Kinsey,A. (1948). Sexual behavior in the human male. Bloomington: Indiana University Press.

Kosciw,J., Greytak, E., Diaz, E., & Bartkiewicz, M. (2OIOi). Tlie 2009 National School Climate Survey: Ttie experi-l enees of lesbian, gay, bisexual and transgender youth in oi nation’s schools. NewYork: GLSEN.

Mayer, K. H., Bradford, j . B., Makadon, H. J., Stall, R. S., Goldhammer, H., & Landers, S. (2008). Sexual gene minority health:What we know and what needs to be done. American Journal of Public Health, 98, 989-995.

Millett, G.A., Flores, S.A., Peterson,j. L., & Bakeman, R. (2007). Explaining disparities in HIV infection among black and white men who have sex with m A meta-analysis of HIV risk behaviors./1/DS, 21, 2083-2091.

National Association of Social Workers. (2008). Code of ethics of the National Association of Social Workers. Washington, DC: Author.

Silvestre, A. (2003). Ending health disparities among vul- nerable LG13T people. Clinical Research and Regulati ry Affairs, 20(2), ix-xii.

U.S. Department of Health and Human Services. (2000, November). Healthy People 2010: Understanding and improving health (2nd ed.). Washington, DC: U.S. Government Printing Office.

Darrell P. Wheeler, PhD, MPH, is dean and profes

Graduate School of Social Work, Loyola University Chicago,

820 North Michigan Avenue, Chicago, IL 60611; e-nihil:

dwheeler@luc.edu. Sarah-Jane Dodd, PhD, is associate profes-

sor, Sitberman School of Social Work, City University of Net

York, Hunter College.

WHEELER AND D O D D / LCBTQ Capacity Building in Health Care Systems: A Social Work Imperative 309