1. Lesbian/Gay/Bisexual
Transgender
Public Health Issues
William C. Buffie, M.D.
OneVoiceIndiana.org
2. Key Points
• Disparities in outcomes
• Reasons: “Minority stress” and unequal
access to health care
• Economic implications
• Role of Family
• Role of Stigma
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. 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”?
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. 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. 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. 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. • 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. • 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. • 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
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. • 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. • 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. 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. • 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. 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. 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. • “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. Suicides
• Zachery Gray Billy Lucas
• Jack Reese Asher Brown
• Raymond Chase Seth Walsh
• Kenneth Weishuhn Jay Corey Jones
• Tyler Clementi Cody Barker
23. Brain Drain
• Maureen Fitzpatrick, M.D.
• Harvard undergrad, son of IUSOM Drs.
Larry Cripe and Mimi Jacob
• Medical and bioscience researchers ...
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. 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. 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. Indiana State
Department 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. 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. 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. • 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. • 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. • 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. • 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. • 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. 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. • 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. 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. 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. 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. 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. 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.
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 be
valid or recognized as a marriage in Indiana. A legal status
identical or substantially similar to that of marriage
for unmarried individuals shall not be valid or
recognized.
45. HJR-6 Timeline:
February 2011: HJR-6 passed House and Senate
Jan-Apr 2013: HJR-6 can be passed for a 2nd time
Nov 2014: HJR-6 can be placed on the state election ballot for public vote
46. Indiana House of
Representatives
HJR-6 Votes
D: 25 11
R: 1 59
Total: 26 70
Red: “Yea” to HJR-6
Blue: “Nay” to HJR-6
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
50. • Economic/competitive disadvantage?
• Dr. Fitzpatrick ...
• Researchers at Lilly, IUMC, ...
• State stigmatized as non-inclusive, non-
welcoming
• Public Health $$ spent??
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. • 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. 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. That's after taking into
account lower income and estate tax
revenues as well as increased spending for
health-care benefits and Social Security.
55. Resolved, that we supporters of OneVoiceIndiana: The Indiana
Coalition for Lesbian/Gay/Bisexual/Transgender Health and
Nondiscrimination:
(1) affirm, in concurrence with the American Medical Association's June
2011 policy H-65.973 Health Care Disparities in Same-Sex Partner Households,
that denying civil union or marriage based on sexual orientation, as
proposed by HJR-6, is discriminatory and imposes harmful stigma on gay
and lesbian individuals and couples and families;
(2) recognize that individuals who are LGBT fall within the spectrum of
normal human experience; and
(3) do, therefore, in the interest of optimal public health outcomes and in the
economic interests of our state oppose legislation, such as HJR-6, that not only
marginalizes and discriminates against a particular minority group, but also
effectively precludes further bipartisan rational discourse relative to
measures!which!may offer!legal and social validation of non-traditional couples
and their families.
56. Bibliography
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60. Lesbian/Gay/Bisexual
Transgender
Public Health Issues
William C. Buffie, M.D.
OneVoiceIndiana.org
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. • 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. 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. • Inclusive (non-heterosexual) language
• “significant other?”
• intentionally non-judgemental, inviting
• not a “lifestyle”
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. Medical Encounter
• History focused on specific risk factors:
• anxiety/depression
• sexual history - risky behaviors; safe sex
• substance abuse
• suicidal ideation
• family acceptance
• victimization/bullying