JPOSNA® Special Edition
2022 Annual Meeting Pre-Course on Diversity, Equity, and Inclusion
Poorer Health in the LGBTQ+ Community Due to Fear of Mistreatment
Yale School of Medicine, New Haven, CT
Correspondence: Corinna CD Franklin, MD, FAOA, Yale School of Medicine, 47 College St., Suite 205, New Haven, CT 06517. E-mail: [email protected]
Received: November 30, 2022; Accepted: November 30, 2022; Published: February 15, 2023
Volume 5, Number S1, February 2023
Abstract
LGBTQ patients face both discrimination and unequal access to care, while also being more likely to experience conditions such as depression, suicide, and substance use, and to be victims of violence and harassment. Discrimination or the fear of it may deter these patients and families from seeking care. It is incumbent upon us to make LGBTQ patients and families feel welcome in our practices in order to allow them to get the best possible pediatric orthopaedic care.
Key Concepts
- The LGBTQ population lacks equal access to care.
- Discrimination or the fear of it discourages LBGTQ people from seeking care.
- POSNA and its members can help LGBTQ patients and families feel welcome by using correct pronouns and inclusive language, displaying or wearing welcoming symbols, and conducting and promoting research into LGBTQ-related issues within pediatric orthopaedics.
Introduction
Caring for marginalized or underserved communities can be fraught with challenges. Doing so well requires openness, sensitivity, and a willingness to learn. The LBGTQ community, though making gains in terms of acceptance, rights, and visibility, still suffers substantial mistreatment in medicine. This can lead to poorer access to care and ultimately poorer health.
Access to Care
Multiple studies have demonstrated that the LGBTQ population lacks equal access to healthcare. Heck et al. found in 2006 that women in same-sex relationships were significantly less likely to have health insurance, have seen a doctor, or have a usual source of healthcare.1 More recently, a 2018 UCLA policy brief noted that in California, despite having similar or better rates of insurance coverage, lesbian, gay, and bisexual women and men are more likely to experience delays in getting needed healthcare.2 Finally, a 2010 study by Grant et al. in which 6,450 transgender men and women were surveyed found that 28% had delayed seeking care because of past discrimination. Furthermore, 19% had experienced outright denial of care, either from doctors or insurance companies.3
Report from the Institute of Medicine
In 2011, the NIH commissioned an Institute of Medicine report on the health of lesbian, gay, bisexual, and transgender people.4 They assembled a consensus committee comprising experts in mental health, biostatistics, clinical medicine, adolescent health and development, aging, parenting, behavioral sciences, HIV research, demography, racial and ethnic disparities, and health services. They concluded that LGBT youth have higher rates of
- suicide and depression,
- smoking and alcohol and substance use,
- homelessness, and
- violence, victimization, and harassment.
They also found that the burden of HIV falls disproportionately on young, Black men. They made a number of recommendations, with the most pertinent for POSNA including
- Data on sexual orientation and gender identity should be collected in electronic health records.
- NIH should encourage grant applicants to address explicitly the inclusion or exclusion of sexual and gender minorities in their samples.
Survey from the Center for American Progress—How Is the LGBTQ Community Treated by Healthcare Professionals?
In 2017, the Center for American Progress (CAP) conducted a survey to better understand how LGBTQ patients experience healthcare.5 For patients who are lesbian, gay, bisexual, or queer, between 6–9% reported difficulties with health professionals, ranging from denial of care or refusal to acknowledge their family to abusive language to unwanted physical contact. These numbers are far worse for transgender patients. Twenty-nine percent of these patients said a physician or other healthcare professional refused to see them, 23% said they were misgendered or called the wrong name, 21% experienced harsh or abusive language, and 29% encountered unwanted physical contact. The CAP concluded that discrimination or the fear of it discourages LGBTQ people from seeking care; 8% of all LGBTQ and 22% of transgender respondents reported avoiding or postponing needed medical care for these reasons.
Mental Health in LGBTQ Youth—Data from the Trevor Project
The Trevor Project conducts a yearly survey on the mental health of LGBTQ youth. The 2022 results included nearly 34,000 respondents, of whom 45% were LGBTQ youth of color and 48% transgender or nonbinary.6 They found that nearly half of their respondents considered suicide in the past year and that 60% of LGBTQ youth who wanted mental healthcare in the past year did not get it. Almost three-quarters of the youth taking the survey indicated that they had experienced discrimination.
A positive finding from the report included that living in accepting communities mitigated suicide risk. The report also outlined the top five ways LGBTQ youth felt supported by parents or caregivers (Figure 1).
Figure 1. In a 2022 Survey on the Mental Health of LGBTQ Youth, The Trevor Project Outlined the Top Five Ways LGBTQ Youth Felt Supported by Parents or Caregivers. View the Entire Report at: https://www.thetrevorproject.org/survey-2022/.

LGBTQ Care in Pediatric Orthopaedics
Little research has been performed on care for LGBTQ patients in pediatric orthopaedics. However, a recent study by Feroe et al. looked at pediatric orthopaedic professionals’ attitudes towards and knowledge of caring for LGBTQ patients. Their survey had 81 respondents from Boston Children’s Hospital and Nationwide Children’s Hospital. Encouragingly, they did find that most respondents felt comfortable treating LGBTQ patients, but that fewer felt confident in their own understanding of the needs of these patients (particularly trans patients). Most respondents were interested in learning more.7
Legislative Threats
It is impossible to discuss this topic without referencing the myriad anti-transgender bills and directives that have been proposed and promoted in the last several years—more than 80 in 2021 alone.8 These bills and orders seek to deny trans youth gender-affirming care, prevent them from participating in sports, and keep them from using the bathrooms that conform to their identity. It should be noted in particular that if gender-affirming care for youth is criminalized, parents may limit seeking out non-urgent orthopaedic care for fear of being reported, thus creating a potential crisis in care for these patients.
What Can We Do?
In our practices, we can use inclusive language and ask about identity and pronouns, which should be asked of everyone and documented in the medical record. We can display welcoming signs and/or wear lanyards and pins to silently show our LGBTQ patients that they are safe in our practices. It is best to avoid making assumptions about family structure and orientation. We can employ a diverse staff and colleagues. Finally, we can all understand that we have more to learn and seek appropriate education so that we are better able to care for this population.
As the larger POSNA community, we can engage in research to understand the health needs and disparities of LGBTQ patients. We must welcome and support LGBTQ colleagues and students. And we can join with groups like the American Academy of Pediatrics (AAP) to oppose anti-trans legislation and advocate for the safety of our patients.
Conclusion
LGBTQ patients face many barriers to getting the care that they need and deserve. However, it is evident that as a community we are eager to do better for these patients. In taking steps as individual practitioners and as POSNA as a whole, we can lead the way in treating the LGBTQ community correctly.
Disclaimer
The author has no conflicts of interest to report.
References
- Heck JE, Sell RL, Gorin SS. Health care access among individuals involved in same-sex relationships. Am J Public Health. 2006;96(6):1111-1118.
- Wolstein J, Charles SA, Babey SH, et al. Disparities in health care access and health Among Lesbians, Gay Men, and Bisexuals in California. Policy Brief UCLA Cent Health Policy Res. 2018;2018(9):1–8.
- Grant JM, Mottet LA, Tanis J, et al. National Transgender Discrimination Survey Report on Health and Health Care. Findings of a Study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force. KEY HEALTH CARE FINDINGS; 2010.
- Institute of Medicine (US) Committee on Lesbian GB and THI and RG and O. The Health of Lesbian, Gay, Bisexual, and Transgender People. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Published online June 24, 2011: 1-347. doi:10.17226/13128
- Discrimination Prevents LGBTQ People From Accessing Health Care - Center for American Progress. Available at: https://www.americanprogress.org/article/discrimination-prevents-lgbtq-people-accessing-health-care/. Accessed July 26, 2022.
- The Trevor Project: 2022 National Survey on LGBTQ Youth Mental Health. Available at: https://www.thetrevorproject.org/survey-2022/. Accessed July 26, 2022.
- Feroe AG, Hutchinson LE, Miller PE, et al. Knowledge, attitudes, and practices in the orthopaedic care of sexual and gender minority youth: a survey of two pediatric academic hospitals. Clin Orthop Relat Res. 2022;480(7):1313-1328.
- 2021 Officially Becomes Worst Year in Recent History for LGBTQ State Legislative Attacks as Unprecedented Number of States Enact Record-Shattering Number of Anti-LGBTQ Measures Into Law - Human Rights Campaign. Available at: https://www.hrc.org/press-releases/2021-officially-becomes-worst-year-in-recent-history-for-lgbtq-state-legislative-attacks-as-unprecedented-number-of-states-enact-record-shattering-number-of-anti-lgbtq-measures-into-law. Accessed July 26, 2022.