How COVID-19 has amplified LGBTQ health care inequities

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

AMA Chief Experience Officer Todd Unger speaks with AMA Director Health Equity Policy & Advocacy Mia Keeys, associate professor of NYU Grossman School of Medicine Richard E. Greene, MD, MPHE, and CEO and co-founder of Queerly Health Derrick Reyes, MA-HSDI, on updates regarding COVID-19 including the impact of the COVID-19 pandemic on the LGBTQ community and how it has amplified disparities in health care within the LGBTQ population.

Learn more at the AMA COVID-19 resource center.

Unger: Hello, this is the American Medical Associations COVID-19 update. Today we're discussing COVID-19's impact on the LGBTQ community. I'm joined today by Mia Keeys, the AMAs health equity policy director in Washington, D.C. Ms. Keeys uses she, her, hers pronouns. Dr. Richard Greene, associate professor at NYU Grossman School of Medicine in New York. Dr. Green uses he, him, his pronouns. Derrick Reyes, CEO and co-founder of Queerly Health in New York. Mx. Reyes uses they, them, theirs pronouns. I'm Todd Unger, AMA's chief experience officer in Chicago. I use he, him, his pronouns.

We know the pandemic amplified existing disparities and inequities in health care, Ms. Keeys, can you explain how this impacts the LGBTQ community?

Keeys: Absolutely. The pandemic makes longstanding barriers to physical as well as mental health care for the LGBTQ community, including access to LGBTQ friendly and appropriate levels of care, care by culturally competent anti-discriminatory and intentionally compassionate physicians and health care professionals. The pandemic essentially makes all of that, the disparities related to that, even more profound and insidious in times of public health crisis, and also in terms of costs, both for money and time for LGBTQ persons, particularly for those who are uninsured this time is especially critical. The community is already three times as likely to be uninsured compared to non-LGBTQ persons.

Finally, perhaps most egregiously tied in this moment is the issue of policy, with the enactment of the ACA the anti-discrimination provisions under section 1557, prohibited discrimination on the basis of race, color, national orientation, so on and so forth, including sexual orientation and gender identity, but these provisions are now essentially under fire as the current administration is threatening to roll back those protected status. It's completely unconscionable, it erodes the civil rights practices and progress of our nation. We're going to really see a lot of people suffer if we don't protect LGBTQ persons in terms of policy.

Dr. Greene: Absolutely. As Ms. Keeys said, access to care is such a huge issue during this time, one of the things that this pandemic has really brought out in our patients, is we're asking most people to stay home, right. Even younger, healthier people who are part of the LGBTQ community who don't have access to outpatient care, don't know who to call and figure out, do I go into an emergency room, or don't I, right? What are my health concerns? What are my health considerations? If I don't have someone I can access to get personalized individual care, because I'm afraid to be stigmatized, or because I'm afraid to be spoken to in ways that are uncomfortable for me, or that make me feel denigrated, then I'm not going to show up for care, and I'm more likely to show up in the emergency department. I'm more likely to contact other people who have COVID when maybe I don't need to.

Unger: Dr. Green, Mx. Reyes, why is this community especially vulnerable to complications from COVID-19 and other health issues?

Dr. Greene: There are a few different issues, I think. Many of them are driven by minority stress, which we know impacts all minority groups, but LGBTQ folks are much more likely to smoke, much more likely to use drugs, much more likely to suffer from depression or anxiety, and so social isolation can make all of that worse. We know that we don't know enough about the impact of HIV or cancer and COVID, and so while people with HIV might not be more likely to get COVID, long-term complications of having HIV might make people more susceptible to some of the complications of COVID. We need to know more, and in the absence of that data just trying to keep people as healthy as possible is going to be our biggest challenge, and that means getting people to contact health care providers.

Reyes: The trend is too that LGBTQ+ folks are far more likely to delay seeking out, or visiting health and wellness centers, and often just completely avoid them. Now we're at a time where we're being asked to avoid going out at all, and the preliminary first step for folks when seeking out care is to contact a health care setting. It's especially concerning because folks just don't know how to navigate, or have had a really bad experience navigating the health care system in this country. The reality is that not every LGBTQ+ person is staying at home right now with supportive families, or with the support network that affirms their experience, so I think a lot about what this does to our mental health as a community, especially for people who their gender affirming surgery have been put off, or consultations for gender affirming hormone therapy. COVID-19 is definitely something that looks like it's set to widen existing LGBTQ+ health disparities.

Keeys: Then to Dr. Greene's earlier point, we don't yet know the rates of COVID-19 as it refers to the LGBTQ community, which is troubling given the risk factors he mentioned in terms of tobacco use, poverty, homelessness, but then also violence, and especially violence against transgender persons. That just makes members of this community especially fearful, and to Mx. Reyes point, maybe even fearful for presenting for care. When we're looking at policies in response to the pandemic, the members of the LGBTQ+ community are left out of the national conversation, and also left out of the data collection, right. Without the data that are specific to gender identity, that are specific to sexual orientation, we risk another crisis of marginalization, similar to that which happened in the 80s and even existing to this day with respect to the HIV crisis. That is particularly disconcerting.

Unger: Dr. Greene, Mx. Reyes brought up the topic of mental health. When you look at societal issues and directives like social distancing, how do these play a role in both the physical and mental well-being of the LGBTQ community?

Dr. Greene: Thank you for asking, I think it's a really important topic for us to talk about. I think social distancing is—as a doctor I understand a really important protection against contracting COVID, but it's also really important for us to remember that people who are already depressed or anxious may have worsening of those symptoms, that people who have waited sometimes years for gender affirming surgery, who have been on wait-lists for years, and suddenly to have them canceled can worsen people's mental states. We know that there's a significantly higher risk of suicide among LGBTQ folks, and so all of these things can exacerbate or worsen the kinds of experiences that people are having. We know from the 80s, and from HIV, as Mx. Reyes pointed out or Ms. Keeys, sorry, pointed out, that stigma only worsens that. When people start to look at people who are starting to break social isolation, because they need contact with people in person, we start to judge that, we start to stigmatize people, and people also might not seek care for those reasons, so maybe at home and suffering.

Unger: Mx. Reyes, these are significant challenges. What can we do to relieve them?

Reyes: Sure. I think one of the best things we can do right now that we've taken on the responsibility of doing at Queerly Health is identifying those practitioners that aren't just LGBTQ+ affirming, but also informed. A lot of practitioners will be perfectly fine treating LGBTQ+ people but aren't necessarily trained on LGBTQ+ health and wellness. What we're doing is setting a bar, a baseline competency of LGBTQ+ health and wellness when we've met our practitioners, and in identifying those practitioners we're making sure that we're doing the leg work for LGBTQ+ people to no longer avoid health and wellness settings.

One of the things we're working on as well is telemedicine. One of the reasons why we even started this benefit corporation is because we saw that the digital health space was just going to gloss over the LGBTQ+ community like traditional health care seem to do, and we just weren't cool with that.

Unger: Could you talk a little bit more about that? What does it mean when you talk about kind of glossing over it? What other things do you need to take into account?

Reyes: Sure. For us for example, LGBTQ+ health care, a lot of it has been siloed to major metropolitan areas in the country, right, and often in nonprofit clinics. They're often at capacity or strapped for cash, and they're not always completely accessible to the LGBTQ+ community. Even me with everything that I know here in New York City, which is a bastion of LGBTQ+ health care, I've been turned away from LGBTQ+ clinics before because they're at capacity. Digital health has this really great capacity to unburden physical health care systems, because you can see more patients in less time, and you can also see patients remotely for about 85% of visits anyway, non-emergency visits.

When we started Queerly Health, there weren't any apps or websites or anything that really took into consideration the LGBTQ+ community, or even listing providers that were, or practitioners I should say, that were LGBTQ+ affirming. A lot of times for us, even when we do have really good health insurance and access to practitioners, it's been really difficult to locate and find those practitioners, so we just avoid it altogether.

Unger: Ms. Keeys, could you talk a little bit about the AMAs resources for LGBTQ population?

Keeys: For sure. First and foremost, I want to lay out three different things in terms of policy, in terms of allyship and then also in terms of being of support to LGBTQ physicians, as well as patients. In terms of policy, the AMA has longstanding and an extensive policy on LGBTQ+ related health, and so I would most certainly encourage our membership body to be in touch with our advocacy office, to learn more about those policies. You can go on our website and learn more. The Center for Health Equity also maintains a COVID-19 specific resource page, where on that page we list out to extensive protocols and practices, best practices in the field, and I believe if I'm not mistaken, Mx. Reyes, we referenced some of the things from Queerly Health, and if not then we will absolutely go back and make sure that it's up there because we appreciate and follow you all's work.

The other in terms of allyship, to Mx. Reyes point, it's not enough for physicians themselves to be LGBTQ affirming, it's also important that they're also culturally and structurally trained and competent in the particular needs of patients who are presenting with unique challenges as a result of their gender status and sexual orientation.

Then finally I think it's really important for persons, whether physicians or other health care providers and professionals, to really take on ownership of allyship, right. Especially for persons who are working in public health and in private settings and also in policy settings, so for myself whenever I orient myself with respect to LGBTQ related health, as an ally, it's very important that I speak on behalf of all persons who historically have been stigmatized, and marginalized and medically underserved. Do keep in touch about our policy, please be in touch about the resource page, and make sure irrespective of sexual orientation or gender status, that we're all coming to the table with openness of mind and compassion of heart.

Unger: Well, thank you, Ms. Keeys, and you can find those resources on health equity at the AMA COVID-19 resource area at AMA-assn.org/COVID-19.

I want to thank our guests today, Ms. Keeys, Dr. Green and Mx. Reyes for being here today and sharing their perspectives. We'll be back with another AMA COVID-19 update tomorrow. Thanks for being with us here today, take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

With an increased number of people reporting worsening mental health in recent years, it is imperative that people are aware of the 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) telephone program.

People experiencing a suicidal, substance use, and/or mental health crisis, or any other kind of emotional distress can call, chat or text 988, and speak to trained crisis counselors. The national hotline is available 24 hours a day, 7 days a week.

The previous National Suicide Prevention Lifeline phone number (1-800-273-8255) will continue to be operational and route calls to 988 indefinitely.