By Ravi Iyengar, MD, and Christopher M. Nolan
Health equity, as defined by the Robert Wood Johnson Foundation, “means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments and healthcare.” When we aim to achieve health equity, we should think about it in a more localized fashion and get to the root causes of bad health, especially for the LGBTQ+ population.
LGBTQ+ individuals have faced a long history of barriers to competent healthcare, compounded by social and economic discrimination, setting up a viscous cycle. We are currently seeing some of the most progressive legislation for LGBTQ+ individuals, but also some of the worst that is specifically targeting transgender and nonbinary people. LGBTQ+ individuals are more likely to experience homelessness and discrimination at work, thus making it difficult to physically and financially access basic healthcare. Additionally, there have been instances in healthcare systems and education that show a strong connection to cisgender, heteronormative biases. Improving an entire healthcare structure may seem a daunting task, but it is important and necessary. Based on a 2015 national survey of nearly 28,000 transgender and gender-nonconforming participants, one-third reported negative experiences in a healthcare setting and having to teach their providers about their own healthcare. Micro- and macroaggressions in the healthcare setting against LGBTQ+ individuals are constant and contribute to worsening physical and mental health outcomes. However, using affirming language and practices can not only contribute to a better mental wellbeing but reduce the rate of suicidal ideation for transgender and nonbinary individuals.
Based on available data, we know LGBTQ+ individuals comprise up to 4.5% of the population in many states. By overlooking instances of systematic biases and lack of education and training in LGBTQ+ health, healthcare will be unable to adequately address the needs of this population. This leads to adverse health outcomes and fuels systemic inequity.
Affirm: The Rush Center for Gender, Sexuality and Reproductive Health was born out of the need to have both affirming and quality healthcare for the LGBTQ+ population, with a focus on making positive, sustainable change in the status-quo of healthcare delivery. Rush University System for Health has long been a leader in LGBTQ+ healthcare, receiving perfect scores on the Human Rights Campaign Foundation’s Healthcare Equality Index since 2009. The health system was the first in Illinois to offer comprehensive coverage to transgender employees and patients, strike down fertility definitions in its benefits plan to be more inclusive, and proactively incorporate sexual orientation and gender identity data into its electronic medical record.
Affirm is a multidisciplinary, interprofessional effort across the Rush University System for Health connecting patients to quality, LGBTQ+ affirming care. Our center seeks to build upon the pillars of clinical care, research, education and training. At our core is our virtual hub of patient care navigators, who provide an initial psychosocial assessment and create individualized care teams surrounding the needs of the patient. Our care teams are dispersed throughout the health system with the intent of widespread LGBTQ+ cultural competency. Affirm has been able to integrate systematic training and education on a department-specific basis, having now trained more than 2,000 faculty and staff across the system.
We are part of the LGBTQ+ community, so the development of a comprehensive center to ensure health equity for the LGBTQ+ population hit even closer to home. We pride ourselves on developing a program built by and for the LGBTQ+ community; however, navigating systematic change and processes throughout a large academic healthcare system provides its own challenges. It is important for healthcare institutions not to dictate care for LGBTQ+ individuals, but to let LGBTQ+ individuals lead and develop what the ideal model should be. We are part of an institution whose mission it is to improve the health of the diverse communities it serves in the Chicagoland area with existing initiatives for the LGBTQ+ community. However, without having executive champions for our cause, we would not have had our platform elevated to appropriate leadership circles. Our executive leadership took notice of our developing LGBTQ+ efforts, and we found executive champions in both our senior vice president for community health equity and vice president for government and external affairs. Second, we had to become comfortable with being uncomfortable in producing a profitability margin for a cause we know is just. Developing a financial plan was necessary for demonstrating sustainability and growth of a new effort with upfront costs. Ultimately, we find serving our community not only bolsters growth but bridges gaps in care and enhances our connections to community partners, organizations and businesses.
Organizations need to come together for us to realize health equity for the LGBTQ+ community. This includes creating programs, updating policies that impact LGBTQ+ patients/employees, volunteering with LGBTQ+ organizations, buying from LGBTQ+ businesses and having goals to hire transgender and nonbinary individuals.
As we reflect on LGBTQ+ Pride Month, we must go back to the roots of Pride—a protest for rights and existence—and recognize the fight for LGBTQ+ equity is far from over. The number of proposed anti-transgender legislature throughout the nation is both appalling and terrifying. Many of the proposed acts seek to promote disclosure/outing, limit access to care and punish healthcare providers supplying that care. This is dangerous and reckless, and it only fuels health inequities within the LGBTQ+ community. Gender-affirming care saves lives, and it is supported by the American Medical Association, the American Academy of Pediatrics and the American Psychological Association. We know if we don’t provide this care, we are doing harm.
Ravi Iyengar, MD, is medical director of Affirm: The Rush Center for Gender, Sexuality and Reproductive Health, and assistant professor, endocrinology, Rush University System for Health, Chicago. Christopher M. Nolan is system manager, community health and benefit; instructor, health systems management; and chair, LGBTQ+ Leadership Council, Rush University System for Health, Chicago.