A good deal of effort in health care today revolves around finding ways to improve patient access to medical and behavioral health services. That might mean building new facilities or finding ways to overcome barriers to care, such as lack of insurance, finances, transportation, housing, or the cost of medications. Yet data show that all these challenges aside, some individuals are still reluctant to seek care because of their sexual orientation or gender identity.
University of Colorado Hospital is ready to take an initial step toward bridging that gap with a new clinic that aims to meet and affirm the mental and behavioral health needs of patients in the LGBT community. The clinic, which is part of the hospital’s Outpatient Psychiatric Practice, is slated to open July 1.
It’s the brainchild of Jay Voigt, manager of the Outpatient Psychiatric Practice, and Robert Davies, MD, a psychiatrist with the University of Colorado School of Medicine and director of the Department of Psychiatry’s resident training program. The idea sparked after Davies read a report by One Colorado Education Fund that reviewed the status of LGBT health care in the state.
The survey of nearly 1,200 LGBT Coloradans painted a bleak picture. For example, more than half said they feared being treated differently if a provider found out they were LGBT. Nearly 30 percent said their sexual orientation had prevented them from getting medical or mental health care.
“It struck me that just as many if not more LGBT people who avoided health care did so because they were more afraid of the treatment they might receive than of actual bad experiences,” Davies said.
Gaps to close
Not surprisingly, the report showed that 92 percent of the people surveyed said they wanted a list of providers with training, knowledge of and sensitivity to LGBT issues. Yet only 46 percent reported having choice and access to “LGBT-competent” providers. Davies saw an opportunity to fill that gap with a clinic not only open to meeting the mental health needs of LGBT patients but also unique in its connection to a broader range of hospital and university services.
Davies garnered support for the idea from Voigt; Department of Psychiatry Chairman Robert Freedman, MD; and Robert Feinstein, MD, medical director of the Outpatient Psychiatry Clinic. He will supervise resident and fellow training along with Debbie Carter, MD, associate professor with Children’s Hospital Colorado’s Department of Psychiatry and Behavioral Sciences. Associate Professor of Psychiatry Brian Rothberg, MD, will also participate, Davies said. The clinic could offer both individual and group sessions and include families, he added.
At the most basic level, the goal of the clinic is to create an environment in which LGBT patients feel “accepted, welcome, and safe” and are served by providers who are comfortable working with them, Voigt said. Preparations will include training staff to ask patients simple but important questions such as which pronoun they prefer that others use to address them, he added.
But the needs and issues of LGBT people go far deeper than can be covered by friendly words and smiles, Voigt said. The new clinic will provide an “affirming treatment environment” that addresses issues of patients who have mostly grown up in a world that is not accepting of their identity, he said.
Nor does the health care community as a whole have a sterling record in its treatment of LGBT patients, Davies said. For example, he labeled their relationship with psychiatry as “tenuous,” the result of labeling homosexuality as a mental disorder until the 1970s. Psychiatric training has for the most part neglected questions of sexual identity, he added.
“We’ve developed theories of growing up that emphasize people solidifying their sense of identity by comparing themselves to others around them,” Davies said. “None of that applies to LGBT people.” On the contrary, he said, LGBT individuals often spend their entire adolescence hiding their identities and enduring a sense of shame “for not being who people they think they are or expect them to be.”
These deeply embedded conflicts can lead to a host of issues if they are not addressed. For example, the One Colorado survey found that four of 10 LGBT respondents reported “feeling down, depressed, hopeless, or having little interest or pleasure in doing things” for at least several days in the past two weeks. Rates of risky behaviors, including binge drinking and smoking, were significantly higher for lesbian, gay and bisexual people surveyed than for heterosexuals. By at least one estimate, some 40 percent of all homeless youths are LGBT, which in turn puts them at greater risk for mental health issues, unsafe sexual behavior and other problems.
Speaking the language, meeting the need
“There are many disparities,” said Rita Lee, MD, associate professor of Internal Medicine and a provider in the University Internal Medicine – Anschutz Clinic at UCH. Lee is one of a handful of providers at UCH who see transgender patients. She notes LGBT health care as an area of interest and served on the One Colorado Education Fund Health Steering Committee.
Lee notes, for example, that lesbian women are less likely to get mammograms and pap tests than heterosexual women. She believes an important reason for that gap and others is the difficulty LGBT patients have finding a provider they can trust to address their medical and behavioral needs.
“There is a huge need for providers who can use the language patients prefer, treat them with respect and dignity, and understand their special health needs,” Lee said. These include vaccination needs for gay and bisexual men and, potentially, hormone issues for transgender patients. The issue comes down to a provider’s willingness to address each patient’s needs, she added. Sexual orientation and gender identity are just two of many factors to consider.
“Each patient occurs in a context,” Lee said. “It’s important to understand all aspects of their humanity.” A patient’s intimate relationships are essential to consider, but they don’t define the individual exclusively, she added.
Lee and other primary care providers could be important referral sources to the clinic, Davies said, but he envisions it eventually being part of a larger network of UCH providers serving LGBT patients. A transgender patient, for example, might get behavioral health care through the clinic, along with services from endocrinologists, urologists, gynecologists, or surgeons.
In the near term, however, much work remains to build a solid and trusted source of support for the LGBT community, Davies said. “Our goal is the education of the next generation of providers to be informed, accepting and welcoming to these patients,” he said.
“We are trying to combat stigma,” Voigt added, “and we’re involving the entire clinic in that discussion and process.”