Addressing Health Disparities via Coordination of Care and Interprofessional Education

Lesbian, gay, bisexual, and transgender (LGBT) persons are a diverse group, but they share a common need for competent, accessible health care, dispensed without intolerance and with an understanding of their unique health needs. Dental practitioners need to understanding that LGBT persons have distinctive health (and oral health) needs. This article reviews the literature on oral and overall health of LGBT persons in the United States, and discusses ways in which dentists can improve the health care they provide to this vulnerable population, including how interprofessional education and collaborative practice may help to reduce oral health disparities within this group.

Key points

  • Lesbian, gay, bisexual, and transgender (LGBT) people share a common need for competent, accessible health care, dispensed without intolerance, and with an understanding of the unique but diverse health needs of the members of this group.

  • Dental practitioners should recognize that, as a group, LGBT persons face greater health risks and have different health needs than heterosexual persons.

  • However, data are sparse in the dental literature regarding the oral health needs of members of the LGBT community. Dental practitioners can learn much from their medical and nursing colleagues regarding the provision of culturally competent care for LGBT persons. It is likely that the best care for this group can only be achieved through interprofessional care among dental, medical, nursing, and other health care practitioners.

Introduction

LGBT stands for lesbian, gay, bisexual, and transgender. Some add the letter Q to LGBT, meaning either queer or questioning, and still others add the letters I and A for intersex and asexual, respectively. Members of this group (LGBT, LGBTQ, LGBTQIA) are also sometimes grouped together as sexual minorities. LGBT persons are a diverse group, but they share a common need for competent, accessible health care, dispensed without intolerance, and with an understanding of the unique health needs of the members of this group. Dental practitioners, like other medical providers, need to recognize the heterogeneity of this group, and understand that, as a group, LGBT persons face greater health risks than heterosexual persons, largely because of how they are often regarded by society in general and by some health care workers.

However, within the last several years, great progress in the acceptance of LGBT persons has occurred, as shown by the support of most Americans for same-sex unions, culminating in the Supreme Court’s 2015 ruling that the 14th Amendment does not allow states to ban same-sex marriage ; however, many people argue that social gains (and the health care gains that are likely to follow) for LGBT people have not occurred equally for each LGBT subgroup. For example, bisexual men and women report worse health than gay men and lesbians, which may be partially attributable to their heightened economic, behavioral, and social disadvantages. It has been also reported that lesbian and bisexual women, for example, may be less likely than gay men to adhere to some cancer-screening guidelines. In addition, it should be recognized that within the LGBT group profound differences are evident with respect to race, ethnicity, and gender. For example, LGBT women are more likely to experience stigma and discrimination than their male LGBT counterparts, which can make health care more costly for them because of discriminatory laws, discrimination by providers, insurance exclusions for transgender people, and inadequate reproductive health coverage. In addition, LGBT persons of color are more likely to be poor than their white LGBT counterparts.

Over the past 2 decades the medical and nursing academic communities have begun to address disparities in LGBT health by recognizing that more attention needs to be paid to understanding the health of those persons who comprise this vulnerable group. An increasing number of studies investigating disparities in health and disease, and in those demographic, social, behavioral, and other factors related to these disparities, have been reported, and the literature has grown. Physicians and nurses have recognized that reducing disparities also requires coordination of care and of education among providers and trainees, and have introduced curricula that respond to this need.

Although some oral health care practitioners and academics have documented similar issues, the dental literature is less robust, and is limited to a few studies of attitudes and behaviors. The oral health community, therefore, may learn from what medicine and nursing has already discovered; namely, that this population deserves special attention, given their increased risk for disease, and, more importantly, that through a coordinated effort of care and training, disparities in health (which are likely to extend to oral health) for this group can be minimized and/or eradicated.

The purposes of this article are:

  • 1.

    To review the literature on oral health and overall health of LGBT persons in the United States and Canada, including data related to clinical findings and health care use.

  • 2.

    To discuss ways in which dentists can improve the health care they provide to this vulnerable population, including how interprofessional education and collaborative practice may help to reduce oral health disparities within this group.

Introduction

LGBT stands for lesbian, gay, bisexual, and transgender. Some add the letter Q to LGBT, meaning either queer or questioning, and still others add the letters I and A for intersex and asexual, respectively. Members of this group (LGBT, LGBTQ, LGBTQIA) are also sometimes grouped together as sexual minorities. LGBT persons are a diverse group, but they share a common need for competent, accessible health care, dispensed without intolerance, and with an understanding of the unique health needs of the members of this group. Dental practitioners, like other medical providers, need to recognize the heterogeneity of this group, and understand that, as a group, LGBT persons face greater health risks than heterosexual persons, largely because of how they are often regarded by society in general and by some health care workers.

However, within the last several years, great progress in the acceptance of LGBT persons has occurred, as shown by the support of most Americans for same-sex unions, culminating in the Supreme Court’s 2015 ruling that the 14th Amendment does not allow states to ban same-sex marriage ; however, many people argue that social gains (and the health care gains that are likely to follow) for LGBT people have not occurred equally for each LGBT subgroup. For example, bisexual men and women report worse health than gay men and lesbians, which may be partially attributable to their heightened economic, behavioral, and social disadvantages. It has been also reported that lesbian and bisexual women, for example, may be less likely than gay men to adhere to some cancer-screening guidelines. In addition, it should be recognized that within the LGBT group profound differences are evident with respect to race, ethnicity, and gender. For example, LGBT women are more likely to experience stigma and discrimination than their male LGBT counterparts, which can make health care more costly for them because of discriminatory laws, discrimination by providers, insurance exclusions for transgender people, and inadequate reproductive health coverage. In addition, LGBT persons of color are more likely to be poor than their white LGBT counterparts.

Over the past 2 decades the medical and nursing academic communities have begun to address disparities in LGBT health by recognizing that more attention needs to be paid to understanding the health of those persons who comprise this vulnerable group. An increasing number of studies investigating disparities in health and disease, and in those demographic, social, behavioral, and other factors related to these disparities, have been reported, and the literature has grown. Physicians and nurses have recognized that reducing disparities also requires coordination of care and of education among providers and trainees, and have introduced curricula that respond to this need.

Although some oral health care practitioners and academics have documented similar issues, the dental literature is less robust, and is limited to a few studies of attitudes and behaviors. The oral health community, therefore, may learn from what medicine and nursing has already discovered; namely, that this population deserves special attention, given their increased risk for disease, and, more importantly, that through a coordinated effort of care and training, disparities in health (which are likely to extend to oral health) for this group can be minimized and/or eradicated.

The purposes of this article are:

  • 1.

    To review the literature on oral health and overall health of LGBT persons in the United States and Canada, including data related to clinical findings and health care use.

  • 2.

    To discuss ways in which dentists can improve the health care they provide to this vulnerable population, including how interprofessional education and collaborative practice may help to reduce oral health disparities within this group.

Lesbian, gay, bisexual, transgender: what’s in a name?

When speaking of, to, or about persons in the LGBT community there are several terms that dental practitioners should be aware of. In addition, practitioners must realize that although the acronym LGBT may be useful as an umbrella term (ie, the general and oral health needs of this community are often grouped together), each of these letters represents a specific, separate population with its own health issues. Importantly, clinicians need to recognize that this group is extremely diverse, comprising both those who identify or present as genders different from the sex assigned to them at birth (those with varying gender identities and gender expressions) and those whose sexual orientation is not solely heterosexual.

The LGBT community comprises groups defined by sexual orientation: including lesbians (women who are attracted to women), gays (men who are attracted to men, or persons attracted to those of the same gender, in general), bisexual persons (those men and women who are attracted to both men and women) and asexual persons (those who generally do not feeling sexual attraction) and by gender identity , including transgender (a person who crosses culturally-defined gender categories) and intersex (those who naturally have sex characteristics that do not fit neatly into society’s definitions of male or female). The term queer includes anyone who chooses to identify as such, while the term questioning refers to anyone exploring his or her own gender identity or expression, and/or sexual orientation. An additional term, gender queer , refers to having a gender identity and/or expression that is outside of the societal norm and/or is beyond gender.

Sex and Gender

In addition, clinicians should distinguish between the terms sex (which refers to a person’s biological status including hormonal, anatomic, and physiologic characteristics; most commonly male and female) and gender , which is a social construct that includes the “attitudes, feelings, and behaviors that a given culture associates with a person’s biological sex.” Clinicians should recognize that sex can be ambiguous; for example, in someone who is born with both male and female physical traits or with ambiguous genitalia (historically, these intersex children were usually assigned the sex of female because of the greater ease and effectiveness of genital surgery). However, studies have shown that the historical approach to gender assignment surgery that was common in the second half of the twentieth century resulted in high rates of mental and sometimes physical health issues.

Gender Identity

Gender identity refers to how a person identifies – as male or female, or another gender (including transgender , bigender , or gender queer ; denunciations of the traditional classification of gender as binary). Gender identity is linked with the term gender expression , which denotes how a person chooses to appear to the world – and includes not only one’s physical appearance, but one’s personality and behavior. Gender role conformity refers to the extent to which an individual’s gender expression adheres to the cultural norms prescribed for people of his or her sex; for example, a gender non-conforming woman may choose to dress and appear in clothes typically associated with men or a gender non-conforming man may choose clothing or makeup that may appear feminine though he makes no effort to hide his maleness. The term cisgender designates a person whose (biologic) sex, gender identity and gender expression are consistent. For example, a “cis male” is a man whose biologic gender is male, he identifies as male, and he appears to the world as a male. In today’s world, there are people who consider themselves gender fluid . That is, they resist being labeled as either “male” or “female” and may move between being male or female at different points in time. Gender dysphoria is an uneasiness, discomfort or outright distress with one’s assigned sex.

Transgender

The term transgender is a catchall term that includes a diverse group of individuals who cross or transcend culturally defined categories of gender. Descriptive terms include transsexual (those who often have had, or desire, hormone therapy and/or surgery so that may live full time as a gender different from the one they were assigned to at birth); cross-dressing (those who present outwardly a gender different from the one they were assigned to at birth for emotional and/or sexual gratification); transgenderists (those who live full time in the cross-gender role, may take hormones, but do not desire surgery); bigender persons (who identify as both male and female); and drag queens and kings (who dress in clothes associated with the other gender usually adopting an ultra-feminine or masculine persona). While the term transgender has received much attention lately as transgender men and women have become more visible (for example, note Bruce Jenner’s very public transition to Caitlyn Jenner in 2015), this term has been around for decades, particularly in literature and film. For example, Armisted Maupin’s series of popular novels, which were later turned into a Public Broadcasting System miniseries (1993) and a theatre production, featured a transgender woman character (played by Olympia Dukakis in the television series). Hillary Swank won a “Best Actress Oscar in 1999 for her portrayal of Brandon Teena, a transgender man who was raped and murdered. Other movies, such as “Transamerica” (2006) introduced Americans to transgender people and the challenges they face. Despite their ubiquity in literature, film and in the real world, transgender persons among those who are most often the victims of the most violent hate crimes. Presently, only 18 states and the District of Columbia have passed laws protecting people against discrimination based on gender expression and/or gender identity. Increasingly, transgender people are finding more support in the medical and mental health professions as they “transition” to their chosen gender, which typically requires the use of hormonal therapy, plastic surgery and in some cases, gender reassignment surgery. In addition, many states and cities now support changing birth certificates and other forms of identification, although some states require medical “proof of sterilization” by sex reassignment surgery in order to warrant a gender change.

Sexual Orientation

Sexual orientation is defined by a person’ preference in partners in intimate human relationship (romantic, sexual, or both; actualized or only imagined) in relation to the person’s own sex/gender. Persons traditionally may identify as heterosexual (straight or hetero), gay , or bisexual , although contemporary designations allow for divisions that are more encompassing. A self-described straight man or woman may have or have had same-sex relationships in the past or occasionally in the present but not consider himself/herself as gay. Similarly, a self-described gay person may have or have had opposite-sex relationships. Still more complicated are persons who engage in same-sex relationships without any qualifiers. More accurate assessment may include exclusively gay, mostly gay, mostly straight, or exclusively straight.

Health practitioners may be interested in knowing a patient’s sexual orientation and current sexual activity to assess risk for disease, including sexually transmitted diseases. Dentists and dental hygienists specifically need to know each patient’s sexual history so they can recognize any increased risk for those conditions and diseases that have oral sequelae, most notably human immunodeficiency virus (HIV) and human papilloma virus (HPV) infection, in order to assess each patient’s risk for HPV-related head and neck cancer and other conditions, to assess the potential benefits of HPV vaccination, and to perform ongoing risk assessments.

What is of practical, essential importance is that health care professionals like dentists need to be both sensitive to and knowledgeable about issues of sexual orientation, gender identity, and gender expression. However, judging someone’s gender using their appearance can be misleading, offensive to the person, or even dangerous for a health care provider. For example, a transgender woman may dress and appear female even though she was assigned the male sex at birth: missing this reality might lead the dentist to overlook that she is taking large doses of steroids on a daily basis. Another example is the physically fit, masculine-appearing young man with well-trimmed facial hair who may have been born female and is taking hormones to transition. In addition, for a gender-fluid person, identifying as male or female on the intake form may become a barrier to effective communication. Later in this article ways to improve the office experience for those in the LGBT community are discussed; briefly, approaches include revising the office or clinic intake form to allow persons to select from at least 3 gender options (male, female, other) is a simple way to show the intention to be inclusive. Another option is to have all restrooms in the practice or selected restrooms in the building be gender-neutral (ie, without a male/female label on the door) to increase comfort and show inclusivity. In terms of using the proper, preferred language and terminology, practitioners should realize there are some words and terms that must be avoided, because they are considered outdated, derogatory, and/or bigoted. These terms include hermaphrodite , sexual preference or sexual identity (as opposed to the correct terms sexual orientation and gender identity ), sex change , sex change operation , preoperative or post-operative (as opposed to the correct term transitioning ) and, of course, epithets. In addition, some in the LGBT community have expressed dismay at the words transvestite (proper term: cross-dressing ), homosexual (proper terms: gay or lesbian ), alternative (seen as overused and non-specific) and tolerance (believing that LGBT persons should be more than “tolerated”).

North American lesbian, gay, bisexual, and transgender population estimates

Estimating the number of people in the various categories in the population is an important, albeit difficult, undertaking that has been fraught with issues making estimates unreliable. The recent Institute of Medicine report The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding reviews the US surveys that have provided population-based estimates, including (1) a 1992 survey in which about 2.8% of the men and 1.4% of the women more than 18 years of age considered themselves homosexual or bisexual; (2) a 2002 US Centers for Disease Control and Prevention survey of adults aged 18 to 44 years that found 2.3% of men identifying themselves as homosexual 1.8% as bisexual, and 1.3% of women identifying themselves as homosexual and 2.8% as bisexual; (3) a 2008 study that found that 2.2% of men identified as gay and 0.7% as bisexual, whereas 2.7% of women identified as lesbian and 1.9% as bisexual; and (4) a 2009 study that estimated that 6.8% of men and 4.5% of women self-identified as lesbian, gay, or bisexual. However, there are no good, recent estimates on the proportion of transgender persons in the United States. Results of the Massachusetts Behavioral Risk Factor Surveillance Survey, one of the few population-based surveys that included a question designed to identify the transgender population, found that 0.5% of adults (aged 18–64 years) in the state identified as transgender in 2007 and 2009. In Canada, 1.7% of adults aged 18 to 59 years reported being gay or lesbian and 1.3% reported being bisexual in 2014.

General health among lesbian, gay, bisexual, and transgender persons

General Health

Although LGBT persons as a group have been shown to be disproportionally affected by several health conditions, including chronic disease, sexually transmitted infections, mental disorders, and injury/violence (including intimate partner violence), disease rates and related conditions vary by subgroup. Although in some cases these health disparities are related to an increased tendency among some within this group for high-risk activities (eg, HIV infection among gay men), in other cases these conditions are related to the long-standing discrimination and social stigma that LGBT persons continue to face. Discrimination may affect a person’s income and employment, and is therefore related to whether the person can obtain and keep health insurance. In addition, social stigma is related to poor mental health and poor coping skills, including risky sexual behaviors and substance abuse. Not being able to be open about sexual orientation and/or gender identity likely increases stress and limits social support; both of these negatively affect health. Understandably, health-related risky behaviors and poorer health are more common among those LGBT people who have experienced the most discrimination; one study of young adults rejected by their own families showed that this group was 8.4 times more likely to have made attempts at suicide, 5.9 times more likely to report high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to have risky sex. Importantly, sexual orientation and gender identity have been shown to interact with other recognized risk factors for poor health, including socioeconomic status, race, and ethnicity. In addition, in these rapidly changing times, groups that might have been at a disadvantage in the past may now no longer be subjected to the same level of discrimination because public attitudes have changed. For example, a recent study showed that self-reported poor health was no worse (and possibly better) among gay men and lesbians compared with heterosexual men and women. Because of the heterogeneity of the LGBT group, we will separately discuss the general health of each of the major sexual minority groups: gay men, lesbians, bisexual persons, and transgender persons separately.

Gay Men

Gay men, as a group, are at higher risk of sexually transmitted diseases compared with heterosexual men. HIV infection continues to be a major issue affecting gay and bisexual men. Between 2009 and 2013, the HIV infection rate increased by 12% in this group; most alarmingly increasing by 22% among those aged 13 to 24 years. Black and Hispanic gay and bisexual men were disproportionally represented in this group: in 2010, black men accounted for 10,600 (36%) and Hispanic/Latino men accounted for 6700 (22%) of all estimated new HIV infections. In addition, HPV and hepatitis infections are also more common in gay men compared with heterosexual men. Gay men also seem to be at increased risk for some cancers. Although most research has focused on the increased incidence of those cancers associated with sexually transmitted viruses, recent studies have shown that gay men have increased risk for skin cancer because of a disparity in sun and tanning bed use between gay and heterosexual men; and for lung cancer, because gay men have higher rates of tobacco use. Gay men, as well as bisexual men, have higher rates of anal cancer (which is associated with HPV infection), Kaposi sarcoma (which is associated with herpes virus type 8 and HIV infections), and non-Hodgkin lymphoma and hepatocellular carcinomas (which are associated with hepatitis B and C infections) compared with heterosexual men. Studies have shown that gay men have higher rates of depression and anxiety compared with heterosexual men. Some studies have shown that gay men are more likely to smoke and use illicit drugs compared with heterosexual men.

Lesbians

As a group, lesbians are more likely to be overweight or obese compared with heterosexual women, and are therefore at higher risk for obesity-associated conditions, including diabetes, cardiovascular disease and stroke, and breast and colon cancer. Lesbians are less likely than heterosexual women to have had a full-term pregnancy, placing them at higher risk for those cancers that are reduced in women who have been pregnant and have breastfed, including breast, endometrial, and ovarian cancers. It has also been reported that lesbians have higher rates of arthritis compared with heterosexual women. Lesbians are more likely to smoke than heterosexual women, increasing their risk for lung cancer and other smoking-related diseases. Although recent data suggest that alcohol use among lesbians has decreased, heavy drinking and drug abuse (eg, moderate marijuana use) have been reported to be more common among lesbians than heterosexual women, especially among younger women. Regarding mental health, lesbians report higher rates of depression and anxiety compared to heterosexual women. Lesbians may use preventive health care services less frequently than heterosexual women, and are less likely to receive routine screenings, such as a Pap tests, clinical breast examinations, and mammograms.

Bisexuals

Several population-based studies have shown that bisexual persons have overall worse health than heterosexuals, gays, and lesbians. Bisexuals are more likely to be poor and are more likely to be unemployed. Bisexual persons have some of the highest rates of disease-related risk behaviors, including smoking and substance abuse disorders. However, within the bisexual population, risks tend to vary by sex/gender and, as is the case for gay men, lesbians, and transgender persons, by other demographic characteristics, including race/ethnicity and socioeconomic status. Like gay men, bisexual men are at increased risk for HIV and HPV infection, and for other sexually transmitted diseases. Bisexual men have been found to have higher hepatitis rates compared with heterosexual men. Bisexual women are more likely to report higher-risk sexual behaviors, smoking, substance abuse, and binge drinking than other groups. Like lesbians, bisexual women are at increased risk for those cancers related to being nulliparous. Studies have shown that mental health issues, including increased worry and anxiety, depression, suicide ideation, and emotional stress, are more prevalent in the bisexual population compared with either the gay/lesbian or heterosexual communities.

Transgender Persons

Information regarding transgender health is limited, and the data that are available come from small studies of convenience samples; for example, those persons attending clinics, rather than population-based samples. In general, the specific health concerns of female-to-male transgender persons are less well understood than those for male-to-female persons. Transgender persons have unique health needs; some of these needs depend on whether they choose to take hormones and/or undergo surgery. Estrogen-progestin hormones are associated with thromboembolic disease, and testosterone has been associated with an increase in liver enzyme levels, loss of bone mineral density, and increased risk for ovarian cancer. However, although the risk for these diseases is likely increased in transgender persons taking these hormones, few studies have evaluated the long-term effects of these hormones in transgender persons. One unique health issue among transgender persons is the problems that are related to a sex/gender identity mismatch. For example, a woman who identifies as male but retains female reproductive organs may avoid having cervical cancer screenings and pelvic examinations. Information regarding the prevalence of mental disorders in transgender persons is also lacking, because no population-based data are available. However, studies have shown that suicide ideation and suicide attempts are common within the transgender population. It has been estimated that between 16% and 60% of transgender persons have experienced physical violence and that 13% to 66% have experienced sexual assault; racial and ethnic minority transgender women are at the highest risk. Although the exact prevalence of HIV infection among transgender persons is not known, one study found that HIV prevalence among a group of transgender women in 12 cities varied between 5% and 68%, and was higher among black and Hispanic transgender women. Studies estimate that between 45% and 74% of transgender persons smoke; alcohol use is also high. In addition, drug use, including marijuana, crack cocaine, methamphetamines, and injection drug use, seems to be common among transgender persons.

Health Care Access and Use

LGBT persons are less likely to have access to appropriate and necessary medical care, including preventive care; are less likely to have health insurance; and are less likely to use some medical care. Many within the LGBT community struggle to access health care because they are uninsured. In the United States, same-sex marriage was not universally recognized before 2015; therefore, access to a partner’s health benefits was limited to those (few, but increasing) states that recognized same-sex marriage. Lesbians and bisexuals are less likely to have health insurance compared with both heterosexuals and gay men and lesbians. Transgender persons are least likely to have insurance, and health insurance that covers appropriate care for transgender patients is lacking. Lesbians and bisexuals are less likely to have a regular health care provider compared with both heterosexuals and gay men and lesbians. Transgender persons report barriers to their use of preventive services and are most likely to report having trouble finding health care providers who are knowledgeable about their unique health issues. Finding a provider who is competent in LGBT health has also been a problem for lesbians, gays, and bisexuals. A recent study found that heterosexual providers implicitly and explicitly favor heterosexual patients rather than LGBT patients.

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Oct 25, 2016 | Posted by in General Dentistry | Comments Off on Addressing Health Disparities via Coordination of Care and Interprofessional Education
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