Interview with Dr. Michael Otte of Advocate Aurora Health

Interview with Dr. Michael Otte of the Barriers to Health Care Experienced by the LGBTQ Community

September 21, 2018  |  Blog Post

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The Institute of Medicine’s (IOM) landmark report “Healthy People 2020” called for the improvement of health, safety, and wellbeing of the lesbian, gay, bisexual, and transgender, and queer (LGBTQ) population. Despite the IOM’s call for action, Dr. Michael Otte, an Aurora Health Care physician, reported that the LGBTQ community continues to face discrimination, resulting in lower rates of health insurance coverage and distrust within the healthcare system. Additionally, he reports chronic stress and higher rates of mental health issues in this community.  

The Center for Healthcare Innovation (CHI) and Dr. Otte discussed healthcare disparities in the LGBTQ population and how to address these inequities.

CHI: Can you talk about your experiences treating the LGBTQ community and some of the challenges they face? How can physicians or medical practices look to break down these barriers?

Dr. Otte: One of the most significant health challenges facing the LGBTQ community has been access to health services. Even in large cities, like Milwaukee, healthcare professionals may lack the knowledge or training related to transgender health issues. This stems from (1) lack of education and (2) comfortability with providing care for transgender patients. Breaking down these barriers requires more education for healthcare professionals. Training should begin in medical or other professional programs. However, clinicians also have access to resources through reputable organizations  such as the Fenway Institute to educate themselves. 

CHI: Can you briefly discuss the concept of “allostatic load” and how this contributes to the health inequity? 

Dr. Otte: “Allostatic load” describes the burden on one’s body from adaptation to constant physical and/or emotional stress. In the short-term, stress is not bad. Rather, it is needed to access energy stores when the fight-or-flight response is activated. When individuals experience chronic stress, significant strain is exacted on their biological system. This “allostatic load” is a risk factor for chronic diseases - coronary vascular disease, obesity, diabetes, and high blood pressure. This is a perpetuating cycle, particularly for LGBTQ individuals, due to legal and illegal discrimination. That is, individuals become ill causing some stress which causes their symptoms to worsen, etc. This compounds everyday stressors, resulting in poorer outcomes.

CHI: Have the stressors faced by the LGBTQ community changed over time?

Dr. Otte: At a high level, many of the stressors faced by the LGBTQ community are unchanged. There has been significant progress. However, on the individual level, this is cyclical with different issues at each stage. At a young age, stressors include self-identification with a group. Stressors evolve with age, e.g. legal system as it relates to insurance and marriage. 

CHI: How can we proactively address the increased chronic disease and mental health risks for members of the LGBTQ community? Have you seen any changes in how physicians and/or practices are addressing these issues?

Dr. Otte: Gathering sexual orientation and gender identity information from patients will allow us to better understand and provide care for the LGBTQ community who face significant health disparities. One of the biggest challenges is identification - we need resources and a shift in culture to encourage LGBTQ patients to be forthcoming with this information. Identification should not be stigmatized as knowledge is essential to providing preventative care, as well creating a safe environment to discuss risks and conditions that disproportionately affect LGBTQ people. The earlier these conversations are initiated with the patient, physicians can partner with patients for better outcomes and healthy living. 

There has been a shift in attitudes towards identification and proactive discussions. However, a greater allocation of resources is required to address health disparities. The community’s pain points have changed, but we are headed in the right direction. Within the healthcare industry, clinicians must shift from a one-size-fits-all approach to an individualized collaborative effort as each patient has different lifestyles and different priorities. Healthcare professionals must empower patients to reach their full potential.

CHI: There is a lack of LGBTQ-specific training in existing medical education. What changes do you recommend to the existing curriculum? How would this help address some of the challenges this community faces?

Dr. Otte: Healthcare professionals must receive cultural competency training. There needs to be more intentional exposure for clinical staff to ensure greater awareness and comfortability. Many professionals and practices are open to diversity and willing to work in this space, but they are not comfortable. Creating an inclusive environment for the LGBTQ community requires additional training similar to specializing in pediatrics, geriatrics, etc. 

For example, physicians require comprehensive training on the healthcare needs of transgender individuals, such as gender affirmation surgery and hormone therapy. They require education on the physical and psychological needs of this population. Such comprehensive training will help with addressing barriers to access and culturally competent care. 

CHI: Can you discuss some of key takeaways and calls to action to “close the gap”?

Dr. Otte: As healthcare professionals, we must encourage all patients, especially the LGBTQ community, towards healthy lifestyles. Within the healthcare system, we must be aware that there is a unique and personalized solution for each individual:

1.     Education and training for all in the healthcare field.From the first encounter with a patient, staff must be gender affirming and provide culturally appropriate care. Both cultural and technical education are required to create better access, partner in health and the journey of healthcare. 

2.     Resources are needed. Healthcare professionals and medical practices require non-threatening methods of providing information and identification. LGBTQ patients are often not forthcoming with information due to stigma and prior discrimination. 

3.     Create welcoming and inclusive environments. Creating safe places – physically, culturally, and environmentally – begins at a young age. During one’s school years, LGBTQ individuals must feel safe and comfortable in accessing resources, etc. 

Authors

Dr. Michael Otte

Interviewer:

Mounika Kata

Health Equity Fellow at CHI

Blog by Dr. Michael Otte:

Health Disparities in the LGBTQ Community

The lesbian, gay, bisexual, transgender and queer (LGBTQ) community has made significant progress within social rights over the past years; however, there continues to be significant differences in the health of this population. These health disparities become even worse if the LGBTQ person is also a member of a marginalized racial or ethnic group. 

Chronic Stress Leads to Allostatic Load

There are lot of reasons for these differences, including cultural and society views, discrimination, and civil rights, but first, I want to discuss is a concept called “allostatic load”.  The idea is that prolonged and repeated stress can lead to ongoing health problems and excessive wear and tear on the body.  Chronic stress can even cause physical changes that can affect your entire body, including your heart, blood pressure and cholesterol.  LGBTQ and minority populations continue to face a larger amount of both legal and illegal discrimination than their heterosexual peers.  Legal issues including differences in marriage, adoption and retirement benefits are just a few of the things that can contribute to chronic stress.  Studies show that members of this community who live in areas where there is a high level of discrimination will die about 12 years earlier on average than if they lived in a more accepting community.  The problem is also a perpetuating issue.  Chronic stress leads to health problems, which leads to more stress, and then to more problems and the cycle continues.

Health Concerns at a Glance

Unfortunately, the LGBTQ population is also at much higher risk for mental health issues including substance abuse, eating disorders, depression and suicide. Members of the LGBTQ community are also more likely to be injured in a fight, sexually abused, and experience dating violence.  In adults and especially in LGBTQ youth, there is a large amount of bullying.  There are minimal laws to protect against this and recent data has shown that LGBTQ youth are 2 to 3 times more likely to attempt suicide.  This has an obvious direct impact to the victim, but also has an indirect effect and causes ongoing intimidation to other members of this community.

In addition, when compared to a similar heterosexual population, the LGBTQ community  is less likely to have health insurance.  This means they are less likely to get the medical help they need and less likely to seek preventive care which in turn can lead to increased chronic disease.

Training for Clinicians

Another aspect that contributes to this healthcare disparity is a lack of training in existing medical education.  I graduated from what I would consider a progressive medical school within the last five years and I did not get any LGBTQ-specific training.  A report by the Journal of the American Medical Association found that on average students received merely five hours of extra LGBTQ health training.

Challenges with Self Disclosing

Another difficulty involves identifying members of this community. Oftentimes, LGBTQ individuals are hesitant to share information regarding their history because it  may lead to both illegal and legal forms of discrimination and may even escalate to  violence.  Recently, there was controversy over the 2020 census and its plans to collect sexual orientation and gender identity data.  Although an attempt to be more inclusive, the survey’s new option to designate  being in a same-sex relationship  excludes lesbian and gay members of the community who are single.  There is also no way to identify transgender and bisexual people who are single or in relationships.  It is a complicated process but organizations need identify ways to collect inclusive and accurate information in a non-threatening way.

Closing the Gaps

So this begs the question, what is the best way to move forward to alleviate these health disparities?  It is important to keep in mind the overall goal is to a lead happy and healthy life.  There are many ways to address these disparities with some more obvious than others.  It is important to create safe neighborhoods and meeting places that foster a culture of acceptance across all generations.

In 2016, the National Institute of Health formally designated sexual and gender minorities as a health disparity population.  This opened access to increased evidence-based research on how to close these disparities.  Healthy people 2020, which provides 10-year national, science-based objectives also identified LGBT goals which include decreased disease transmission and improved physical and mental wellbeing.

Medical education continues to evolve to be more comprehensive in both the cultural and technical aspects of treating the LGBTQ community.  Organizations have made efforts to offer more resources along with increasing as access to training that demonstrates how to discuss a patient’s sexual orientation and gender identity in a sensitive and culturally competent way.  Health care systems are also offering LGBTQ-specific training to providers and other staff.

There are many health disparities in the LGBTQ population but there is also growing momentum to address these.  It is an ongoing process but incredibly encouraging to see all of the positive changes and drive to decrease the gap in health.