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Lesbian/Gay/Bisexual
    Transgender

Public Health Issues
     William C. Buffie, M.D.

     OneVoiceIndiana.org
Key Points

• Disparities in outcomes
• Reasons: “Minority stress” and unequal
  access to health care
• Economic implications
• Role of Family
• Role of Stigma
Bias
• family, friends, patients
• research, Christian Pluralist, author
• state medical association advocacy work
  since 2007 ... American Journal of Public
  Health article June 2011
Clinical Case
• stigma internalized by individual and family
• emotional stress manifest by risky behaviors
  and adverse events
• emotional and financial costs
• avoidable??
• inherent to the “gay lifestyle”?
Data

• evidence-based
• peer-reviewed
• validated by expert consensus --> policies
  and position statements:
•   American Medical Association (AMA)
•   American Academy of Child & Adolescent Psychiatry (AACAP)
•   American Academy of Family Physicians (AAFP)
•   American Academy of Pediatrics (AAP)
•   American Bar Association (ABA)
•   American College of Obstetrics and Gynecology (ACOG)
•   American Medical Women’s Association (AMWA)
•   American Psychiatric Association (APA)
•   American Psychoanalytic Association
•   American Psychological Association
•   North Carolina Psychological Association
•   American Anthropology Association
•   Indiana State Medical Association (ISMA)
•   National Association of Social Workers (NASW)
U.S. Demographics
• Estimated that 4-8% of U.S. women and
  men are LGBTQ (15 million?)
• More than 1,000,000 same-sex couples in
  U.S. are found in every Congressional
  district and in every county in Indiana
• More than 1 million children are being
  raised by LGBT couples or individuals
• Estimated 3.1 million live together in same-
  sex relationships
Indiana Demographics

• Estimated same-sex couples make up 3.8%
  of the population -- 16,328 couples
• 11.5 same-sex couples/1000 households in
  Indianapolis
• 3697 same-sex couples raising children
Health Disparities
• Bullying victims/hate crimes
 • 86% report being verbally or physically abused
 • 44% physically abused at schools
 • 58% incidence of sexual assault
• Rejection by family or caregivers -- 8-fold
  increase in teen homelessness (25-30%)
• 70% of LGBT foster care children are victims of
  violence; 78% run away or are removed from
  unhealthy situations
• 6-fold increase in rates of mental health
  disorders
• 2-3-fold increase in substance abuse
• higher incidence of obesity and physical
  inactivity
• 8-fold increase rates of attempted suicide
  and 3-fold increase in successful suicides
  • 47% have considered suicide
  • 36% have attempted suicide
• All contributing to:
 • higher incidence of HTN and
    cardiovascular disease
 • higher incidence of bulimia or anorexia
 • higher prevalence of risky sexual
    behavior/increased rates of STIs
   • syphilis outbreaks, HPV, gonorrhea,
      chlamydia, HIV/AIDS
• Cirrhosis - hep C&B, alcohol
• Cancer
 • breast - obesity, nulliparous, access
 • cervical - fewer screenings (72% of
    heterosexual peers)
  • anal - MSM
  • prostate/colon/testicular - access
  • lymphoma/Kaposi’s sarcoma
  • hepatocellular
WHY?
Access/Finances
• 40% higher overall mortality if uninsured
• Health insurance denied to partners
 • partnered gay men 42% as likely to have
    employer-sponsored dependent coverage
 • lesbians: 28% as likely compared to
    heterosexual peers
 • costs pushed into the public domain
• IF domestic partnership benefits available,
  cost may be prohibitive (i.e. a taxed
  benefit)
• COBRA benefits not guaranteed
• FMLA and visitation rights denied
• Denial of Social Security benefits to
  surviving partner and children
• No legal standing for surviving partner in
  cases of accidental or negligent death
• IRA rollovers treated as “a stranger” -->
  lump sum distribution immediately taxed
• Immigration law does not recognize legal
  standing of family of those married legally
  elsewhere
• Some countries: illegal or capital offense
• Lack of job protection outside of
  Indianapolis
Defining Normal
• Power + Prejudice = “isms”
• Heterosexism: 2nd class citizens deemed
  to be outside the spectrum of normal
  human behavior (despite de-classified as a
  “disease” state in the U.S. in 1973 and by
  the World Health Organization in 1990)
• The “other”
• Subtle and overt messages to gays and
  lesbians every day:
• Innocent questions
 • “girl friend?”
 • hospital/office intake forms “marital”
    status, “spouse” etc
• Role models/advertisements
• Bullies/jokes/derogatory terms
• Pulpit
• Newspaper stories of rejection/hate crimes
• Institutionalized stigma (1138 federal
  statutes invoke “marriage”)
Minority Stress
• nonconformity to societal norms
• stigma = daily stress and conflict -- NOT a
  singular event; LGBT = invisible minority
• fear of rejection by family, friends, church, co-
  workers, employers -- ALL internalize
  societal prejudice
• For SOME --> cycle of self-doubt, shame, risky
  behaviors and victimization resulting in adverse
  outcomes
Institute of Medicine
• Report from the Institute of Medicine, March
  2011 (committee on LGBT Health Issues and
  Research Gaps and Opportunities/project
  approved by the Governing Board of the
  National Research Council, whose members
  are drawn from the councils of the National
  Academy of Sciences, the National Academy
  of Engineering, and the Institute of
  Medicine/was convened at the request of the
  National Institutes of Health in 2010)key
  conclusion:
• “The minority stress model attributes the
  higher prevalence of anxiety, depression, and
  substance use found among LGB as
  compared with heterosexual populations to
  the additive stress resulting from
  nonconformity with prevailing sexual
  orientation and gender norms. The
  committee’s use of this framework is
  reflected in the discussion of stigma as a
  common experience for LGBT populations
  and, in the context of this study, one that
  affects health.”
Suicides
• Zachery Gray       Billy Lucas
• Jack Reese         Asher Brown
• Raymond Chase      Seth Walsh
• Kenneth Weishuhn    Jay Corey Jones
• Tyler Clementi     Cody Barker
Brain Drain

• Maureen Fitzpatrick, M.D.
• Harvard undergrad, son of IUSOM Drs.
  Larry Cripe and Mimi Jacob
• Medical and bioscience researchers ...
Hate Crimes
• Matthew Shepherd, Mollie Olgin, Mary
  Chapa, Ryan Skipper, Max Pelofske ...
• FBI Stats:
 • 2008 1617 against LGBT
 • 2009 14 hate crimes/day against LGBT
 • 16% of national hate crimes directed at
    LGBT individuals
Bottom Line
• Most basic human need is to be valued
• LGBT identities are within the spectrum of
  normal human behavior
• Families, when disrupted -> fractured social
  and financial safety nets which are vital to
  one’s health
• Marginalization through stigma and
  discrimination restrict access to health care
  and adversely affect outcomes
HIV/AIDS
• 1.2 million cases in U.S.
• 20% unaware -> epidemiologic nightmare
• MSM 44-fold increased risk
• Young Blacks MSM additional 2-fold risk
• $20,000/year/individual for cost of rx,
  labs, clinic visits
Indiana State
Department of Health
• January 1, 2011 – December 31, 2011
• New HIV Cases: 385 (50% MSM)
• New AIDS Cases: 133 (38% MSM)
• Total Persons Living with HIV (without an
  AIDS diagnosis) as of 12/31/2011:
  4638
• Total Persons Living with AIDS:
  5587
Economics
• individual case study: $1,260,000
 • teen suicide attempt/hospitalization:    25K
 • AIDS hospitalization: 35K
 • HIV dx and rx over 40 years: 800K
 • Hep C labs, liver bx, clinic, rx: 200K
 • late cancer dx and rx: 200K
Health Benefits of
     Legal Marriage
• Mortality data show that the married state
  provides the least stress and the greatest
  social and material support
• Holds true regardless of race, ethnicity,
  socioeconomic status, religion, education,
  or sexual orientation
• The legal and social validation of
  nontraditional families and relationships
  positively affects health outcomes
• The Health and Marriage Equality in Massachusetts
  survey administered by the Massachusetts
  Department of Public Health in 2009 (5th year of
  marriage equality):
 • 72% more committed to partner
 • 62% families more accepting and supportive
 • 69% sense of greater acceptance by one’s
    community
 • significantly less depression and anxiety
 • reduction in sense of stigmatization and
    marginalization
•   30% report that one member of the couple
    receives health benefits from an employer as a
    result of being married
•   82% more likely to come out to a co-worker
•   83% more likely to come out to healthcare
    providers
•   nearly all respondents (93%) agreed or
    somewhat agreed that their children are happier
    and better off as a result of their marriage
• Gay men post-marriage equality
 • 13% reduction in healthcare visits
 • 14% reduction in healthcare costs
 • 50% reduction in high risk behaviors for
    HIV and STD’s
 • significant reductions in mental health
    visits and costs regardless of
    partnered status in 12 months post-
    legalization
• Lesbian couples post-marriage equality
 • marriage -> strong predictor of improved
    physical, psychological and financial well
    being
• Midlife and older men with or without
  HIV/AIDS
  • independent of multiple variables being
    legally married was significantly
    protective of mental health disorders
  • c/w minority stress model affecting youth
  • general aging-related stressors --
    financial, loneliness, health concerns
• Danish mortality study post-marriage
  equality
 • progressively declining mortality rates
    with time
 • overall mortality rates remain high
    though at about 33% higher than married
    heterosexual counterparts
Savings?
• billing records -> reduction in HTN,
  depression, and adjustment disorders
• 50% reduction in high risk behaviors for
  HIV and STD’s
• 20% reduction in suicide attempts
• 14% reduction in healthcare costs
• Indiana: assume a 10% reduction in
  prevalence HIV/AIDS --> $20 million/yr
  savings in just HIV dx/rx costs alone
• Costs to the state over a generation: $$$
 • other medical expenses
 • disability or unemployment expense
 • loss of tax revenue: $$$
 • epidemiologic effects of
    homelessness/rejection??
  • each high school drop out costs the
     nation $260,000
  • lifetime cost of one year’s national drop
     outs: $319 billion
AMA

• recognizes that denying civil marriage based
  on sexual orientation is discriminatory and
  imposes harmful stigma on gay and lesbian
  individuals and couples and their families;
AAFP

• Support civil marriage for same-
  gender couples to contribute to overall
  health and longevity, improved family
  stability and to benefit children of gay,
  lesbian, bisexual, transgender (GLBT)
  families.
AMWA
• Stands unified in a broad policy of
  nondiscrimination against lesbian, bisexual
  and gay individuals, urging the following:
  National legislation to end
  discrimination by sexual orientation in
  housing, employment, marriage and tax laws,
  child custody and adoption laws, to redefine
  family to encompass the full diversity of all
  family structures and to ratify marriage for
  gay, lesbian, and bisexual people.
AAP
• Support the right of every child and family to
  the financial, psychologic, and legal security
  that results from having legally
  recognized parents who are committed to
  each other and to the welfare of their
  children.
ISMA
• Recognizes that exclusion from civil unions
  or marriage contributes to health care
  disparities affecting same-sex households;
• Will work to reduce health care disparities
  among members of same-sex households,
  including minor children; and
• Will support measures providing
  same-sex households with the same
  rights and privileges to health care,
  health insurance and survivor benefits, as
  afforded opposite-sex households.
Current State of
Marriage Equality
•   Subject: Critical Decision Unit meeting
    When: Thursday, November 29, 2012 7:00 AM-8:00 AM.
    Where: 2nd floor Administrative Conference Room (Administration)
House Joint Resolution 6 (HJR-6):

    [Indiana’s constitutional ban on non-traditional unions]


Only a marriage between one man and one woman shall be
valid or recognized as a marriage in Indiana. A legal status
identical or substantially similar to that of marriage
for unmarried individuals shall not be valid or
recognized.
HJR-6 Timeline:


February 2011: HJR-6 passed House and Senate

Jan-Apr 2013: HJR-6 can be passed for a 2nd time

Nov 2014: HJR-6 can be placed on the state election ballot for public vote
Indiana House of
  Representatives
   HJR-6 Votes

      D: 25 11
      R: 1 59
   Total: 26 70




Red: “Yea” to HJR-6
Blue: “Nay” to HJR-6
Indiana Senate
   HJR-6 Votes

      D: 10 3
      R: 0 37
   Total: 10 40




Red: “Yea” to HJR-6
Blue: “Nay” to HJR-6
Impact of HJR-6?
• Health/Minority Stress?
 • Survey to 34,653 LGB individuals in 2001
    and 2002 (Wave 1) on a range of
    psychological health indicators
 • Same survey in 2004 and 2005 (Wave 2)
    after 14 states approved constitutional
    amendments limiting marriage to
    opposite-sex unions
Constitutional                         No Constitutional
 Disorder                   Amendment                               Amendment
                      Wave 1, %   Wave 2, %   Change, %   AOR     Wave 1, % Wave 2, % Change, %   AOR



Any mood disorder       22.7        31.0       36.6       1.67*     22.5      17.2     -23.6      0.69

Generalized Anxiety
                        2.7         9.4       248.2       4.20*     5.6        8.2      48.0      1.54
    Disorder

 Alcohol Disorder       21.7        30.8       41.9       1.80*     16.4      21.2      28.9      1.41


Comorbid Disorder       17.6        27.6       36.3       2.00*     13.7      14.9       8.5      1.11

 * P<0.05, Significant difference before and after amendment
• Economic/competitive disadvantage?
 • Dr. Fitzpatrick ...
 • Researchers at Lilly, IUMC, ...
 • State stigmatized as non-inclusive, non-
    welcoming
  • Public Health $$ spent??
Revenues
• Williams Institute/UCLA School of Law and
  Lee Badgett, professor of economics,
  Amherst, senior policy director for public
  health in Massachusetts
   • Marriage/tourism
   • tax revenues
• Massachusetts:  an estimated $111 million
  to the state economy.
• New York City:  an estimated $259 million
  in economic impact and $16 million in City
  revenues.
• Washington D.C. :    $52.2 million over
  three years, which would generate
  increases in local government tax and fee
  revenues by $5.4 million and create
  approximately 700 new jobs.
• Iowa: $12 to $13 million boost; likely to
  have added $850,000 to $930,000 in tax
  revenue to state and local coffers
National Impact
• If same-sex marriage rights were granted
  nationwide, same-sex weddings would
  generate a net $1 billion each year for the
  Federal budget over the next 10 years,
  according to a 2004 report by Congressional
  Budget Office. That's after taking into
  account lower income and estate tax
  revenues as well as increased spending for
  health-care benefits and Social Security.
What can we do?
Resolved, that we supporters of OneVoiceIndiana: The Indiana
Coalition for Lesbian/Gay/Bisexual/Transgender Health and
Nondiscrimination:
(1) affirm, in concurrence with the American Medical Association's June
2011 policy H-65.973 Health Care Disparities in Same-Sex Partner Households,
that denying civil union or marriage based on sexual orientation, as
proposed by HJR-6, is discriminatory and imposes harmful stigma on gay
and lesbian individuals and couples and families;

(2) recognize that individuals who are LGBT fall within the spectrum of
normal human experience; and

(3) do, therefore, in the interest of optimal public health outcomes and in the
economic interests of our state oppose legislation, such as HJR-6, that not only
marginalizes and discriminates against a particular minority group, but also
effectively precludes further bipartisan rational discourse relative to
measures!which!may offer!legal and social validation of non-traditional couples
and their families.
Bibliography
(1) Gates GJ. Same-sex couples and the gay, lesbian, bisexual population: new estimates from the
American Community Survey. Available at: http://www.2.law.
ucla.edu/williamsinstitute/publications/SameSexCouplesandGLBpopACS.pdf. Published October 2006.
Accessed February 14, 2011.
(2) Center for Health Promotion. National Survey of Sexual Health and Behavior. Available at:
http://www.nationalsexstudy.indiana.edu. Accessed February 14, 2011.
(3) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and
Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for
Better Understanding. The Institute of Medicine. Copyright 2011 by the National Academy of Sciences.
(4) Buffie WC. Public Health Implications of Same-Sex Marriage. Am J Public Health. 2011;101(6):986-
990.
(5) Australian Medical Association. Position Statement on Sexual Diversity and Gender Identity.
Kingston, Australian Capital Territory: Australian Medical Association; 2002.
(6) Riggle E, Rostosky S. The consequences of marriage policy for same-sex couples’ well-being. In:
The Politics of Same-Sex Marriage. Chicago, IL: University of Chicago Press; 2007
(7) Levitt H, Ovrebo E, Anderson-Cleveland M, et al. Balancing dangers: GLBT experience in a time
of anti-GLBT legislation. J Couns Psychol. 2009;56(1):67-81.
(8) Pawelski JG, Perrin D, Foy J, et al. The effects of marriage, civil union, and domestic partnership
laws on the health and well-being of children. Pediatrics. 2006;118(1):349-364.
(9) Ryan C, Huebner D, Diaz R, Sanchez J. Family rejection as a predictor of negative health
outcomes in White and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009;123(1):346-352.
(10) Cochran SD, Sullivan JG, Mays V. Prevalence of mental disorders, psychological distress and
mental health services use among lesbian, gay and bisexual adults in the United States. J Consult Clin
Psychol. 2003;71(1):53-61.
(11) Hatzenbuehler ML, McLaughlin K, Keyes K, Hasin D. The impact of institutional discrimination
on psychiatric disorders in lesbian, gay, and bisexual populations: a prospective study. Am J Public
Health. 2010;100(3):452-459.
(12) Johnson NJ, Backlund E, Sorlie P, Loveless C. Marital status and mortality: the National
Longitudinal Mortality Study. Ann Epidemiol. 2000;10(4):224-238.
(13) Herdt G, Kertzner R. I do, but I can’t: the impact of marriage denial on the mental health and
sexual citizenship of lesbians and gay men in the United States. Sex Res Soc Policy. 2006;3(1):33-49.
(14) Centers for Disease Control and Prevention. Marital status and health: United States, 1999-
2002. Adv Data. 2004:351. Available at http://www.cdc.gov/nchs/data/ad/ad351.pdf. Accessed February
14, 2011.
(15) Ramos C, Goldberg NG, Badgett MV. The effects of marriage equality in Massachusetts: a survey
of the experiences and impact of marrage on same-sex couples. Available at http://williamsinstitute.
law.ucla.edu/wp-content/uploads/Ramos-Goldberg-Badgett-MA-Effects-Marriage-Equality-May-
2009.pdf. Accessed April 15, 2012.
(16) Wilper AP, Woolhandler S, Lasser K, McCormick D, Bor D, Himmelstein D. Health insurance
and mortality in US adults. Am J Public Health. 2009;99(12):2289-2295.
(17) Ponce N, Cochran S, Pizer J, Mays V. The effects of unequal access to health insurance for same-
sex couples in California. Health Aff (Millwood). 2010;29(8):1539-1548.
(18) Hatzenbuehler ML, O’Cleirigh C, Grasso C, Mayer K, Safren S, Bradford J. Effect of same-sex
marriage laws on health care use and expenditures in sexual minority men: a quasi-natural
experiment. Am J Public Health. 2012;102(2):285-291.
(19) Badgett MVL. Will providing marriage rights to same-sex couples undermine heterosexual
marriage? Sex Res Soc Policy. 2004;1(3):1-10.
(20) Wainright JL, Russell S, Patterson C. Psychological adjustment, school outcomes, and romantic
relationships of adolescents with same-sex parents. Child Dev. 2004;75(6):1886-1898.
(21) American Medical Association. H-65.973 Health care disparities in same-sex partner households.
Available at http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/glbt-
advisory-committee/ama-policy-regarding-sexual-orientation.page. 2009. Accessed March 26, 2012.
(22) American Bar Association. Resolution 111. Available at http://www.abanow.org/2010/07/am-
2010-111/. 2010. Accessed March 26, 2012.
(23) American Medical Women’s Association. Position paper on principals of lesbian health issues.
Available at http://www.amwa-doc.org/gallery2-227/LesbianHealthIssues. Accessed April 11, 2012.
(24) American Psychiatric Association. Support of legal recognition of same-sex civil
marriage: position statement. Arlington (VA): APA; 2005. Available at:
http://archive. psych.org/edu/other_res/lib_archives/archives/200502.pdf.
Accessed March 26, 2012.
(25) North Carolina Psychological Association. Position statement opposing defense
of marriage amendment. Available at
http://www.protectncfamilies.org/sites/protectncfamilies/files/psychologists.pdf.
2011. Accessed April 12, 2012.
(26) Indiana State Medical Association. Resolution 11-32A. Available at
http://www.ismanet.org/legislation/public_policy.htm (Click on “Health Care System”). 2011.
Accessed April 12, 2012.
(27) Indiana General Assembly. First regular session 117th general assembly (2011). House Enrolled
Joint No. 6. Available at http://www.in.gov/legislative/bills/2011/PDF/RES/HJ0006.4.pdf. 2011.
Accessed March 23, 2012.
(28) Rothblum, Emily, et al. Journal of Homosexuality
(29) U.S. Department of Health and Human Services/Substance Abuse and Mental Health Services
Administration/Center for Substance Abuse Prevention: Top Health Issues for LGBT Populations
Information and Resource Kit, 2012
(30) Hatzenbuehler et al. Am J of Public Health; 2012 Feb; 102 (2): 285-91. Effect of same-sex
marriage laws on health care use and expenditures in sexual minority men: a quasi-natural experiment.
(31) Ducharme JK, Kollar MM. J of Homosexuality; 2012 April; 59 (4): 580-91. Does the “Marriage
Benefit” extend to same-sex union?: evidence from a sample of married lesbian couples in Massachusetts.
(32) Wight RG, et al. AM J of Public Health; 2012 March; 102 (3): 503-10. Stress and mental health
among midlife and older gay-identified men.
(33) Buchmueller T, Carpenter C. Am J of Public Health; 2010, March; 100 (3): 489-95. Disparities in
Health Insurance Coverage, Access, and Outcomes for Individuals in Same-Sex versus Different-Sex
Relationships, 2000-2007.
(34) Ponce N, et al. Health Affairs; 2010 June; 29 (8): 1539-48. The Effects of Unequal Access to Health
Insurance For Same-Sex Couples in California.
(35) Buchmueller T, Carpenter C. 2011 July; Draft: The Effect of Requiring Private Employers to Extend
Health Benefit Eligibility to Same-Sex Partners of Employees: Evidence from California.
(36) Amos, Jason. Alliance for Excellent Education: 2008. Dropouts, Diplomas, and Dollars: U.S. High
Schools and the Nation’s Economy.
(37) Hatzenbuehler ML. Pediatrics; 2011 May; 127 (5): 896-903. The Social Environment and Suicide
Attempts in Lesbian, Gay, and Bisexual Youth.
(38) Klausner JD, et al. Journal of Homosexuality; 2006: 51(4): 137-144. Same-sex Domestic
Partnerships and Lower Risk behaviors for STD’s, including HIV Infection.
Lesbian/Gay/Bisexual
    Transgender

Public Health Issues
     William C. Buffie, M.D.

     OneVoiceIndiana.org
Appendix for health
care institutions and
 medical providers
Human Rights
         Campaign
• Healthcare Equality Index (HEI)
   • 2011: 375 institutions nationally
   • Only 2 in Indiana -- Ball Memorial and
      Clarian (now IU Health)
• Rating Criteria:
• Patient nondiscrimination policies
  • includes sexual orientation/gender
     identity
• Visitation policies
  • equal access for same-sex couples or
     parents
• Cultural competency training and client
  services
• Employment policies and benefits
Welcoming Strategies
• intake forms
 • relationship status - M/S/D/W/Partnered
 • partner/spouse
• social history questionnaires
 • Gender identity - M/F/transgender
 • sexual orientation
 • hit or threatened
• Inclusive (non-heterosexual) language
 • “significant other?”
 • intentionally non-judgemental, inviting
 • not a “lifestyle”
• Visual cues demonstrating inclusivity and
  awareness
• Cultural competency training for staff
• Non-discrimination policies for patients
  and staff
• Respect (through policies) visitation rights
  and healthcare decision-making rights
• Support legislative efforts that afford equal
  access to health care
Medical Encounter
• History focused on specific risk factors:
 • anxiety/depression
 • sexual history - risky behaviors; safe sex
 • substance abuse
 • suicidal ideation
 • family acceptance
 • victimization/bullying
• Vaccination status
 • hepatitis A and B
 • HPV
 • HIV?
Education
• For patients
 • www.itgetsbetter.org
 • www.thetrevorproject.org
 • Indiana Youth Group
 • PFLAG
• For Physicians:
• www.glma.org, www.lgbthealth.net
OneVoice Research 2012
OneVoice Research 2012
OneVoice Research 2012
OneVoice Research 2012

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OneVoice Research 2012

  • 1. Lesbian/Gay/Bisexual Transgender Public Health Issues William C. Buffie, M.D. OneVoiceIndiana.org
  • 2. Key Points • Disparities in outcomes • Reasons: “Minority stress” and unequal access to health care • Economic implications • Role of Family • Role of Stigma
  • 3. Bias • family, friends, patients • research, Christian Pluralist, author • state medical association advocacy work since 2007 ... American Journal of Public Health article June 2011
  • 4. Clinical Case • stigma internalized by individual and family • emotional stress manifest by risky behaviors and adverse events • emotional and financial costs • avoidable?? • inherent to the “gay lifestyle”?
  • 5. Data • evidence-based • peer-reviewed • validated by expert consensus --> policies and position statements:
  • 6. American Medical Association (AMA) • American Academy of Child & Adolescent Psychiatry (AACAP) • American Academy of Family Physicians (AAFP) • American Academy of Pediatrics (AAP) • American Bar Association (ABA) • American College of Obstetrics and Gynecology (ACOG) • American Medical Women’s Association (AMWA) • American Psychiatric Association (APA) • American Psychoanalytic Association • American Psychological Association • North Carolina Psychological Association • American Anthropology Association • Indiana State Medical Association (ISMA) • National Association of Social Workers (NASW)
  • 7. U.S. Demographics • Estimated that 4-8% of U.S. women and men are LGBTQ (15 million?) • More than 1,000,000 same-sex couples in U.S. are found in every Congressional district and in every county in Indiana • More than 1 million children are being raised by LGBT couples or individuals • Estimated 3.1 million live together in same- sex relationships
  • 8. Indiana Demographics • Estimated same-sex couples make up 3.8% of the population -- 16,328 couples • 11.5 same-sex couples/1000 households in Indianapolis • 3697 same-sex couples raising children
  • 9. Health Disparities • Bullying victims/hate crimes • 86% report being verbally or physically abused • 44% physically abused at schools • 58% incidence of sexual assault • Rejection by family or caregivers -- 8-fold increase in teen homelessness (25-30%) • 70% of LGBT foster care children are victims of violence; 78% run away or are removed from unhealthy situations
  • 10. • 6-fold increase in rates of mental health disorders • 2-3-fold increase in substance abuse • higher incidence of obesity and physical inactivity • 8-fold increase rates of attempted suicide and 3-fold increase in successful suicides • 47% have considered suicide • 36% have attempted suicide
  • 11. • All contributing to: • higher incidence of HTN and cardiovascular disease • higher incidence of bulimia or anorexia • higher prevalence of risky sexual behavior/increased rates of STIs • syphilis outbreaks, HPV, gonorrhea, chlamydia, HIV/AIDS
  • 12. • Cirrhosis - hep C&B, alcohol • Cancer • breast - obesity, nulliparous, access • cervical - fewer screenings (72% of heterosexual peers) • anal - MSM • prostate/colon/testicular - access • lymphoma/Kaposi’s sarcoma • hepatocellular
  • 13. WHY?
  • 14. Access/Finances • 40% higher overall mortality if uninsured • Health insurance denied to partners • partnered gay men 42% as likely to have employer-sponsored dependent coverage • lesbians: 28% as likely compared to heterosexual peers • costs pushed into the public domain
  • 15. • IF domestic partnership benefits available, cost may be prohibitive (i.e. a taxed benefit) • COBRA benefits not guaranteed • FMLA and visitation rights denied • Denial of Social Security benefits to surviving partner and children • No legal standing for surviving partner in cases of accidental or negligent death
  • 16. • IRA rollovers treated as “a stranger” --> lump sum distribution immediately taxed • Immigration law does not recognize legal standing of family of those married legally elsewhere • Some countries: illegal or capital offense • Lack of job protection outside of Indianapolis
  • 17. Defining Normal • Power + Prejudice = “isms” • Heterosexism: 2nd class citizens deemed to be outside the spectrum of normal human behavior (despite de-classified as a “disease” state in the U.S. in 1973 and by the World Health Organization in 1990) • The “other” • Subtle and overt messages to gays and lesbians every day:
  • 18. • Innocent questions • “girl friend?” • hospital/office intake forms “marital” status, “spouse” etc • Role models/advertisements • Bullies/jokes/derogatory terms • Pulpit • Newspaper stories of rejection/hate crimes • Institutionalized stigma (1138 federal statutes invoke “marriage”)
  • 19. Minority Stress • nonconformity to societal norms • stigma = daily stress and conflict -- NOT a singular event; LGBT = invisible minority • fear of rejection by family, friends, church, co- workers, employers -- ALL internalize societal prejudice • For SOME --> cycle of self-doubt, shame, risky behaviors and victimization resulting in adverse outcomes
  • 20. Institute of Medicine • Report from the Institute of Medicine, March 2011 (committee on LGBT Health Issues and Research Gaps and Opportunities/project approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine/was convened at the request of the National Institutes of Health in 2010)key conclusion:
  • 21. • “The minority stress model attributes the higher prevalence of anxiety, depression, and substance use found among LGB as compared with heterosexual populations to the additive stress resulting from nonconformity with prevailing sexual orientation and gender norms. The committee’s use of this framework is reflected in the discussion of stigma as a common experience for LGBT populations and, in the context of this study, one that affects health.”
  • 22. Suicides • Zachery Gray Billy Lucas • Jack Reese Asher Brown • Raymond Chase Seth Walsh • Kenneth Weishuhn Jay Corey Jones • Tyler Clementi Cody Barker
  • 23. Brain Drain • Maureen Fitzpatrick, M.D. • Harvard undergrad, son of IUSOM Drs. Larry Cripe and Mimi Jacob • Medical and bioscience researchers ...
  • 24. Hate Crimes • Matthew Shepherd, Mollie Olgin, Mary Chapa, Ryan Skipper, Max Pelofske ... • FBI Stats: • 2008 1617 against LGBT • 2009 14 hate crimes/day against LGBT • 16% of national hate crimes directed at LGBT individuals
  • 25. Bottom Line • Most basic human need is to be valued • LGBT identities are within the spectrum of normal human behavior • Families, when disrupted -> fractured social and financial safety nets which are vital to one’s health • Marginalization through stigma and discrimination restrict access to health care and adversely affect outcomes
  • 26. HIV/AIDS • 1.2 million cases in U.S. • 20% unaware -> epidemiologic nightmare • MSM 44-fold increased risk • Young Blacks MSM additional 2-fold risk • $20,000/year/individual for cost of rx, labs, clinic visits
  • 27. Indiana State Department of Health • January 1, 2011 – December 31, 2011 • New HIV Cases: 385 (50% MSM) • New AIDS Cases: 133 (38% MSM) • Total Persons Living with HIV (without an AIDS diagnosis) as of 12/31/2011: 4638 • Total Persons Living with AIDS: 5587
  • 28. Economics • individual case study: $1,260,000 • teen suicide attempt/hospitalization: 25K • AIDS hospitalization: 35K • HIV dx and rx over 40 years: 800K • Hep C labs, liver bx, clinic, rx: 200K • late cancer dx and rx: 200K
  • 29. Health Benefits of Legal Marriage • Mortality data show that the married state provides the least stress and the greatest social and material support • Holds true regardless of race, ethnicity, socioeconomic status, religion, education, or sexual orientation • The legal and social validation of nontraditional families and relationships positively affects health outcomes
  • 30. • The Health and Marriage Equality in Massachusetts survey administered by the Massachusetts Department of Public Health in 2009 (5th year of marriage equality): • 72% more committed to partner • 62% families more accepting and supportive • 69% sense of greater acceptance by one’s community • significantly less depression and anxiety • reduction in sense of stigmatization and marginalization
  • 31. 30% report that one member of the couple receives health benefits from an employer as a result of being married • 82% more likely to come out to a co-worker • 83% more likely to come out to healthcare providers • nearly all respondents (93%) agreed or somewhat agreed that their children are happier and better off as a result of their marriage
  • 32. • Gay men post-marriage equality • 13% reduction in healthcare visits • 14% reduction in healthcare costs • 50% reduction in high risk behaviors for HIV and STD’s • significant reductions in mental health visits and costs regardless of partnered status in 12 months post- legalization
  • 33. • Lesbian couples post-marriage equality • marriage -> strong predictor of improved physical, psychological and financial well being • Midlife and older men with or without HIV/AIDS • independent of multiple variables being legally married was significantly protective of mental health disorders • c/w minority stress model affecting youth • general aging-related stressors -- financial, loneliness, health concerns
  • 34. • Danish mortality study post-marriage equality • progressively declining mortality rates with time • overall mortality rates remain high though at about 33% higher than married heterosexual counterparts
  • 35. Savings? • billing records -> reduction in HTN, depression, and adjustment disorders • 50% reduction in high risk behaviors for HIV and STD’s • 20% reduction in suicide attempts • 14% reduction in healthcare costs • Indiana: assume a 10% reduction in prevalence HIV/AIDS --> $20 million/yr savings in just HIV dx/rx costs alone
  • 36. • Costs to the state over a generation: $$$ • other medical expenses • disability or unemployment expense • loss of tax revenue: $$$ • epidemiologic effects of homelessness/rejection?? • each high school drop out costs the nation $260,000 • lifetime cost of one year’s national drop outs: $319 billion
  • 37. AMA • recognizes that denying civil marriage based on sexual orientation is discriminatory and imposes harmful stigma on gay and lesbian individuals and couples and their families;
  • 38. AAFP • Support civil marriage for same- gender couples to contribute to overall health and longevity, improved family stability and to benefit children of gay, lesbian, bisexual, transgender (GLBT) families.
  • 39. AMWA • Stands unified in a broad policy of nondiscrimination against lesbian, bisexual and gay individuals, urging the following: National legislation to end discrimination by sexual orientation in housing, employment, marriage and tax laws, child custody and adoption laws, to redefine family to encompass the full diversity of all family structures and to ratify marriage for gay, lesbian, and bisexual people.
  • 40. AAP • Support the right of every child and family to the financial, psychologic, and legal security that results from having legally recognized parents who are committed to each other and to the welfare of their children.
  • 41. ISMA • Recognizes that exclusion from civil unions or marriage contributes to health care disparities affecting same-sex households; • Will work to reduce health care disparities among members of same-sex households, including minor children; and • Will support measures providing same-sex households with the same rights and privileges to health care, health insurance and survivor benefits, as afforded opposite-sex households.
  • 43. Subject: Critical Decision Unit meeting When: Thursday, November 29, 2012 7:00 AM-8:00 AM. Where: 2nd floor Administrative Conference Room (Administration)
  • 44. House Joint Resolution 6 (HJR-6): [Indiana’s constitutional ban on non-traditional unions] Only a marriage between one man and one woman shall be valid or recognized as a marriage in Indiana. A legal status identical or substantially similar to that of marriage for unmarried individuals shall not be valid or recognized.
  • 45. HJR-6 Timeline: February 2011: HJR-6 passed House and Senate Jan-Apr 2013: HJR-6 can be passed for a 2nd time Nov 2014: HJR-6 can be placed on the state election ballot for public vote
  • 46. Indiana House of Representatives HJR-6 Votes D: 25 11 R: 1 59 Total: 26 70 Red: “Yea” to HJR-6 Blue: “Nay” to HJR-6
  • 47. Indiana Senate HJR-6 Votes D: 10 3 R: 0 37 Total: 10 40 Red: “Yea” to HJR-6 Blue: “Nay” to HJR-6
  • 48. Impact of HJR-6? • Health/Minority Stress? • Survey to 34,653 LGB individuals in 2001 and 2002 (Wave 1) on a range of psychological health indicators • Same survey in 2004 and 2005 (Wave 2) after 14 states approved constitutional amendments limiting marriage to opposite-sex unions
  • 49. Constitutional No Constitutional Disorder Amendment Amendment Wave 1, % Wave 2, % Change, % AOR Wave 1, % Wave 2, % Change, % AOR Any mood disorder 22.7 31.0 36.6 1.67* 22.5 17.2 -23.6 0.69 Generalized Anxiety 2.7 9.4 248.2 4.20* 5.6 8.2 48.0 1.54 Disorder Alcohol Disorder 21.7 30.8 41.9 1.80* 16.4 21.2 28.9 1.41 Comorbid Disorder 17.6 27.6 36.3 2.00* 13.7 14.9 8.5 1.11 * P<0.05, Significant difference before and after amendment
  • 50. • Economic/competitive disadvantage? • Dr. Fitzpatrick ... • Researchers at Lilly, IUMC, ... • State stigmatized as non-inclusive, non- welcoming • Public Health $$ spent??
  • 51. Revenues • Williams Institute/UCLA School of Law and Lee Badgett, professor of economics, Amherst, senior policy director for public health in Massachusetts • Marriage/tourism • tax revenues
  • 52. • Massachusetts: an estimated $111 million to the state economy. • New York City: an estimated $259 million in economic impact and $16 million in City revenues. • Washington D.C. : $52.2 million over three years, which would generate increases in local government tax and fee revenues by $5.4 million and create approximately 700 new jobs. • Iowa: $12 to $13 million boost; likely to have added $850,000 to $930,000 in tax revenue to state and local coffers
  • 53. National Impact • If same-sex marriage rights were granted nationwide, same-sex weddings would generate a net $1 billion each year for the Federal budget over the next 10 years, according to a 2004 report by Congressional Budget Office. That's after taking into account lower income and estate tax revenues as well as increased spending for health-care benefits and Social Security.
  • 54. What can we do?
  • 55. Resolved, that we supporters of OneVoiceIndiana: The Indiana Coalition for Lesbian/Gay/Bisexual/Transgender Health and Nondiscrimination: (1) affirm, in concurrence with the American Medical Association's June 2011 policy H-65.973 Health Care Disparities in Same-Sex Partner Households, that denying civil union or marriage based on sexual orientation, as proposed by HJR-6, is discriminatory and imposes harmful stigma on gay and lesbian individuals and couples and families; (2) recognize that individuals who are LGBT fall within the spectrum of normal human experience; and (3) do, therefore, in the interest of optimal public health outcomes and in the economic interests of our state oppose legislation, such as HJR-6, that not only marginalizes and discriminates against a particular minority group, but also effectively precludes further bipartisan rational discourse relative to measures!which!may offer!legal and social validation of non-traditional couples and their families.
  • 56. Bibliography (1) Gates GJ. Same-sex couples and the gay, lesbian, bisexual population: new estimates from the American Community Survey. Available at: http://www.2.law. ucla.edu/williamsinstitute/publications/SameSexCouplesandGLBpopACS.pdf. Published October 2006. Accessed February 14, 2011. (2) Center for Health Promotion. National Survey of Sexual Health and Behavior. Available at: http://www.nationalsexstudy.indiana.edu. Accessed February 14, 2011. (3) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. The Institute of Medicine. Copyright 2011 by the National Academy of Sciences. (4) Buffie WC. Public Health Implications of Same-Sex Marriage. Am J Public Health. 2011;101(6):986- 990. (5) Australian Medical Association. Position Statement on Sexual Diversity and Gender Identity. Kingston, Australian Capital Territory: Australian Medical Association; 2002. (6) Riggle E, Rostosky S. The consequences of marriage policy for same-sex couples’ well-being. In: The Politics of Same-Sex Marriage. Chicago, IL: University of Chicago Press; 2007 (7) Levitt H, Ovrebo E, Anderson-Cleveland M, et al. Balancing dangers: GLBT experience in a time of anti-GLBT legislation. J Couns Psychol. 2009;56(1):67-81. (8) Pawelski JG, Perrin D, Foy J, et al. The effects of marriage, civil union, and domestic partnership laws on the health and well-being of children. Pediatrics. 2006;118(1):349-364. (9) Ryan C, Huebner D, Diaz R, Sanchez J. Family rejection as a predictor of negative health outcomes in White and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009;123(1):346-352.
  • 57. (10) Cochran SD, Sullivan JG, Mays V. Prevalence of mental disorders, psychological distress and mental health services use among lesbian, gay and bisexual adults in the United States. J Consult Clin Psychol. 2003;71(1):53-61. (11) Hatzenbuehler ML, McLaughlin K, Keyes K, Hasin D. The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: a prospective study. Am J Public Health. 2010;100(3):452-459. (12) Johnson NJ, Backlund E, Sorlie P, Loveless C. Marital status and mortality: the National Longitudinal Mortality Study. Ann Epidemiol. 2000;10(4):224-238. (13) Herdt G, Kertzner R. I do, but I can’t: the impact of marriage denial on the mental health and sexual citizenship of lesbians and gay men in the United States. Sex Res Soc Policy. 2006;3(1):33-49. (14) Centers for Disease Control and Prevention. Marital status and health: United States, 1999- 2002. Adv Data. 2004:351. Available at http://www.cdc.gov/nchs/data/ad/ad351.pdf. Accessed February 14, 2011. (15) Ramos C, Goldberg NG, Badgett MV. The effects of marriage equality in Massachusetts: a survey of the experiences and impact of marrage on same-sex couples. Available at http://williamsinstitute. law.ucla.edu/wp-content/uploads/Ramos-Goldberg-Badgett-MA-Effects-Marriage-Equality-May- 2009.pdf. Accessed April 15, 2012. (16) Wilper AP, Woolhandler S, Lasser K, McCormick D, Bor D, Himmelstein D. Health insurance and mortality in US adults. Am J Public Health. 2009;99(12):2289-2295. (17) Ponce N, Cochran S, Pizer J, Mays V. The effects of unequal access to health insurance for same- sex couples in California. Health Aff (Millwood). 2010;29(8):1539-1548.
  • 58. (18) Hatzenbuehler ML, O’Cleirigh C, Grasso C, Mayer K, Safren S, Bradford J. Effect of same-sex marriage laws on health care use and expenditures in sexual minority men: a quasi-natural experiment. Am J Public Health. 2012;102(2):285-291. (19) Badgett MVL. Will providing marriage rights to same-sex couples undermine heterosexual marriage? Sex Res Soc Policy. 2004;1(3):1-10. (20) Wainright JL, Russell S, Patterson C. Psychological adjustment, school outcomes, and romantic relationships of adolescents with same-sex parents. Child Dev. 2004;75(6):1886-1898. (21) American Medical Association. H-65.973 Health care disparities in same-sex partner households. Available at http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/glbt- advisory-committee/ama-policy-regarding-sexual-orientation.page. 2009. Accessed March 26, 2012. (22) American Bar Association. Resolution 111. Available at http://www.abanow.org/2010/07/am- 2010-111/. 2010. Accessed March 26, 2012. (23) American Medical Women’s Association. Position paper on principals of lesbian health issues. Available at http://www.amwa-doc.org/gallery2-227/LesbianHealthIssues. Accessed April 11, 2012. (24) American Psychiatric Association. Support of legal recognition of same-sex civil marriage: position statement. Arlington (VA): APA; 2005. Available at: http://archive. psych.org/edu/other_res/lib_archives/archives/200502.pdf. Accessed March 26, 2012. (25) North Carolina Psychological Association. Position statement opposing defense of marriage amendment. Available at http://www.protectncfamilies.org/sites/protectncfamilies/files/psychologists.pdf. 2011. Accessed April 12, 2012. (26) Indiana State Medical Association. Resolution 11-32A. Available at http://www.ismanet.org/legislation/public_policy.htm (Click on “Health Care System”). 2011. Accessed April 12, 2012.
  • 59. (27) Indiana General Assembly. First regular session 117th general assembly (2011). House Enrolled Joint No. 6. Available at http://www.in.gov/legislative/bills/2011/PDF/RES/HJ0006.4.pdf. 2011. Accessed March 23, 2012. (28) Rothblum, Emily, et al. Journal of Homosexuality (29) U.S. Department of Health and Human Services/Substance Abuse and Mental Health Services Administration/Center for Substance Abuse Prevention: Top Health Issues for LGBT Populations Information and Resource Kit, 2012 (30) Hatzenbuehler et al. Am J of Public Health; 2012 Feb; 102 (2): 285-91. Effect of same-sex marriage laws on health care use and expenditures in sexual minority men: a quasi-natural experiment. (31) Ducharme JK, Kollar MM. J of Homosexuality; 2012 April; 59 (4): 580-91. Does the “Marriage Benefit” extend to same-sex union?: evidence from a sample of married lesbian couples in Massachusetts. (32) Wight RG, et al. AM J of Public Health; 2012 March; 102 (3): 503-10. Stress and mental health among midlife and older gay-identified men. (33) Buchmueller T, Carpenter C. Am J of Public Health; 2010, March; 100 (3): 489-95. Disparities in Health Insurance Coverage, Access, and Outcomes for Individuals in Same-Sex versus Different-Sex Relationships, 2000-2007. (34) Ponce N, et al. Health Affairs; 2010 June; 29 (8): 1539-48. The Effects of Unequal Access to Health Insurance For Same-Sex Couples in California. (35) Buchmueller T, Carpenter C. 2011 July; Draft: The Effect of Requiring Private Employers to Extend Health Benefit Eligibility to Same-Sex Partners of Employees: Evidence from California. (36) Amos, Jason. Alliance for Excellent Education: 2008. Dropouts, Diplomas, and Dollars: U.S. High Schools and the Nation’s Economy. (37) Hatzenbuehler ML. Pediatrics; 2011 May; 127 (5): 896-903. The Social Environment and Suicide Attempts in Lesbian, Gay, and Bisexual Youth. (38) Klausner JD, et al. Journal of Homosexuality; 2006: 51(4): 137-144. Same-sex Domestic Partnerships and Lower Risk behaviors for STD’s, including HIV Infection.
  • 60. Lesbian/Gay/Bisexual Transgender Public Health Issues William C. Buffie, M.D. OneVoiceIndiana.org
  • 61. Appendix for health care institutions and medical providers
  • 62. Human Rights Campaign • Healthcare Equality Index (HEI) • 2011: 375 institutions nationally • Only 2 in Indiana -- Ball Memorial and Clarian (now IU Health) • Rating Criteria:
  • 63. • Patient nondiscrimination policies • includes sexual orientation/gender identity • Visitation policies • equal access for same-sex couples or parents • Cultural competency training and client services • Employment policies and benefits
  • 64. Welcoming Strategies • intake forms • relationship status - M/S/D/W/Partnered • partner/spouse • social history questionnaires • Gender identity - M/F/transgender • sexual orientation • hit or threatened
  • 65. • Inclusive (non-heterosexual) language • “significant other?” • intentionally non-judgemental, inviting • not a “lifestyle”
  • 66. • Visual cues demonstrating inclusivity and awareness • Cultural competency training for staff • Non-discrimination policies for patients and staff • Respect (through policies) visitation rights and healthcare decision-making rights • Support legislative efforts that afford equal access to health care
  • 67. Medical Encounter • History focused on specific risk factors: • anxiety/depression • sexual history - risky behaviors; safe sex • substance abuse • suicidal ideation • family acceptance • victimization/bullying
  • 68. • Vaccination status • hepatitis A and B • HPV • HIV?
  • 69. Education • For patients • www.itgetsbetter.org • www.thetrevorproject.org • Indiana Youth Group • PFLAG • For Physicians: • www.glma.org, www.lgbthealth.net