*Co-authored with Hayley Penan*
This is Part II of the National Health Law Program’s two part blog series on the topic of health care refusals and how they undermine standards of care. Part I of the blog series was a very topline review of the topics covered in the original Health Care Refusals report. Part II of the blog series explores the impact of health care refusals, discrimination, and mistreatment on LGBTQ patients and their families.
In the United States, seven percent of people identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ). Health disparities persist for the LGBTQ population, and these are compounded for LGBT people of color. LGBTQ patients and their families also experience specific barriers when accessing health care, including discrimination and refusals of care based on religious and moral objections to their LGBTQ status.
Standards of care for LGBTQ patients generally reflect the standards of care recommended for non-LGBT patients. However, a notable area in which the health care experience of LGBTQ patients differs is through health care refusals, discrimination, and mistreatment. Health care refusals for LGBTQ patients and families can fall into either the individual or institutional categories. Individual physicians and other health providers may refuse to provide services based on a personal moral objection to serving LGBT patients. Similarly, religiously-controlled health care systems may have policies in place to deny care to LGBT patients. Such refusals and restrictions are based on religious or moral belief and not on standard of care.
The United States Conference of Catholic Bishops maintains that “homosexual acts . . . violate the true purposes of sexuality. As such, they note that “the Catholic Church has consistently taught that homosexual acts ‘are contrary to the natural law. . . . Under no circumstances can they be approved.’” This stance impacts access to the standard of care for LGBTQ individuals in a number of ways, including the care available to LGBTQ individuals and their ability to have family present and involved in medical decision-making, among other scenarios. The Church’s beliefs about sexuality and gender have also been applied in the context of gender-affirming care. Many Catholic hospitals will not provide and many Catholic health insurance plans exclude coverage for gender-affirming care. This does not comport with the standard of care. There have been documented and litigated incidences of Catholic health plans refusing to cover reconstruction surgery or hysterectomies for transgender patients. Refusing to provide these medically necessary procedures does not comply with the standard of care.
LGBTQ identity-based institutional refusals have also included denying hospital visitation and medical decision-making for same sex couples. This issue was a hallmark of the experience of LGBTQ individuals during the AIDS crisis, when longtime partners were regularly denied hospital visitation and lacked adequate legal protections. Sadly, this issue is still experienced by LGBTQ couples and families across the country. This type of discrimination does not meet standard of care as laid out by leading medical professional organizations.
The American College of Physicians provide that “[t]he definition of ‘family’ should be inclusive of those who maintain an ongoing emotional relationship with a person, regardless of their legal or biological relationship… [and] encourages all hospitals and medical facilities to allow all patients to determine who may visit and who may act on their behalf during their stay, regardless of their sexual orientation, gender identity, or marital status.” The American Medical Association likewise “encourages all hospitals to add to their rules and regulations, and to their Patient’s Bill of Rights, language permitting same sex couples and their dependent children the same hospital visitation privileges offered to married couples.” Refusals to allow family members of LGBTQ patients the same hospital visitation and medical decision-making rights as other patients are thus in violation of the standard of care.
Discrimination and mistreatment of LGBTQ patients does not simply impact those who are refused care. It has a real impact too on the health behavior of LGBTQ patients as well. A 2020 survey of the LGBTQ community found that 15 percent of overall respondents, and 28 percent of transgender respondents, reported postponing or avoiding necessary medical care when they were sick or injured because of disrespectful or discriminatory experiences. Meanwhile, 16 percent of overall respondents, and 40 percent of transgender respondents, reported postponing or altogether avoiding preventive screenings due to discriminatory experiences.
In the same survey, other LGBTQ patients reported a variety of negative experiences with health care providers, including providers using harsh or abusive language, intentionally refusing to recognize family members, initiating unwanted physical contact, and being visibly uncomfortable due to the patients’ actual or perceived sexual orientation. The situation is particularly difficult for transgender patients, of whom:
- 25 percent report providers refusing to give them medical treatment related to their gender transition;
- 18 percent report providers completely refusing to see them because of their actual or perceived gender identity;
- 19 percent report providers using harsh or abusive language while treating them;
- 20 percent report providers being physically rough or abusive; and
- 32 percent report a provider intentionally misgendering them or using the wrong name.
Standards of care for LGBTQ patients and families do not significantly diverge from standards of care for non-LGBTQ patients and families. However, the experience of health care for LGBTQ patients and families can be accompanied by health care refusals, discrimination, and mistreatment. It may be that the provision of culturally congruent medical care could help improve the experience of LGBTQ patients and families. Yet beyond culturally congruent care, providers and institutions should not be permitted to refuse medical care to LGBTQ patients that would otherwise be provided to non-LGBTQ patients, on the basis of their moral or religious opposition to their patients’ identity. Nor should discrimination and mistreatment of LGBTQ patients be tolerated. Such actions and behavior run contrary to standard of care, and can lead to delays in care, discouragement from accessing needed care, and direct emotional and physical harm for LGBTQ patients.
*Hayley Penan worked at NHeLP from 2017 to 2019
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