Lesbian/Gay/BisexualTransgender

Public Health Issues

William C. Buffie, M.D.

OneVoiceIndiana.org

Key Points

• Disparities in outcomes

• Reasons: “Minority stress” and unequalaccess to health care

• Economic implications

• Role of Family

• Role of Stigma

Bias

• family, friends, patients

• research, Christian Pluralist, author

• state medical association advocacy worksince 2007 ... American Journal of PublicHealth article June 2011

Clinical Case

• stigma internalized by individual and family

• emotional stress manifest by risky behaviorsand adverse events

• emotional and financial costs

• avoidable??

• inherent to the “gay lifestyle”?

Data

• evidence-based

• peer-reviewed

• validated by expert consensus --> policiesand 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 inU.S. are found in every Congressionaldistrict and in every county in Indiana

• More than 1 million children are beingraised 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 inIndianapolis

• 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-foldincrease in teen homelessness (25-30%)

• 70% of LGBT foster care children are victims ofviolence; 78% run away or are removed fromunhealthy situations

• 6-fold increase in rates of mental healthdisorders

• 2-3-fold increase in substance abuse

• higher incidence of obesity and physicalinactivity

• 8-fold increase rates of attempted suicideand 3-fold increase in successful suicides

• 47% have considered suicide

• 36% have attempted suicide

• All contributing to:

• higher incidence of HTN andcardiovascular disease

• higher incidence of bulimia or anorexia

• higher prevalence of risky sexualbehavior/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% ofheterosexual 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 haveemployer-sponsored dependent coverage

• lesbians: 28% as likely compared toheterosexual peers

• costs pushed into the public domain

• IF domestic partnership benefits available,cost may be prohibitive (i.e. a taxedbenefit)

• COBRA benefits not guaranteed

• FMLA and visitation rights denied

• Denial of Social Security benefits tosurviving partner and children

• No legal standing for surviving partner incases of accidental or negligent death

• IRA rollovers treated as “a stranger” -->lump sum distribution immediately taxed

• Immigration law does not recognize legalstanding of family of those married legallyelsewhere

• Some countries: illegal or capital offense

• Lack of job protection outside ofIndianapolis

Defining Normal• Power + Prejudice = “isms”

• Heterosexism: 2nd class citizens deemedto be outside the spectrum of normalhuman behavior (despite de-classified as a“disease” state in the U.S. in 1973 and bythe World Health Organization in 1990)

• The “other”

• Subtle and overt messages to gays andlesbians 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 federalstatutes invoke “marriage”)

Minority Stress

• nonconformity to societal norms

• stigma = daily stress and conflict -- NOT asingular event; LGBT = invisible minority

• fear of rejection by family, friends, church, co-workers, employers -- ALL internalizesocietal prejudice

• For SOME --> cycle of self-doubt, shame, riskybehaviors and victimization resulting in adverseoutcomes

Institute of Medicine• Report from the Institute of Medicine, March

2011 (committee on LGBT Health Issues andResearch Gaps and Opportunities/projectapproved by the Governing Board of theNational Research Council, whose membersare drawn from the councils of the NationalAcademy of Sciences, the National Academyof Engineering, and the Institute ofMedicine/was convened at the request of theNational Institutes of Health in 2010)keyconclusion:

• “The minority stress model attributes thehigher prevalence of anxiety, depression, andsubstance use found among LGB ascompared with heterosexual populations tothe additive stress resulting fromnonconformity with prevailing sexualorientation and gender norms. Thecommittee’s use of this framework isreflected in the discussion of stigma as acommon experience for LGBT populationsand, in the context of this study, one thataffects 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, MaryChapa, Ryan Skipper, Max Pelofske ...

• FBI Stats:

• 2008 1617 against LGBT

• 2009 14 hate crimes/day against LGBT

• 16% of national hate crimes directed atLGBT individuals

Bottom Line• Most basic human need is to be valued

• LGBT identities are within the spectrum ofnormal human behavior

• Families, when disrupted -> fractured socialand financial safety nets which are vital toone’s health

• Marginalization through stigma anddiscrimination restrict access to health careand 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 StateDepartment 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 anAIDS 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 ofLegal Marriage

• Mortality data show that the married stateprovides the least stress and the greatestsocial and material support

• Holds true regardless of race, ethnicity,socioeconomic status, religion, education,or sexual orientation

• The legal and social validation ofnontraditional families and relationshipspositively affects health outcomes

• The Health and Marriage Equality in Massachusettssurvey administered by the MassachusettsDepartment of Public Health in 2009 (5th year ofmarriage equality):

• 72% more committed to partner

• 62% families more accepting and supportive

• 69% sense of greater acceptance by one’scommunity

• significantly less depression and anxiety

• reduction in sense of stigmatization andmarginalization

• 30% report that one member of the couplereceives health benefits from an employer as aresult of being married

• 82% more likely to come out to a co-worker

• 83% more likely to come out to healthcareproviders

• nearly all respondents (93%) agreed orsomewhat agreed that their children are happierand 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 forHIV and STD’s

• significant reductions in mental healthvisits and costs regardless ofpartnered status in 12 months post-legalization

• Lesbian couples post-marriage equality

• marriage -> strong predictor of improvedphysical, psychological and financial wellbeing

• Midlife and older men with or withoutHIV/AIDS

• independent of multiple variables beinglegally married was significantlyprotective of mental health disorders

• c/w minority stress model affecting youth

• general aging-related stressors --financial, loneliness, health concerns

• Danish mortality study post-marriageequality

• progressively declining mortality rateswith time

• overall mortality rates remain highthough at about 33% higher than marriedheterosexual counterparts

Savings?• billing records -> reduction in HTN,

depression, and adjustment disorders

• 50% reduction in high risk behaviors forHIV and STD’s

• 20% reduction in suicide attempts

• 14% reduction in healthcare costs

• Indiana: assume a 10% reduction inprevalence HIV/AIDS --> $20 million/yrsavings 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 ofhomelessness/rejection??

• each high school drop out costs thenation $260,000

• lifetime cost of one year’s national dropouts: $319 billion

AMA

• recognizes that denying civil marriage basedon sexual orientation is discriminatory andimposes harmful stigma on gay and lesbianindividuals and couples and their families;

AAFP

• Support civil marriage for same-gender couples to contribute to overallhealth and longevity, improved familystability and to benefit children of gay,lesbian, bisexual, transgender (GLBT)families.

AMWA• Stands unified in a broad policy of

nondiscrimination against lesbian, bisexualand gay individuals, urging the following:National legislation to enddiscrimination by sexual orientation inhousing, employment, marriage and tax laws,child custody and adoption laws, to redefinefamily to encompass the full diversity of allfamily structures and to ratify marriage forgay, lesbian, and bisexual people.

AAP

• Support the right of every child and family tothe financial, psychologic, and legal securitythat results from having legallyrecognized parents who are committed toeach other and to the welfare of theirchildren.

ISMA• Recognizes that exclusion from civil unions

or marriage contributes to health caredisparities affecting same-sex households;

• Will work to reduce health care disparitiesamong members of same-sex households,including minor children; and

• Will support measures providingsame-sex households with the samerights and privileges to health care,health insurance and survivor benefits, asafforded opposite-sex households.

Current State ofMarriage Equality

• Subject: Critical Decision Unit meetingWhen: 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 bevalid or recognized as a marriage in Indiana. A legal statusidentical or substantially similar to that of marriagefor unmarried individuals shall not be valid orrecognized.

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

Total:

Red: “Yea” to HJR-6Blue: “Nay” to HJR-6

251

1159

26 70

D: R:

Indiana House ofRepresentatives

HJR-6 Votes

Indiana SenateHJR-6 Votes

Red: “Yea” to HJR-6Blue: “Nay” to HJR-6

Total:

100

337

10 40

D: R:

Impact of HJR-6?

• Health/Minority Stress?

• Survey to 34,653 LGB individuals in 2001and 2002 (Wave 1) on a range ofpsychological health indicators

• Same survey in 2004 and 2005 (Wave 2)after 14 states approved constitutionalamendments limiting marriage toopposite-sex unions

Disorder

ConstitutionalAmendment

No ConstitutionalAmendment

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 AnxietyDisorder

2.7 9.4 248.2 4.20* 5.6 8.2 48.0 1.54

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 andLee Badgett, professor of economics,Amherst, senior policy director for publichealth in Massachusetts

• Marriage/tourism

• tax revenues

• Massachusetts: an estimated $111 millionto the state economy.

• New York City: an estimated $259 millionin economic impact and $16 million in Cityrevenues.

• Washington D.C. : $52.2 million overthree years, which would generateincreases in local government tax and feerevenues by $5.4 million and createapproximately 700 new jobs.

• Iowa: $12 to $13 million boost; likely tohave added $850,000 to $930,000 in taxrevenue to state and local coffers

National Impact

• If same-sex marriage rights were grantednationwide, same-sex weddings wouldgenerate a net $1 billion each year for theFederal budget over the next 10 years,according to a 2004 report by CongressionalBudget Office. That's after taking intoaccount lower income and estate taxrevenues as well as increased spending forhealth-care benefits and Social Security.

What can we do?

Resolved, that we supporters of OneVoiceIndiana: The IndianaCoalition for Lesbian/Gay/Bisexual/Transgender Health andNondiscrimination:

(1) affirm, in concurrence with the American Medical Association's June2011 policy H-65.973 Health Care Disparities in Same-Sex Partner Households,that denying civil union or marriage based on sexual orientation, asproposed by HJR-6, is discriminatory and imposes harmful stigma on gayand lesbian individuals and couples and families;

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

(3) do, therefore, in the interest of optimal public health outcomes and in theeconomic interests of our state oppose legislation, such as HJR-6, that not onlymarginalizes and discriminates against a particular minority group, but alsoeffectively precludes further bipartisan rational discourse relative tomeasures!which!may offer!legal and social validation of non-traditional couplesand their families.

Bibliography(1) Gates GJ. Same-sex couples and the gay, lesbian, bisexual population: new estimates from theAmerican 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 andOpportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation forBetter 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 timeof 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 partnershiplaws 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 healthoutcomes in White and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009;123(1):346-352.

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(18) Hatzenbuehler ML, O’Cleirigh C, Grasso C, Mayer K, Safren S, Bradford J. Effect of same-sexmarriage laws on health care use and expenditures in sexual minority men: a quasi-naturalexperiment. Am J Public Health. 2012;102(2):285-291.(19) Badgett MVL. Will providing marriage rights to same-sex couples undermine heterosexualmarriage? Sex Res Soc Policy. 2004;1(3):1-10.(20) Wainright JL, Russell S, Patterson C. Psychological adjustment, school outcomes, and romanticrelationships 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 civilmarriage: 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 defenseof marriage amendment. Available athttp://www.protectncfamilies.org/sites/protectncfamilies/files/psychologists.pdf.2011. Accessed April 12, 2012.(26) Indiana State Medical Association. Resolution 11-32A. Available athttp://www.ismanet.org/legislation/public_policy.htm (Click on “Health Care System”). 2011.Accessed April 12, 2012.

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Lesbian/Gay/BisexualTransgender

Public Health IssuesWilliam C. Buffie, M.D.

OneVoiceIndiana.org

Appendix for healthcare institutions andmedical providers

Human RightsCampaign

• Healthcare Equality Index (HEI)

• 2011: 375 institutions nationally

• Only 2 in Indiana -- Ball Memorial andClarian (now IU Health)

• Rating Criteria:

• Patient nondiscrimination policies

• includes sexual orientation/genderidentity

• Visitation policies

• equal access for same-sex couples orparents

• Cultural competency training and clientservices

• 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 andawareness

• Cultural competency training for staff

• Non-discrimination policies for patientsand staff

• Respect (through policies) visitation rightsand healthcare decision-making rights

• Support legislative efforts that afford equalaccess 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