How one medical school is addressing LGBT healthcare disparities

Adam Neff said a desire to stay in his hometown led him to pick the University of Louisville School of Medicine. But another reason drew Neff—the school's program addressing LGBT healthcare disparities.

"I am actually part of the LGBT community," Neff said. "So knowing that this kind of work was going on around training the next generation of physicians certainly made me very confident of my choice."

In 2014, the school became the pilot site for the eQuality project, which incorporates the Association of American Medical Colleges' guidelines on LGBT health practices within their existing curricula. Louisville is the nation's first medical school program to address the healthcare needs of lesbian, gay, bisexual, transgender and nonconforming patients, as well as those with atypical sexual development—a community that experiences a large healthcare disparity.

Those patients often avoid seeing doctors, meaning other diseases that could be prevented are left undiagnosed and untreated, said Dr. Amy Holthouser, associate dean for medical education at the University of Louisville medical school.

The LGBT community as a whole has a higher uninsured rate. But many individuals also experience discrimination from providers, Holthouser said.

That leads LGBT individuals to avoid care or delay it until their health suffers. LGBT adults tend to have higher rates of chronic health conditions than the rest of the population and LGBT youth are two to three times more likely to attempt suicide and experience homelessness. Gay men are at higher risk of infection with HIV and other sexually transmitted diseases while lesbians and bisexual women are more likely to be obese and less likely to be screened for cancer. The LGBT population as a whole has higher rates of smoking, drinking and substance use than the general population.

The University of Louisville has been recognized as one of the most LGBT-friendly campuses in the nation by the not-for-profit organization Campus Pride. So it wasn't a surprise when its medical school implemented 50 new hours of training specific to LGBT health issues. The average, according to a 2011 study published in JAMA, is five hours total.

Holthouser said students learn to view delivering care for LGBT individuals as a normal part of their medical practice, rather than some anomaly that requires specialized education. "We want our patients to get really good, compassionate care," Holthouser said. "We want to make sure once the patient comes to you that you don't create a healthcare disparity because you're just not comfortable."

Holthouser said clinicians need to be taught not to ask offensive questions and to understand that some protocols should change.

"You can treat pneumonia the same, you can treat influenza the same, you can treat broken bones the same," she said. "But there are some things that do change around vaccine recommendations, cancer screening and sexually transmitted infection screening."

Other national efforts are addressing those issues.

The year after the AAMC unveiled its guidelines, the group surveyed 126 medical schools and found more than 60% of them included related courses and training.

The Obama administration's efforts to protect gender identity under federal anti-discrimination laws have also led more hospitals to implement policies and continuing medical education programs to better serve LGBT patients. However, the Trump administration recently stressed that LGBT individuals would not be given the same federal protections when being served by faith-based providers, potentially making it easier for providers to refuse treatment.

Still, there are signs of advances in bridging the healthcare gap. When the Human Rights Campaign authored its first annual Health Equity Index in 2007, it found 73% of the 78 facilities surveyed offered diversity or cultural competency training to personnel. Ten years later, 85% of the 590 hospitals surveyed that year reported similar training.

Even though the University of Louisville is considered a relatively progressive campus, Holthouser admits the eQuality program has faced hurdles.

"I think in the current national political climate people are very quick to politicize this content and to see it as an option," Holthouser said, meaning some clinicians might still choose whether or not to see LGBT patients. "This issue is not a moral issue or a political issue; it's about a population of patients with healthcare disparities."

Neff, for one, thinks the eQuality program has helped give students a safe place to work out scenarios. More than 600 students have gone through eQuality.

"Hopefully students won't mis-gender someone or won't use the wrong pronouns or assume a hetero-normative type of lifestyle," Neff said. "We hope that by making mistakes in the classroom it leads to better patient care in the future."