In the United States, LGBTQ+ communities face a range of inequities when seeking healthcare services. In fact, a brief from the Assistant Secretary for Planning and Evaluation noted LGBTQ+ individuals were more likely to be uninsured, delay in accessing care, and be concerned about their medical bills compared to their heterosexual counterparts.
So, why do these inequities exist? To answer that question and share the knowledge, the UAB Minority Health and Health Disparities Research Center has collaborated on the Heersink School of Medicine Office for Diversity and Inclusion’s Pride Month series.
The National LGBT Health Education Center notes there are many reasons why LGBTQ+ people have difficulty accessing care and notes most barriers can be summarized in three categories: 1) Pervasive experiences with stigma and discrimination; 2) Limited access to services; and 3) Little health knowledge or literacy.
Are these factors greater in the South? The answer is yes. Increased levels of poverty, rurality, and religiosity exacerbate some of the LGBTQ+ inequities that exist in other regions of the country.
There are several UAB faculty members who are contributing to the change that needs to happen to improve these inequities — Olivia Van Gerwen, M.D.; Krishmita Siwakoti, M.D.; and Sarah MacCarthy, Sc.D. Each one of these individuals shared their knowledge on the subject, as well as ways they and other UAB health care providers are working to make these conditions better.
A Deeper Look
Let’s take a closer look to understand how these factors contribute to the gap in healthcare access for the LGBTQ+ community.
According to Dr. MacCarthy, the high levels of LGBTQ-related stigma and discrimination ultimately impact laws and policies, as well as social networks. In practice, it can isolate people from the love and support of their family and friends at home, school, work, church, and beyond.
Olivia Van Gerwen, M.D.
In Dr. Van Gerwen’s experience, stigma and discrimination can lead to improper care in instances such as when an LGBTQ+ patient is at their gynecologist appointment. If the doctor asks, “How often are you intimate with your husband,” they might not feel comfortable correcting the doctor, and in turn won’t receive the specific care they need.
Further, there are substantial barriers to accessing quality healthcare. Even if a patient has insurance and can afford to go to a provider, often LGBTQ+ individuals have negative experiences when seeking care – few providers have the knowledge and training on how to provide LGBTQ+ affirming care. Others let personal biases diminish the patient and provider interaction. This can cause LGBTQ+ individuals to put off seeking care.
“If a patient doesn't feel that they have a doctor, healthcare facility, or provider that is safe for them to visit, they may put it off until the very last minute and find themselves dealing with a complication that puts them in the hospital instead of just needing to go to a clinic,” Dr. Van Gerwen said.
Lastly, lack of health knowledge can lead to many different health issues down the line, Dr. Van Gerwen said. If a patient is unaware of appropriate health maintenance recommendations, for example transgender men potentially needing regular Pap smears, the risk of cancer goes up.
Creating a Ripple
Change can start with just one person. Luckily, there are several UAB initiatives working toward better health outcomes for the LGBTQ+ community, including the Gender Health Clinic, the 1917 Clinic, health insurance coverage for transgender-specific care for transgender employees, and more.
Dr. Van Gerwen, an assistant professor in the Division of Infectious Diseases, is jointly appointed in the Department of Obstetrics and Gynecology. She provides HIV care at the UAB 1917 Clinic — the premiere HIV clinic in Alabama — and also works at the Gender Health Clinic at UAB Medicine — which she helped start.
Magic City Wellness Center
“I prescribe HIV pre-exposure prophylaxis (PrEP), STI testing, Pap smears, and contraception counseling. I also am the Assistant Medical Director of the UAB Vaginitis Clinic, which is a place for people who have chronic vaginitis — a complicated infectious vaginal issue. We care for all people who experience this issue, including LGBTQ+ patients,” Dr. Van Gerwen said.
Her focus for research is geared toward the transgender population, and exploring barriers to sexual health promotion. She recently conducted a qualitative study where she did interviews and focus groups with transgender women in the South.
“We talked to them about what makes them not want to seek sexual health services, and also got their opinions about why spaces may not be welcoming for them. We are very interested in their thoughts on what would make them more likely to utilize these interventions and clinical services.”
According to Dr. Van Gerwen, the study found that the transgender women said a big issue was lack of respect and increased stigma in healthcare settings. “The patients want to be treated just like any other person, which seems like common sense. But it was very much a shared experience across the entire cohort we spoke with,” she said.
Krishmita Siwakoti, M.D.Similarly, Dr. Krishmita Siwakoti, endocrinologist and Assistant Professor in the UAB Department of Medicine, provides related care to adult transgender and gender non-binary individuals in her position as the Medical Director of the Gender Health Clinic.
During her medical training, especially her fellowship years at Yale, Dr. Siwakoti had the opportunity to care for transgender individuals.
“I found that experience very fulfilling,” she said. “When I joined UAB in 2019, my mentor presented to me an opportunity to lead a clinic dedicated to gender health care, and I gladly accepted it.”
Dr. Siwakoti said that in order to make actual change happen in regard to health inequities, training and awareness need to play a critical role for healthcare providers in LGBTQ-related etiquettes and healthcare. Making office and hospital environments LGBTQ-friendly, accompanied with improved insurance coverage and more community-level support, could make a huge difference, she said.
Another effort made by the university was to hire the first-ever Magic City LGBTQ Health Studies Endowed Professorship at the UAB School of Public Health. Dr. Sarah MacCarthy received the title in 2020, and in her first months at UAB has begun building her base of research, training, and community partnerships that will elevate efforts to address LGBTQ+ health across Birmingham and beyond.
“What I'm hoping to do is make sure that I listen and learn and bolster the work of local organizations so that together we can figure out how to prioritize and address their most pressing concerns,” she said.
In her role, Dr. MacCarthy has the goal of creating a safe and trusting space for everyone to be able to talk through challenges, as well as take action on their ideas of how to move Birmingham and Alabama forward.
“I am working to better highlight the amount of LGBTQ+ work that already exists both within and outside of UAB,” she said. “My aim is to aid the circumstances in which the current leaders of these organizations, schools, and communities can increase and accelerate their trajectory toward success.”
Collaborating with LGBTQ+ Communities
These efforts by UAB contribute to the growing range of services available for LGBTQ+ communities in Birmingham and across Alabama. For example, the Magic City Wellness Center is Alabama’s first comprehensive healthcare facility for LGBTQ+ people living in the state. Its mission is to provide wellness and medical care for the LGBTQ+ community in a safe, welcoming, and affirming environment. Led by Scott Weisberg, MD, the Magic City Wellness Center provides a range of primary care and specialty services, such as PrEP services and free mental health counseling.
Illustrating a commitment to collaboration, the Magic City Wellness Center and the UAB Gender Health Clinic are committed to working together to increase awareness of and access to LGBTQ+ medical care in Birmingham and across Alabama. The primary commitment of both organizations is to the communities they serve, who deserve to have well-informed choices about where and how they receive medical care.
Each organization provides high-quality, evidence-based care, but reflecting different care philosophies. For example, both offer care that is based on sound science. However, focusing exclusively on LGBTQ+ communities, Dr. Weisberg and his staff at the Magic City Wellness Center often draw on the standards of care established by the World Professional Association for Transgender Health (WPATH).
UAB providers take a more generalized focus on LGBTQ+ individuals as just one of several patient groups, adopting guidance from a variety of guidelines including WPATH and the Endocrine Society. Given the rapidly evolving literature in transgender medicine, providers at both sites practice evidence-based medicine based on the most recent data available. This diversity of approaches is important to offer LGBTQ+ people of Alabama options as they choose quality care.
Together, these efforts illustrate the collective effort to make Birmingham and the state of Alabama not just a safe, but resilient, place for LGBTQ+ communities.