The dominant strategy adopted to improve the access of LGBT people to appropriate, non-homophobic health care has been the creation and expansion of LBGT clinics. These clinics began as special sessions (principally treating STI's) within LGBT community centers or at free or community health clinics. Over time the combination of HIV/AIDS funding and other third party reimbursement (public and private) for health services have caused these clinics to separate from (and in many cases eclipse in size) their home institutions. The largest LGBT health clinics - including Callen Lorde in New York City, Chase Brexton in Baltimore, Fenway in Boston, Howard Brown in Chicago, and the Los Angeles Gay & Lesbian Community Service Center - serve thousands of patients annually and provide services ranging from primary care and family planning to mental health and substance abuse counseling. A second, related strategy has been the development of LGBT-orientated specialty clinics - largely for HIV care and substance abuse treatment. These specialized settings are a haven for many urban LGBT people; administrative systems, institutional policies, assessments, and providers are attuned to and take into consideration the family structures and special health care needs of LGBT people.
There are, however, major limitations to the specialized clinic strategy. The first is a challenge shared by other community health centers - access may be limited for people without private insurance. To serve people covered by Medicaid (just one subset of people without private insurance) requires extensive state certification, an administrative barrier to these relatively grass roots institutions. For those who sur mount it, they enter the world of inadequate reimbursement common to other providers of poverty healthcare. Thus, a trade-off exists between access for all and financial viability. The second challenge to the LGBT clinic model is that such clinics are typically centered in and largely staffed by members of the dominant gay community, which is generally white and middle class. Members of other communities express discomfort having to select among their identities in order to receive LGBT-sensitive services.
Similarly, LGBT clinics may lack appropriate services or be uncomfortable for elders. In general, the "gay culture" remains very youth oriented despite the aging of the first post Stonewall generation and the impending old age of the baby boomers. A related, but distinct problem, with using LGBT clinics to solve all health care access and quality problems for LGBT people is the need to make referrals for specialty services. With the exception of some HIV, mental health, and substance abuse services, all other specialty care must be referred out. Lastly, LGBT clinics require a critical population mass to survive, and many LGBT people live in midsized cities unable to sustain them.
One solution to these interlocking problems is to enhance the skills, training, and attitudes of all health care providers about LGBT health needs and issues rather than isolate care into a few specific settings. Especially for practitioners planning to practice in major urban areas, cultural competency in the health and lifestyle issues of LGBT communities seems as critical as such competency regarding ethnic minorities. Therefore, models of undergraduate, graduate, and continuing education should be adopted from other diversity and cultural competency programs. As with these other training models, factual information is merely one component; exercises and exploration that reveal and challenge people's attitudes are equally important. Another approach to helping LGBT patients feel comfortable is to make healthcare settings an appealing workplace for LGBT people so that employees feel comfortable being visible and "out" at work. The presence of "people like me" goes a long way toward dispelling discomfort.
In addition to issues of attitudes and comfort, institutional barriers that pose access barriers to LGBT people must also be addressed. For instance, institutions should develop and disseminate forms and policies that more accurately capture people's sexual orientation, gender identity, living arrangements, and families. The ubiquitous policy barrier to health care access for LGBT people is the lack of employment-based health insurance because domestic partners are less commonly covered than spouses, such coverage is typically expensive when offered, and there is some evidence that LGBT people may cluster in occupations less likely to provide health coverage (service, arts, retail, etc.). Solutions include inducements for employers to offer domestic partner coverage, such as the laws enacted by the cities of San Francisco and New York requiring such coverage for all City contractors. Further development of health insurance purchasing cooperatives for freelancers, part-time workers, and artists is another strategy to increase coverage.
The numerous policy barriers to medical decision-making, inheritance rights, and visitation options are most efficiently addressed by simply recognizing same-sex marriage, as all these rights accrue automatically to the married. In the interim, expanding access to the legal services required to execute the numerous legal documents that make the wishes of the partners clear must suffice. Obviously, affording these services is difficult for many LGBT people. These are among the legal services offered at no cost by AIDS service organizations; however, other community institutions that serve LGBT people should offer them at low or no cost.
Efforts to change the health behavior within the LGBT community have focused almost exclusively on preventing HIV and other STIs. Despite this emphasis, several steps whose effectiveness is well documented have not been fully taken. Salient among these is the widespread availability of sterile syringes, through exchanges and from pharmacies without prescription. This ongoing issue has HIV prevention significance for LGB who are injecting drug users, as well as for trans-gender people who use syringes to inject hormones. None of the existing syringe exchanges cater explicitly to LGB populations (though one in New York City has specific programming for transgender people). Despite extraordinarily high rates of HIV seroprevalence and the frequency of voluntary and coerced sexual behavior and drug use in prisons and jails, neither condoms nor sterile syringes are available to those incarcerated. Finally, the early conceptual divide between HIV risk due to sexual behavior and HIV risk due to drug using behavior continues to impede adequate sexual risk reduction among drug users, adequate harm reduction from drug use among those at risk due to sexual behaviors, and adequate approaches to the intersections between drug use and sex (as in the current use of crystal meth among gay men). Another preventive service that should be integrated into all standard practice for MSM is hepatitis B vaccination. Of course, to identify the people who should be vaccinated, more appropriate sexual histories are a prerequisite.
Other public health campaigns (e.g., to encourage smoking cessation, increase exercise, decrease excess weight, avoid driving while intoxicated, use seat belts and bike helmets) should include images and messages targeting LGBT people just as they do members of other minority groups. In addition, research into appropriate structural interventions to reduce smoking and other substance abuse for segments of the LGBT community are needed. Lastly, causes of poor health in the LGBT community that are related directly and indirectly to homophobia and its consequent stress (e.g., depression, substance abuse, violence) can most effectively be prevented by continued efforts to improve the social conditions, antidiscrimination protections, and acceptance of LGBT people.
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