Healthcare systems are failing the LGBTQIA+ community and transgender individuals in particular. Too often they are not getting the care they need.
The stigma and discrimination of recent decades die hard and continue to negatively impact LGBTQIA+ healthcare outcomes in many cases. New approaches and new attitudes to delivering healthcare, without discrimination, are needed to ensure that this community thrives.
A key challenge facing LGBTQIA+ patients is varying attitudes to the community in different parts of the world and even in different states or regions.
Increased health risks
One important dimension of health for trans people in particular is socio-economic disadvantage. “Unemployment rates are two to four times the national average and a third of trans people have been homeless and on the street at some point in time,” says Corrine Goodwin, Executive Director of Eastern PA Trans Equity Project.
“When you're homeless and you're unemployed and you're not getting good healthcare, you often resort to doing whatever you have to do to put a roof over your head, and unfortunately a lot of times that is sex work. So, now we have issues with contraception and STIs and HIV, and if you're a trans woman of color these issues only get magnified.”
According to Goodwin, transgender people are 66% less likely to use contraception and 170% more likely to have experienced rape or sexual violence.
Mental health is another important area to address. Transgender people suffer a greater incidence of behavioral health issues, substance use and suicidal ideation and attempts.
Addressing mental and sexual health are therefore critical components in achieving health and wellness for this community.
Deterrents to seeking healthcare
Approaches by some within healthcare are a barrier here, since the assumptions healthcare providers often make can undermine the provision of care. “A good third of trans folks have had negative experiences with healthcare, and 20% of us have been outright refused healthcare,” says Goodwin. “It's no wonder that 28% of trans people delay seeking healthcare because they're just afraid of those types of experiences.”
Treating patients in an undignified manner has a significant impact on immediate and long-term health outcomes. Goodwin explains that trans individuals will put off seeing a healthcare provider or visiting an emergency room unless it's something very serious, and this has the potential to create long-term health problems.
Discrimination by health care providers occurs frequently. “Whether it’s being misgendered, laughed at or being turned away, it 
happens all the time, and often, no one seems to correct it,” says Aoife Ward, Customer Support Representative at B. Braun Medical, Inc. “This makes it hard for members of the LGBTQIA+ community to trust anyone with their health.”
Social determinants of health further impact access to care for LGBTQIA+ patients. Those in more rural communities can find themselves on a region-to-region hunt for centers providing affirmative care. “In each state, there are only a few places providing tailored care, and depending on how big your state is, the cost of transportation to get to two or three consults can be cost prohibitive, not to mention that many members of the community are uninsured,” says Ward.
Facilities and clinics which tailor care to LGBTQIA+ individuals also experience unreasonably long waiting lists, further deterring an already reluctant group from seeking care.
Overcoming stigma
Engaging and empowering the LGBTQIA+ community, when it comes to their health, requires getting past the deep-seated stigma with which they are associated.
“The keys to overcoming stigma are awareness, training, and familiarity,” says Goodwin. For example, we do a lot of work with medical students, doctors and nurses, as well as administrators to raise their awareness around the number of gender-expansive patients they are likely seeing, the challenges they face, and how they can do small, simple things to reduce their patients’ anxiety.”
Actions like placing a rainbow decal in their professional space, using appropriate pronouns, and explaining the rationale behind their questions pertaining to hormones can go a long way in building trust with patients. “Once they put these practices into action, they will end up with a better patient encounter and better outcomes.”
Pharma has a role to play in understanding the health needs of this community and in better addressing them, says Ramcess Jean-Louis, Global Chief Diversity, Equity, and Inclusion Officer at Pfizer. “It is a well-known fact that LGBTQIA+ individuals frequently encounter culturally insensitive or incompetent medical care, which results in avoidance.
“To improve health outcomes of LGBTQIA+ individuals we must ensure an inclusive, knowledgeable, and culturally sensitive health care environment. This includes advancing anti-discriminatory practices and policies in health care settings and developing clinical environments that welcome all patients,” says Jean-Louis.
Building trust through supportive practices
Funding and grant programs can also look beyond STI prevention and treatments to reach more equitable ground. “LGBTQIA+ healthcare is about more than STI's, it's about ensuring that affirming care is available across the spectrum in an affordable manner,” says Goodwin.
Pfizer’s partnership with SAGE, an advocacy group dedicated to improving quality of life for LGBTQIA+ older people, addressed a variety of healthcare challenges faced by the LGBTQIA+ older population through educational endeavors. “Together, we developed patient materials for seniors on adult vaccination, hypertension, diabetes, and Alzheimer's disease,” says Jean-Louis.
Developing partnerships and sponsorships with LGBTQIA+ entities are concrete practices Pharma can implement to support the LGBTQIA+ community while building alliances. “For more than 15 years, Pfizer has sponsored initiatives by the Gay and Lesbian Medical Association (GLMA), the world's largest and oldest association of LGBTQIA+ health care professionals, working to ensure equality in health care for LGBTQIA+ patients and health care providers,” says Jean-Louis.
Additionally, “We have a supplier base that represents the diverse patients we serve. Certified Lesbian, Gay, Bisexual, and Transgender Business Enterprise (LGBTBE) is one of the classifications accepted by Pfizer’s Supplier Diversity Program. We want to help diverse suppliers thrive by not only providing business, but also opportunities for long-term relationships, mentorship and development opportunities.”
Supporting LGBTQIA+ colleagues within one’s organization, by establishing benefits and policies that guarantee greater equity for LGBTQIA+ employees, is equally essential in building trusting relationships with the LGBTQIA+ community and advancing health equity.
“Pfizer’s benefit offerings include domestic partner health coverage and enhanced benefits for transgender health needs. Ongoing financial education support has included offering seminars highlighting planning considerations for LGBTQIA+ colleagues,” says Jean-Louis. Furthermore, “Pfizer has implemented a workplace gender transition guide that delineates protocols and responsibilities for transitioning employees, their supervisors, colleagues and human resources professionals.”
Increase knowledge and education among healthcare providers
Pharma companies are in a position to challenge biases within their own organizations and among the health care providers they interact with. There is a lack of knowledge and perhaps confidence among healthcare providers in treating members of the LGBTQIA+ community, especially those who are transgender or gender non-conforming.
“Equitable care includes letting patients know what all their options for treatment are. If there’s a lack of experience and knowledge among healthcare providers, and they can’t give patients their options, then they can’t provide equitable care,” says Ward.
“All patients should feel comfortable and empowered to share essential health information, including that pertaining to their sexual identity and behaviors, so that healthcare providers can have the relevant information they need to determine the appropriate course of action, from preventive care to treatments. The same is true for manufacturers looking to deliver medical breakthroughs.”
Hormone replacement therapy for transgender patients, for example, is practical to monitor and uses the same conventional monitoring protocols and testing you would use for cisgender patients receiving hormone replacement therapy.
However, that tends to be overlooked and transgender patients are painfully aware of this. “There are two large healthcare networks in our area, and one of them, right now, doesn't have a single endocrinologist that will prescribe hormone therapy for trans persons,” says Goodwin.
Since the pharmaceutical industry and medical practice are inevitably intertwined, pharma’s role in informing healthcare providers can have a direct influence on healthcare treatments and practices.
Goodwin adds, that as developers and suppliers of life saving therapies, such as hormones, the pharmaceutical sector can send a message to general practitioners that they are capable of providing affirming healthcare, and that it doesn't require advanced, specialized training. Steps towards providing equitable care can be as simple as developing a CME or a CEU or initiating conversations with providers about supporting LGBTQIA+ patients.
“With the digital disruption accelerated by the pandemic, we are transforming how Pfizer engages with both healthcare providers and patients,” says Jean-Louis, “Our CLEAR Health Literacy Checker was developed in partnership with Northwestern University to ensure that we are following best practices in all our professional and patient education materials. This includes guidance on creating relevant, and culturally sensitive content for diverse populations.”
Understanding your patient population and mirroring language are powerful ways to send an LGBTQIA+ inclusive message. “I 
think, for patients really, it's all about the way you speak to them,” says Frank Spinelli, Senior Director, Patient Engagement in Global Medical Strategy and Operations, Gilead Sciences. “The lexicon is changing rapidly, sex assigned at birth, how you identify, your sexual orientation, understanding nonbinary, understanding trans individuals, learning this and striving to be better.”
To further develop the conversation, community advisory boards are crucial in determining patient needs and what both patients and healthcare providers find important. “I always say in patient affairs, we are the bridge from the patient's beliefs and what the physician feels they need, and we funnel that into our internal stakeholders, and we say this is what we're hearing and that's how you amplify the patient voice,” says Spinelli.
Jean-Louis also notes that representation of diverse communities within medical research and clinical trials is critical in understanding how medications and vaccines truly impact the population. “Poor diversity in early- and late-stage medical research is a major threat to health equity. We strive to build trusted, equitable and collaborative relationships with patient advocacy organizations to make sure patient voices are heard and amplified throughout the entire journey from discovery and development to delivery of medicines and vaccines.”
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