People who are lesbian, gay, bisexual or transgender face some of the poorest health outcomes and experience severe health disparities in relation to other Missouri residents, according to a report by the Missouri Foundation for Health. 

The report says poor health outcomes for this group are due to many factors, including lack of health coverage and "social and economic systems that have not supported and protected minorities."

Drawing on state and local data as well as information from other sources, the report paints a picture of a Missouri LGBT population that is 1.5 times more likely to be uninsured than other residents. This group also has less access to culturally competent care, receives less preventive care, and is likely to engage in unhealthy behaviors, such as smoking and alcohol use, to cope with stress stemming partly from trauma and social and economic discrimination.

The report includes these findings:

• LGBT Missourians are more than twice as likely to not get needed medical care compared to the general population.
• Fewer than 15 of 5,704 primary-care providers in Missouri in 2009 had registered with the Gay and Lesbian Medical Association’s provider network to let LGBT individuals know the providers welcome them as patients.
• More than two-thirds of health care organizations nationwide do not require doctors to attend cultural competency training that includes LGBT health issues.
• LGBT Missourians who are members of racial and ethnic minority groups experience higher rates of negative health outcomes than the LGBT population in general.

The report says a major barrier to care is that LGBT individuals don’t always know which providers will treat them. An MFH official says the number of doctors on the provider list for LGBT individuals might have improved since 2009 when fewer than 15 primary-care physicians had added their practices to the provider network list.

The report says those on the list practiced in St. Louis, Kansas City, Columbia and Springfield.

“In other words, rural Missourians who seek LGBT-affirming medical care and behavioral health services cannot rely on publicly available information to identify a welcoming and trustworthy provider,” the report says.

Even with health insurance, transgender individuals face additional disparities because most insurance plans do not cover hormone treatment, sex or gender realignment surgery, and gynecological exams for a trans man or prostate exams for a trans woman.

“In Missouri, sexual and gender minorities are more than twice as likely to do without medical care or surgery when it is needed,” the report says, adding that the disparities are even more pronounced when race or ethnicity is taken into account. For example, it said LGBT Latino adults were least likely of all groups to have a regular source of care.

Lack of easy access to preventive care, such as cancer screening, the report says, is especially harmful to lesbians, causing them to have the highest risk factors for breast cancer. Lesbians are also at increased risk for some gynecological cancers and are significantly less likely to report receiving Pap smears in the past 12 months, the report said.

The report also said one in four transgender patients reports being verbally harassed in doctor’s offices, emergency departments and medical settings. It added that the plight of LGBT individuals seeking care is worsened by the absence of culturally competent care providers, saying a welcoming medical office makes it easier for LGBT patients to discuss their sexuality.

“This can improve treatment and enhance providers’ ability to care for the whole person and better understand the population they are serving,” the report says.

It also helps for LGBT individuals to know which primary physicians are willing to provide the care, says Ryan Barker, director of health policy at the MFH.

One “big statistic that jumped out at me is that when it comes to the LGBT population, there is often nervousness or fear about going to the medical provider.” Barker says some of the LBGT reluctance to visit providers may be due to not knowing about the existence of a provider database, however small. He says success in addressing the disparities in Missouri may include getting the word out to LGBT patients that the database exists, and alerting medical professionals to add their practices to the database if “you’re comfortable and culturally competent” to treat the LGBT population.

The report says some of the health issues for LGBT individuals could be solved through better policies on access to care, clinical care, prevention and health behaviors.

Its recommendations on access include public insurance programs that cover certain care for transgender individuals, legal and employer recognition of same-sex relationships and domestic partner insurance.

Clinical care recommendations include a patient’s bill of rights that include sexual orientation. In addition, the report calls for visitation policies that include same-sex couples and families, cultural competency in medical training and the inclusion of sexual orientation and gender identity on health intake forms.

Barker says some issues raised in the report could be addressed through the Affordable Care Act. He says creation of a health insurance exchange or marketplace under ACA will allow people to buy affordable health insurance.

"We do know that health insurance will reduce some of the disparities. The other thing is that ACA tries to increase the quality of health care. That also will have an impact.”

Also helping the situation is a new Health and Human Services initiative that promises to pay more attention to LGBT health issues.

The MFH report notes that there needs to be more demographic data from LGBT populations. It adds that no representative random survey has been done to examine LGBT health disparities nationally. HHS is changing some of its policies to add LGBT populations to some studies and to do more research on LGBT medical needs.

“Opportunities exist for policies to better protect and promote the health and well-being of all Missourians, regardless of their sexual orientation or gender identity,” the report says.

“The challenge remains for schools, medical providers, employers and public agencies to acknowledge the presence of LGBT individuals in our communities and address the factors that are contributing to their health needs.”