Accessing the Future (in a voting year): ways forward for LGBTQ+ health access

In today’s podcast, Dr. Ng speaks with EIC Brandy Schillace about issues of LGBTQ+ and health accessibility. Already a difficult prospect, access to care for this population has become increasingly precarious during the COVID epidemic. Dr. NG describes some of the problems faced by patients and by clinicians—and looks for ways of making a better future.

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Dr. NG, with short cropped hair, square glasses, and a colorful COVID mask. He is smiling under there, I'm pretty sure.Henry Ng, MD, MPH is a physician, educator and advocate for LGBTQ health. The focus of his work is to provide culturally and clinically competent care to medically vulnerable populations.  Dr. Ng has been involved in LGBTQ health care since 2007 and currently he is a physician in the Center for LGBTQ+ Health and the Transgender Surgery and Medicine Program at the Cleveland Clinic Foundation.

Dr. Ng’s academic interests are in LGBT Health, health disparities, and public/population health. He served as an associate editor for the journal, LGBT Health and is a senior associate editor for the journal, Annals of LGBTQ Public and Population Health.

On Twitter: @thedrhenry

TRANSCRIPT

BRANDY SCHILLACE: Hello, and welcome back to the Medical Humanities podcast. I’m Brandy Schillace. And today we’re here with Henry Ng, MD, MPH. He is a physician, educator, and advocate for LGBTQ+ health. The focus of his work is to provide culturally- and clinically-competent care to medically vulnerable populations. Dr. Ng has been involved in LGBTQ healthcare since 2007, and currently he’s a physician in the Center for LGBTQ+ Health and Transgender Surgery and Medicine Program at the Cleveland Clinic Foundation. Welcome, Henry!

 

NG: Good morning! Thanks so much for having me today.

 

BRANDY: I’m so glad you could be with us. As you know, one of the topics we’ve been talking about at Medical Humanities Journal and also at our blog and podcast has been accessibility. And of course, in a year like this one, that seems to matter more than ever. So, I wanted to bring you on to talk about how accessibility affects people who are LGBTQ and other sort of gender non-conforming people and how they try to access healthcare in the systems here in the United States.

 

NG: Wow. That’s a really important topic, and it’s so layered and complex. But I definitely will try to take a stab at it. And I’ll definitely say that the challenges that sexual and gender minority people—you might hear me say LGBTQ+ or LGBTQ or sexual and gender minority people. I’m gonna use those all interchangeably when I talk about folks who otherwise are not heterosexual or cisgender—I think that all these challenges that they already have been experiencing for decades that have been slowly improving in some ways, have now really been laid bare by the COVID pandemic. Because it really has fleshed out and demonstrated for all of us how folks with less privilege have more health problems, more challenges in navigating the world to live their best lives and to be most healthy.

 

I think I’ll take a stab at this by thinking of one model that I think is really useful. This comes from the Institute of Medicine’s paper back in 2011 that talked about LGBT health. Now it’s, I think, under the National Academy of Sciences. But back then, there was a framework that looked at minority stress theory and social ecology to think about all these kind of factors, both intrapersonal, interpersonal, structural, societal, that I think all can contribute to health disparities and decrease health outcomes. And the piece with them that is accessing health. So, I think if you think of the kind of the big structure concerns and issues, a lot of health organizations historically haven’t been overtly welcoming for sexual and gender minority people. They haven’t demonstrated that there was any particular interest in providing them care that recognized this part of their identity and that it was important or valuable.

 

BRANDY: Right.

 

NG: And I think we see that from little things like, well, if you’re a transgender person and you have only binary bathrooms for men and for women, and you’re a non-binary person, do you really feel safe accessing a restroom in a healthcare facility for you if it’s not single use?

 

BRANDY: Right.

 

NG: I mean, navigating those spaces are so important, right? So, if you can’t even figure out if you could safely use the restroom in a place, will you really even be able to go there for some of your other care?

 

BRANDY: Mmhmm.

 

NG: A lot of the experiences that patients have told me about over the years had to do, especially with our trans patients and our non-binary patients, they told me about frank exclusion and discrimination that they faced. So, healthcare professionals and providers have frankly told them, “I don’t take care of people like you. I don’t do these types of things.” So, they felt rejected or excluded for sometimes just basic care.

 

BRANDY: Mmhmm.

 

NG: We kind of jokingly say there’s no such thing as lesbian broken leg syndrome, right?!

 

BRANDY: [laughs]

 

NG: So, meaning that if you happen to be a sexual or gender minority person, if you broke your leg, I think your leg is still a thing in medicine that those of us who have learned how to do that do.

 

There are more specific things in terms of taking care of LGBTQ people, for example, like hormonal care for trans folks. That is something that is a more focused health issue. But then again, I always tell the trainees I work with, this isn’t rocket science. There’s a body of knowledge behind that. We can learn it.

 

So, I think that some of the interactions with health professionals themselves—and I say broadly, health professionals. We’re talking about all different kinds of caregivers, whether they’re physicians, physician assistants, our many, many nurses, social workers, physical therapists, occupational therapists, pharmacists, all the folks who are part of the healthcare team.

 

BRANDY: Right. And I think we can add psychiatric care too.

 

NG: Oh, yes, absolutely. Mental health care, psychology, therapy, counseling. All those pieces are super important for medical care, very broadly, surgical care, etc. And so, there’s that human piece where, if your provider and professional that you’re working with doesn’t demonstrate both some cultural sensitivity to your identity and have some nimbleness and agility to be able to address you in the way that you wanna be addressed in however you identify that’s respectful, that doesn’t feel great. And at the same time, we also need to have clinical knowledge of how to take care of people and know when gender and sexuality concerns are maybe at the center of a conversation, and we make sure that we have the appropriate knowledge to care for somebody, and also when it might be on the periphery. Like when I was jokingly talking about lesbian broken leg syndrome.

 

BRANDY: Mmhmm.

 

NG: So, sometimes it’s an issue; sometimes it’s not. But always, it’s in the background. So, those are the interpersonal things.

 

We have some other structural things, too, that we know that sexual and gender minority folks oftentimes have challenges with employment and accessing healthcare insurance. We know that insurance is necessary but insufficient for providing care, right?

 

BRANDY: Yes. Just quickly, because a lot of our listeners are not necessarily based in the United States. We have about a 50/50 audience.

 

NG: Yes, yes.

 

BRANDY: So, quickly, for those in the audience who are not in the United States, could you say a little bit about how insurance can be really prohibitive in the United States for care?

 

NG: Oh, absolutely. Absolutely. So, the United— And here I am. I’m not a health policy wonk, so to speak.

 

BRANDY: [laughs]

 

NG: But I do have a working knowledge of how healthcare works in the United States. So, basically, in the U.S., if you are seeking healthcare, obviously the service needs to be paid for by someone. So, if you are employed, the healthcare can be purchased through your employer if your employer is a large enough organization or group that offers healthcare insurance for you to purchase. OK? So, that’s through some private organization. In the United States we have large companies like Blue Cross Blue Shield, Aetna, United Healthcare, groups like that, that will provide the opportunity for patients to get coverage. So, in case they are hospitalized or sick, or if they otherwise just need different types of medical or surgical care or referrals or medicines, the insurance will help pay for a portion of that or all of that, depending on what the plan looks like. For those who are unemployed or for those who are older than 65 or under—

 

BRANDY: Or self-employed.

 

NG: —self-employed or otherwise under a certain income level, there are public forms of health insurance. And we call these Medicare or Medicaid. Medicare for those who are older, generally, and then Medicaid for those living with disabilities and also those who are under-resourced or sometimes not employed. So, public forms of insurance also exist to pay for healthcare services. They don’t always cover the same services in the same way. So, sometimes getting medications that you would like to have for your treatment may be excluded or simply not covered for one reason or another or more expensive.

 

BRANDY: Right, right. Yeah. And one of the issues there is like who gets to decide what’s a condition that matters?

 

NG: Exactly, yeah.

 

BRANDY: And I think really— Particularly, I’m thinking if you’re a non-binary person and you’re saying that you need treatment. And as so often happens, non-binary doesn’t fit in any of the boxes. And so someone goes, “Well, I don’t see what the problem is. Why should we cover this treatment?”

 

NG: Right. So, yeah. It ends up being very complicated for that reason. And then the last part I’ll say is that there are a large number of people who are not insured at all.

 

BRANDY: Mm, mmhmm.

 

NG: They’re in a situation where they’re not employed. They may not know that they can apply for public health insurance. They may have recently lost their job and are between forms of employment. Or they’re in a kind of employment that doesn’t offer very good healthcare options to purchase, or simply they can’t afford to purchase it even on the different markets that we have for the Affordable Care Act, which is one of the laws that was created during the Obama administration to help address issues related to poor access of healthcare. So, there are a lot of holes and challenges of just getting the financial coverage and support to pay for stuff. So, that’s one big, broad barrier.

 

And even within the health insurance universe, as you just alluded to, Brandy, there are exclusions. So, both public and private healthcare may certainly choose to not pay for or cover a certain type of treatment or medication. And with our current administration, there’s not a lot of opportunity to appeal that. Previously, there was through the Department of Health and Human Services. A lot of us would actually make some concerns and complaints through this part of the Affordable Care Act that’s called 1557. This was a non-discrimination piece. And we would say, “Hey, X, Y, Z, insurance company or pharmacy or whomever, if you’re not paying for the service or you’re not providing the service, this is a discrimination. This is wrong.” And we were actually able to make a lot of changes through sending emails and phone calls. Actually did that early on during the first part of the implementation of this law.

 

I would call on behalf of a lot of our patients who said, “Hey, my hormonal medications or my care as a transgender person, they’re being rejected, and I don’t know why. There’s not a reason why.” So, we’d say, “Okay, let’s make a complaint and advocate on your behalf.” And for many people, that ended up changing some of the access that they had. We saw Medicare, or rather Medicaid, first Medicare, then Medicaid, actually expand and begin coverage of some of these hormonal care services for trans people, including things like pre-exposure prophylaxis coverage: medications that we use to prevent HIV transmission.

 

BRANDY: Mm, mmhmm.

 

NG: And you’ll hear us talk about PrEP when we talk about that type of medicine use. They’re very expensive medicines. And getting these types of medications for our patients, providing access to them is really important. But there can be so many just challenges, exclusions for those things. So, now with the political environment the way it is, when there are issues with things not being covered or rejected, we still do the best we can to appeal. But simply there are fewer levers that we can pull in order to advocate for our patients.

 

BRANDY: Yeah.

 

NG: And we’ll have to see what happens moving forward after the 3rd of November this year. [chuckles]

 

BRANDY: [laughs]

 

NG: In the United States, in case you don’t know, that is… that’s Election Day!

 

BRANDY: Yeah, it is! [laughs]

 

NG: So, we will see what will happen. Because depending on what leaders we have in the White House, we may see continuation of the current policies, or we may see a significant change in direction of those.

 

BRANDY: Right.

 

NG: I, for one, am advocating for situations where we’re in an environment where we can provide more care for more people.

 

BRANDY: Right.

 

NG: And I think that’s what I would be hoping for.

 

BRANDY: Well, and I think getting back to something you alluded to earlier about how the pandemic has changed things, too. And we’ve been having some conversations with disability activists as well, and a similar situation is in the best of times, in the best of times, with the best of situations, when the economy’s good and people aren’t suffering from pandemic illness, you still have discrimination against vulnerable populations.

 

NG: Mmhmm.

 

BRANDY: You still have discrimination in insurance, in medicine, among providers, as you’ve said, against LGBTQ, against disability, against minorities, racial minorities, fiscal minorities. You still have that. Now, you add on top of that political kerfuffle [chuckles] and—

 

NG: [laughs] That’s a very nice way to put it.

 

BRANDY: Yeah, I was just trying to think of a word that was polite.

 

NG: [laughs]

 

BRANDY: And a pandemic. And suddenly, there’s these pressures. And the pressures are financial and the pressures are medical and the pressures are all of these different things. So, you look at all of that levered on top of a system that was already not being fair to these groups of people. And so, I am sure that you’ve seen a greater incidence of stress on your patients, which itself is a medical condition.

 

NG: Oh, yes. Absolutely. I think that the stresses of the pandemic, directly and indirectly, for sexual and gender minority people, especially as those identities intersect with racial/ethnic identities, those who are living in under-resourced communities, those who are differently-abled, those who find themselves kind of in this onion peel layer of I have all these identities, and they all are not helping me where I am because of the way society and structures have created the universe! It’s not me that’s a problem!

 

BRANDY: Right.

 

NG: We’re seeing a lot of folks who are stressed beyond belief, and their typical resources that they would use for support are also taken away. So, we have to socially distance, we have to wear masks, we have to use technology when we can try to connect both for healthcare and everything else. I mean, think about people who have the privilege of using Instacart to get food delivered to their homes. In the U.S., we have many different types of app services for our smartphones, if we can afford it, to have food delivery, to have all these things that we could get. But again, this belies privilege.

 

BRANDY: Mmhmm.

 

NG: You have to have a smartphone. You have to have Internet access. You have to have resources to pay for these things. Because it’s more expensive than otherwise going to the store yourself. So, we see that our folks who oftentimes are sexual and gender minority people who are Black and brown, who are differently-abled. They’re the folks actually who are essential workers in many different ways, not just in healthcare, but everywhere else. So, they work in service industries still, preparing our food and providing all these services that we have day to day. When we wanna go to the gas station, who’s working there? Who’s providing the care? Who is providing the service? And these are folks who are exposed to COVID every single day. They may or may not contract it. Some folks already have poor health to begin with, or they have not been able to access healthcare, and health issues that they have, have already progressed a bit more. So, that places them at higher risk for a negative outcome should they get COVID. They can’t avoid COVID as well as other people if they are reliant on public transportation, for example, as opposed to driving with their own car. So, you can’t exactly socially isolate when you’re on a large train or a bus or some other type of thing.

 

BRANDY: Right, right.

 

NG: So, those are all those issues. And then their supports have been eliminated. Folks in our communities have faced different struggles and challenges, including those in mental health, substance use, and substance abuse. So, groups like Alcoholics Anonymous or coming out support groups and other types of social support have moved to an online platform. So, for those who have the tools to access them, that’s great. Well, “great” in air quotes. But if you don’t, certainly not. And even if you can access them, I have a lot of patients who’ve told me, “This doesn’t feel the same.”

 

BRANDY: Right.

 

NG: You know, “I don’t have the camaraderie and support of these people, these human beings right next to me where I feel like I belong. Now, I’m still all by myself all day, but I get to be quote “with somebody” unquote for my social support for maybe a half an hour to an hour, assuming that my Wi-Fi worked that day, [chuckles] and I didn’t get dropped from the Zoom call or what not.

 

BRANDY: Yeah! Which incidentally, listeners, we had that problem at the beginning of podcast today!

 

NG: Exactly!

 

BOTH: [laugh]

 

NG: And to say perfectly well, I am privileged. I have a smartphone. I have Wi-Fi. And I still have these issues.

 

BRANDY: Right, yes.

 

NG: So, I’m really sensitive to my patients who do not. You talk about accessibility. Part of my work in seeing patients is providing both virtual care as well as in-person care. About a third of my visits per week are virtual, meaning I don’t see them, obviously, in person. I’m interacting with somebody using technology of some kind whether it’s a smartphone or a regular phone or a computer. And sometimes it works great. But I work in a very well-resourced organization. But the technology sometimes fails just from the technology platform standpoint. Sometimes the applications are slow or buggy, or there’s been some upgrade that not everyone knows about, even at large systems like the one I work for. And our patients struggle to get through. And that’s even when they have resources.

 

BRANDY: Right.

 

NG: And then we have folks who might be a bit older, and they’re less comfortable using forms of technology, or they simply don’t have Wi-Fi access. They do not have a smartphone. We can’t do those face-to-face type of virtual visits. We’re reliant on phone calls. I have a difficult time assessing if someone has a pneumonia on a phone call.

 

BRANDY: Yeah!

 

NG: But sometimes that’s actually what I have to do.

 

BRANDY: Yeah, yeah.

 

NG: So, the way we even practice medicine has changed such a great way as we try to figure out how to help people with more limited tools at times, and also thinking about where they are in terms of their social situations and their immediate environment that also limits the way we could interact with them. So, those are some of our challenges.

 

BRANDY: Yeah. And I think that’s really important because what you’re bringing up is, of course, issues of access are never in a single area. It’s not as though access is over here.

 

NG: Mmhmm.

 

BRANDY: Access permeates every aspect of our lives.

 

I just wanted to say a few more things about who you are and what you do, because I know in addition to being a doctor, which you are—

 

NG: [laughs]

 

BRANDY: —you are an Associate Professor at Case Western Reserve University, which was my alma mater. And I believe you work for a journal, too, are you not, an Associate Editor for the Annals of LGBTQ Public and Population Health.

 

NG: I am. So, I’m one of a I wanna say a large number. [laughs] There are over 50 of us! So, there are many, many, many.

 

BOTH: [laugh] So, part of a large crew—

 

BRANDY: Still matters, man.

 

NG: Absolutely. Part of a large crew of folks who have a particular interest in both public health, population health, and how it intersects with sexual and gender minority people’s lives. And so, yeah, it’s been an absolute pleasure working with this group of leaders and thought leaders and whatnot. It’s been really wonderful.

 

BRANDY: Yeah, and I know, if I’m not mistaken, you also do a lot with diversity and inclusion initiatives, and that’s something that is really important. And still, one of the things that we’ll be addressing in next year themes and content for the journal is just how much institutions— And I work for a journal. I work for an academic journal. And academic journals and academic systems in general tend to be really terrible at diversity and inclusion.

 

NG: [laughs]

 

BRANDY: So, it’s true, and it’s hard. And sometimes there aren’t solutions readily available. And so, a lot of times the solution is just admitting that there are these huge problems that we have to address. And speaking of which, what I’d like to end with is, given all of these situations, all these issues of access that are made so much more difficult by the pandemic, do you have thoughts that you’d like to share with our listeners for the future? Some sparks of hope or ideas for us, ways that we can help, ways that we can kind of think about things in the future to help us live in a better world?

 

NG: Mm. I think it’s definitely important to have hope and to think about ways that we can grow and adapt in this type of environment. I think that one thing to reflect on is certainly that the world has now changed fundamentally, and it’s probably gonna stay very different for a long time.

 

BRANDY: Mmhmm.

 

NG: It’s gonna affect us in terms of our travel, our interactions with each other, how we conduct our communications personally and virtually. I think that there are a lot of things that we have seen that may be at least some changes for the better. Some of these changes actually are the use of technology to reach, I think, people who are otherwise more geographically isolated. For some of our patients that we care for, who are in communities maybe two, three, four hours away, and they still elect to come to see us. Because either we offer care that’s not available in their home community, or we deliver it in a way that they feel is more affirming for them. They choose to come to see us. And this is true for healthcare organizations that provide care for LGBTQ people, I think, around the country. Folks will choose to drive 35 minutes or more regularly to see somebody for those reasons. One thing that our use of technology has done is to make things a little bit easier, at least at times, to be able to connect with a provider and to get the care that you need virtually without having to slog 100, 200, 300 miles in order to see somebody.

 

BRANDY: Mmhmm.

 

NG: That’s a very resource-intense ask of our patients in order to do that.

 

I think that we’re also seeing the healthcare field itself adapt to education and learning in ways that are helpful. We’re using technology ourselves to continue to meet and to learn about different health issues and topics. And I’m actually seeing, at the Cleveland Clinic, for example, some inclusion of LGBTQ content in that. And it’s always been a challenge for busy providers, busy health professionals who are running around trying to take care of our patients from day to day but to still get our learning in. And the virtual tools have made it a bit easier for that to happen, which means we can actually spread messages and share messages and concerns and have these types of conversations and learn how we can do things better. And this includes our diversity, inclusion work as well.

 

So, I think that this has created a bit more ability to network and to share ideas and to communicate, so I think that’s very positive. I’m hopeful to see that we’ll have a lot of creative ideas coming forward in the next year about how we continue to grow and improve the way that we provide care for people. But I think that one of the most important things that we need to do in the United States as Americans is to make sure that we have our voices and our concerns heard.

 

BRANDY: Yeah.

 

NG: So, that’s using your voice, and a big piece of that is voting.

 

BRANDY: Yeah.

 

NG: So, I’m gonna remain as apolitical as possible because that’s necessary for me. But what I will say is, regardless of who you want to support as our leadership locally or nationally, you have a voice. And this is one of the rights and privileges that we have as Americans. And this is not something that’s afforded necessarily the same way around the world. I do think it’s a very powerful thing that we get to use. And if we don’t use it, we have squandered this opportunity. So, I think one of the most important things that we can do is to use our voices, use our ballots, vote for the change that we want to see. And to do that and encourage our friends to do the same.

 

BRANDY: Thank you so much, Henry. And I’m really, really pleased that you could be with us today, and I hope that you’ll join us again another time!

 

NG: Brandy it was an absolute pleasure. Thanks so much for inviting me to participate today.

 

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