June is Pride Month and June 2020 was a watershed month for those affiliated with the LGBTQIA community. What are all the letters for, and what do the extra letters mean (yes there are more these days)? The standard seems to settle around Lesbian, Gay, Bisexual, Transgender, Queer, or Questioning Intersex and Allied (meaning supportive of the movement) or Asexual. It seems important to be inclusive given the broadening visibility and importance of this community and the clear need to make sure that our practices and policies in life, and particularly in healthcare, recognize this community’s issues and needs.
During the past 5 to 10 years there have been many societal changes associated with being LGBTQIA including greater acceptance of being “out”, more visibility in social settings, the workplace and in public office, and some progress in the mainstream acceptance of those who are part of this population in one form or another. Nowhere is this more visible than in two landmark US Supreme Court decisions. The first one was five years ago in June 2015 which struck down individual state prohibitions on same-sex marriages. Barack Obama recently posted memories of that day and how it felt to witness the emotional impact of that change on couples who had previously not been able to legally recognize their relationships. The most recent Supreme Court ruling this past month was on June 15, 2020, when the US Supreme Court ruled that the Title VII Civil Rights Act of 1964, which bans discrimination based on race, religion, national origin, and sex, protects gay and transgender workers from workplace discrimination as well. The June 2020 Supreme Court ruling came as the result of a 6-3 vote, with the majority opinion written by Trump-appointed Justice Neil Gorsuch. This decision marks a dramatic change in the civil rights of the LGBTQIA population whose ability to be fired based on sexual orientation was, until now, very real. Counter to that and a setback for the LGBTQIA population was a decision by the Trump administration earlier in June 2020 to roll back a provision implemented by the Obama administration which had extended healthcare protection under the Affordable Care Act (also known as Obamacare) to the transgender population. Obamacare prohibited providers who received Federal funds from discriminating based on gender identity. This provision was removed this month, which, according to Health and Human Services, will result in an anticipated $2.9 billion in savings over the next five years.
All in all, beyond Federal rulings, June 2020 felt like a momentous month for several oppressed and mistreated sectors in America. As horrific events unfolded that impacted the Black population the resulting events raised awareness and understanding by the white population of America of underlying issues and behaviors that have been in place in our culture since our country was founded. I have seen more white people asking questions and acknowledging that there is something to understand. There is some real movement towards change, not that it will all happen at once but even some change is a huge step that has been needed for a long time. Likewise, the significant progress that has been made in the LGBTQIA arena is meaningful. Strides in civil rights associated with employment, the right not to be fired based on your sexual orientation or declared gender, represents a huge step not only in identity but in their ability to advance above poverty and retain healthcare benefits. And let’s not forget there is overlap in many instances between individuals who would be most affected by Black Lives Matter and by the LGBTQIA, movement both of which have been marginalized, creating a double whammy effect for many.
Add to all the above the COVID-19 pandemic which has impacted the lives of all Americans but has been especially hard on both the Black population, as we discussed in previous writings, and on the LGBTQIA population. For the LGBTQIA population, the risk posed by the COVID-19 pandemic has come from several directions. First is that the majority of jobs heavily impacted by COVID-19 had a bigger impact on the LGBTQIA population than the average person. LGBTQIA adults are heavily employed in roles that were economically impacted. This means that their employers were forced to shut down, or they are employed as first responders/essential workers and are at greater risk of contracting COVID-19. According to the Human Rights Campaign (HRC), which has analyzed these data, these five industries account for about 40% of where the majority of LGBTQIA people are employed:
Other factors that caused the pandemic to impact the LGBTQIA population to a greater extent include lack of access to healthcare services due to either financial status or insurance. HRC data shows that there is a very high rate of poverty among the LGBTQIA population (1 in 10 are below the poverty line) meaning that they may not be able to afford healthcare services or preventive healthcare measures. This is especially true of LGBTQIA adults of color. All of this translates into a situation where an LGBTQIA person who contracts COVID-19 may not be able to access testing or healthcare or get leave from work if that individual is even employed. Individuals in this community are also frequently subject to discrimination due to their poverty level. They are raising their children in these conditions, putting them into the vicious cycle of poor housing and housing discrimination, with greater risk of poor health conditions and poor access to health services. According to HRC, 17% of LGBTQIA adults do not have any kind of health insurance compared to 12% of non-LGBTQIA adults.
In the case of older LGBTQIA adults, HRC also points out that they face isolation and lack of support to a greater degree than non-LGBTQIA adults due to a variety of issues. Since older adults, in general, were at risk of increased isolation, mental health issues, and a higher risk of COVID-19 during this pandemic it stands to reason that this problem would increase even more for older LGBTQIA adults who face additional obstacles.
At even greater risk are LGBTQIA youth, according to HRC. There is a very high percentage of homelessness among LGBTQIA youth as well as an increased risk of suicide and other mental health issues. LGBTQIA youth frequently face family rejection, with close to 70% indicating that their family makes negative comments about LGBTQIA people. Since LGBTQIA youth are extremely likely to experience homelessness, they often rely on schools and public programs for food. School closings due to COVID-19 took away much of their support. This is one reason that New York City public schools stayed open as long as they did in the early stages of the pandemic, recognizing that they were often the source of meals for a large portion of homeless youth.
Beyond this data, the LGBTQIA population also has some other characteristics, according to HRC, that put them at greater risk for COVID-19, including a greater propensity to smoke than the rest of the population.This is important given that COVID-19 frequently manifests with respiratory symptoms and smoking is one of its big risk factors. HRC also indicates that 20% of LGBTQIA adults over age 50 have diabetes, which would be another COVID-19 risk factor. Although the number of LGBTQIA individuals with HIV is unknown due to confidentiality, clearly anyone with HIV be at high risk if exposed to COVID-19.
Aside from medical issues, the LGBTQIA population faces unique mental health needs. As is often true in a population that has been marginalized and discriminated against, identity and support issues have already created significant mental health and substance abuse treatment needs in this population well before the onset of COVID-19. Fortunately, in recent years many treatment providers who specialize in supporting this population have emerged, often offering specialized services focusing on things like identity development, substance abuse, trauma work, etc. There are several organizations that have arisen in an effort to provide support for these youth. They offer people that those in need can talk to who understand what they are going through and can help them before it is too late. One such organization is the Trevor Project which offers crisis intervention approaches and other programs, along with training programs and links other organizations together in different locales. As was true of many people who struggle with mental health and substance abuse, many of the LGBTQIA population who already faced these issues found that the COVID-19 crisis exacerbated any mental health or substance abuse struggles they have so things have been extra difficult since March of 2020.
In Chicago where I live, we have celebrated PRIDE Month every June with a big PRIDE Parade that has taken place every year since June of 1970. It is colorful, joyful, usually has a theme, and is heavily attended. In 2019 organizers estimated that there were approximately 1 million people at Chicago’s PRIDE Parade, many of whom were there to show their support of the LGBTQIA community. This year, of course, it had to be canceled or “postponed” due to COVID-19. But the concept and how much it has become a part of our city’s culture is, in some ways, a symbol of how much LGBTQIA has become almost mainstream, or as some say, has been “assimilated” rather than “radicalized”, This does not make everyone involved with the movement happy. But it has probably furthered acceptance of the LGBTQIA population, particularly into daily life and the workplace and made it easier for them to access things like healthcare services. Hopefully, LGBTQIA youth will be less at risk of being judged by their families and peers, greatly improving their odds of succeeding at home and at school. And seriously, it’s about time. The LGBTQIA needs access to healthcare services as much as any of us, possibly more as the data has shown, and that includes being treated with respect and understanding without judgment by those of us who are here to help.
Take care. Sending you calm & healthy wishes.
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