This month the NCIBH spoke with Allison Myers, MD, MPH, Assistant Professor of Clinical Family Medicine and Community Health, Director of Quality Improvement and Scholarly Activity, Department of Family Medicine and Community Health at the University of Pennsylvania.
Dr. Myers is a family medicine physician who practices full-spectrum primary care for patients of all ages and genders. Her clinical specialties include prenatal and birth care, office-based procedures, and the provision of primary and hormonal care for transgender patients. Dr. Myers pursued her Master’s degree in Public Health with thesis work focused on structural determinants of HIV transmission. She has been an LGBTQ+ health advocate since medical school when she founded a citywide health professional student coalition to address LGBTQ+ health disparities.
In this month's featured interview, we discussed Dr. Myers’ recommendations for the top 3 educational priorities for primary care providers for high quality LGBTQ+ integrated behavioral health in primary care.
Top 3 things we need to teach primary care providers
1. Best practices around language, terminology, and communication when working with LGBTQ patients.
2. The unique health, health care, and social disparities that affect gender and sexual minorities.
3. Using a trauma-informed approach to caring for LGBTQ+ folks that acknowledges the impact of minority stress on mental and physical health.
What do you think are the key issues for primary care education for the intersection of LGBTQ+ care and behavioral health? What should educators focus on?
According to data from the National Trans Health Discrimination Survey, 19% of respondents have been denied care completely at some point in a medical setting; 24% of MTF patients and 42% of FTM patients have postponed necessary care due to discrimination by providers, and 28% reported verbal harassment in a doctor's office, emergency department, or other medical setting. Compared to the general population (2%), the suicide attempt rate among trans folks is 41%
LGBTQ+ folks are part of a marginalized group of folks who face both health care and health disparities. They have unequal access to care compared to their cisgender and heterosexual peers and also suffer from higher rates of psychological distress, substance abuse, and preventable medical illnesses. These disparities start from a young age, with as many as 40% of youth experiencing homelessness or housing insecurity identifying as LGBTQ+, an early upstream factor that often leads to high risk behaviors (e.g survival sex). Familial disapproval coupled with chronic bullying and macro- and micro-aggressions in the forms of heterosexism/homophobia, cissexism/transphobia layered with intersectional identities and their co-existing discrimination (e.g. racism, ableism, xenophobia, religious intolerance, sexism, etc) lead to high levels of minority stress. As such, LGBTQ+ people often suffer from depression, anxiety, and PTSD. It is critical that medical and mental health providers contextualize the care they provide to their sexual and gender minority clients, take a trauma-informed approach to care, and focus on mental health and wellness and not just mental illness. To that end, it's important to assess patients' support networks, if they can be out at work/school and how they impact them, do they have other LGBTQ+ people in their life?
What are the top learning needs of primary care providers in that intersection? If you could design primary care education goals for the intersection - what would they be?
I think the biggest struggle we have in primary care is connecting LGBTQ+ patients in need of psychiatric care with psychiatrists who identify as LGBTQ-friendly, and especially transgender-competent providers. We have a wonderful network of therapists and psychologists to refer patients to, but lack a robust network of psychiatrists, so I think the top learning needs are actually within the medical field. We must recognize that the DSM and psychiatry has historically pathologized gender and sexual minorities. Therefore, to better serve our trans and gender non-binary (GNB) patients who need mental health care, I'd advocate for mandatory education in medical school and residency related to the specific health needs and disparities of LGBTQ+ patients. I believe physicians have a duty to treat all patients, within the scope of their practice; trans and GNB patients have been scarred by the medical field, and we need to restore trust before we can truly work towards a common goal of maximizing physical and mental health.
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