PowerPoint Presentation

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LAY OF THE LAND: ENSURING EQUITABLE HEALTH

OUTCOMES FOR GAY AND BISEXUAL MEN

SEAN CAHILL, PHD

NASTAD National HIV and Hepatitis TA Meeting

October 11, 2023

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PRESENTER

Sean Cahill, PhD

Director, Health Policy Research, Fenway Institute

Affiliate Assoc. Clinical Prof., Bouve College of Health Sciences,

Northeastern University

Adjunct Assoc. Professor, Department of Health Law, Policy and

Management, Boston University School of Public Health

Member, Mass. Special Legislative Commission on LGBT Aging

DISCLOSURE

Glaxo Smith Kline funds a research project we are leading at the Fenway

Institute in partnership with Mpact: Global Action for Gay Men’s Health and

Rights examining knowledge of and attitudes toward Hepatitis A & B

vaccination among gay and bisexual men and transgender and nonbinary

people. Sean Cahill is Principal Investigator for the project.

Sean Cahill is on the Patient Advocate Steering Committee for Prostate

Cancer Clinical Trials for Janssen Global Services representing gay and

bisexual men and transgender women.

Neither of these activities has influenced the material discussed in this

presentation.

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OUTLINE

I. Why sexual orientation and gender identity (SOGI) data

collection

II. Advances in the last decade

III. Disparities affecting LGBTQI+ people caused in part by

discrimination and barriers to access

IV. Political and cultural context of anti-LGBTQ legislation—

structural discrimination

V. Impact of discrimination on health, well-being of

LGBTQI+ people, public health

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WHY COLLECT SEXUAL ORIENTATION AND

GENDER IDENTITY DATA?

• SOGI is an important aspect of a patient’s identity, life

• Honest communication and trust between patient and provider

• Conveys cultural responsiveness, that a health practice values

LGBTQ+ patients

• SOGI also relates to a patient’s family structure, support system

• Part of a patient-centered approach to care for LGBTQ+ patients

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WHY COLLECT SOGI DATA?

• Can inform therapeutic and preventive services and screenings:

• HIV/STI screenings for gay & bisexual men, transgender women

• Referrals to LGBTQ-responsive cancer support, grief counseling

(Streed, Grasso, Reisner, Mayer, AJPH, 2020)

• SOGI correlates with health disparities in disease burden, risk behaviors,

access to care, insurance coverage

• Example: Higher rates of Hepatitis A & B among gay and bisexual men--10% of

new Hepatitis A cases and 20% of new Hepatitis B cases each year occur among

gay and bisexual men (CDC, 2013)

• Collecting SOGI data a first step toward understanding, addressing,

eliminating disparities

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DRAMATIC EXPANSION OF VOLUNTARY SOGI DATA

COLLECTION IN HEALTH CARE OVER PAST DECADE

• Inclusion of SOGI in Meaningful Use Stage 3 guidelines in 2015,

now called Promoting Interoperability

• SOGI included in Interoperability Standards Advisory since

2016, US Core Data for Interoperability since 2021

• SOGI data required by BPHC for 1400 FCHCs since 2016

• Hundreds of large hospital systems, University of California

hospital system collecting SOGI

• Biden Harris Administration expanding SOGI data collection

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HIGHEST RATES OF SOGI DATA COLLECTION

AMONG SOUTHERN, BLACK SERVING FQHCS

Analysis of 2020-2021 FQHC data: SOGI data were missing for 29.1%

and 24.0% of patients, respectively. Among patients with reported

SOGI data, 3.5% identified as sexual minorities and 1.5% identified as

gender minorities. Southern FQHCs and those caring for more low-

income and Black patients were more likely to have above-average

SOGI data completeness.

Liu M, King D, Mayer KH, et al. Sexual Orientation and Gender Identity Data

Completeness at US Federally Qualified Health Centers, 2020 and 2021. Am J Public

Health. 2023;113(8):883-892.

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BEST PRACTICES

Culturally responsive, affirming care—train staff

Collect and use SOGI and sex characteristics data and

anatomical inventory to inform preventive screenings,

clinical decision support, population health management

Adopt SOGI nondiscrimination policy in your practice or

organization, advocate for SOGI nondiscrimination in local,

state and federal public policy

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NEED FOR SOGISC DATA COLLECTION IN CANCER,

CVD SURVEILLANCE, DEATH CERTIFICATES

• NCI’s Surveillance, Epidemiology, and End Results (SEER)

Program should collect, report SOGISC data in cancer

prevalence, outcomes

• CDC’s National Program of Cancer Registries should require

that states collect and report SOGISC data

• Nat’l Cardiovascular Data Registry, Paul Coverdell Nat’l Acute

Stroke Registry, STEMI registries should collect, report SOGI

• US Standard Certificate of Death should include SOGI

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SEXUAL ORIENTATION IDENTITY QUESTIONS,

SOGI BEING ADDED TO STI SURVEILLANCE

• SO identity question and response options are

being been added to case surveillance forms for

HIV, syphilis, chlamydia, gonorrhea, Hep A, B, C

(acute A,B,C; chronic B,C; perinatal B).

• SO identity has also been added to Mpox case

report form (gender identity was already there).

• Ryan White HIV/AIDS Program still does not

collect SO identity data for clients (does GI)

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DISPARITIES IN STI PREVALENCE

SOGI disparities, intersect with racial and ethnic

disparities

Gonorrhea — Proportion of STD Clinic Patients Testing Positive by Age

Group, Sex, and Sex of Sex Partners, STD Surveillance Network (SSuN), 2021

NOTE: Results are based on data obtained from unique patients in 10 participating jurisdictions (Baltimore City, California

[excluding San Francisco], Columbus, Florida, Indiana, Multnomah County, New York City, Philadelphia, San Francisco, and

Washington) with known sex of sex partners attending SSuN STD clinics who were tested ≥1 times for gonorrhea in 2021

(n=47,139).

Gonorrhea — Rate of Reported Cases by Race/Hispanic

Ethnicity and Sex, United States, 2021

* Per 100,000

ACRONYMS: AI/AN = American Indian or Alaska Native; Black/AA = Black or African American; NH/PI = Native Hawaiian or other Pacific Islander

NOTE: Total includes all cases including those with unknown race/Hispanic ethnicity.

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LGBT PEOPLE EXPERIENCE HIGHER RATES OF:

Cardiovascular disease risk factors (mental distress, lifetime depression

diagnosis, smoking) among LGB people, risk factors and myocardial infarction

among transgender people

▪ Caceres, Makarem, Hickey et al., Am J Health Promot. 2019; Alzahrani et al., Circ Cardiovasc Qual Outcomes, 2019.

Diabetes among LGB women and men

▪ Beach et al., LGBT Health, 2018; Corliss et al., Diabetes Care, 2018.

Obesity among sexual minority women

▪ Azagba, Shan, Latham, Int J Environ Res Pub Health, 2019; Carceras et al., Am J Health Promot, 2019

Kidney disease among older LGB+ people

▪ Chandra, Hertel, Cahill, et al., J American Society of Nephrology, 2023.

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HIGHER RATES OF SUBSTANCE USE

▪Meghan Schuler et al. analysis of 2015-2017 National Survey of

Drug Use and Health data (SAMHSA)

▪All LGB subgroups had elevated lifetime pain reliever misuse rates

relative to same-gender heterosexuals.

▪Lifetime heroin use was elevated among LGB women and bisexual

men; bi women had 4 times the odds of injection heroin use.

▪LGB women and gay men had 1.4-2.4 times the odds of past-year

opioid misuse; bisexual women had 2.5 times the odds of OUD.

▪ Schuler, Dick, Stein. Drug Alcohol Depend. 2019.

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DEPRESSION, LONELINESS MAJOR ISSUES

FOR OLDER GAY AND BI MEN WITH HIV

Older PLWH—most of whom in the U.S. are gay and bisexual men—experience

higher rates of loneliness,

social isolation,

and lack of social support.

1. Kim, Fredriksen-Goldsen. Gerontologist. 2016.

2. Grov, Golub, Parsons et al. AIDS Care. 2010.

3. Matsumoto, Yamaoka, Takahashi et al. Sci Rep. 2017.

Depression is now a leading cause of morbidity and mortality among older

people living with HIV, exceeding even that caused by HIV.

Untreated

depression correlates with poorer health outcomes among older PLWH.

4. Bromberg, Paltiel, Busch, & Pachankis. Soc Psychiatry Psychiatr Epidemiol. 2021.

5. Laurence, Mncube-Barnes, Laurence, et al. J Health Care Poor Underserved. 2019.

DISCRIMINATION A MAJOR FACTOR IN DISPARITIES;

HURTS LGBTQI+ PEOPLE’S HEALTH AND WELL-BEING,

ACCESS TO CARE

• More than 1 in 3 LGBTQI+ Americans faced discrimination in past year

(half of trans & nonbinary people, POC, people with disabilities; two

thirds of intersex people).

• More than 20% of LGBTQI+ Americans report postponing or avoiding

medical treatment due to discrimination (nearly 1 in 3 trans &

nonbinary individuals).

• Medina C, Mahowald L, Discrimination and Barriers to Well-Being: The State of the

LGBTQI+ Community in 2022 (Center for American Progress)

• 69% of those who reported discrimination said it affected their

psychological well-being; 44% said it affected their physical well-being

• Singh and Durso, Center for American Progress, 2017

More frequent exposure to negative depictions of trans people

in the media was significantly associated with clinically

significant symptoms of:

• depression (adjusted odds ratio [aOR] = 1.18; 95% confidence

interval [CI] = 1.08–1.29; p = 0.0003);

• anxiety (aOR = 1.26; 95% CI = 1.14–1.40; p < 0.0001);

• PTSD (aOR = 1.25; 95% CI = 1.16–1.34; p < 0.0001);

• and global psychological distress (aOR = 1.28; 95% CI = 1.15–

1.42; p < 0.0001).

EXPOSURE TO NEGATIVE IMAGES OF TRANSGENDER

PEOPLE → NEGATIVE BEHAVIORAL HEALTH EFFECTS

PRIOR TO THE CURRENT WAVE OF POLITICAL/POLICY ATTACKS,

LGBTQI+ PEOPLE ALREADY EXPERIENCED DISCRIMINATION,

MEDICAL MISTRUST

• Slew of recent anti-LGBTQ+ policy attacks, many anti-

transgender policy attacks, have exacerbated these

dynamics

• Rise in anti-LGBTQ+ hate speech, threats, violence, online

harassment

• Rise in racist, anti-Semitic hate speech, violence,

harassment through social media

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SIGNIFICANT PRE-EXISTING MEDICAL MISTRUST,

ESPECIALLY AMONG KEY LGBTQ+ GROUPS

• LGBTQ+ people of color

• Transgender people

• Older LGBTQ+ people

• Intersex people

Cahill et al., AIDS Care. 2017; D’Avanzo et al. Behav Med, 2019; Blakemore, HISTORY, 2020;

Organisation International Intersex Europe, COVID-19 Survey Report, 2020

COVID-19, MPOX LIKELY EXACERBATED MEDICAL MISTRUST

• Black LGBT people, especially Black lesbian and bisexual women, much

less likely to be vaccinated for COVID-19, according to CDC MMWR

• Significant Mpox vaccine hesitancy among Black, Latino gay, bi men

THIS CONTRIBUTES TO, REPRODUCES RACIAL

AND ETHNIC DISPARITIES

KEY QUESTION

How do we ensure that the roll out of DoxyPEP for STI

prevention does not reinforce pre-existing racial and

ethnic disparities, as we say with PrEP for HIV

prevention roll out and Mpox vaccine roll-out?

Many states with high levels of anti-LGBT political

activism also have large populations of Black, Hispanic

and Native American people. This could worsen

disparities.

NEED FOR SOGI NONDISCRIMINATION

IN HEALTH CARE

2021: SOGI Nondiscrim. Exec.

Order; Office of Civil Rights Notice:

Admin. will interpret Section 1557

of ACA, Title IX sex nondiscrim. to

include SOGI discrimination;

awaiting final rule

Equality Act: stuck in Senate,

introduced 1974, strong majority

public support (80% of U.S. public

supports according to March 2022

PRRI poll)

THANK YOU

Sean Cahill, PhD

Director, Health Policy Research

The Fenway Institute

scahill@fenwayhealth.org