This summer has seen both monumental policy victories and setbacks for the gender and sexual minority community in the United States. The Supreme Court decision that Title VII of the Civil Rights Act includes protection for both gender identity and sexual orientation paved the way for new protections in the workplace. June also marked the five-year anniversary of the Supreme Court marriage equality ruling, providing “equal dignity in the eyes of the law” for same-sex couples.

Despite these wins, equal access to healthcare remains out of reach for too many LGBTQ+ people in the U.S. The executive branch’s June decision to restrict the interpretation “on the basis of sex” in the Health Care Rights Law to assigned sex rather than gender identity means that transgender patients can legally be refused healthcare – including COVID-19 testing and treatment – due to their gender. This move compounds issues in access to healthcare faced by other communities – LGBTQ+ patients with disabilities and Black LGBTQ+ patients, for example, have long encountered discrimination, refusal of services, and other major setbacks. The disproportionate impact from the pandemic further underscores health equity as an urgent challenge for LGBTQ+ policy.

LGBTQ+ Health Inequities: What the Data Show

Every 10 years, the Department of Health and Human Services creates a series of health goals for the decade known as “Healthy People.” In 2010, “Lesbian, Gay, Bisexual, and Transgender Health” was added as a topic for the first time to Healthy People 2020. This topic addresses the long history of health inequities for the LGBTQ+ community, including legal discrimination in healthcare and health insurance. According to Healthy People 2020, HIV/AIDS, suicide, and substance use rates continue to remain high for gender and sexual minorities.

While acknowledging health inequities is an important first step, research on these populations is incomplete and can be difficult to conduct. Even basic national data on the number of LGBTQ+ people in the United States is unreliable due to a combination of failing to ask for gender and sexual orientation, small sample sizes, and fear of ramifications from gender or sexual orientation disclosure.

Emergency Medicine: A Key Pillar of Care

Many LGBTQ+ patients avoid regular primary care. This trend may have multiple causes, including lack of access to quality health insurance, fear, and experiences of discrimination or even harm in healthcare settings. Instead, a disproportionate number of LGBTQ+ patients utilize emergency medicine. Indeed, many LGBTQ+ patients actually use emergency medicine as primary care. Among gender minority patients, this use is roughly 4% for white patients, but doubles to 8% for Latinx patients and jumps to 17% for Black patients.

Many LGBTQ+ patients actually use emergency medicine as primary care. This puts emergency medical healthcare providers and staff in a uniquely influential position.

This puts emergency medical healthcare providers and staff in a uniquely influential position. Providing culturally-sensitive and appropriate care can set a positive tone for continuing hospital admittance and follow-up appointments, potentially leading to more primary care visits. Examples of culturally-sensitive care include using correct pronouns, not asking intrusive medical history questions or performing unnecessary physical exams unrelated to the medical issue at hand, and displaying visual indicators of LGBTQ+-friendly spaces.

Examples of culturally-sensitive care include using correct pronouns, not asking intrusive medical history questions or performing unnecessary physical exams unrelated to the medical issue at hand, and displaying visual indicators of LGBTQ+-friendly spaces.

Poor care can lead to a three-pronged problem: the original medical issue may go unaddressed, patients may experience psychological or physical harm, and they may be unlikely to seek care in the future.

One strategy to avoid these outcomes among in-hospital emergency room settings has been to give advanced training on LGBTQ+ patient care to providers. Recent research specifically in the emergency department setting indicates that this strategy may be successful in providing quality care to LGBTQ+ patients.

However, less is known about the prehospital setting, including ambulance personnel such as EMTs and paramedics. Because ambulances are motor vehicles, the regulation of prehospital emergency medicine generally falls under the domain of the National Highway Traffic Safety Administration. NHTSA recognizes LGBTQ+ patients as a special patient population for training prehospital emergency medical providers. But unlike for other special patient populations such as pediatric patients, LGBTQ+-specific content is not currently required as part of the National Emergency Medical Services Education Standards.

LGBTQ+-specific sensitivity training and education for healthcare personnel should be required. For prehospital emergency medicine providers, this would come from NHTSA in the form of a statement mandating LGBTQ+ patient care as a subtopic of the Special Patient Populations category for certification and recertification of all prehospital certification levels.

Envisioning More Inclusive Health Policy

While improvements to patient care in emergency medicine are critical, ultimately, primary care settings need to be comprehensively safe spaces for LGBTQ+ patients to avoid the need for alarmingly high rates of emergency medicine utilization in the first place.

While improvements to patient care in emergency medicine are critical, ultimately, primary care settings need to be comprehensively safe spaces for LGBTQ+ patients to avoid the need for alarmingly high rates of emergency medicine utilization in the first place.

At the policy level, the same protections in healthcare that are extended to cisgender and heterosexual people must also be given to LGBTQ+ people. This includes banning discrimination solely based on gender or sexual orientation in any professional setting. Comprehensive and equitable health insurance must be widely provided to LGBTQ+ patients, including equitable coverage for sexual health and reproductive technology. And to realize true equity in healthcare, LGBTQ+ patient sensitivity training must also go hand-in-hand with anti-racist training for healthcare providers at all levels.

LGBTQ+ people deserve equal access to quality health care. Investing in health equity would both improve patient care in the field and lessen the patient load in emergency medicine – especially crucial during such a widespread pandemic.