By: Madison Davis MPH Candidate, Brown University School of Public Health

The History Behind Pride Month

       The month of June celebrates LGBTQ+ Pride Month after the Stonewall Uprising on June 28^th in 1969. In the 1960s, it was common for police to unjustly raid gay bars in New York City. In the past, the patrons would accept the raids passively despite them being unfounded. However, on June 28^th, the patrons of the Stonewall Inn bar would no longer allow the harassment to be met with inaction. The patrons fought back on police who raided the bar that night. This resistance allowed for a new precedent to be set: the LGBTQ+ community would not allow discrimination and persecution to continue.

       The following year, on June 28^th, 1970, New York City residents marched in the streets to celebrate and commemorate the Stonewall Uprising. This would later be considered the first pride parade. This uprising and its subsequent celebration led to a major shift in the LGBTQ+ rights movement and marked an important catalyst in the push for equality.

Timeline of the LGBTQ+ Rights Movement

LGBTQ+ and Healthcare

The Use of Pre-Exposure Prophylaxis (PrEP)

       The creation of PrEP is a major step in the fight against the HIV/AIDs epidemic. PrEP is a medication that reduces your chances of getting HIV by 99% if exposed via sex. PrEP can be administered in the form of a pill or shots: Truvada and Descovy being the two approved pills and Apretude being the approved shot. There is flexibility with administration. If a person were to want to switch from pills to shots or vice versa, they could speak with their healthcare provider.

       Individuals recommended to use PrEP  include those who have had anal or vaginal sex in the past 6 months and have a sexual partner who has HIV, have not used a condom consistently, or have been diagnosed with an STI in the past 6 months. PrEP can be used by any person over 77lbs and are at risk of HIV.

       Those with insurance or state Medicaid have access to PrEP at no cost. If an individual does not have insurance, then they can use one of the following programs to obtain PrEP at little or no cost: Ready, Set PrEP, Co-Pay Assistance Program, ViiVConnect, or PrEP Assistance Program.

       In order to start taking PrEP either an in-person or virtual appointment with a healthcare provider must be scheduled and an in-person or at-home HIV test must be completed. Once prescribed, routine visits are necessary for subsequent HIV tests and refills.

       On-Demand PrEP refers to a way to take PrEP only when an individual is at risk for HIV. This means they would use a 2-1-1 schedule: taking 2 pills 24 hours before sex, 1 pill 24 hours after the first dose, and 1 pill 24 hours after the second dose. This method has been effective in preventing HIV among gay and bisexual men who have anal sex without a condom; however, this has not been tested for heterosexual or transgender individuals who are at risk. This approach is not approved by the FDA and not recommended by the CDC.

LGBTQ-Competent Care

       LGBTQ-competent care is pivotal in decreasing barriers to access and improving the experience for the LGBTQ community. As of 2019, individuals a part of the LGBTQ community report not having sufficient choice or access to LGBTQ-competent providers who are in-network with their insurance. Additionally, they report being denied coverage for LGBTQ-specific medical service such as HIV medications, PrEP, hormones, PEP, HPV, and gender-affirming care.

       There are also major barriers to care for the LGBTQ+ community. Some of these include resources to pay out of pocket, not enough adequately trained providers, the assumption by providers that the individual is cis-gendered and heterosexual, provider fear or dislike of LGBTQ+ people, and not knowing how to access LGBTQ-component providers. 

The qualities of a competent providers include:

• Being comfortable with sexual orientation and gender identity
• Asking about sexual orientation, gender identity, and relationship status
• Having LGBTQ-inclusive forms that list sexual orientation, gender identity, and relationship status
• Using gender-neutral language when talking about reproductive health, sexual health, and or relationship status
• Having signs, posters, and other visible signals that the office setting is LGBTQ-inclusive
• Including sexual orientation and gender identity in the organization’s posted non-discrimination statement
• Having gender-neutral restrooms
• Having LGBTQ people on staff
• Asking and addressing patients by their correct pronouns
• Asking and addressing patients by their chosen name if different from legal name
• Having trained frontline and medical support staff on LGBTQ competency
• Having knowledge on transgender-specific and related health care needs
• Being comfortable with patients who identify as transgender
• Addressing patient’s transgender-specific healthcare needs, not only other medical needs
• Having office forms and policies that are transgender-inclusive
• Having specific knowledge or training to deliver healthcare services to LGBTQ people

       By integrating the above qualities into your practice, your LGBTQ patients will feel more comfortable with your practice and are more likely to receive high-quality, patient-centered care.

Gender-Affirming Care

       Gender-affirming care encompasses medical practices such as hormone replacement therapy, surgical interventions, and non-medical care such as legal or social support while transitioning. This type of care is recognized as medically necessary by both national and global organizations. At this time, however, Alabama, Arkansas, Arizona, and Texas have restricted youth-access to gender-affirming care. The restrictions on gender-affirming care include:

• Criminalizing or imposing professional disciplinary action against healthcare providers who offer this care
• Penalizing parents aiding in youth-access to this care
• Allowing individuals to file for damages against providers who provide such care
• Limit insurance coverage or payment for such care

       However, the American Medical Association, American Academy of Pediatrics, the Endocrine Society, American Psychological Association, American Psychiatric Association, and the World Professional Association of Transgender Health have all released statements supporting gender-affirming care and deeming it medically necessary for both youths and adults. 

Importance

       LGBTQ+ youth report higher rates of depression, anxiety and suicidality when compared to their non-LGBTQ+ peers. Transgender youth specifically report higher suicide risk outcomes including having felt sad or hopeless, considering attempting suicide, making a suicide plan, attempting suicide, or had a suicide attempt treated by a provider when compared to their cis-gendered peers. Furthermore, a lack of access to gender-affirming care has been significantly tied to worse mental health outcomes. Within healthcare spaces, LGBTQ individuals report higher rates of negative experiences with providers when compared to non-LGBTQ individuals.

       Being an LGBTQ-competent provider and providing gender-affirming care is necessary to providing patient-centered, quality care. These are basic steps that can be taken on the provider side to ensure patients are feeling respected and valued by their provider. Furthermore, access to competent care significantly impacts patient’s mental health. Revisit the above qualities of a LGBTQ-competent provider and explore ways to include gender-affirming care in your practice.

Blood Donation

       Prior to 2015, a man who had sex with other men at any point in their lifetime were banned from donating blood. In December of 2015, the FDA revised this ban to exclude men who had sex with men in the last 12 months. However, in 2020, the FDA revised this policy again to say exclude men who had sex with men in the past 3 months.

       There are rigorous and extensive tests that donated blood undergoes, including tests for the presence of HIV, hepatitis, syphilis, and other blood-borne diseases. However, for the approximately 12 million units tested per year, approximately 10 HIV-infected units have slipped through due to faulty results. Given this, the FDA still excludes men who had sex with men in the last 3 months from donating.

       However, the federal policy is not preventing risky behavior but rather a general group from donating. Women who have unprotected sex with multiple men and women are still able to donate, but a man who has protected sex with another man is unable to donate. This highlights a clear example of the FDA discriminating against a group rather than a risk factor. The Human Rights Campaign suggests the FDA should alter their pre-donation questionnaire to inquire about risky sexual behavior rather than sexual orientation or gender identity.     

Conclusion

       As healthcare providers, it is our job to provide compassionate, high-quality, and patient-centered care regardless of the patient’s sexual orientation or gender identity. By adjusting our practice to include gender-affirming care where appropriate, educating ourselves on LGBTQ+ history, and learning how to provide LGBTQ-competent care, we can help improve mental health, improve access to care, and make an impactful difference in the lives of our LGBTQ+ patients.

References 

1. About PrEP.  Center for Disease Prevention and Control. https://www.cdc.gov/hiv/basics/prep/about-prep.html
2. Blood Donations.  Human Rights Campaign. https://www.hrc.org/resources/blood-donations
3. Closing the Gap: The Turning Point for LGBTQ Health. (2019). https://drive.google.com/file/d/1wE_87-h1JP1Ge8m_rb7SnrvBZjN8LE7L/view
4. Dawson, L., Kates, J., & Musumeci, M. (2022). Youth Access to Gender Affirming Care: The Federal and State Policy Landscape. https://www.kff.org/other/issue-brief/youth-access-to-gender-affirming-care-the-federal-and-state-policy-landscape/#:~:text=Gender%2Daffirming%20care%20is%20a,affirm%20an%20individual’s%20gender%20identity.%E2%80%9D
5. Guillen, L. Same-Sex Marriage Now the Law of the Land. https://www.nolo.com/legal-encyclopedia/same-sex-marriage-now-the-law-the-land.html#:~:text=Gay%20Marriage%20Is%20Legal%20in,cannot%20ban%20same%2Dsex%20marriage
6. Klein, K. (2022). Gender-Affirming Care and HCH: Definitions, Resources, and Opportunities Insights from the HCH Helpdesk.
7. Pride Month: The History and Meaning Behind It. (2021).  Mental Health Association in Delaware. https://www.mhainde.org/pride-month-the-history-and-meaning-behind-it/?gclid=CjwKCAjwtcCVBhA0EiwAT1fY7-0AckBX2npBjmy36pEBopLCmuXsFgWpAdMVnFRTP13rLrVkCvF6ghoCoW8QAvD_BwE
8. Stonewall Riots. (2017).  A&E Television Networks. https://www.history.com/topics/gay-rights/the-stonewall-riots
9. Suits, D. (2021). Change to policy allows transgender Soldiers to serve openly. Army News Service. https://www.army.mil/article/247785/change_to_policy_allows_transgender_soldiers_to_serve_openly