Pride Month Faculty Spotlight: Q&A with Dr. Carl Streed Jr., MD, MPH, FACP
Department of Medicine administrator Nellie Ferrara sits down with General Internal Medicine physician and Research Director for BMC’s Center for Transgender Medicine and Surgery for a discussion on LGBTQ health and inclusion in medicine.
Q: Right now we’re witnessing the Black Lives Matter movement where inequality and injustices against African Americans are being brought to light and exposed. But when you think about injustices you also think about injustice in the LGBTQ community. The Supreme Court just ruled that the 1964 Civil Rights Act protects LGBTQ workers from being discriminated against. How does this impact your patients?
A: Before the Supreme Court’s decision in Bostock, the Commonwealth of Massachusetts thankfully already afforded significant protections for LGBTQ persons (https://www.lgbtmap.org/equality_maps/profile_state/MA); The recent Supreme Court decision actually gets the rest of the country up to speed on employer non-discrimination. For our patients in Massachusetts, where we already include protections from discrimination based on sexual orientation and gender identity, the immediate impact will vary. With full protection under Title VII no matter where they work or their employer is based, people can be assured they cannot be fired for coming out. This is significant for LGBTQ patients, and really everyone, because the current healthcare system still ties health insurance benefits to employment, which accounts for a majority of health insurance coverage in the US and Massachusetts in particular (https://www.kff.org/other/state-indicator/total-population/?dataView=0¤tTimeframe=0&selectedDistributions=employer&sortModel=%7B%22colId%22:%22Employer%22,%22sort%22:%22desc%22%7D). As our healthcare system relies on insurance, Bostock implies protecting someone’s access to health care, which includes gender affirming care, HIV Pre-Exposure Prophylaxis, etc for everyone.
Q: While this is a significant victory for those in the workplace, there is still work to do in terms of healthcare where discrimination is still a big issue especially during the current Presidential Administration. What kind of affect does discrimination have on an individuals health?
A: We know for a fact that experiences of stigma and discrimination affect the health and well-being of individuals and communities. It has been well described in what is called “Minority Stress Theory,” which notes how stressors (such as discrimination) can lead to increased rates of smoking, drinking, mental distress, and inflammation and immune dysregulation which all adversely affect our health (Mirowsky, J. & Ross, C.E. Social causes of psychological distress, (de Gruyter, New York, 1989); Pearlin, L.I. The sociological study of stress. J Health Soc Behav 30, 241-256 (1989); Lick, D.J., Durso, L.E. & Johnson, K.L. Minority Stress and Physical Health Among Sexual Minorities. Perspect Psychol Sci 8, 521-548 (2013); Bostwick, W.B., Boyd, C.J., Hughes, T.L. & McCabe, S.E. Dimensions of sexual orientation and the prevalence of mood and anxiety disorders in the United States. Am J Public Health 100, 468-475 (2010); Wheldon, C.W., Kaufman, A.R., Kasza, K.A. & Moser, R.P. Tobacco Use Among Adults by Sexual Orientation: Findings from the Population Assessment of Tobacco and Health Study. LGBT Health 5, 33-44 (2018); Lindley, L.L., Walsemann, K.M. & Carter, J.W., Jr. The association of sexual orientation measures with young adults’ health-related outcomes. Am J Public Health 102, 1177-1185 (2012))
Not surprisingly then, among groups of people who experience discrimination based on their minoritized identities (race, sexual orientation, gender identity, etc), we see higher rates of anxiety and depression, we see higher rates of smoking and drinking, and we see higher rates of hypertension and heart attacks. Of course, all of these presuppose that the discrimination it self isn’t what is killing people directly, which it is (police brutality, hate crimes).
Q: Has there been any kind of change recently that has happened that could potentially create a domino effect on the road to equality in healthcare? If no, what do you think needs to happen next?
A: While I think the Bostock decision is enormous because it appropriately interprets discrimination based on sex to include sexual orientation and gender identity, I don’t know if we’re going to see rapid change. The various steps needed to achieve equity in healthcare require us to not only update policies and the law (like Bostock), but also how we train our health care workforce, and value the lives and work of LGBTQ persons.
Q: How are you and other healthcare workers advocating for the LGBTQ community and are there ways that individuals who aren’t physicians or nurses can advocate to promote equality in healthcare?
A: Advancing health equity doesn’t benefit the few, it benefits everyone. Everyone has a sexual orientation and gender identity and how society responds to these affects your health. We’re all living and suffering in a society built on white supremacy and cis-heteronormativity. Acknowledging our diversity and dismantling the systems that harm us will require us working together, not in parallel or in tandem, but together.
In addition to advocating for our LGBTQ patients one-on-one and within our healthcare system, we advocate for updates in insurance coverage for gender affirming care, expansion of SOGI data collection to better characterize LGBTQ populations and health disparities, and push for required education and training to prepare future clinicians to care for LGBTQ persons.
Q: Is there anything you’re currently working on that you would like us to know about?
A: We have several projects looking at the current health status of transgender persons seeking care within BMC. We are also collaborating with researchers and clinicians outside of BU/BMC to understand how various LGBTQ-specific policies affect the well-being of LGBTQ youth and adults.
Thank you so much Dr. Streed for taking the time to answer my questions.