Obtaining sufficient healthcare presents challenges to many people in the LGBTQ community, who are unsure of the way their doctors will treat them, or whether doctors will be willing to treat them at all. Some physicians are addressing those challenges head-on.
"Our main focus is how we can be advocates for marginalized patients," says Ravi Grivois-Shah, M.D., MPH, and a delegate to the American Academy of Family Physicians ( AAFP ) GLBT constituency. The AAFP is an organization of almost 125,000 family physicians from all 50 states and Washington, D.C., as well as several U.S. territories. Its GLBT constituency, a group of LGBTQ family physicians and allies who are members of the organization, works with Academy leadership to push for organizational policy changes, national legislation, and to establish best practices for addressing the obstacles LGBTQ patients face, from discrimination in the doctor's office to lack of community resources.
Grivois-Shah completed his medical training at the University of Illinois' Chicago campus and provided care to underserved patients in Chicago for nearly a decade, from Howard Brown Health to Near North Health Services Corporation ( where he served as medical director ), before relocating to Tucson, Ariz., in 2014, as a clinical associate professor of family and community medicine at the University of Arizona College of Medicine. He joined the AAFP in 2005, and since 2009 has taken a leading role in addressing LGBTQ health disparities with the GLBT constituency.
The constituency was first established in 2001 to focus on issues that affected LGBTQ physicians and their patients, he says. These issues included workplace equity, obtaining fair child leave policies for new fathers, and revising the national blood donation policy, which has historically discriminated against gay men. ( The U.S. Food and Drug Administration lifted its lifetime ban for blood donations from men who have sex with men in 2015. The AAFP pushed for the organization to lift the ban, stating that it supports standards "based on sound scientific evidence." )
Today, the GLBT constituency works especially hard to address the needs of their LGBTQ patients, many of whom lack appropriate education, doctors who are equipped and willing to address their health concerns, and support of loved ones.
Recognizing community needs
"One of the goals [of the GLBT constituency] is to make sure family physicians are educated and able to provide care for the community," says Grivois-Shah. Many LGBTQ individuals do not feel fully accommodated by the healthcare environment and are uncertain what information they can disclose to their care providers. "We know that a lot of patients who are LGBTQ delay care, and have concerns about getting safe, respectful care."
In large cities such as Chicago, resources are available for LGBTQ patients. But patients in other areas—particularly non-urban environments—can run into challenges finding safe care. Because of these disparities, the GLBT constituency aims to help the AAFP address healthcare issues and social determinants of health, as well as help create safe spaces both inside and outside the physician's office.
For example, says Grivois-Shah, doctors' offices should have posters and pamphlets that recognize all genders and sexual orientations, and the entire office staff—from doctors to nurses to front-desk administrators—should know appropriate terms to use when addressing patients.
Doctors should also be aware of population health risks. Of course, LGBTQ people have the same health needs as the general population, he notes, but there are some special healthcare needs. One area of concern is that the community has a disproportionate risk of suicide due to harassment from peers and rejection by families. Therefore, physicians should make sure their LGBTQ patients have adequate family support or access to resources that can help them deal without support from loved ones.
When it comes to sexual health and issues such as HIV, doctors must be able to ask questions in a respectful, non-judgmental way. Both doctors and patients must be educated on resources available for maintaining sexual health, such as Truvada for PrEP.
But Grivois-Shah also believes physicians must advocate beyond the walls of their offices. By pushing for legislative reform ( for example, on issues such as reparative therapy ) and school policy reform ( for example, to form gay-straight alliances in schools ), they can work with their LGBTQ patients to advocate for the community's needs. "How we [are] involved in the advocacy realm has such an impact on our patients."
Pushing for legislative reform
As a major medical organization, the AAFP advocates for policy reform at the local, state, and federal levels. For example, in September 2016, the group reaffirmed its policies against discrimination by approving a resolution "that specifically opposes state and federal laws that compromise the safety and health of transgender people," according to a press release. The Academy has long opposed discrimination on grounds including sexual orientation and gender identity, but the recent spate of so-called "bathroom bills" throughout the country ( the Human Rights Campaign notes 17 of these bills nationally in 2015 ) led many AAFP members, headed by the GLBT constituency, to urge leaders to take a more vocal stance on the issue.
"Although these issues can be divisive, clearly so-called bathroom bills are discriminatory, and the AAFP has longstanding policy against discrimination," said AAFP President-Elect John Meigs Jr., M.D.
Also in 2016, the Academy reaffirmed its stance on reparative, or "conversion," therapy, which it has opposed since 2007: "The AAFP recommends that parents, guardians, young people, and their families seek support and services that provide accurate information on sexual orientation and sexuality, increase family and school support, and reduce rejection of sexual minority persons of all ages," as stated on the academy's website.
As Grivois-Shah points out, only five American states and Washington, D.C., have laws banning reparative therapy for minors. Therefore, the support of a major credible healthcare organization such as the AAFP can help influence both state and federal legislation.
"What our constituency is facing now is so much different from a decade ago," he observes. While he and his colleagues have had their fair share of challenges, they have been successful in persuading the AAFP as a whole—which he emphasizes has "strong and supportive" policies—to adopt stances on several large issues.
For example, "It took many years for us to incrementally get to the point where we had a strong policy supporting marriage equality," he says. But since 2012, the organization has officially supported it.
"There are things that we as physicians can do to help optimize LGBTQ health in the community," says Grivois-Shah. This means being educated and creating safe environments within the doctor's office, but also "going above and beyond" the clinic setting. "The voice of physicians really carries weight on these issues."
Truvada for PrEP
According to the AIDS Foundation of Chicago, about 25,500 people in Chicago live with HIV or AIDS. Research from the Centers for Disease Control and Prevention shows that more than one in five new HIV diagnoses in 2014 were for young people aged 13-24, with young gay and bisexual males accounting for most of those diagnoses. As the LGBTQ population is heavily affected by the disease, Ravi Grivois-Shah, M.D., MPH, clinical associate professor of family and community medicine at the University of Arizona College of Medicine, says that both doctors and patients need to be aware of how they can help prevent it.
One of the most accessible—but not widely known—tools available for HIV prevention is PrEP, or pre-exposure prophylaxis: daily prescription medications that people at high risk for contracting HIV can take to reduce that risk.
Truvada is the name of the drug recommended by major health organizations, and can be used both for PrEP and, with other medications, to treat the infection if contracted. Studies have proven its prevention effectiveness when taken daily in conjunction with practicing safer sex.
While few physicians are skilled in administering full HIV treatment, Truvada is an easily prescribed, low-risk, and accessible medication. ( A study published in the Oxford Journal in early 2016 found that PrEP—specifically Truvada—"favorably compares to aspirin in terms of user safety." ) If patients are familiar with Truvada, says Grivois-Shah, they will know to ask their physicians whether it is a viable option for them.
For patients outside urban settings, these resources are often difficult to come by. "A lot of communities don't have anybody" prepared or willing to offer those resources, he says.
The good news for Chicagoans is that there are several local resources that make Truvada financially accessible. For a current list of Chicago-area PrEP clinics and providers, visit the AIDS Foundation of Chicago web page at www.aidschicago.org/i-need/prep/prep-clinics-and-providers .
