Dr. Carl G. Streed Jr., M.D., MPH
Assistant professor of medicine,
Boston University Medical Center
Here we are in June which is Pride Month, and your practice of medicine has a strong component of care for the LGBTQ population. As an openly gay provider, how has your own self-identity impacted or influenced your practice? What, if any, challenges have you encountered?
As an out gay man myself, there is a natural component to what is personal and caring for your own community. More broadly, when I was in medical school I found that the training, in general, can be deficient in providing culturally competent care for LGBTQ individuals. In seeing that deficiency, I became a vocal advocate while in training which snowballed into LGBTQ care becoming a large component of my practice, advocacy and research within health care systems. When I look at challenges, there is no requirement that medical schools provide training on providing care to LGBTQ persons, although people acknowledge specific training is necessary.
Today, what do you see as the top 3-4 health issues in the LGBTQ community? And what are your ideas on how to address these issues?
I do my best to not lump every identity together, because some items are specific to subgroups. However, broadly, one of the main issues is access to health care, consistently LGBTQ individuals delay care due to inadequate financial resources or lack of affirming care. Within the U.S., we know that access is often tied to employee status and we know that LGBTQ individuals tend to be in lower income industries. There are still issues in terms of heart attacks and hypertension among gay men and transgender individuals as well as smoking and alcohol abuse. Again, another large component is the lack of data collection – even with a strong recommendation in several states to collect SOGI data. Some LGBTQ individuals still experience poor encounters and discrimination by health care professions, which highlights the need for training in providing complete and compassionate care.
"My advice would be, try not to think of LGBTQ care as another 'check box.' "
“SOGI” may be a new term for many. Can you explain the meaning and letters behind SOGI? Moreover, can you shed light on how it can be stratified to address disparities - how can hospitals and health systems effectively stratify SOGI data?
SOGI, or sexual orientation and gender identity, can be looked at in several ways. Sexual orientation, a self-identity, like gay, lesbian, bisexual, and heterosexual. Gender identity, or a person’s internal sense of self is an important component as it may be different from an individual’s sex assigned at birth, which is the preferred term. Often, people have been taught sex assigned at birth ends at male and female, but, in fact, we know there is much more to the spectrum. Asking questions related to SOGI should be a routine aspect of demographic intake. SOGI questions are, at times, more palatable to the general public compared to, let’s say, socioeconomic status or income. LGBTQ people recognize and understand it, providing a little information as to why you are collecting it up front goes a long way. On the flipside, people must get comfortable asking these questions and doing so from a nonjudgmental place.
"A place with a culture of diversity and inclusion is more likely going to be able to share that positive experience with patients served."
The groundbreaking IOM Report on LGBT Health in 2011 had some common issue areas to address including the disparities experienced by LGBT persons both in terms of access to care and in health outcomes and the need for data and more research. That was nearly 10 years ago. Do you believe these have been adequately addressed over time and what priorities still need improvement?
The lack of data has been one of the most problematic issues. When we look at the data we do have, which we feel stands up to critical analysis, we absolutely see health disparities like limited access to affirming health care, discrimination, disparities in cancer outcomes, cardiovascular problems, chronic conditions and substance use. The report really highlights that we need better data as it relates to SOGI, and that asking these questions needs to be a part of our routine surveys. The report also shows the need for more training on LGBTQ topics across the health system.
What would be your advice to a physician peer in primary care, not specifically in an LGBTQ-identified clinic, but in a more general-practice setting for how to foster a welcoming and competent practice for LGBTQ patients?
My advice would be, try not to think of LGBTQ care as another “check box.” As clinicians, we are taught to be lifelong learners. There are many textbooks, federal guidelines on LGBTQ care, etc. I always remind people to reach out to a resource if they need an answer – someone will be able to locate it. It is also important for clinicians to realize, as data indicates, LGBTQ people live everywhere in the United States and in every county. There are a few items that could be a check box, however, such as: collecting SOGI data, inclusive intake forms and proper advertisement.
What advice would you give to health system leaders in terms of how the system could enhance support for culturally sensitive and competent care for LGBTQ populations?
Upfront, there needs to be required training for all staff, not just clinicians. It should be offered annually and as a component of new hire training. Data collection, not only for patients – but internally is important as well. This helps us to understand how we are doing for our own staff, which will ultimately reflect onto our patients. A place with a culture of diversity and inclusion is more likely going to be able to share that positive experience with patients served.
"We are having more and more residents and fellows seeking post-graduate training specific to LGBTQ health, especially transgender health."
We’ve seen how COVID-19 has disproportionally impacted people from marginalized backgrounds, especially communities of color. What has been the impact of COVID-19 on LGBTQ patients?
The problem is, we are not specifically collecting SOGI data as a part of the reporting around the pandemic. Only recently have we improved collecting REaL data and that alone is reflecting what we anticipate in a pandemic. Unfortunately, communities who have been marginalized and discriminated against often experience a higher burden as it relates to infectious disease. I think we will likely see that reflected in the LGBTQ community as well, once we have better data collection.
Based on your experience, what gives you hope in reducing the disparities in the LGBTQ community?
Seeing how many students are speaking up for this in their curriculum is heartening. Additionally, we are having more and more residents and fellows seeking post-graduate training specific to LGBTQ health, especially transgender health. It is this active seeking of information and training that gives me hope that we will be able to reduce disparities in health care access and outcomes for LGBTQ communities.