Racial and LGBT Health Inequities

Racial and LGBT Health Inequities

Louisiana Office of Public Health

STD-HIV/AIDS Program

Kathleen Welch

What are Health Inequities?

Differences in health status and in the distribution of health determinants between different population groups.

External determinants of health

Differences in social conditions outside the control of the individuals concerned

Differences are avoidable and rooted in social justice

Health inequities can be defined as differences in health status or in the distribution of health determinants between different population groups. For example, differences in mobility between elderly people and younger populations or differences in mortality rates between people from different social classes. It is important to distinguish between inequality in health and inequity. Some health inequalities are attributable to biological variations or free choice and others are attributable to the external environment and conditions mainly outside the control of the individuals concerned. In the first case it may be impossible or ethically or ideologically unacceptable to change the health determinants and so the health inequalities are unavoidable. In the second, the uneven distribution may be unnecessary and avoidable as well as unjust and unfair, so that the resulting health inequalities also lead to inequity in health.

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What are Health Inequities?

Equality = SAMENESS

Only works if everyone starts from the SAME place

Equity = FAIRNESS

Making sure people get access to the same opportunities

Racial Inequities in the US

Racial inequities in health in the U.S. are large and pervasive.

Almost 100,000 black persons die prematurely each year who would not die if there were no racial inequities in health

For some health outcomes, the inequities are worsening.

Pathogenic factors linked to race continue to affect health even when socioeconomic status (SES) is controlled.

For most of the 15 leading causes of death

including heart disease, cancer, stroke, diabetes, kidney

disease, hypertension, liver cirrhosis and homicide, African

Americans (or blacks) have higher death rates than whites

(Kung et al. 2008). These elevated death rates exist across

the life-course with African Americans and American

Indians having higher age-specific mortality rates than

whites from birth through the retirement years (Williams

2005). Other data indicate that almost 100,000 black persons

die prematurely each year who would not die if therewere no racial inequities in health (Levine et al. 2001).

For some health outcomes, the inequities are

worsening. Trend data for heart disease and cancerthe

two leading causes of death in the United Statesindicate

that blacks and whites had comparable death rates for these

conditions in 1950, but African Americans now have

higher mortality rates than whites05; NCHS 2007).

Research also reveals that pathogenic factors linked to

race continue to affect health even when socioeconomic

status (SES) is controlled. In national data there are

residual racial differences in health at every level of SES

for multiple indicators of health status, including self-rated

health, heart disease mortality, hypertension and obesity

(Pamuk et al. 1998). This pattern exists for a broad range

of other outcomes. A striking example comes from national

data on infant mortality by mothers education for all

women age 20 years and older. African American women

with a college degree or more education have a higher rate

of infant mortality than white, Hispanic (or Latino), and

Asian and Pacific Islander women who have not completed

high school (Pamuk et al. 1998). Further evidence of the

markedly elevated disease risk for African Americans

comes from national data on chronic disease risk factors for

blacks, whites and Hispanics age 40 and over (Crimmins

et al. 2007). This study assessed indicators of blood pressure

risk (systolic, diastolic, and pulse rate), inflammation

risk (C-reactive protein, fibrinogen, albumin) and metabolic

risk (total cholesterol, HDL cholesterol, BMI and

glycated hemoglobin). A summary indicator of total risk

counted how many of these 10 risk factors were outside of

the normal range. This study found that even after adjustment

for income, education, gender and age, blacks had

higher scores on blood pressure, inflammation, and total

risk. Importantly, blacks maintained a higher risk profile

even after adjusting for health behaviors (smoking, poor

diet, physical activity and access to care).

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Rates of Black & White Persons Living with an HIV Diagnosis, by County, 2010

Black Rates

White Rates

* Data are not shown to protect privacy. ** State health department requested not to release data.

Rates of Persons Living with an HIV Diagnosis & Poverty Rates, by County, 2010

Persons Living with an HIV diagnosis

Poverty Rates

* Data are not shown to protect privacy. ** State health department requested not to release data. Data not available because the data source does not publish these data for this jurisdiction.

Racial Inequities in Louisiana

WhitesBlacksHispanics

Poverty Rate 17%45%40%

Males/No High School Diploma2.5%17.7%11.8%

Incarceration Rate4.251657.5745.3

Life Expectancy76.572.178.6

Death Rate 832.81057.4384.9

Infant Mortality Rate6.613.93.9

Heart Disease Death Rate211.4262.499.4

Cancer Death Rate189.9239.5 87.8

Cerebrovascular Death Rate40.861.3NSD

Diabetes Death Rate21.646.1NSD

Breast Cancer Death Rate 22.035.3NSD

Firearms Death Rate13.226.8NSD

Adult Overweight/Obesity Rate64.7%74.3%72.3%

Uninsured for Nonelderly18%30%51%

Kaiser Family Foundation.(2012). State Health Facts. Retrieved fromhttp://www.statehealthfacts.org/index.jsp

Racial inequities in LA are even more extreme than in other parts of the US. This is true for the South. Of the 8 grantees selected for the CAPUS grant seven were from the South. The CDC and other federal agencies have made it a priority to allocate more funding for the South than other parts of the USin regards to HIV prevention and treatment

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Racial Inequities in Louisiana: HIV/AIDS (2012)

Louisiana ranked 4th highest in HIV case rates and 3rd highest in AIDS case in the US.

Baton Rouge ranked 2nd and New Orleans 4th in AIDS case rates for MSAs.

Blacks account for only 32% of Louisianas population yet:

67% of people living with HIV in LA are black.

HIV diagnosis rate for blacks is more than 7 times higher than for whites. (Whites: 7.1/100,000; Blacks: 56.7/100,000)

AIDS diagnosis rate for blacks is more than 12 times higher than for whites

Racial Inequities in Louisiana: STDs

In 2013, Louisiana ranked 1st for gonorrhea, 2nd for Chlamydia and 3rd for P&S syphilis case rates in the nation.

Blacks accounted for 78% of P&S syphilis cases, 85% of gonorrhea cases, 75% of Chlamydia cases.

How can Racism Affect Health Status?

Direct Effects

Physiologic stress allostatic load (McEwen and Seeman, 1999. A cumulative physiologic wear and tear.

Can affect multiple biological systems (nervous, endocrine, immune, cardiovascular) and lead to premature illness and mortality (Seeman, 2004).

Red blood cell oxidative stress

Can accelerate cellular aging, telomere shortening in response to life stress

Psychological Stress

The authors conclude: "This is a preliminary report of an association between racial discrimination and oxidative stress. It is a first step to understanding whether there is a relationship between the two. Our findings suggest that there may be identifiable cellular pathways by which racial discrimination amplifies cardiovascular and other age-related disease risks. If increased red blood cell oxidative stress is associated with experiencing racial discrimination in African Americans, this could be one reason that many age-associated chronic disease have a higher prevalence in this group."

*Oxidative stress is the process by which free radicals, or reactive oxygen species, damage cellular components including DNA, proteins and lipids.

Can accelerate cellular aging, telomere shortening in response to life stress (Epel, 2006)

Telomeres essential for protecting chromosome endsmarker for longevity and cellular health

Nurtures impact on nature

Carol Greider at John Hopkins, When the telomere gets to be very short there are consequences and an increased risk of age-related ailments.

Positive behaviors can stave off telomere erosion.

A German study showed that people in their 40s and 50s had telomeres about 40% shorter than people in their 20s if they were sedentary, but only 10% shorter if they were dedicated runners.

Werner, C; Furster T, Widmann, T, et al. Physical Exercise Prevents Cellular Senescence in Circulating Leukocytes and in the Vessel Wall Circulation. 2009; 120: 2438-2447.

In a study of over 4800 residents of Maastricht who screened negative for mental illness and paranoid traits at baseline, those who said that they had suffered from discrimination/racism were twice as likely to develop psychotic symptoms in the following three years.10

There is still not a well understood mechanism of action, racism is difficult to quantify and measure, Thus whether for political or analytical expediency researchers tend to avoid studying direct influences of racism on health in favor of indirect pathwaysFor example, is the poorer response to antihypertensive treatment in African-Caribbeans due to biology or is it a reflection of the role of perceived racism in its development and persistence? Investigation of racism's pathophysiological, cognitive, or psychophysiological correlates may offer new avenues for treatment and more efficacious management. Developing a deeper understanding of possible links between racism and health is a prerequisite for initiatives to decrease impact at a community and individual level.

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Differences in Access to Care

Closure, relocation or privatization of hospitals that primarily serve the minority community

Transfer of unwanted patients (patient dumping) by hospitals and institutions

Limiting the access of Medicaid patients to the full array of providers by sending these patients provider lists that contain only providers that accept Medicaid

Targeting specific areas for managed care enrollment while ignoring inner-city areas or other less desirable districts

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Differences in Quality of Care

Less aggressive treatment of minority patients

Minorities more likely to be treated by providers with worse performance records or those who are less well trained

Found across a wide range of disease areas and clinical services

Found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account

Found across a range of clinical settings, including public and private hospitals, teaching and non-teaching hospitals, etc.

Scope and Relevance of Care

Lack of stable relationships with primary care providers

Minority patients, even when insured at the same level as whites, are more likely to receive care in emergency rooms and have less access to private physicians

Financial incentives to limit services may disproportionately and negatively affect minorities

Fragmentation of healthcare financing and delivery

Health Inequities Scenario

LGBT Health Data Collection

LGBT Health Data Collection

LGBT Health Inequities

Individuals of the LGBT community are more likely to:

Rate their health as poor

Have chronic conditions (i.e., cancer diagnoses, obesity, cardiovascular disease, chronic headaches)

Have higher prevalence of earlier onset of disabilities

Have higher prevalence of HIV/STDs

Experience psychological distress and have higher rates of binge drinking and substance use

Differences in health inequities depending on LGBT subgroup

HIV/AIDS in the LGBT Community

In 2010, gay and bisexual men and other MSM, represented 2% of the US population but accounted for:

56% of all people in the US living with HIV

66% of new HIV infection

Black MSM accounted for 36% of new HIV infections in 2010 and saw the highest increase in HIV rates among all sub-populations between 2008 and 2010

1 in 4 transgender women of color are estimated to be HIV positive (28%), most of which do not know their status

HIV/AIDS in the LGBT Community: Louisiana

The percentage of adult HIV diagnoses in LA that are attributed to MSM increased from a low of 40% in 2002 to a high of 53% in 2011

The majority of new diagnoses among MSM in LA are black and under the age of 35

HIV/AIDS in the LGBT Community: Louisiana

Men and Women

Men Only

STDs in the LGBT Community

STD rates are higher among some LGBT groups and rates have been increasing for some infections

MSM account for more than 7 in 10 (72%) new syphilis cases in the US and 15% -25% of all new Hepatitis B infections

MSM are 17 times more likely to develop anal cancer (commonly caused by HPV) than men who only have sex with women

LGBT Stigma and Discrimination

History of discrimination and stigma is related to negative mental health and behavioral health conditions

LGBT members are 2.5 times more likely to experience depression and anxiety, and substance misuse

Lack of acceptance from family members is correlated with higher rates of mental illness and substance use

LGBT Stigma and Discrimination

Laws reinforce discrimination, stigma, and health inequities

LGBT Rights in Louisiana

Statewide employment discrimination law on basis of orientation allowed to expire in 2008

Hate crime law does not cover transgender individuals

No recognition of marriage among same-sex couples

No statewide recognition of partner health insurance benefits

Same-sex partners treated as legal strangers in medical decision making

Medical leave under the Family and Medical Leave Act

Homophobia and Transphobia in the Healthcare System

Individuals in the LGBT community are less likely to seek treatment and preventative care due to stigma and discrimination faced in healthcare settings

Less likely to regularly seek care from the same provider; more likely to seek care in the emergency room

LGBT individuals are more likely to be:

Refused care

Denied insurance coverage

Face harassment and unequal treatment

Experience blaming of ones orientation or gender identity for the cause of an illness

Disparity in clinical care persists among older LGBT adults age 65 and above, despite universal availability of similar care through Medicare

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Homophobia and Transphobia effects on the Healthcare System

LGBT-specific or gender-specific health issues may not be addressed competently or at all

Physicians uncomfortable with sexuality issues

Only 11 to 37 percent take sexual history on new adult patients

Stigma compounded

Only 18 to 49 percent disclose sexual orientation to physician

Homophobia and Transphobia effects on the Healthcare System

Most health professionals have not undergone any LGBT-inclusive culturally competency training

More than 2/3 of health care organizations offering cultural competency trainings on LGBT issues do not require physicians to attend

The average medical student spends about 5 hours learning about LGBT issues, the majority of which is focused on HIV/AIDS

Important for providing a safe space for disclosing ones sexual orientation and gender identity. Also important for reducing personal biases and providing equal level of care and treatment.

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Issues for Adolescents

Suicide and Depression

Leading cause of death in questioning/gay males

LGBT youths that experience family rejection are 8 times more likely to attempt suicide than LGBT peers not experiencing family reject

Rites of Passage denial

Stifles normal social development

Violence

Average HS student hears 25.5 anti-gay slurs daily

58% of homeless LGBT youths reported being sexually assaulted compared to 33% of homeless non-LGBT youths

Suicide and Depression

Suicide is a leading cause of death, especially of questioning/gay male adolescents - physicians are urged to consider sexual orientation as a risk factor.

Nearly one third of all adolescent male suicide attempts are linked to a crisis over sexual orientation.

LGBT Youth are denied many Rites of Passage unique to Adolescence

Rites of Passage unique to adolescence include:

oClassroom romances, first date, first kiss, Senior Prom

oNo role models or relationship models to identify with

oLack of healthy outlets for sexual exploration/experimentation

Failure to experience these activities stifles the normal Social Development of LGBT Youth.

Violence against Youth is frequent and has significant impact

Average High School student hears 25.5 Anti-Gay Slurs each day.

1 in 3 LGBT Youth in a Chicago had an object thrown at them and 1 in 5 had been kicked, punched, or beaten because of their Sexual Orientation.

Seattle study found LGBT Youth were 6 times more likely to be targets of offensive comments or attacks and 3 times more likely to be injured in a fight.

Significant number of victims of Anti-Gay Violence are actually Straight.

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Issues for Adolescents

Most Important Problems Identified by Non-LGBT Youth

Class/exams/grades (25%)

College/career (14%)

Financial pressures related to college or job (11%)

Most Important Problems Identified by LGBT Youth

Non-accepting families (26%)

School bullying problems (21%)

Fear of being out or open (18%)

Human Rights Campaign, Growing Up LGBT in America: HRC Youth Survey Report Key Findings, HRC, June 2012.

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Health Issues for Women

In the United States there are an estimated 6 -11 million lesbians that:

Access health care less frequently than heterosexual women

Are less likely to receive routine gynecological exams

Have an increased risk of cancers, tobacco use, sexually transmitted disease, chronic diseases

Evidence for a greater incidence of

Breast cancer

Cervical cancer

Cancers due to HPV

Lung cancer

Lesbians have double to triple the risk compared to heterosexual women

Greater prevalence of risk factors (obesity, alcohol consumption, nulliparity, lower screening rates)

Stated risk factors arent exclusive to lesbians, but the possible concentration of risks within a single group is unique

Individuals dont know their risk is higher

In one study, the average time between pap smears for:

Heterosexual women was 8 months

Lesbian women was 21 months

Lower screening rates may result in later detection, increasing morbidity and mortality

Lower incidence of birth control pill use

BC decreases risk of ovarian cancer

Documented higher rates of smoking for LGBT populations - especially adolescents & those with lower SES

Probable increased exposure to second hand smoke smoking is cultural norm in many LGBT social settings (bars, dance clubs, youth centers)

Known to be transmitted between women

Human papillomavirus

Can result in tissue changes leading to cervical cancer

Bacterial vaginosis

Candidasis

Trichimonas

Lesbians more likely to be overweight/obese; higher BMI, more smokers, lower preventive health care visits increase risk of heart disease, diabetes, and cancer

Assessing CVD risk

Study compared lesbian women to heterosexual sisters

Ages 40 and up

Findings in lesbian women

Higher BMI

Greater waist circumference

Larger waist-to-hip ratio

More likely to have ever smoked

More likely to have weight cycling history

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Health Issues for Women

Health Issues for Men

In the United States there an estimated 9 18 million gay men that:

Access health care less frequently than heterosexual men

Have an increased risk of HIV, sexually transmitted disease, tobacco use, cancers (anal cancers and colorectal cancers)

17 to 20 times more likely to develop anal cancer, which has been linked to HPV

Anal pap screening is rare

May have an increased prevalence of anorexia and bulimia

2001 Harvard study of 122 men - 14% gay men suffer from bulimia; 22% from anorexia; social pressure to conform to physical ideals is common

Cancers due to HIV/AIDS

Kaposis sarcoma

Non-Hodgkins lymphoma

Anal cancer

Hodgkins disease

Known to be transmitted between men

HIV/AIDS

Hepatitis A and B Virus

Gonorrhea

Syphilis

Chlamydia

Human Papilloma Virus

Gay men subfactor group Bears more likely to be overweight/obese

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Health Issues for Transgender Persons

Many barriers to healthcare for transgender individuals

More likely to live in poverty and not access or delay care and treatment because of costs

More likely to be refused care in the healthcare setting

Barriers to insurance coverage exist in Medicare, Medicaid, private insurance and veterans health care.

Deny coverage on gender-specific routine care

Not cover transition surgery or transition-related care

Health Issues for Transgender Persons

Transgender individuals experience lower rates of cancer screenings, particularly for cancer in reproductive organs

May be not be given or refused screenings or treatment specific to reproductive organs

MTF Transsexuals

Prostate cancer - prostate gland not removed

High risk of HIV and STDs

FTM Transsexuals

Breast cancer - risk still present though breast reduction surgery was performed

Ovarian cancer - ovaries may not have been removed

Cervical Cancer - cervix may still be present

Health Issues for Transgender Persons

Intersection of Racial and LGBT Inequities

Inequities are compounded for racial minorities in the LGBT community

Possible cultural aspects impact family support

National HIV/AIDS Strategy

The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.

As noted by President Barack Obama, the vision for the National HIV/AIDS Strategy

In order for our country to become a place where new HIV infections are rare we must ensure that every person has unfettered access to high quality, life-extending care, free from stigma and discrimination.

It is with those marching orders that we move forward our stigma work at NASTAD and NCSD.

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What Does It Take.

Commitment to social justice

Ability to collect and use data to demonstrate racial inequities in health

Willingness to ask questions and listen to answers

Tools for understanding and assessing how racism is manifested

What Does It Take.

Ability to shift from a focus on individual personal health behaviors to a focus on institutions and systems (requires training and skill building)

Community leadership/coalitions addressing racism

Desire to work across issues

Willingness to shift existing resources to support anti-racism work