Chicago LGBTQ Disparities: Working toward Health Equity

Chicago LGBTQ Disparities:
Chicago Department of Public Health

Working toward Health Equity

The Chicago LGBTQ Health and Wellness Microconference

November 30, 2012

Bechara Choucair, MD
Commissioner
@choucair on

Rahm Emanuel Bechara Choucair, MD
Mayor Commissioner

Presentation Outline

1. Health Equity and LGBT

2. LGBTQ Health in Chicago

3. Healthy Chicago Public Health Agenda

4. Solutions: LGBT Community Action Plan

5. Solutions: Your Charge

Social Justice and Health Disparities
• Health disparities are differences in the rate of disease,
incidence, prevalence, morbidity, mortality or survival rates

• The root causes of disparities are inequalities
• U.S. history of discrimination has made race, ethnicity, sexual
orientation, and gender identity determinants in access to
health care and in health status

Historical Basis for LGBT
Health Disparities
• The categorization of people based on sexual attraction and
behavior emerged in the 19th century

• Consensual same-sex sexual behavior was illegal during most
of 20th century

• Homosexuality was considered to be mental illness

The Health of Lesbian, Gay, Bisexual, and Transgender People Building a Foundation for Better Understanding ,
Institute of Medicine, March 2011

Current Basis for LGBT Health Disparities
• Sexual orientation and gender identity disparities are rooted
in oppression and discrimination against LGBT people

– Legal discrimination in access to health insurance,
employment, housing, marriage, adoption
– Lack of laws to protect against school bullying
– Lack of social programs appropriate for LGBT community
– Shortage of health care providers who are culturally
competent and knowledgeable

Source: Healthy People 2020, LGBT Health Overview, Understanding LGBT Health

Promoting Social Justice
Reduces Health Disparities
• Food Stamps (1961)

• Civil Rights Act (1964)

• Voting Rights (1965)

• Desegregation of Medical Facilities (1963-1965)

Gamble and Stone, U.S. Policy on Health Inequities: The Interplay of Politics and Research, Journal of Health Politics,
Policy and Law, Vol. 31, No. 1, Feb. 2006

LGBT Population
• Racially, ethnically, culturally, geographically diverse

• 3.4% of U.S. population self-identifies as LGB, but there are
generational differences (UCLA, Gallop)
– 6.4% of 18-29 year-olds self-identify
– 3.2% of 30-49 year-olds self-identify
– 1.9% over age 65 self-identify

• Other estimates are as high as 10%

• 2007 estimates: 114,500 LGBT persons in Chicago

• U.S. transgender population estimate:
– 1:500 for Male to Female
– 1:500 for Female to Male (Lynn Conway)

Why are LGBT so Invisible?
• Lack of epidemiological studies
– Sexual orientation and gender identity variables not typically
included in study designs

• Population hard to identify even for dedicated researchers
– Reluctance of community members to self-identify
– Many recruiting techniques do not work well with this
community
– No perceived advantage to being “out”

LGBT Disparities
• Tobacco
• Obesity
• STD/HIV/AIDS
• Cancer
• Heart Disease
• Violence
• Health Care Access

Tobacco Use Among LGBT

Tobacco Types LGBT Heterosexual

Cigarettes 32.8% 19.5%

Cigars/Cigarillos 12.2% 6.6%

Any Tobacco 38.5% 25.2%

King BA, Dube SR, Tynan MA (2012). Current Tobacco Use Among Adults in the United States: Findings
from the National Adult Tobacco Survey. American Journal of Public Health . 102(11): e93-e100
November 2012, Vol. 102, No. 11 : pp. e93-e100

Why Is Smoking More Common
Among LGBT?
• Higher levels of stress

• Early smoking

• Adverse role models

• Social norms

• Big tobacco targeting

• Cognitive disconnect

LGBT and Obesity
• Many studies suggest that lesbian women are more likely to be
overweight and obese than heterosexual women. A 2007 study
found:
o Lesbians are over 2 times as likely to be overweight, and
obesity as heterosexual women
o Bisexual women showed no such increase in the odds of overweight
and obesity

• Higher prevalence rates of obesity among lesbians who are
African-American, live in rural or urban areas, have lower levels of
education, of low socioeconomic status.

• Some research has indicated that adult lesbians are not sufficiently
physically active.
Am J Public Health. 2007 June; 97(6): 1134–1140. Overweight and Obesity in Sexual-Minority Women:
Evidence From Population-Based Data; Ulrike Boehmer, PhD, Deborah J. Bowen, PhD, and Greta R. Bauer, PhD

2009 HIV/AIDS Diagnoses, Chicago
Characteristic AIDS HIV
Number Percent Number Percent
MSM 349 53.8% 676 61.9%
(Male Sex w/Male)

Injection Drug Use 111 17.1% 135 12.4%
(IDU)

MSM & IDU 30 4.6% 23 2.1%

Heterosexual 148 22.8% 231 21.2%

Other (Perinatal, Blood ---- ---- 7 0.6%
Transfusion, Hemophilia)

Source: Healthy Chicago STI/HIV Surveillance Report, Chicago Department of Public Health, Fall 2011

Major Racial Disparities in HIV
2011 Behavioral Surveillance Data

% HIV Positive
All Ages Youth (18 -29)

Black MSM 35% 28%
White MSM 17% 10%
Hispanic MSM 13% 8%

Source: Healthy Chicago MSM Behavioral Surveillance Report, Chicago Department of Public Health, December 2012

HIV-related behaviors, past 12 months,
Chicago MSM, 2011

Unprotected male-male anal sex 59%
Used any illicit drug 53%

Tested for HIV infection 70%
Tested for STI 53%

Received free condoms 82%
Participated in an HIV behavioral 24%
intervention
Source: Healthy Chicago MSM Behavioral Surveillance Report, Chicago Department of Public Health, December 2012

Transmission of 2010 Syphilis Cases,
Chicago
Transmission Number Percent
Group

MSM 340 49.6%

Heterosexual Males 86 12.5%

Females 84 12.2%

Male Unknown 176 25.7%

Source: Healthy Chicago STI/HIV Surveillance Report, Chicago Department of Public Health, Fall 2011

Lesbians, Bisexuals and Breast Cancer
• Lesbians are at significantly higher risk for developing
breast cancer than heterosexual women, but rates are
inconsistent.

• Risk factors for breast cancer among lesbians include
fewer full-term pregnancies, fewer mammograms and/or
clinical breast exams, and being overweight.

• Bisexual women ages 50–79 years are more likely to self-
report higher rates of breast cancer.
-Risk factors for breast cancer include fewer pregnancies, and
consumption of alcohol
National Women’s Health Information Center. (Lesbian and bisexual health. From http://womenshealth.gov/f
aq/lesbian-health.cfm (accessed May 31, 2011); Dibble, S.L., Roberts, S.A., & Nussey, B. (2004). Comparing breast
cancer risk between lesbians and their heterosexual sisters. Women’s Health Issues, 14(2), 60–68.

Gay Men and Cancer
• Gay men are at an increased risk for several types of cancer—
including prostate, testicular, and colon cancers.
– Colorectal cancer tests by gay/bisexual African Americans were 12%–
14% lower than that of heterosexual African Americans
– Gay men have 1.9 greater odds of a cancer diagnosis compared with
heterosexual men

• Gay and bisexual men ~17x more likely to develop anal cancer than
heterosexual men.

• Men with weakened immune systems, including those who have HIV
– More likely than other men to develop anal cancer
– More likely to get severe cases of genital warts that are harder to treat

Cancer. 2011 Aug 15;117(16):3796-804. doi: 10.1002/cncr.25950. Epub 2011 May 9.Cancer survivorship and sexual
orientation; Boehmer U, Miao X, Ozonoff Asencio; Heslin, K.C., Gore, J.L., King, W.D., & Fox, S. (2008). Sexual
orientation and testing for prostate and colorectal cancers among men in California. Med Care, 46(12), 1240–1248;
CDC HPV and Men - Fact Sheet downloaded from www.cdc.gov/std/hpv/stdfact-hpv-and-men.htm

Heart Disease Disparities
• Factors that raise the risk for heart disease - including
physical inactivity, obesity, and smoking - are more
prevalent among lesbians than other women

• Tobacco use and alcohol use are prevalent among gay men

National Women’s Health Information Center. (n.d.) Lesbian and bisexual health. From http://womenshealth.gov/faq/
L esbian-health.cfm (accessed May 31, 2011); World Heart Federation. (2012). Cardiovascular disease risk factors.
From http://www.world-heart-federation.org/ cardiovascular-health/cardiovascular-disease-risk-factors/

Bisexuals and Heart Disease
• Bisexual women are more likely to report:
– Higher smoking rates than heterosexual women
– Higher blood pressure levels than heterosexual and lesbian women
– Higher body mass index (BMI) than heterosexual women
– Higher cholesterol levels than heterosexual and lesbian women
– Higher alcohol use than heterosexual women

• Some studies show that bisexual women are more likely to self-
report higher rates of heart disease than heterosexual women, but
still have lower rates than lesbians

Dobinson, C. (2007). Top ten bisexual health issues. As cited in Miller, M., André, A., Ebin, J., and Bessonova, L. (2007).
Bisexual health: An introduction and model practices for HIV/STI prevention programming. New York:
National Gay and Lesbian Task Force Policy Institute, the Fenway Institute at Fenway Community Health, and BiNet USA.

LGBT and Violence
• A significantly higher percentage of lesbian or gay adults
(56.4 percent) and bisexual adults (47.4 percent) report
experiencing intimate partner violence, as compared with
straight adults (17.5 percent)

• Lesbian women and gay men report experiencing harassment
or physical violence from family members due to their sexual
orientation

SAMSHA http://store.samhsa.gov/shin/content/SMA12-4684/SMA12-4684.pdf

LGB Youth and Violence

CDC 2003 Youth Risk Behavior Survey

Stigma, Discrimination, and
Health Care Access
• Discrimination shapes how
- LGBT persons interact with health system
- Health providers interact with LGBT community
- Health institutions address LGBT needs

System-Level Barriers to Health Care
• Institutional refusal to provide care
• Non-inclusive intake forms
– Gender ID
– Orientation relationship status
– Family structure

System-Level Barriers:
Health Insurance
• Percent of Adults with Health Insurance Coverage
-82% Heterosexual
-77% Lesbian, Gay, Bisexual
-57% Transgender
• Many insurance policies do not cover unmarried partners

• Policies do not include gender identity or gender expression

• ‘Gender doesn’t match diagnosis’
– Transwomen often not covered for prostate cancer screenings
– Transmen often not covered for cervical cancer screenings

System-Level Barriers:
Providers

• Provider / counselor assumption of
– Heterosexuality
– Traditional families
– Exclusion of partner/family of choice

• Provider ignorant of appropriate resources

Individual-Level Barriers to LGBT
Access to Care

• Prior negative experiences with providers/counselors

• Shame limiting openness

• Confidentiality concerns

HEALTHY CHICAGO
CHICAGO DEPARTMENT OF PUBLIC HEALTH

TRANSFORMING THE
HEALTH OF OUR CITY
CHICAGO ANSWERS THE CALL

Healthy Chicago’s Guiding Principles:
Health Equity
• Good health is based on multiple complex, inter-related
factors, e.g., social and environmental
• Improved public health requires a commitment to health
equity and the elimination of disparities

• Health improvement efforts require diverse partners

• A healthy city begins with a strong social fabric and sense of
community

HEALTHY CHICAGO

Limitations of Healthy Chicago
• Focus is on overall population

• Initial strategies are developed, but more work is needed

• Not all potential implementers are identified

LGBT Community Action Plan

• LGBT workgroup
o Community organizations, health care providers, researchers and
other stakeholders
o Convened in September, 2011

• Charged with developing roadmap to address the health
needs of Chicago’s LGBT community

• Considered strategies that aligned with Healthy Chicago
priorities

LGBT Community Action Plan

• Released March 2012

• Supplement to the Healthy
Chicago agenda

• 22 new strategies to address
LGBT needs
HEALTHY CHICAGO
LGBT COMMUNITY
ACTION PLAN
March 2012

In Progress: LGBT Action Plan Strategies
• Increase tobacco cessation efforts in the LGBT community

• Tobacco Prevention Project Partnership with Howard Brown
Health Center
• Bitch to Quit Cessation Program
• Media, social media campaigns
• Provider reminder system
• Ongoing research

• Include sexual orientation and gender identity indicators on
CDPH’s impending citywide community health survey
instruments to better identify health disparities

• Healthy Chicago Survey
– Population-based telephone survey
– Data will be used for assessing health-related needs in the City, for
program planning and policy development, and for program
evaluation
– Will collect sexual orientation and gender identity data

• Partner with LGBT community providers to identify and treat
persons with sexually transmitted infections
– 20 city-wide CBOs funded with a total of 42 programs to provide
services to Men to have Sex with Men (MSM), Prevention with
Positives, and other community-level interventions targeting LGBT

• Partner with LGBT-serving organizations to provide enhanced HIV
prevention, screening & treatment linkage services targeted to the
LGBT community
– Community mobilization and enhanced strategies to raise awareness,
increase testing, and improve linkage to care are making a difference
– Increased HIV testing, partner services

• Conduct HIV behavioral surveillance surveys on men who have sex
with men, and share findings
– Documenting full spectrum of HIV risk behavior through National HIV
Behavioral Surveillance System
– In the past year, CDPH conducted 140 research field visits and over
500 interviews

• Maintain community task force on LGBT substance abuse
issues
– Task Force web site up at www.chicagoLGBTsubstance.com
– 65 members from over 30 organizations

Looking Forward: Office of LGBT Health

• Hiring an Office of LGBT Health Director
• Establishing an LGBT Health Advisory Council
– Create an ongoing forum for input
– Expand capacity and expertise guiding CDPH work
– Application process to be announced on-line

Looking Forward:
LGBT Action Plan Strategies
• Promote collection of sexual orientation data in electronic
medical records prior to the ACA 2014 mandate and
encourage collection of gender identity data

• Work with the Chicago Commission on Human Relations and
the Chicago Police Department to improve transgender hate
crime tracking (Violence Prevention)

Looking Forward:
• Support LGBT organizations in the adoption of policies that
increase access to healthy foods, encourage physical activity,
and limit tobacco use

• Deliver targeted, culturally competent obesity risk and
preventive behavioral interventions to lesbians and bisexual
women

Looking Forward:

• Promote the adoption of breastfeeding among lesbian
mothers

• Provide education to parents on supporting healthy
environments for children with alternative sexual orientation
or gender expression

Looking Forward:
• Empower the LGBT community to address violence by publicizing
resources for reporting violence, holding seminars on strategies to
avoid violent situations, and informing community members of
sources of victim assistance

• Conduct bullying training for school staff and faculty with a focus
on how LGBT students are disproportionately impacted and on
appropriate interventions in schools to end bullying

Looking Forward:
• Convene researchers who focus on LGBT health to share
findings, inform service delivery, and prompt new LGBT
health research

• Dedicate resources to incorporate LGBT health into planning,
outreach, and public information activities

Looking Forward:
• Provide educational information to housing managers, apartment
landlords, and employers about living and working with persons
who are HIV positive

• Promote participation in LGBT health electives for Chicago area
medical students

• Develop and implement a strategy to provide cultural competency
training about the LGBT community to health care providers and
institutions

Looking Forward:
• Advocate for increased State funding to include support of
LGBT persons suffering from anxiety, suicidal ideation, or
other conditions

• Promote the inclusion of same-sex couples in programs
aimed at healthy pregnancies, childbirth, and early childhood
health

Call to Action
• Healthy Chicago & LGBT Action Plan address big issues requiring
efforts from many facets of the community

• More research is needed to
– Uncover disparities
– Identify vectors and co-morbidities
– Find solutions
– Analyze health outcomes by sexual orientation and gender identity

• More advocacy is needed to secure resources and promote social
justice

Final Charge
• Too often, continuing disparities lead to a perception that a
population is its pathology

• It is imperative that not happen

• Research must also look to the LGBT community’s successful
coping mechanisms

• Research must also look to the LGBT community’s strengths

Ongoing Research:
HIV Surveillance Report Release Today
• 1:30 pm immediately following conference luncheon

• Highlights trends in risk and prevention behaviors among gay
men in Chicago

• Many hopeful signs among the findings:
– HIV testing and prevention interventions
– Being aware of one’s infection
– HIV treatment

facebook.com/ChicagoPublicHealth

Gplus.to/ChiPublicHealth

@ChiPublicHealth

312.747.9884

CityofChicago.org/Health

HealthyChicago@CityofChicago.org

Chicago LGBTQ Disparities: Working toward Health Equity

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