Racial and LGBT Health Inequities in Louisiana
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Racial and LGBT Health Inequities - Kathleen Welch
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Racial and LGBT Health Inequities in Louisiana
- 1. Racial and LGBT Health Inequities Louisiana Office of Public Health STD-HIV/AIDS Program Kathleen Welch
- 2. 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
- 3. 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
- 4. 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.
- 5. 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.
- 6. 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.
- 7. Racial Inequities in Louisiana Whites Blacks Hispanics Poverty Rate 17% 45% 40% Males/No High School Diploma 2.5% 17.7% 11.8% Incarceration Rate 4.25 1657.5 745.3 Life Expectancy 76.5 72.1 78.6 Death Rate 832.8 1057.4 384.9 Infant Mortality Rate 6.6 13.9 3.9 Heart Disease Death Rate 211.4 262.4 99.4 Cancer Death Rate 189.9 239.5 87.8 Cerebrovascular Death Rate 40.8 61.3 NSD Diabetes Death Rate 21.6 46.1 NSD Breast Cancer Death Rate 22.0 35.3 NSD Firearms Death Rate 13.2 26.8 NSD Adult Overweight/Obesity Rate 64.7% 74.3% 72.3% Uninsured for Nonelderly 18% 30% 51% Kaiser Family Foundation.(2012). State Health Facts. Retrieved from http://www.statehealthfacts.org/index.jsp
- 8. 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 Louisiana’s 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
- 9. 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.
- 10. 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
- 11. 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
- 12. 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.
- 13. 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
- 15. LGBT Health Data Collection
- 16. LGBT Health Data Collection
- 17. 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
- 18. 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
- 19. 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
- 20. HIV/AIDS in the LGBT Community: Louisiana Men and Women Men Only
- 21. 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
- 22. 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
- 23. 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
- 24. 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
- 25. 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
- 26. 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
- 27. 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
- 28. Issues for Adolescents Most Important Problems Identified by Non-LGBT Youth 1. Class/exams/grades (25%) 2. College/career (14%) 3. Financial pressures related to college or job (11%) Most Important Problems Identified by LGBT Youth 1. Non-accepting families (26%) 2. School bullying problems (21%) 3. Fear of being out or open (18%) Human Rights Campaign, “Growing Up LGBT in America: HRC Youth Survey Report Key Findings,” HRC, June 2012.
- 29. 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
- 30. Health Issues for Women
- 31. 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
- 32. 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
- 33. 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
- 34. Health Issues for Transgender Persons
- 35. Intersection of Racial and LGBT Inequities Inequities are compounded for racial minorities in the LGBT community Possible cultural aspects impact family support
- 36. 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.
- 37. 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
- 38. 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
Notas do Editor
- 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.
- 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 cancer—the two leading causes of death in the United States—indicate 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).
- 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 US—in regards to HIV prevention and treatment
- 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 ends—marker for longevity and cellular health “Nurture’s 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.
- Disparity in clinical care persists among older LGBT adults age 65 and above, despite universal availability of similar care through Medicare
- Important for providing a safe space for disclosing one’s sexual orientation and gender identity. Also important for reducing personal biases and providing equal level of care and treatment.
- 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: o Classroom romances, first date, first kiss, Senior Prom o No role models or relationship models to identify with o Lack 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.
- 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 aren’t exclusive to lesbians, but the possible concentration of risks within a single group is unique Individuals don’t 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
- 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 Kaposi’s sarcoma Non-Hodgkin’s lymphoma Anal cancer Hodgkin’s 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
- 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.