EDUCATION/RESIDENTS’ PERSPECTIVE
Improving Care for Lesbian, Gay, Bisexual, and Transgender Patients in the Emergency Department Sara Jalali, MD*; Lauren M. Sauer, MS *Corresponding Author. E-mail: [email protected].
0196-0644/$-see front matter Copyright © 2015 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2015.02.004
A podcast for this article is available at www.annemergmed.com.
[Ann Emerg Med. 2015;66:417-423.] INTRODUCTION Providing quality care in the emergency department (ED) has become more challenging as the patient census becomes increasingly diverse.1 Studies have shown that marginalized populations face greater social inequalities and health disparities, placing them at higher risk for disease burden and death.2 The lesbian, gay, bisexual, and transgender (LGBT) community is no exception. An estimated 9 million people in the United States identify themselves as LGBT.3 Although the abbreviation “LGBT” serves as a commonly accepted inclusive term, there is significant diversity of sexuality and gender identity within this community. Figure 1 outlines the commonly used LGBT terms, but these are not meant to define a person’s sexual practices or orientation.4,5 Despite what popular stereotypes tell us, one’s sexual orientation or gender identity is not always evident, and patients often hide this information from providers for fear of discrimination.5,6 Medical education has proven to be effective in improving providers’ comfort level, attitude, and communication for the care of LGBT patients.7-9 However, without standards for LGBT health education, providers are often poorly prepared to care for this at-risk population, resulting in patients’ distrust and avoidance in seeking prompt medical care.5 Until recently, there have been no educational guidelines that teach providers how to effectively care for LGBT patients. The ED is a place where all people should feel safe seeking medical care, so having a better understanding of the disparities and health care risks the LGBT patients face may help emergency providers communicate more effectively with these at-risk patients. TYRA’S STORY Tyra Hunter was a male-to-female transgender person who had lived as a woman since her early teens. Volume 66, no. 4 : October 2015
In 1995, Ms. Hunter was critically injured in a motor vehicle crash in Washington, DC. Emergency medical technicians (EMTs) arrived on the scene and began resuscitative efforts. As they cut off her clothes to assess injuries, the EMTs discovered that Ms. Hunter was biologically male. Instead of continuing to resuscitate her, the EMTs ridiculed Ms. Hunter. Her care was similarly inadequate on her arrival to DC General Hospital, and subsequently, Ms. Hunter died. Because of transphobia, preconceived judgments, and a lack of understanding about who she was, the first responders failed to treat Ms. Hunter as a human needing basic lifesaving measures. In 1998, a jury found the District of Columbia, including both the out-of-hospital providers and the hospital itself, liable for Ms. Hunter’s death and awarded her mother $2.9 million.10,11 LEGAL ISSUES At the state level, laws pertaining to LGBT health care rights are complex and variable. Recent antidiscrimination laws have improved the protection of LGBT medical personnel and staff in the workplace. Recent changes to same-sex marital rights affect insurance coverage, family leave, or legal matters related to next-of-kin or medical decisionmaking for spouses and children.12-14 However, many of these laws apply only in the states that recognize same-sex marriage, leaving a large portion of the US population without these legal protections. At the hospital level, although an increasing number of facilities are incorporating LGBT-inclusive nondiscriminatory policies, many hospitals still do not have explicit regulations in place.15 To provide the best care for LGBT patients, emergency providers should be informed about their state’s laws and hospital policies. In 2010, the Department of Health and Human Services issued a regulation to protect the rights of visitation by allowing patients to choose their own visitors at facilities that participate in Medicare and Medicaid. In the event Annals of Emergency Medicine 417
Improving Care for LGBT Patients in the Emergency Department
Jalali & Sauer
Figure 1. Commonly used LGBT terms.4,5 LGBT, Lesbian, gay, bisexual, and transgender; FTM, female-to-male; MTF, male-tofemale.
of incapacitation of an LGBT patient, family, friends, or significant others may still be allowed to visit without having to provide legal documentation.16 In the case of unmarried couples, or in states in which same-sex marriage, domestic partnership, or civil union is not legal, LGBT people may prepare advance directives to designate a health care proxy to make medical decisions. Because there are still reports of LGBT people being denied their appropriate legal rights to visitations and medical decisions, it is important for emergency providers to understand these regulations so that patients are not deprived of support from their loved ones.17 An estimated 6 million children are raised by LGBT parents in the United States.18 As such, emergency providers should understand the legal complexities surrounding LGBT parents seeking emergency care for their children. Adoption laws can present complications for same-sex couples in which only 1 parent has legal parenting rights. This may be the case for unmarried couples, married couples in states that do not recognize same-sex marriage, or in states that do not allow a 418 Annals of Emergency Medicine
second parent of the same-sex couple to legally adopt the child. The lack of nationwide laws to protect the parent-child relationship in LGBT families puts their children at risk for discrimination, inadequate health insurance, and variable consent, visitation, and medical decisionmaking.19 HEALTH CARE CONSIDERATIONS FOR LGBT PATIENTS Effects of General LGBT Marginalization and Discrimination Social stigma, discrimination, and homo- and transphobia against LGBT people negatively affect their quality of life by affecting their employment, income, access to health insurance, and health behavioral choices.20 Figure 2 summarizes the specific health care risks faced by LGBT patients. Furthermore, it highlights the potential effect of understanding and screening for these risk factors in this particularly vulnerable and diverse population. Volume 66, no. 4 : October 2015
Jalali & Sauer
Improving Care for LGBT Patients in the Emergency Department
Figure 2. Specific health care risks faced by LGBT patients.
Effects of Marginalization in the Health Care System Economic barriers to care. As with other minorities, LGBT patients are more likely to face barriers to accessing medical care.21 This could be due to geography, lack of provider education, or insurance barriers.21,22 The transgender population is particularly at risk for being Volume 66, no. 4 : October 2015
denied health insurance or claim coverage,21,23 making access to or payment for medical care challenging.24 The Patient Protection and Affordable Care Act allows all people to obtain health insurance and covers the bulk of preventive and emergency care, but many states still deny coverage for transgender patients who seek services related Annals of Emergency Medicine 419
Improving Care for LGBT Patients in the Emergency Department
to sex change, such as gender-affirming hormone therapy or surgery.25 Furthermore, the act does not change biases among health care providers or ensure the quality of care. Barriers because of discrimination. When LGBT patients do seek medical care, they are often dissatisfied with the care they receive.26,27 Marginalized groups may have a heightened sense of awareness of discriminatory behavior displayed by providers, even when the providers’ intentions are positive. Simple actions, such as poor eye contact, infrequent follow-up care, or awkward body language, may be easily interpreted as provider discomfort or discrimination.28 LGBT patients have reported lack of provider education as one of the barriers to accessing medical care; many report mistreatment, verbal abuse, and refusal of care by providers.29 Transgender patients have reported overt experiences with discrimination, including gender insensitivity, displays of discomfort, denial of services, substandard care, verbal and physical abuse, and forced placement into psychiatric facilities.30 Reported negative experiences also include insensitivity to medical
Figure 3. Tips for EDs to improve the care of LGBT patients.
420 Annals of Emergency Medicine
Jalali & Sauer
Figure 4. Tips for more effective communication with LGBT patients.
complaint, fixation and assumption about gender identity, improper use of gender pronoun, and inadequate provider education.31 A recent study in Ontario found that half of transgender ED users who presented in their preferred gender reported negative experiences, mostly related to offensive language or being told the provider was unable to provide care because of lack of knowledge; more than half of the transgender ED users had to educate their provider about transgender issues. The study also showed that 21% of respondents avoided the ED because of these negative experiences.5 An article by Bonvicini and Perlin32 described 5 common assumptions by providers about gay and lesbian patients that create barriers to effective communication and care. These include assumptions about a patient’s sexual orientation, sexual behaviors, family structure, role of significant others and family in his or her health care, and the effect on messages sent through the health care practice. Awareness of these assumptions, knowledge of health care barriers, and evaluation of one’s own biases will allow emergency providers to positively change the care and outcome of the LGBT population. Figure 3 provides recommendations for the health care setting to facilitate LGBT care in the ED. Figures 4 and 5 offer tips for effective communication with LGBT patients. CURRENT EDUCATIONAL PRACTICES Medical School Education The incorporation of LGBT health care education into standard medical curricula is often insufficient. The Journal of the American Medical Association published a Stanford study that surveyed deans of medical schools across the Volume 66, no. 4 : October 2015
Jalali & Sauer
Improving Care for LGBT Patients in the Emergency Department
Recognizing the need for change within medical education, the Association of American Medical Colleges recently published a comprehensive guide to address the needs of LGBT education in the health care system.4 Available online as a free download (http://offers.aamc.org/ lgbt-dsdhealth), this landmark publication serves to provide education about the health needs of LGBT people, offer guidance for medical schools to integrate this material into their curriculum, and assess competency in learners to determine effectiveness of change. As more institutions adopt these changes, new physicians entering residencies across multiple disciplines will be better prepared to treat LGBT patients.
Figure 5. Tips for more effective communication with transgender patients.
United States and Canada. It found that medical school curricula provided a median of 5 hours of education on LGBT issues; one third reported zero hours of education in the clinical years, and 6.8% reported zero hours in the preclinical years. Overall, approximately 4% of programs provided zero hours combined. This study showed that although most schools taught students to ask sensitive social history questions, many did not teach them the differences between behavior and sexual identity.33 There was also no educational standard for teaching students how to incorporate reported sexual history with the other aspects of the patient’s evaluation, such as sensitivity during physical examination. Several other educational studies have shown that incorporating LGBT education in medical school curricula by providing educational sessions or standardized patient encounters positively affected the level of knowledge, comfort, history taking, impression of the population, and overall understanding of LGBT health care barriers. Students have also acknowledged the relevance and need for incorporating LGBT education into their curriculum.9
Emergency Medicine Residency Education The Accreditation Council for Graduate Medical Education does not currently include LGBT-related education in the emergency medicine curriculum, but sensitivity to gender and sexual orientation are briefly mentioned in program requirements.34 There is a paucity of residency-related literature on this topic. A recent survey found that only approximately a quarter of emergency medicine residencies included LGBT-specific lectures, and approximately a third incorporated LGBT health in their curriculum; the mean lecture time was 45 minutes and the median was zero minutes. The study demonstrated the infrequent integration of LGBT-related education in emergency medicine residencies but showed that program directors wanted to integrate more of this education into their curricula.29 Emergency medicine residencies would benefit from having access to LGBT health care educational resources. The material can be presented as single lectures dedicated to LGBT health in the ED or tied into various emergency medicine–relevant topics for more longitudinal education. Programs could also consider inviting expert speakers for additional didactics. Table 1 highlights some LGBT educational resources for medical students and residents that may be helpful for anyone interested in this topic. Last,
Table 1. Resources for LGBT health care education. Title AAMC: Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born With DSD AAMC MedEdPORTAL: Lesbian, Gay, Bisexual, Transgender (LGBT), and Differences of Sex Development (DSD) Patient Care Collection ACGME LGBT Health Resource Guide Fenway Institute’s National LGBT Health Education Center UCSF Center of Excellence for Transgender Health UCSF LGBT Resource Center
Citation/URL Register and download at: http://offers.aamc.org/lgbt-dsd-health
https://www.mededportal.org/about/initiatives/lgbt/ http://bit.ly/1vphUsW http://www.lgbthealtheducation.org/ http://transhealth.ucsf.edu/ http://lgbt.ucsf.edu
AAMC, Association of American Medical Colleges; ACGME, Accreditation Council for Graduate Medical Education; UCSF, University of California, San Francisco.
Volume 66, no. 4 : October 2015
Annals of Emergency Medicine 421
Improving Care for LGBT Patients in the Emergency Department
residency programs may consider adopting standardized methods for evaluating the effect of this education, potentially through the Accreditation Council for Graduate Medical Education Milestones as related to compassion, integrity, respect, and ethical principles.35 CONCLUSION Some may argue that there is no need for special training and education of LGBT patient care because, as emergency providers, we are expected to treat every patient without judgment or discrimination. However, the lack of education and exposure leaves many providers poorly prepared to establish effective communication with their LGBT patients regardless of intent. Tyra Hunter’s death was almost 20 years ago, but many LGBT patients continue to face barriers to accessing adequate medical care. Understanding that LGBT people exist within every community and that many pass through medical facilities each day, often unidentified, is important to help providers assume a person’s sexual orientation or gender identity less often. We hope that with enhanced advocacy and effective educational curricular reforms, emergency providers will have the appropriate skills and empathy to assist LGBT patients whenever they seek medical care, preventing events such as Tyra Hunter’s death. Supervising editors: Cindy H. Hsu, MD, PhD; Donald M. Yealy, MD Author affiliations: From the Johns Hopkins School of Medicine, Department of Emergency Medicine, Baltimore, MD (Jalali, Sauer); and the Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD (Sauer). Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.
REFERENCES 1. Padela AI, Punekar IR. Emergency medical practice: advancing cultural competence and reducing health care disparities. Acad Emerg Med. 2009;16:69-75. 2. Varga LM, Surratt HL. Predicting health care utilization in marginalized populations: black, female, street-based sex workers. Womens Health Issues. 2014;24:e335-e343. 3. Gates G. How many people are lesbian, gay, bisexual, and transgender? Williams Institute. April 2011. Available at: http://williamsinstitute.law. ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011. pdf. Accessed February 20, 2015. 4. Association of American Medical Colleges (AAMC) Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development. Implementing curricular and institutional climate changes to improve health care for individuals who are LGBT, gender nonconforming, or born with DSD. A resource for medical educators. 2014. Available at: http://offers.aamc.org/lgbt-dsd-health. Accessed December 2, 2014.
422 Annals of Emergency Medicine
Jalali & Sauer 5. Bauer GR, Scheim AI, Deutsch MB, et al. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Ann Emerg Med. 2014;63:713-720. 6. Shaffer N. Transgender patients: implications for emergency department policy and practice. J Emerg Nurs. 2005;31:405-407. 7. Kelley L, Chou CL, Dibble SL, et al. A critical intervention in lesbian, gay, bisexual, and transgender health: knowledge and attitude outcomes among second-year medical students. Teach Learn Med. 2008;20: 248-253. 8. Sanchez NF, Rabatin J, Sanchez JP, et al. Medical students’ ability to care for lesbian, gay, bisexual, and transgendered patients. Fam Med. 2006;38:21-27. 9. Sequeira GM, Chakraborti C, Panunti BA. Integrating lesbian, gay, bisexual, and transgender (LGBT) content into undergraduate medical school curricula: a qualitative study. Ochsner J. 2012;12:379-382. 10. Klein A. Victims slain for nonconformity, report says. Washington Post. Published on December 12, 2006. Available at: http://www. washingtonpost.com/wp-dyn/content/article/2006/12/14/ AR2006121401917.html. Accessed June 30, 2014. 11. Rosendall R. Victory in Tyra Hunter case: statement by GLAA president. December 11, 2008. Available at: http://www.glaa.org/archive/1998/ margiehunter1211.shtml. Accessed June 30, 2014. 12. Gonzales G, Blewett LA. National and state-specific health insurance disparities for adults in same-sex relationships. Am J Public Health. 2014;104:e95-e104. 13. Marriage rights and benefits. NOLO Legal Services. Available at: http://www.nolo.com/legal-encyclopedia/marriage-rights-benefits30190.html. Accessed June 30, 2014. 14. Wolfson E. Why Marriage Matters. New York, NY: Simon & Schuster; 2004; appendix B. Available at: http://www.freedomtomarry.org/ pages/from-why-marriage-matters-appendix-b-by-evan-wolfson. Accessed February 20, 2015. 15. Hanneman T. Healthcare equality index 2014. Human Rights Campaign. 2014. Available at: http://www.hrc.org/hei/about-the-hei#. U-J9to2wJSk. Accessed October 27, 2014. 16. Centers for Medicare & Medicaid Services. Revised appendix A, interpretive guidelines for hospitals, and appendix W, interpretive guidelines for critical access hospitals (CAHs); December 2, 2011. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/ Transmittals/downloads/R75SOMA.pdf. Accessed October 27, 2014. 17. Riou G. Hospital Visitation and Medical Decision Making for Same-Sex Couples. Washington, DC: Center for American Progress; 2014. Available at: http://www.americanprogress.org/issues/lgbt/news/2014/ 04/15/88015/hospital-visitation-and-medical-decision-making-for-samesex-couples/. Accessed October 27, 2014. 18. Gates G. LGBT Parenting in the United States. Williams Institute; 2013. Available at: http://williamsinstitute.law.ucla.edu/research/ census-lgbt-demographics-studies/lgbt-parenting-in-the-unitedstates/. Accessed October 27, 2014. 19. Securing Legal Ties for Children Living in LGBT Families: A State Strategy and Policy Guide. Movement Advancement Project, Family Equality Council, and Center for American Progress; 2012. Available at: http://www.lgbtmap.org/file/securing-legal-ties.pdf. Accessed October 27, 2014. 20. Centers for Disease Control and Prevention. Stigma and discrimination. Available at: http://www.cdc.gov/msmhealth/stigma-and-discrimination. htm. Accessed October 27, 2014. 21. McKay B. Lesbian, gay, bisexual, and transgender health issues, disparities, and information resources. Med Ref Serv Q. 2011;30: 393-401. 22. Centers for Disease Control and Prevention (CDC). Lesbian, gay, bisexual and transgender health. Available at: http://www.cdc.gov/ lgbthealth/about.htm. Accessed June 30, 2014. 23. Cray A, Baker K. FAQ: health insurance needs for transgender Americans. Center for American Progress. October 2012. Available at:
Volume 66, no. 4 : October 2015
Jalali & Sauer
24.
25. 26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
http://cdn.americanprogress.org/wp-content/uploads/2012/10/ TransgenderHealth.pdf. Accessed June 30, 2014. Cruz TM. Assessing access to care for transgender and gender nonconforming people: a consideration of diversity in combating discrimination. Soc Sci Med. 2014;110:65-73. Out2Enroll. Sellers Dorsey Foundation. Available at: http://www. out2enroll.org. Accessed June 30, 2014. Bjorkman M, Malterud K. Lesbian women’s experiences with health care: a qualitative study. Scand J Prim Health Care. 2009;27: 238-243. Henkel G. Health issues to consider among transgender patients. ACEPNow. 2014. Available at: www.acepnow/com/article/respectfulcommunication-key-reducing-barriers-care-transgender-patients-ed/. Accessed February 20, 2015. Rintamaki L, Scott A, Kosenko K, et al. Male patient perceptions of HIV stigma in health care contexts. AIDS Patient Care STDS. 2007;21: 956-969. Moll J, Krieger P, Moreno-Walton L, et al. The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: what do we know? Acad Emerg Med. 2014;21:608-611. Kosenko K, Rintamaki L, Raney S, et al. Transgender patient perceptions of stigma in health care contexts. Med Care. 2013;51:819-822. Brown JF, Fu J. Emergency department avoidance by transgender persons: another broken thread in the “safety net” of emergency medicine care. Ann Emerg Med. 2014;63:721-722. Bonvicini KA, Perlin MJ. The same but different: clinician-patient communication with gay and lesbian patients. Patient Educ Couns. 2003;51:115-122. Obedin-Maliver J, Goldsmith ES, Steward L, et al. Lesbian, gay, bisexual, and transgender–related content in undergraduate medical education. JAMA. 2011;306:971-977. Accreditation Council for Graduate Medical Education (ACGME) program requirements for graduate education in emergency medicine. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ 2013-PR-FAQ-PIF/110_emergency_medicine_07012013.pdf. Accessed February 20, 2015. ACGME: the Emergency Medicine Milestones Project. Available at: http://acgme.org/acgmeweb/Portals/0/PDFs/Milestones/ EmergencyMedicineMilestones.pdf. Accessed February 20, 2015. Blosnich JR, Farmer GW, Lee JG, et al. Health inequalities among sexual minority adults: evidence from ten US states, 2010. Am J Prev Med. 2014;46:337-349. King M, Semlyen J, Tai SS, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay, and bisexual people. BCM Psychiatry. 2008;8:70. Landers S, Gilsanz P. The Health of Lesbian, Gay, Bisexual, and Transgender (LGBT) Persons in Massachusetts. Massachusetts Department of Public Health; 2009. Available at: http://www.mass. gov/eohhs/docs/dph/commissioner/lgbt-health-report.pdf. Accessed February 20, 2015. Tjaden P, Thoennes N. Extent, Nature, and Consequences of Intimate Partner Violence: Findings From the National Violence Against Women
Volume 66, no. 4 : October 2015
Improving Care for LGBT Patients in the Emergency Department
40.
41.
42. 43.
44.
45.
46. 47.
48.
49.
50. 51. 52.
53.
54.
55.
56.
Survey. Washington, DC: US Dept of Justice, National Institute of Justice; 2000:29-31. Report NCJ 181867. Available at: https://www. ncjrs.gov/pdffiles1/nij/181867.pdf. Accessed June 30, 2014. Rothman EF, Exner D, Baughman AL. The prevalence of sexual assault against people who identify as gay, lesbian, or bisexual in the United States: a systematic review. Trauma Violence Abuse. 2011;12:55-66. Federal Bureau of Investigation (FBI). Hate crime statistics: incidents and offenses. Available at: http://www.fbi.gov/about-us/cjis/ucr/hate-crime/ 2011/narratives/incidents-and-offenses. Accessed June 30, 2014. Bailey JV, Farquhar C, Owen C, et al. Sexually transmitted infections in women who have sex with women. Sex Transm Infect. 2004;80:244-246. GLMA: Health Professionals Advancing LGBT Equality. Ten things gay men should discuss with their healthcare provider. Available at: http:// glma.org/index.cfm?fuseaction¼Page.viewPage&pageID¼690. Accessed June 30, 2014. Mercer CH, Bailey JV, Johnson AM, et al. Women who report having sex with women: British national probability data on prevalence, sexual behaviors, and health outcomes. Am J Public Health. 2007;97:1126-1133. Feldman JL, Goldberg J. Transgender Primary Medical Care: Suggested Guidelines for Clinicians in British Columbia. Vancouver, BC: Vancouver Coastal Health, Transgender Health Program; 2006. Spack NP. Management of transgenderism. JAMA. 2013;309:478-484. Silenzio VMB, Pena JB, Duberstein PR, et al. Sexual orientation and risk factors for suicidal ideation and suicide attempts among adolescents and young adults. Am J Public Health. 2007;97: 2017-2019. Garofalo R, Wolf RC, Wissow LS, et al. Sexual orientation and risk of suicide attempts among a representative sample of youth. Arch Pediatr Adolesc Med. 1999;153:487-493. Kosciw JG, Greytak EA, Bartkiewicz MJ, et al. The 2011 National School Climate Survey: The Experiences of Lesbian, Gay, Bisexual and Transgender Youth in Our Nation’s Schools. New York, NY: Gay, Lesbian Straight Education Network; 2012. Kruks G. Gay and lesbian homeless/street youth: special issues and concerns. J Adolesc Health. 1991;12:515-518. Fenway Health. Available at: http://www.fenwayhealth.org. Accessed June 30, 2014. Center for American Progress. Available at: https://www.american progress.org/issues/lgbt/news/2013/06/21/67411/lgbt-inclusivesex-education-means-healthier-youth-and-safer-schools/. Accessed December 2, 2014. Marshal MP, Friedman MS, Stall R. Sexual orientation and adolescent substance use: a meta-analysis and methodological review. Addiction. 2008;203:546-556. AARP: Movement Advancement Project. (2010.) Improving the lives of LGBT older adults. Available at: http://www.lgbtmap.org/file/ improving-the-lives-of-lgbt-older-adults.pdf. Accessed June 30, 2014. Aging and health report—health equity and LGBT elders of color, Services & Advocacy for GLBT Elders (SAGE). Available at: http://issuu. com/lgbtagingcenter/docs/full-report-final-11-16-11. Accessed June 30, 2014. MetLife–MetLife Mature Market Institute. (2010.) Still out, still aging. Westport, CT. Available at: http://www.plumlivinghealth.com/images/ mmi-still-out-still-aging.pdf. Accessed February 20, 2015.
Annals of Emergency Medicine 423
Improving Care for Lesbian, Gay, Bisexual, and Transgender Patients in the Emergency Department Sara Jalali, MD*; Lauren M. Sauer, MS *Corresponding Author. E-mail: [email protected].
0196-0644/$-see front matter Copyright © 2015 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2015.02.004
A podcast for this article is available at www.annemergmed.com.
[Ann Emerg Med. 2015;66:417-423.] INTRODUCTION Providing quality care in the emergency department (ED) has become more challenging as the patient census becomes increasingly diverse.1 Studies have shown that marginalized populations face greater social inequalities and health disparities, placing them at higher risk for disease burden and death.2 The lesbian, gay, bisexual, and transgender (LGBT) community is no exception. An estimated 9 million people in the United States identify themselves as LGBT.3 Although the abbreviation “LGBT” serves as a commonly accepted inclusive term, there is significant diversity of sexuality and gender identity within this community. Figure 1 outlines the commonly used LGBT terms, but these are not meant to define a person’s sexual practices or orientation.4,5 Despite what popular stereotypes tell us, one’s sexual orientation or gender identity is not always evident, and patients often hide this information from providers for fear of discrimination.5,6 Medical education has proven to be effective in improving providers’ comfort level, attitude, and communication for the care of LGBT patients.7-9 However, without standards for LGBT health education, providers are often poorly prepared to care for this at-risk population, resulting in patients’ distrust and avoidance in seeking prompt medical care.5 Until recently, there have been no educational guidelines that teach providers how to effectively care for LGBT patients. The ED is a place where all people should feel safe seeking medical care, so having a better understanding of the disparities and health care risks the LGBT patients face may help emergency providers communicate more effectively with these at-risk patients. TYRA’S STORY Tyra Hunter was a male-to-female transgender person who had lived as a woman since her early teens. Volume 66, no. 4 : October 2015
In 1995, Ms. Hunter was critically injured in a motor vehicle crash in Washington, DC. Emergency medical technicians (EMTs) arrived on the scene and began resuscitative efforts. As they cut off her clothes to assess injuries, the EMTs discovered that Ms. Hunter was biologically male. Instead of continuing to resuscitate her, the EMTs ridiculed Ms. Hunter. Her care was similarly inadequate on her arrival to DC General Hospital, and subsequently, Ms. Hunter died. Because of transphobia, preconceived judgments, and a lack of understanding about who she was, the first responders failed to treat Ms. Hunter as a human needing basic lifesaving measures. In 1998, a jury found the District of Columbia, including both the out-of-hospital providers and the hospital itself, liable for Ms. Hunter’s death and awarded her mother $2.9 million.10,11 LEGAL ISSUES At the state level, laws pertaining to LGBT health care rights are complex and variable. Recent antidiscrimination laws have improved the protection of LGBT medical personnel and staff in the workplace. Recent changes to same-sex marital rights affect insurance coverage, family leave, or legal matters related to next-of-kin or medical decisionmaking for spouses and children.12-14 However, many of these laws apply only in the states that recognize same-sex marriage, leaving a large portion of the US population without these legal protections. At the hospital level, although an increasing number of facilities are incorporating LGBT-inclusive nondiscriminatory policies, many hospitals still do not have explicit regulations in place.15 To provide the best care for LGBT patients, emergency providers should be informed about their state’s laws and hospital policies. In 2010, the Department of Health and Human Services issued a regulation to protect the rights of visitation by allowing patients to choose their own visitors at facilities that participate in Medicare and Medicaid. In the event Annals of Emergency Medicine 417
Improving Care for LGBT Patients in the Emergency Department
Jalali & Sauer
Figure 1. Commonly used LGBT terms.4,5 LGBT, Lesbian, gay, bisexual, and transgender; FTM, female-to-male; MTF, male-tofemale.
of incapacitation of an LGBT patient, family, friends, or significant others may still be allowed to visit without having to provide legal documentation.16 In the case of unmarried couples, or in states in which same-sex marriage, domestic partnership, or civil union is not legal, LGBT people may prepare advance directives to designate a health care proxy to make medical decisions. Because there are still reports of LGBT people being denied their appropriate legal rights to visitations and medical decisions, it is important for emergency providers to understand these regulations so that patients are not deprived of support from their loved ones.17 An estimated 6 million children are raised by LGBT parents in the United States.18 As such, emergency providers should understand the legal complexities surrounding LGBT parents seeking emergency care for their children. Adoption laws can present complications for same-sex couples in which only 1 parent has legal parenting rights. This may be the case for unmarried couples, married couples in states that do not recognize same-sex marriage, or in states that do not allow a 418 Annals of Emergency Medicine
second parent of the same-sex couple to legally adopt the child. The lack of nationwide laws to protect the parent-child relationship in LGBT families puts their children at risk for discrimination, inadequate health insurance, and variable consent, visitation, and medical decisionmaking.19 HEALTH CARE CONSIDERATIONS FOR LGBT PATIENTS Effects of General LGBT Marginalization and Discrimination Social stigma, discrimination, and homo- and transphobia against LGBT people negatively affect their quality of life by affecting their employment, income, access to health insurance, and health behavioral choices.20 Figure 2 summarizes the specific health care risks faced by LGBT patients. Furthermore, it highlights the potential effect of understanding and screening for these risk factors in this particularly vulnerable and diverse population. Volume 66, no. 4 : October 2015
Jalali & Sauer
Improving Care for LGBT Patients in the Emergency Department
Figure 2. Specific health care risks faced by LGBT patients.
Effects of Marginalization in the Health Care System Economic barriers to care. As with other minorities, LGBT patients are more likely to face barriers to accessing medical care.21 This could be due to geography, lack of provider education, or insurance barriers.21,22 The transgender population is particularly at risk for being Volume 66, no. 4 : October 2015
denied health insurance or claim coverage,21,23 making access to or payment for medical care challenging.24 The Patient Protection and Affordable Care Act allows all people to obtain health insurance and covers the bulk of preventive and emergency care, but many states still deny coverage for transgender patients who seek services related Annals of Emergency Medicine 419
Improving Care for LGBT Patients in the Emergency Department
to sex change, such as gender-affirming hormone therapy or surgery.25 Furthermore, the act does not change biases among health care providers or ensure the quality of care. Barriers because of discrimination. When LGBT patients do seek medical care, they are often dissatisfied with the care they receive.26,27 Marginalized groups may have a heightened sense of awareness of discriminatory behavior displayed by providers, even when the providers’ intentions are positive. Simple actions, such as poor eye contact, infrequent follow-up care, or awkward body language, may be easily interpreted as provider discomfort or discrimination.28 LGBT patients have reported lack of provider education as one of the barriers to accessing medical care; many report mistreatment, verbal abuse, and refusal of care by providers.29 Transgender patients have reported overt experiences with discrimination, including gender insensitivity, displays of discomfort, denial of services, substandard care, verbal and physical abuse, and forced placement into psychiatric facilities.30 Reported negative experiences also include insensitivity to medical
Figure 3. Tips for EDs to improve the care of LGBT patients.
420 Annals of Emergency Medicine
Jalali & Sauer
Figure 4. Tips for more effective communication with LGBT patients.
complaint, fixation and assumption about gender identity, improper use of gender pronoun, and inadequate provider education.31 A recent study in Ontario found that half of transgender ED users who presented in their preferred gender reported negative experiences, mostly related to offensive language or being told the provider was unable to provide care because of lack of knowledge; more than half of the transgender ED users had to educate their provider about transgender issues. The study also showed that 21% of respondents avoided the ED because of these negative experiences.5 An article by Bonvicini and Perlin32 described 5 common assumptions by providers about gay and lesbian patients that create barriers to effective communication and care. These include assumptions about a patient’s sexual orientation, sexual behaviors, family structure, role of significant others and family in his or her health care, and the effect on messages sent through the health care practice. Awareness of these assumptions, knowledge of health care barriers, and evaluation of one’s own biases will allow emergency providers to positively change the care and outcome of the LGBT population. Figure 3 provides recommendations for the health care setting to facilitate LGBT care in the ED. Figures 4 and 5 offer tips for effective communication with LGBT patients. CURRENT EDUCATIONAL PRACTICES Medical School Education The incorporation of LGBT health care education into standard medical curricula is often insufficient. The Journal of the American Medical Association published a Stanford study that surveyed deans of medical schools across the Volume 66, no. 4 : October 2015
Jalali & Sauer
Improving Care for LGBT Patients in the Emergency Department
Recognizing the need for change within medical education, the Association of American Medical Colleges recently published a comprehensive guide to address the needs of LGBT education in the health care system.4 Available online as a free download (http://offers.aamc.org/ lgbt-dsdhealth), this landmark publication serves to provide education about the health needs of LGBT people, offer guidance for medical schools to integrate this material into their curriculum, and assess competency in learners to determine effectiveness of change. As more institutions adopt these changes, new physicians entering residencies across multiple disciplines will be better prepared to treat LGBT patients.
Figure 5. Tips for more effective communication with transgender patients.
United States and Canada. It found that medical school curricula provided a median of 5 hours of education on LGBT issues; one third reported zero hours of education in the clinical years, and 6.8% reported zero hours in the preclinical years. Overall, approximately 4% of programs provided zero hours combined. This study showed that although most schools taught students to ask sensitive social history questions, many did not teach them the differences between behavior and sexual identity.33 There was also no educational standard for teaching students how to incorporate reported sexual history with the other aspects of the patient’s evaluation, such as sensitivity during physical examination. Several other educational studies have shown that incorporating LGBT education in medical school curricula by providing educational sessions or standardized patient encounters positively affected the level of knowledge, comfort, history taking, impression of the population, and overall understanding of LGBT health care barriers. Students have also acknowledged the relevance and need for incorporating LGBT education into their curriculum.9
Emergency Medicine Residency Education The Accreditation Council for Graduate Medical Education does not currently include LGBT-related education in the emergency medicine curriculum, but sensitivity to gender and sexual orientation are briefly mentioned in program requirements.34 There is a paucity of residency-related literature on this topic. A recent survey found that only approximately a quarter of emergency medicine residencies included LGBT-specific lectures, and approximately a third incorporated LGBT health in their curriculum; the mean lecture time was 45 minutes and the median was zero minutes. The study demonstrated the infrequent integration of LGBT-related education in emergency medicine residencies but showed that program directors wanted to integrate more of this education into their curricula.29 Emergency medicine residencies would benefit from having access to LGBT health care educational resources. The material can be presented as single lectures dedicated to LGBT health in the ED or tied into various emergency medicine–relevant topics for more longitudinal education. Programs could also consider inviting expert speakers for additional didactics. Table 1 highlights some LGBT educational resources for medical students and residents that may be helpful for anyone interested in this topic. Last,
Table 1. Resources for LGBT health care education. Title AAMC: Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born With DSD AAMC MedEdPORTAL: Lesbian, Gay, Bisexual, Transgender (LGBT), and Differences of Sex Development (DSD) Patient Care Collection ACGME LGBT Health Resource Guide Fenway Institute’s National LGBT Health Education Center UCSF Center of Excellence for Transgender Health UCSF LGBT Resource Center
Citation/URL Register and download at: http://offers.aamc.org/lgbt-dsd-health
https://www.mededportal.org/about/initiatives/lgbt/ http://bit.ly/1vphUsW http://www.lgbthealtheducation.org/ http://transhealth.ucsf.edu/ http://lgbt.ucsf.edu
AAMC, Association of American Medical Colleges; ACGME, Accreditation Council for Graduate Medical Education; UCSF, University of California, San Francisco.
Volume 66, no. 4 : October 2015
Annals of Emergency Medicine 421
Improving Care for LGBT Patients in the Emergency Department
residency programs may consider adopting standardized methods for evaluating the effect of this education, potentially through the Accreditation Council for Graduate Medical Education Milestones as related to compassion, integrity, respect, and ethical principles.35 CONCLUSION Some may argue that there is no need for special training and education of LGBT patient care because, as emergency providers, we are expected to treat every patient without judgment or discrimination. However, the lack of education and exposure leaves many providers poorly prepared to establish effective communication with their LGBT patients regardless of intent. Tyra Hunter’s death was almost 20 years ago, but many LGBT patients continue to face barriers to accessing adequate medical care. Understanding that LGBT people exist within every community and that many pass through medical facilities each day, often unidentified, is important to help providers assume a person’s sexual orientation or gender identity less often. We hope that with enhanced advocacy and effective educational curricular reforms, emergency providers will have the appropriate skills and empathy to assist LGBT patients whenever they seek medical care, preventing events such as Tyra Hunter’s death. Supervising editors: Cindy H. Hsu, MD, PhD; Donald M. Yealy, MD Author affiliations: From the Johns Hopkins School of Medicine, Department of Emergency Medicine, Baltimore, MD (Jalali, Sauer); and the Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD (Sauer). Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.
REFERENCES 1. Padela AI, Punekar IR. Emergency medical practice: advancing cultural competence and reducing health care disparities. Acad Emerg Med. 2009;16:69-75. 2. Varga LM, Surratt HL. Predicting health care utilization in marginalized populations: black, female, street-based sex workers. Womens Health Issues. 2014;24:e335-e343. 3. Gates G. How many people are lesbian, gay, bisexual, and transgender? Williams Institute. April 2011. Available at: http://williamsinstitute.law. ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011. pdf. Accessed February 20, 2015. 4. Association of American Medical Colleges (AAMC) Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development. Implementing curricular and institutional climate changes to improve health care for individuals who are LGBT, gender nonconforming, or born with DSD. A resource for medical educators. 2014. Available at: http://offers.aamc.org/lgbt-dsd-health. Accessed December 2, 2014.
422 Annals of Emergency Medicine
Jalali & Sauer 5. Bauer GR, Scheim AI, Deutsch MB, et al. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Ann Emerg Med. 2014;63:713-720. 6. Shaffer N. Transgender patients: implications for emergency department policy and practice. J Emerg Nurs. 2005;31:405-407. 7. Kelley L, Chou CL, Dibble SL, et al. A critical intervention in lesbian, gay, bisexual, and transgender health: knowledge and attitude outcomes among second-year medical students. Teach Learn Med. 2008;20: 248-253. 8. Sanchez NF, Rabatin J, Sanchez JP, et al. Medical students’ ability to care for lesbian, gay, bisexual, and transgendered patients. Fam Med. 2006;38:21-27. 9. Sequeira GM, Chakraborti C, Panunti BA. Integrating lesbian, gay, bisexual, and transgender (LGBT) content into undergraduate medical school curricula: a qualitative study. Ochsner J. 2012;12:379-382. 10. Klein A. Victims slain for nonconformity, report says. Washington Post. Published on December 12, 2006. Available at: http://www. washingtonpost.com/wp-dyn/content/article/2006/12/14/ AR2006121401917.html. Accessed June 30, 2014. 11. Rosendall R. Victory in Tyra Hunter case: statement by GLAA president. December 11, 2008. Available at: http://www.glaa.org/archive/1998/ margiehunter1211.shtml. Accessed June 30, 2014. 12. Gonzales G, Blewett LA. National and state-specific health insurance disparities for adults in same-sex relationships. Am J Public Health. 2014;104:e95-e104. 13. Marriage rights and benefits. NOLO Legal Services. Available at: http://www.nolo.com/legal-encyclopedia/marriage-rights-benefits30190.html. Accessed June 30, 2014. 14. Wolfson E. Why Marriage Matters. New York, NY: Simon & Schuster; 2004; appendix B. Available at: http://www.freedomtomarry.org/ pages/from-why-marriage-matters-appendix-b-by-evan-wolfson. Accessed February 20, 2015. 15. Hanneman T. Healthcare equality index 2014. Human Rights Campaign. 2014. Available at: http://www.hrc.org/hei/about-the-hei#. U-J9to2wJSk. Accessed October 27, 2014. 16. Centers for Medicare & Medicaid Services. Revised appendix A, interpretive guidelines for hospitals, and appendix W, interpretive guidelines for critical access hospitals (CAHs); December 2, 2011. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/ Transmittals/downloads/R75SOMA.pdf. Accessed October 27, 2014. 17. Riou G. Hospital Visitation and Medical Decision Making for Same-Sex Couples. Washington, DC: Center for American Progress; 2014. Available at: http://www.americanprogress.org/issues/lgbt/news/2014/ 04/15/88015/hospital-visitation-and-medical-decision-making-for-samesex-couples/. Accessed October 27, 2014. 18. Gates G. LGBT Parenting in the United States. Williams Institute; 2013. Available at: http://williamsinstitute.law.ucla.edu/research/ census-lgbt-demographics-studies/lgbt-parenting-in-the-unitedstates/. Accessed October 27, 2014. 19. Securing Legal Ties for Children Living in LGBT Families: A State Strategy and Policy Guide. Movement Advancement Project, Family Equality Council, and Center for American Progress; 2012. Available at: http://www.lgbtmap.org/file/securing-legal-ties.pdf. Accessed October 27, 2014. 20. Centers for Disease Control and Prevention. Stigma and discrimination. Available at: http://www.cdc.gov/msmhealth/stigma-and-discrimination. htm. Accessed October 27, 2014. 21. McKay B. Lesbian, gay, bisexual, and transgender health issues, disparities, and information resources. Med Ref Serv Q. 2011;30: 393-401. 22. Centers for Disease Control and Prevention (CDC). Lesbian, gay, bisexual and transgender health. Available at: http://www.cdc.gov/ lgbthealth/about.htm. Accessed June 30, 2014. 23. Cray A, Baker K. FAQ: health insurance needs for transgender Americans. Center for American Progress. October 2012. Available at:
Volume 66, no. 4 : October 2015
Jalali & Sauer
24.
25. 26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
http://cdn.americanprogress.org/wp-content/uploads/2012/10/ TransgenderHealth.pdf. Accessed June 30, 2014. Cruz TM. Assessing access to care for transgender and gender nonconforming people: a consideration of diversity in combating discrimination. Soc Sci Med. 2014;110:65-73. Out2Enroll. Sellers Dorsey Foundation. Available at: http://www. out2enroll.org. Accessed June 30, 2014. Bjorkman M, Malterud K. Lesbian women’s experiences with health care: a qualitative study. Scand J Prim Health Care. 2009;27: 238-243. Henkel G. Health issues to consider among transgender patients. ACEPNow. 2014. Available at: www.acepnow/com/article/respectfulcommunication-key-reducing-barriers-care-transgender-patients-ed/. Accessed February 20, 2015. Rintamaki L, Scott A, Kosenko K, et al. Male patient perceptions of HIV stigma in health care contexts. AIDS Patient Care STDS. 2007;21: 956-969. Moll J, Krieger P, Moreno-Walton L, et al. The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: what do we know? Acad Emerg Med. 2014;21:608-611. Kosenko K, Rintamaki L, Raney S, et al. Transgender patient perceptions of stigma in health care contexts. Med Care. 2013;51:819-822. Brown JF, Fu J. Emergency department avoidance by transgender persons: another broken thread in the “safety net” of emergency medicine care. Ann Emerg Med. 2014;63:721-722. Bonvicini KA, Perlin MJ. The same but different: clinician-patient communication with gay and lesbian patients. Patient Educ Couns. 2003;51:115-122. Obedin-Maliver J, Goldsmith ES, Steward L, et al. Lesbian, gay, bisexual, and transgender–related content in undergraduate medical education. JAMA. 2011;306:971-977. Accreditation Council for Graduate Medical Education (ACGME) program requirements for graduate education in emergency medicine. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ 2013-PR-FAQ-PIF/110_emergency_medicine_07012013.pdf. Accessed February 20, 2015. ACGME: the Emergency Medicine Milestones Project. Available at: http://acgme.org/acgmeweb/Portals/0/PDFs/Milestones/ EmergencyMedicineMilestones.pdf. Accessed February 20, 2015. Blosnich JR, Farmer GW, Lee JG, et al. Health inequalities among sexual minority adults: evidence from ten US states, 2010. Am J Prev Med. 2014;46:337-349. King M, Semlyen J, Tai SS, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay, and bisexual people. BCM Psychiatry. 2008;8:70. Landers S, Gilsanz P. The Health of Lesbian, Gay, Bisexual, and Transgender (LGBT) Persons in Massachusetts. Massachusetts Department of Public Health; 2009. Available at: http://www.mass. gov/eohhs/docs/dph/commissioner/lgbt-health-report.pdf. Accessed February 20, 2015. Tjaden P, Thoennes N. Extent, Nature, and Consequences of Intimate Partner Violence: Findings From the National Violence Against Women
Volume 66, no. 4 : October 2015
Improving Care for LGBT Patients in the Emergency Department
40.
41.
42. 43.
44.
45.
46. 47.
48.
49.
50. 51. 52.
53.
54.
55.
56.
Survey. Washington, DC: US Dept of Justice, National Institute of Justice; 2000:29-31. Report NCJ 181867. Available at: https://www. ncjrs.gov/pdffiles1/nij/181867.pdf. Accessed June 30, 2014. Rothman EF, Exner D, Baughman AL. The prevalence of sexual assault against people who identify as gay, lesbian, or bisexual in the United States: a systematic review. Trauma Violence Abuse. 2011;12:55-66. Federal Bureau of Investigation (FBI). Hate crime statistics: incidents and offenses. Available at: http://www.fbi.gov/about-us/cjis/ucr/hate-crime/ 2011/narratives/incidents-and-offenses. Accessed June 30, 2014. Bailey JV, Farquhar C, Owen C, et al. Sexually transmitted infections in women who have sex with women. Sex Transm Infect. 2004;80:244-246. GLMA: Health Professionals Advancing LGBT Equality. Ten things gay men should discuss with their healthcare provider. Available at: http:// glma.org/index.cfm?fuseaction¼Page.viewPage&pageID¼690. Accessed June 30, 2014. Mercer CH, Bailey JV, Johnson AM, et al. Women who report having sex with women: British national probability data on prevalence, sexual behaviors, and health outcomes. Am J Public Health. 2007;97:1126-1133. Feldman JL, Goldberg J. Transgender Primary Medical Care: Suggested Guidelines for Clinicians in British Columbia. Vancouver, BC: Vancouver Coastal Health, Transgender Health Program; 2006. Spack NP. Management of transgenderism. JAMA. 2013;309:478-484. Silenzio VMB, Pena JB, Duberstein PR, et al. Sexual orientation and risk factors for suicidal ideation and suicide attempts among adolescents and young adults. Am J Public Health. 2007;97: 2017-2019. Garofalo R, Wolf RC, Wissow LS, et al. Sexual orientation and risk of suicide attempts among a representative sample of youth. Arch Pediatr Adolesc Med. 1999;153:487-493. Kosciw JG, Greytak EA, Bartkiewicz MJ, et al. The 2011 National School Climate Survey: The Experiences of Lesbian, Gay, Bisexual and Transgender Youth in Our Nation’s Schools. New York, NY: Gay, Lesbian Straight Education Network; 2012. Kruks G. Gay and lesbian homeless/street youth: special issues and concerns. J Adolesc Health. 1991;12:515-518. Fenway Health. Available at: http://www.fenwayhealth.org. Accessed June 30, 2014. Center for American Progress. Available at: https://www.american progress.org/issues/lgbt/news/2013/06/21/67411/lgbt-inclusivesex-education-means-healthier-youth-and-safer-schools/. Accessed December 2, 2014. Marshal MP, Friedman MS, Stall R. Sexual orientation and adolescent substance use: a meta-analysis and methodological review. Addiction. 2008;203:546-556. AARP: Movement Advancement Project. (2010.) Improving the lives of LGBT older adults. Available at: http://www.lgbtmap.org/file/ improving-the-lives-of-lgbt-older-adults.pdf. Accessed June 30, 2014. Aging and health report—health equity and LGBT elders of color, Services & Advocacy for GLBT Elders (SAGE). Available at: http://issuu. com/lgbtagingcenter/docs/full-report-final-11-16-11. Accessed June 30, 2014. MetLife–MetLife Mature Market Institute. (2010.) Still out, still aging. Westport, CT. Available at: http://www.plumlivinghealth.com/images/ mmi-still-out-still-aging.pdf. Accessed February 20, 2015.
Annals of Emergency Medicine 423
