Dr. Brittany Brooks meets with a patient at Open Arms Healthcare Center, a clinic in Jackson, MS, that focuses on alleviating healthcare disparities for underserved populations, with a particular focus on LGBT people. 
© 2018 Nina Robinson / The Verbatim Agency / Getty Images

The Trump administration is considering regulatory changes that would worsen barriers many lesbian, gay, bisexual, and transgender (LGBT) people in the United States face in obtaining health care, Human Rights Watch said in a report released today. The US Department of Health and Human Services (HHS) should reconsider those changes, which would leave LGBT people more vulnerable to discrimination.

The 34-page report, “‘You Don’t Want Second Best’: Anti-LGBT Discrimination in US Health Care,” documents some of the obstacles that LGBT people face when seeking mental and physical healthcare services. Many LGBT people are unable to find services in their area, encounter discrimination or refusals of service in healthcare settings, or delay or forego care because of concerns of mistreatment.

“Discrimination puts LGBT people at heightened risk for a range of health issues, from depression and addiction to cancer and chronic conditions,” said Ryan Thoreson, an LGBT rights researcher at Human Rights Watch. “Instead of treating those disparities as a public health issue, HHS is developing politicized rules that will make them much worse.”

Two upcoming regulatory changes are likely to worsen these barriers, Human Rights Watch said. In January 2018, HHS issued a proposed rule that would broaden existing religious exemptions in healthcare law, giving sweeping discretion to insurers and providers to deny service to patients because of their moral or religious beliefs. In April 2018, the Trump administration announced plans to roll back a regulation that clarifies that federal law prohibits healthcare discrimination based on gender identity. If finalized, these changes would further undermine the limited antidiscrimination protections that currently exist for LGBT people.

Human Rights Watch interviewed 81 people for the report, including providers and individuals who said they had experienced discrimination in healthcare settings.

Existing protections for LGBT people in health care are uneven. In 2016, the Obama administration issued a regulation clarifying that Section 1557 of the Affordable Care Act, which prohibits sex discrimination in health care, also prohibits discrimination against transgender people. Eight states and religious healthcare providers challenged the regulation in court, and the Trump administration has signaled it plans to roll it back.

Protections at the state level are lacking. As of July 2018, 37 states do not expressly ban health insurance discrimination based on sexual orientation or gender identity. New Jersey prohibits discrimination based on gender identity but not sexual orientation. In 10 US states, transition-related health care is expressly excluded from Medicaid coverage, limiting options for low-income transgender people.

LGBT people interviewed for the report described difficulty finding hormone replacement therapy, HIV prevention and treatment options, fertility and reproductive services, and even just welcoming primary care services. Judith N., a transgender woman in East Tennessee, said, “I spent years looking for access to therapy and hormones and I just couldn’t find it.”

Others described discriminatory treatment by providers. Trevor L., a gay man in Memphis, recalled an incident when he took an HIV test at his annual checkup in 2016: “and they sat down and started preaching to me – not biblical things, but saying, you know this is not appropriate, I can help you with counseling, and I was like, oh, thank you, I’ve been out for 20 years and I think I’m okay. It’s almost like they feel they have the right to tell you that it’s wrong.”

In addition to discrimination, many LGBT people are refused services outright because of their sexual orientation or gender identity. In a nationally representative survey conducted by the Center for American Progress in 2017, 8 percent of lesbian, gay, and bisexual respondents and 29 percent of transgender respondents reported that a healthcare provider had refused to see them because of their sexual orientation or gender identity in the past year. Interviewees described being denied counseling and therapy, refused fertility treatments, denied a checkup or other primary care services, and in one instance, told that a pediatrician’s religious beliefs  precluded her from evaluating a same-sex couple’s 6-day-old child.

Both providers and LGBT people noted that concerns about discrimination and mistreatment led LGBT people to delay or forego care. A 2015 survey of almost 28,000 transgender people found that, in the year preceding the survey, 23 percent did not seek care they needed because of concern about mistreatment based on gender identity.

Many interviewees expressed concern that laws permitting providers to refuse service on moral or religious grounds would make care even harder to obtain. Persephone Webb, a transgender activist in Knoxville, Tennessee, said that “[i]t tells people who are prone to being bigoted to be a little braver, and a little braver. And we see through this – we know this is an attack on LGBT people.”

Instead of finalizing the proposed changes, HHS should preserve antidiscrimination protections and withdraw sweeping exemptions that put patients at risk, Human Rights Watch said. Lawmakers at the state and federal level should prohibit discrimination in health care on the basis of sexual orientation and gender identity, and should repeal exemptions that allow providers to refuse to serve patients because of their sexual orientation or gender identity.

“When LGBT people seek medical care, the oath to do no harm too often gives way to judgment and discrimination,” Thoreson said. “Lawmakers need to make clear that patients come first, regardless of their sexual orientation or gender identity.”