Image: Ted Eytan / Flickr
From homosexuality’s roots as a “mental illness” to the acquisition of marital benefits, we look at the history of LGBTQ healthcare coverage in the United States.
Over the last few decades, societal perceptions of the Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) community changed drastically. With many legislative changes to their rights and freedoms as recent as two years ago, many of these changes are providing them more protection from discrimination. Perhaps most notable was the overturn of section 3 of the Defense of Marriage Act (DOMA), the legislation that kept same-sex couples from being recognized as spouses in the eyes of the federal government.
In addition to legal changes, Americans in general are more tolerant of homosexuality than they were in the past. In 2013, the percentage of Americans stating they believe that homosexuality should be accepted rose to 60 percent, a significant increase from 49 percent reported in 2007. While significant progress has been made in terms of LGBTQ rights and acceptance, there’s still work to be done when it comes to equality in the name of healthcare. Still plagued by decades of discrimination and unfair treatment, the LGBTQ community faces many challenges when combating health disparities and access to equal healthcare. While we’ve reached a point at which gay healthcare startups can operate freely and various organizations can offer services for issues like mental health, the LGBTQ community has had to fight to allow for such things to exist.
1940s – 1970s: Homosexuality as a Mental Illness
The latest Gallup poll shows that 4.1 percent of the American population identifies as lesbian, gay, bisexual, or transgender. This equates to more than 10 million American adults who have long battled societal stigmas that are commonly felt when interacting within healthcare. These stigmas are deeply rooted in a history that criminalized and institutionalized homosexuals.
As recently as the 1940s, laws prevented same-sex consensual sex behavior. The Institute of Medicine reported that psychiatry and psychology professionals deemed homosexuality to be a mental illness. By 1952 it was deemed a sociopathic personality disturbance, leading to massive job loss within the homosexual community; this classification grouped them with rapists and pedophiles. It also lead to many attempted “medical procedures” that attempted change them from homosexuality to heterosexuality. Some of the milder attempts included hormone treatments and aversive conditioning. Inhumane procedures such as lobotomies, electroshock, and castration were also used.
Due to the societal rejection of the homosexual community and the disturbing medical practices used in an attempt to “cure” them, it’s easy to understand why distrust towards healthcare professionals still persists today. It’s also important to note that because many homosexuals lived in secret, there’s virtually no historical data on them, making it impossible to understand how their physical and mental health were affected during this time.
The 1970s marked the beginning of change for the the public perception of homosexuality. In 1973, the American Psychiatric Association removed homosexuality as a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM). The removal of mental illness as a designation for homosexuality led to state-by-state repeal of laws criminalizing sodomy. Soon after, the Untied States saw a slow but continued growth of homosexual communities across major metropolitan areas.
1980s – early 1990s: HIV/AIDS Epidemic
In 1981, the first gay male was diagnosed with what we would eventually call Acquired Immune Deficiency Syndrome (AIDS). Within 10 years the disease would go on to kill more than 120,000 people, many of whom were gay males. This massively devastating disease spread quickly and without an understanding of the cause.
Today, we know that it develops from Human Immunodeficiency Virus (HIV) and can be spread through human bodily fluids including blood, semen, vaginal fluids, and breast milk; it took several years before the methods of infection were discovered. By that time, however, the general population had already strongly associated HIV with sexual transmission by gay males.
The government’s response, or lack thereof, lead to further distrust between the gay community and public officials. President Ronald Regan received criticism for not acknowledging the disease until 1985, by which time thousands of Americans had died of the disease.
Today, HIV and AIDS remain one of the most important health issues for the LGBTQ community. The CDC reported that gay and bisexual men accounted for 67 percent of all diagnoses in 2015.
The survival rate of HIV patients has improved due to improved treatments, but these treatments are expensive and require life long care. The antiretroviral drugs used to help mitigate the negative side effects of HIV cost thousands of dollars each month. One study published in 2015 cited insufficient health insurance as a barrier to care for HIV positive patients.
2010s: Battle for Health Insurance Access
There have been recent improvements in equal access to health insurance for the LGBTQ community. Firstly, the Affordable Care Act (Obamacare) gave states the option to expand Medicaid, meaning more access for individuals below the federal poverty level. Secondly, with the creation of the subsidized health insurance marketplaces, there’s coverage available to those who don’t qualify for Medicaid but can’t afford insurance on their own. Finally, the ACA prevented health insurance companies from denying coverage based on pre-existing conditions such as HIV, mental health conditions, or being transgender.
Overturning DOMA in 2013 also allowed same-sex couples to be legally married. This opened up marital benefits for the gay community, such as extending health care coverage to a spouse. Tax benefits were also extended to same-sex married couples, meaning they can use combined income levels when applying for subsidies within health insurance marketplaces or when applying for Medicaid. Depending on the same-sex couples’ level of income, this could allow them greater access to coverage.
Continued Barriers to Care
The LGBTQ community has a tumultuous relationship with health professionals. This past, mixed with the societal stigmas that are still present today, have been reflected in studies into LGBTQs attitudes towards health professionals. One-in-five LGBT people have admitted to withholding information from their doctors about sexual practices. Rates are even more discouraging among transgenders, where approximately 30 percent will postpone or avoid seeking medical care when they are sick or injured due to fear of discrimination.
There is a clear barrier between caregivers and patients that will need to be bridged to solve health inequalities prevalent amongst LGBTQs. In 2011 strides were made by the accrediting body of over 20,000 healthcare organizations. The Joint Commission prohibited health care organizations from discriminating due to sexual orientation, gender identity or gender expression. This will hopefully allow for a more inclusive environment in which LGBTQs feel a stronger sense of trust with their doctors.
Over history, LGBTQ individuals have suffered inequality, discrimination, and inhumane attempts to convert them from who they truly are. Though they have received more rights in recent years, there is a lasting effect from decades of stigma. This stigma has lead to distrust in health professionals, increased risk for mental health conditions, and greater barriers to care. There is still much work to be done before LGBTQs are able to feel truly equal within the healthcare system.
LGBT Healthcare Coverage: Additional Resources
Cognizant of the many unique issues impacting the LGBTQ community, we’ve put together these resources to alleviate some of the struggles with getting adequate LGBT healthcare coverage: