In many states across the United States recently enacted and proposed legislation compromises the fundamental rights of members of sexual and gender minority (SGM) groups. Many of these policies limit access to much needed health care and thus put SGM individuals at risk for discrimination and worse mental health outcomes. One example is the directive issued by Texas Governor Greg Abbott to investigate parents for child abuse if they seek gender-affirming care for their children. Other states have introduced bills which would criminalize the delivery of gender-affirming care. In a perspective piece published in the New England Journal of Medicine, Michael Liu, MPhil and Sahil Sandhu, MSc, both students from Harvard Medical School, and Alex Keuroghlian, MD MPH, Director of the MGH Gender Identity Program, argue that these developments cannot be ignored and that the health care sector must do more to protect SGM individuals’ rights.
As policymakers continue to target SGM people, the health care sector can play a critical role in mitigating resulting harm and advocating for evidence-based policies protecting health and well-being. We believe the Triple Aim framework — which consists of enhancing patients’ care experiences, improving population health, and reducing per-capita costs of care — can help identify existing challenges and next steps for promoting SGM health.
Triple Aim refers to a framework developed by the Institute for Healthcare Improvement (IHI) and describes an approach to optimizing health system performance. The design of innovative programs requires improvements at all levels of the system and must be developed to simultaneously pursue three dimensions:
- Improving the patient experience of care (including quality and satisfaction);
- Improving the health of populations; and
- Reducing the per capita cost of health care.
The authors note that while certain conditions, including cardiovascular disease, cancer, depression, and substance use disorders, are more common in SGM individuals compared to those in the general population, members of SGM groups are more likely to have negative health care experiences and are therefore more likely to avoid health care or to delay treatment as a result of the discrimination they experience in this setting. Eliminating barriers to and increasing access to gender-affirming care has been shown to improve mental health outcomes; however, improving care for this population will also require workforce development to ensure that health professionals can support the specific needs of SGM people.
In addition, the authors encourage physicians and professional organizations to advocate against harmful legislation and to support protective policies affirming fundamental rights of SGM people. For example, the Equality Act would amend the 1964 Civil Rights Act to protect LGBTQ people from discrimination in employment, housing, jury service, and federally funded programs.
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Almazan AN, Keuroghlian AS. Association Between Gender-Affirming Surgeries and Mental Health Outcomes. JAMA Surg. 2021 Apr 28: e210952.
Liu M, Sandhu S, Keuroghlian AS. Achieving the Triple Aim for Sexual and Gender Minorities. N Engl J Med. 2022 Jul 23.
Medicine and LGBTQ Health Policies (Harvard Medicine News)
Transforming Transgender Care (The Harvard Gazette)
Alex Keuroghlian, MD MPH is the Michele and Howard J Kessler Chair and Director of the MGH Division of Public and Community Psychiatry and Associate Professor of Psychiatry at Harvard Medical School. In addition, he is the Director of the MGH Gender Identity Program, Director of Education and Training Programs at the Fenway Institute, and Director of the National LGBTQIA+ Health Education Center.
