Recognizing the increasing disparities in care for lesbian, gay, bisexual, transgender, or queer (LGBTQ) individuals in several medical specialties is becoming critical, especially in pain management. The percentage of American adults who identify as LGBTQ increased from 3.5% in 2012 to 4.5% in 2017.^[1]

Higher Levels of Chronic Pain

Disparities in LGBTQ health care are not new and have unfortunately persisted over the years. A major contributor is a lack of understanding of the patient population’s unique needs.^[2] LGBTQ patients report higher levels of chronic pain,^[3] higher degrees of functional limitations because of their pain,^[4] and increased reports of multiple sites of pain compared to heterosexuals.^[5] Other studies have described that LGBTQ individuals have a higher risk of developing headaches, abdominal pain, pelvic pain, and chronic pain than heterosexuals.^[6] Katz-Wise et al. found that mostly heterosexual women and homosexual men reported a higher incidence of headaches than same-gender completely heterosexual individuals, whereas mostly heterosexual and bisexual women were more likely to report muscle or joint pain than completely heterosexual women.^[7] Alternatively, homosexual men tended to report less muscle or joint pain than heterosexual men, which may be attributable to generally lower body mass indexes in homosexual men versus heterosexual counterparts, or greater societal and familial acceptance for homosexual men compared to other members of the LGBTQ community.^[7]

LGBTQ patients report higher levels of chronic pain, higher degrees of functional limitations because of their pain, and increased reports of multiple sites of pain compared to heterosexuals.

A number of factors crucial to LGBTQ patients’ overall pain management treatment may contribute to increased risk of chronic pain in this population. Discriminated LGBTQ youth have higher levels of depression and suicidality.^[8] Katz et al. indicated that in addition to chronic pain, sexual minorities reported more suicidal ideation and depression compared to heterosexuals.^[7] Other studies have indicated a possible link between depression and suicidality and increased reports of pain, which may factor into the higher incidence of chronic pain in LGBTQ patients. Furthermore, LGBTQ individuals have a greater incidence of internalizing symptoms (anxiety and depression), possibly because of discrimination and the subsequent stressors related to discrimination.^[7] For example, LGBTQ patients often experience peer victimization and family rejection creating psychological stress. Additionally, LGBTQ youth are bullied more at school (34%), more likely to get in fights, and struggle more frequently with emotional stress than their heterosexual peers.^[9] They also are at higher risk for harassment and injury with a weapon, further contributing to psychological traumas that can complicate their pain management.^[9] Providers need to keep these comorbidities in mind while treating LGBTQ patients’ chronic pain conditions.^[3]

Less Access to Care

Discrimination and its associated stressors not only contribute to an increased risk for chronic pain but also affect LGBTQ patients’ access to health care, overall interactions with healthcare professionals, and possibly health-related treatment outcomes. One such challenge has historically been a lack of health care coverage. Luckily, lack of coverage has improved since 2014 now that most insurance companies cannot deny coverage to patients because of pre-existing medical conditions such as HIV, sexually transmitted diseases, depression, or substance abuse. Subsequently, the number of insured LGBTQ patients has increased significantly in recent years.^[10]

Discrimination and Mistreatment

Although coverage and care are improving for LGBTQ patients, a 2018 report indicated that LGBQT patients often encounter discrimination and mistreatment at the doctor’s office.^[11] In the Center for American Progress survey, 8% of LGBTQ patients reported that a health care provider refused to see them, 6% said the health care provider refused to give them care related to their actual or perceived sexual orientation, 9% indicated that the health care provider used harsh or abusive language, and 6% indicated that they encountered unwanted physical contact from the provider—and those numbers were almost doubled for transgender patients.^[11] As a result of such discrimination, LGBTQ patients may avoid or delay care, which can impact their health care outcomes. In the same survey, patients reported difficulty and challenges in finding different providers or health systems if they wish to change care.^[11]

In conclusion, evidence suggests that sexual minorities encounter discrimination and disparities in the health care system. They also have special needs and risks that need to be addressed by health care providers as they receive care for chronic pain, or other disease conditions.

Health care providers should not let their beliefs influence the care that they provide or how they treat unique or vulnerable patient populations. Patients have a fundamental right to receive compassionate and high-quality health care. Providers must not discriminate against patients for any reason, but should instead seek opportunities to further understand the special needs of different patient populations.

In addition, increased provider awareness and educational content related to the special needs of the LGBTQ community are needed. Those efforts should better prepare health care providers to comprehensively care for this patient population.

References

1. In U.S., estimate of LGBT population rises to 4.5%. 2018. https://news.gallup.com/poll/234863/estimate-lgbt-population-rises.aspx. Accessed August 1, 2019.
2. The Joint Commission. Advancing effective communication, cultural competence and patient and family centered care for the lesbian, gay, bisexual and transgender (LGBT) community: a field guide. 2014. Oakbrook Terrace, Illinois: The Joint Commission. http://www.jointcommission.org/lgbt/default.aspx.
3. Safren S, Heimberg R. Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents. J Consult Clin Psychol. 1999;67:859–866.
4. Case P, Austin SB,  Hunter DJ, et al. Sexual orientation, health risk factors, and physical functioning in the Nurses’ Health Study II. J Womens Health. 2004;13:1033–1047. https://doi.org/10.1089/jwh.2004.13.1033
5. Cochran S, Mays V. Physical health complaints among lesbians, gay men, and bisexual and homosexually experienced heterosexual individuals: results from the California quality of life survey. J Public Health. 2007;97:2048–2055. https://doi.org/10.2105/AJPH.2006.087254
6. Roberts AL, Rosario M, Corliss HL, Wypij D, Lightdale JR, Austin SB. Sexual orientation and functional pain in U.S. young adults: the mediating role of childhood abuse. PLoS One. 2013;8:e54702. https://doi.org/10.1371/journal.pone.0054702
7. Katz-Wise SL, Everett B, Scherer EA, Gooding H, Milliren CE, Austin SB. Factors associated with sexual orientation and gender disparities in chronic pain among U.S. adolescents and young adults. Prev Med Rep. 2015;2:765–772. https://doi.org/10.1016/j.pmedr.2015.09.011
8. Addressing the health needs of sex and gender minorities in New Mexico. 2018. https://nmhealth.org/publication/view/report/4514/. Accessed August 1, 2019.
9. Olsen EO, Kann L, Vivolo-Kantor A, et al. School violence and bullying among sexual minority high school students, 2009–2011. J Adolesc Health. 2014,55:432–438. https://doi.org/10.1016/j.jadohealth.2014.03.002
10. Gates G. Demographics and LGBT health. J Health Soc Behav. 2013;54:72–74. https://doi.org/10.1177/0022146512474429
11. Mirza SA, Rooney C. Discrimination prevents LGBTQ people from accessing health care. 2018. https://www.americanprogress.org/issues/lgbt/news/2018/01/18/445130/discrimination-prevents-lgbtq-people-accessing-health-care. Accessed August 1, 2019.