By: Isabella DiStefano, FCLC ’21
In the United States, women’s health care is significantly lacking. Women are at a greater risk of developing psychological disorders, autoimmune disorders, chronic conditions, and certain types of cancer (Gunja et al., 2018). Additionally, the United States sees the highest rate of maternal mortality (Gunja et al., 2018). This could be for a variety of reasons, including but not limited to the fact that the Unites States sees the highest rates of cesarean sections and the greatest lack of prenatal care (Gunja et al., 2018). Or perhaps the high rates of diabetes, heart disease, and obesity seen in U.S. women play a role in these observed health outcomes (NIH, 2014). Furthermore, access to care is impeded by cost. An astounding statistic showed that over 25% of women in the Unites States reported spending $2,000 or more on out-of-pocket medical bills in the past year, while only 5% or less of women from other wealthy nations in the study reported having spent an equivalent amount (Gunja et al., 2018). As a result of these high costs, the United States sees the highest rates of women skipping needed health care compared to 10 other wealthy nations, with around 38% of women admitting to avoiding care (Gunja et. al. 2018).
Poor access to primary care leads to less diagnoses and management of diseases, and subsequently a decrease in lifelong health. These negative effects are further compounded in women who fall into additional minority groups, including LGBTQ+ women and women of color (WOC). These individuals face an additional burden of stigmatization and improper treatment as a result of their minority status. Some significant barriers to accessing health care facing the LGBTQ+ community include lack of provider knowledge, discrimination, lack of proper treatment, delaying or forgoing care, refusal of treatment, and verbal or physical mistreatment (Trinh et al., 2017). In a similar manner, WOC are often burdened with discriminatory or biased judgements from providers, leading to a lesser quality of care and higher rates of mortality (NIH, 2014). To make matters worse, there is a startling lack of legislation prohibiting race-biased and discriminatory practices. It can effectively be stated that those who are not White heterosexual males will receive worse care in the U.S. health care system. If one falls into more than one minority group—in this case, woman, person of color, and queer—the deficit in the care they receive grows additively. This theory was first coined by Kimberle Crenshaw in 1989 as intersectionality theory (Cole, 2009).
This paper will utilize an intersectional approach to analyze the U.S. health care system’s treatment of women, queer women, and WOC as it pertains to the ethics of clinical practice. The Meyer (2003) Minority Stress Theory will be applied to provide a framework for the experiences of sexual minority (SM) women and WOC (Russell & Fish, 2016). Statistics showing the discrepancies in treatment faced by women will allow for a more complete understanding of the severity of the issue at hand and will provide supporting evidence to the claim that U.S. women are receiving a lesser quality of care than men, a trend which is further exemplified in minority women.
Sexual Minority Women
Studies have reported that LGBTQ+ women receive inadequate care as a result of a lack of provider knowledge (Mirza & Rooney, 2018). Patients have reported discrimination and mistreatment from medical staff and physicians including verbal and physical abuse, unwanted contact, and refusal to deliver treatment (Mirza & Rooney, 2018). Care is often delayed or foregone because members of the queer community feel uncomfortable returning to a medical office after having received this type or treatment, or because they fear that this will happen to them if they do go (Mirza & Rooney, 2018). There is also discrimination on the level of insurer policies. This underrepresented group needs systemic protection from this type of treatment. Yet only 16 states have legislation in place protecting queer people from private health insurance discrimination based on sexual orientation and gender identity, and only 22 states have anti-discriminatory Medicaid policies (Movement Advancement Project, 2020). This means that an estimated 46% of LGBTQ+ individuals live in a state that does not protect them from LGBTQ+ private or state insurer discrimination (Movement Advancement Project, 2020).
A study conducted by Trinh et al. (2017) concluded that women who self-identified as SM (including gay, lesbian, and bisexual women) were less likely to have a regular health care provider than heterosexual women. White SM women were more likely to have hypertension, cancer, and obesity than White heterosexual women. It has been seen that regardless of race or ethnicity, SM women are likely to feel depressed more frequently than heterosexual women (Russell & Fish, 2016). This can be further understood through the Meyer (2003) Minority Stress Theory, which posits that chronic exposure to negative prejudice, such as marginalization, discrimination, and stigmatization, lead to a state of prolonged compromised mental health, which can often lend itself to more severe physical symptoms (Russell & Fish, 2016).
A specific group of women within the queer community who are perhaps the most marginalized due to extreme social stigmas and prejudices are transgender women. As a result of societal bias, these women are at an even greater risk of receiving improper treatment in health care compared to cisgender women. It is reported that one in five transgender adults is uninsured (The Commonwealth Fund, 2020). Additionally, transgender women are faced with health care barriers that are staggeringly disproportionate to those of cisgender women. A study from the Centers for Disease Control and Prevention (CDC) showed that of all people diagnosed with human immunodeficiency virus (HIV) in the United States between 2009 and 2014, 84% were transgender women (CDC, 2019). In fact, of all the HIV tests conducted in 2017, transgender women received a positive diagnosis at three times the rate of the national average (CDC, 2019). HIV and acquired immunodeficiency syndrome (AIDS) are complex illnesses that require continuous, compassionate care, and consultation with a physician. Yet, it is reported that 28% of transgender people have experienced verbal harassment in a medical setting, and as a result, only 40% report having disclosed their gender identity to their health care providers (The Commonwealth Fund, 2020). When an individual such as a transgender woman feels rejected by the medical community or fears seeking regular medical treatment from a primary care provider, it becomes extremely difficult to prevent a syndrome such as HIV from progressing to its more severe form, AIDS. Additionally, transgender women require a medical provider who does not surround their gender identity with stigma or shame, but rather one who is educated on transgender-specific issues and can provide them with information on things such as pre-exposure prophylaxis (PrEP), hormone treatments, surgical procedures, sexual health practices, and therapy.
All of these startling statistics can be summed up in one generalization: queer women are more likely to have a lower quality of health than their heterosexual, cisgender counterparts. It is possible that this is a result of the unique experiences that they undergo in their daily lives, such as increased psychological distress from experiences of stigma, prejudice, and interpersonal or institutional discrimination, as described by the Meyer (2003) Minority Stress Theory (Russell & Fish, 2016). The real assault to injury comes when the members of this medically predisposed community are then rejected by the health care system, leading to even poorer health outcomes. It is in no way equitable to refuse care to an individual because of the stigmas of society that deem them “less worthy” than others.
Women of Color
Despite the fact that White women are more likely to report participating in risky behaviors such as smoking, excessive alcohol consumption, and other substance use, and are more likely to be diagnosed with cancer, they still see significantly greater health outcomes than WOC (NIH, 2014). In fact, contradicting the high rate of diagnosis, White women are the least likely to die of cancer among women of all races (NIH, 2014). Of the 157 million women in the United States, 56 million (36.1%) are WOC (NIH, 2014). The fact that, compared to WOC, White women are more likely to have seen a dentist in the past six months, are more likely to begin receiving prenatal care in the first trimester, and are less likely to be uninsured (and are more likely to have private insurance) could contribute to the incidence of worse health outcomes in WOC compared to White women (NIH, 2014). These statistics suggest that it is not simply race or ethnicity that predisposes certain people to worse health than others. Rather, it is human bias. While women already face greater disparities in health care than men, WOC have the added intersectional burden of the racial stigmas and prejudices of the health care providers impacting their treatment.
A 2014 study from the NIH showed that alcoholism most frequently occurs in American Indian and Alaskan Native people, with a staggering 25% higher occurrence in Native women compared to women of all races. As a result, American Indian and Alaskan Native women see higher death rates from alcoholism, cirrhosis, and other liver diseases. Additionally, the suicide rate of this population is 1.7 times the rate of the general population. This could potentially be in part a result of domestic violence being seen in 39% of Native women—the highest rate in the Unites States. Furthermore, Native women have higher rates of sexually transmitted infections (STIs), obesity, and diabetes than White women (NIH, 2014).
Unfortunately, only about one-third of Native women receive treatment for issues of disease and violence, citing lack of childcare, opposition from their partners, or fear of stigmatization as reasons for avoiding care (NIH, 2014). Native women have also repeatedly cited mistrust of health care providers and fear of facing prejudice as reasons they often avoid medical care (NIH, 2014). There is a reason for their fears, as there is a morbid history of unethical medical and health research done on Native people by European colonizers and the U.S. government. Not only were large populations of Native people wiped out by smallpox, but the U.S. federal government also conducted unapproved surgeries and sterilizations on American Indians until the 20th century (NIH, 2014). It is no surprise that while the Native populations see growing rates of cancer, they are extremely reluctant to seek the help of modern medicine for something they believe to be the “White man’s” disease (NIH, 2014). The fact that these women cannot trust the medical system to aid them without fear of receiving false information, bias, prejudice, or shame from their own community means that the American health care system is failing them.
There are 50.5 million individuals identifying as Hispanic or Latinx in the continental United States, 25 million of whom are women (NIH, 2014). Latina women are significantly more likely to have diabetes compared to White women, with a 66% higher risk of diagnosis than non-Hispanic Whites of the same age (NIH, 2014). Additionally, Hispanic/Latina women have higher rates of obesity, chronic liver diseases and cirrhosis, have a higher risk of mortality as a result of homicide, and are found to be less educated about sex and sexuality than men, leading to a greater risk of HIV/AIDS (Zambrana & Dill, 2006).
Hispanic/Latina women report that they often avoid accessing health care because they are more likely to encounter discrimination, prejudice, or exclusion based on language or skin color (Zambrana & Dill, 2006). Furthermore, it is noted that Hispanic households are more likely than White households to be headed by women, yet Hispanic women are three times as likely as White women and nearly twice as likely as Black women to be full-time workers and lack health insurance (NIH, 2014). In fact, Hispanic women are the group most likely to be uninsured among Americans under 65 years old, meaning that care is far more difficult to obtain (NIH, 2014). Thirty-two percent of Hispanic/Latina women report having delayed or forgone care because of cost (Zambrana & Dill, 2006). This means that not only is health care more difficult for Hispanic women to access, but that it is likely more difficult for their families to access as well.
As of the last U.S. census, Black or African American individuals made up 42 million people, 20.4 million of whom were women (NIH, 2014). The statistics and stigma surrounding the treatment of Black women in the U.S. health care system are perhaps the most well-known example of bias impacting treatment. It may not be surprising that Black women are more likely to die of a heart attack than White women (Chinn et al., 2020; NIH, 2014). However, the treatment disparity between Black and White women is far more extensive than it may first seem.
In a study conducted by the NIH (2014), it was found that Black women had a higher rate of mortality as a result of heart disease, cancer, stroke, HIV/AIDS, pneumonia, cerebrovascular disease, and diabetes than their White counterparts. Furthermore, Black women aged 20 years or older were 44.3% more likely to have hypertension than their White counterparts (NIH, 2014). This study also found a relationship between increased housing value and lower report of physician diagnosed hypertension—a major risk factor for coronary heart disease and cerebrovascular disease. It has also been found that Black women have higher rates of obesity and are at greater risk of delivering a low-birth-weight infant, a leading risk factor in infant mortality (Chinn et al., 2020). In fact, it is seen that 12.7 out of every 1,000 live births result in infant mortality for Black women, compared to 5.5 out of every 1,000 live births seen in non-Hispanic Caucasian women (NIH, 2014). Black women also see the highest neonatal and postnatal deaths (Chinn et al., 2020). Additionally, Black women are significantly more likely to contract sexually transmitted infections (STIs) than White women. Furthermore, 63.5% of HIV-positive women are Black or African American (CDC, 2019).
The summation of these results suggests that Black American women have more undetected diseases, higher disease and illness rates, and a greater rate of chronic conditions (e.g., hypertension and diabetes), which contribute to a shorter average lifespan disproportionate to income level (Chinn et al., 2020). Black women see lower rates of health insurance, with women of reproductive age (15–44 years old) experiencing the lowest rates (Chinn et al., 2020). Without insurance, one’s financial ability to access preventative care, routine screenings, or chronic condition management is severely reduced. In fact, 26% of Black women report having delayed or forgone care because of the associated cost (NIH, 2014).
Aside from cost, social factors play a large role in care as well. As described by the Meyer (2003) Minority Stress Theory, racism, prejudice, and race-based exclusion are important factors to consider when looking at the psychosocial stress that Black Americans experience. Increased daily stress can be considered a possible explanation for the higher prevalence of hypertension that is seen in Black women (NIH, 2014). Additionally, the bias of health care professionals can largely account for lack of equal treatment. A medical professional may withhold pain medication for a Black patient because they either believe falsely or were incorrectly taught that Black people can handle a higher pain threshold, or perhaps they falsely believe that Black people are more likely to abuse opioids (Chinn et al., 2020). A Black woman who comes into the emergency room with a myocardial infarction is often undiagnosed as a result of a provider’s bias or racial discrimination (Chinn et al., 2020). A heart attack is already more difficult to diagnose in women than in men; if Black women are negatively viewed as simply complaining, or being loud or obnoxious, diagnosis can become nearly impossible. A Black woman may sit in the emergency waiting room longer than a White man because the discriminatory bias of the provider causes the woman to be perceived as overly dramatic and not as serious of a case, and the condition of the woman worsens while treatment is mere feet away (Chinn et al., 2020). This treatment of Black women particularly relates to the origins of Intersectionality Theory, as the Combahee River Collective was a group of Black feminists who first described intersectionality in relation to their double marginalized position of being both Black and women (Trinh et al., 2017). It could not be any clearer from the statistics: Black women are disproportionately disadvantaged and discriminated against in U.S. health care.
Sexual Minority Women Of Color
As described by the Intersectionality Theory, adverse health effects can be further compounded in queer WOC who may face exclusion from the LGBTQ+ community as a result of their race, as well as rejection from their own culture as a result of their sexuality (Trinh et al., 2017). Black queer women are a staggering three times more likely to have a stroke than Black heterosexual women, despite the fact that strokes already disproportionately affect Black individuals compared to their White counterparts (Chinn et al., 2020). To further exacerbate this concern, Black SM women are less likely to have insurance than either Black heterosexual women or White queer women, and are therefore less likely to receive treatment if a physical ailment does occur (Trinh et al., 2017). It was also found that Hispanic/Latina SM women were less likely to have had a mammogram in the past year and were more likely to delay health care due to costs than their heterosexual counterparts, both of which lead to a greater risk of breast cancer (Zambrana & Dill, 2006). Additionally, of all HIV-positive transgender women in the Unites States, over 51% identify as Black or African American (CDC, 2019). As intersectionality theory describes, the unique stigma that surrounds people of color, queer people, and women combine to create the compounded plight of queer women of color in the American health care system.
A study published by Sekoni et al. (2017) examined the effects of educating medical professionals on the disparities between cisgender heterosexual individuals health care and LGBTQ+ health care. The medical professionals read journal articles on topics including stigma and discrimination, sexuality and sexual history, and LGBTQ+-specific health concerns. The participants in the study were assessed both before and after the period during which they received this education. The results showed that after education, the knowledge of the providers increased, and their attitudes were considered to have become more inclusive, though it was noted that there was uncertainty surrounding the best method to implement this educational process. Sekoni et al. (2017) believe that training will benefit both health care professionals and their patients, improving the quality of care for queer people.
Similarly, a 2018 study conducted by the American College of Physicians (ACP) examined discrepancies in U.S. women’s health care, causing this organization to put forth recommendations as to how to improve equality and patient outcomes (Daniel et al., 2018). The study examined the currently available legislation, literature, and other educational resources that are available with regards to women’s health care. The recommendations included comprehensive training of health care professionals on women’s health issues and changing public policy to ensure that affordable, accessible, and nondiscriminatory care is available to all women. Additionally, the ACP advocated for the autonomy of a woman to make her own health care decisions on issues such as reproductive rights and for the increased training of physicians for treatment of issues such as sexual or domestic violence and abuse. Perhaps the most impactful recommendation came in regard to biomedical research. The ACP concluded that women, as well as WOC and SM women, were significantly underrepresented in biomedical and medical research studies, leading to a reduction in the specificity of treatments available for the health concerns of women. Increased education provides a potential remedy to even the playing fields of health care. No longer would an individual have to face intersectional disadvantages, as providers would be equally knowledgeable on care for all genders, races, and sexualities. Improved quality of and access to care will allow people to meet their basic health needs, thereby providing them with a foundation upon which they can build up to self-actualization. Furthermore, educating providers will bring to light the moral discrepancies among the treatment afforded to minority groups and will hold providers ethically accountable to provide the best treatment of which they are capable.
Though over 7 million working-aged women in the United States have gained access to health care since the implementation of the Affordable Care Act (ACA), this may not be a long-lasting effect (The Commonwealth Fund, 2020). The Trump administration has indicated its intent to repeal coverage for maternity care and preexisting conditions, both of which will greatly affect women. The administration put forth a ruling in July 2020 on anti-discriminatory health care, in which the Department of Health and Human Services now only defines “sex discrimination” as applying to a person facing discrimination for the gender they were assigned at birth, not discrimination due to sexuality or sexual orientation (ACA, 2020). This rule is in essence combating one of the protections laid out by Section 1557 of the ACA, which prohibits discrimination based on race, skin color, nationality, sex, age, or disability (ACA, 2020). The administration has further indicated its desire to reverse the 2015 ruling of Obergefell v. Hodges, which legalized gay marriage (Obergefell v. Hodges, 2015). This would impact the legal rights of queer women to make medical decisions for their spouse, to be covered by the same insurance plan, and to utilize family planning options. Even though this administration is no longer in office, these events highlight some of the threats to health care that Americans have the potential to face if legislation is lacking.
It has clearly been shown that individuals who live with the intersectional positions of woman, queer, and person of color face worse health outcomes, higher rates of mortality, and higher rates of discrimination and prejudice at the hands of health care professionals than men, White individuals, and heterosexual individuals. This is further compounded in queer WOC, whose intersectional identity creates additional barriers between health care professionals and fair treatment. This is complicated by lack of access to affordable care and lack of provider knowledge on patient-specific issues. These factors can potentially be ameliorated by protective legislation and education of health care professionals. The notion that providers should treat a patient to the best of their medical ability applies to all people regardless of sexuality, gender identity, race, or ethnicity. It is quite plainly immoral to provide a patient with anything but the best treatment as a direct effect of one’s own bias, prejudice, or lack of desire to gain knowledge on patient-specific issues, as this inhibits an individual from accessing their basic right to health.
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