The LGBTQ Community & COVID-19: Seeking Solutions for Patient Safety

Dr. Shu:
Since patients who identify as LGBTQ live at the intersections of multiple marginalized identities, they might be less likely to say yes to the COVID-19 vaccine. Further complicating this is a fact that this patient population is more likely to live in poverty, lack access to medical care, and have paid medical leave. So what are some factors that are leading to these disparities? And how can we help keep our LGBTQ patients safe amid the pandemic?

Coming to you from the ReachMD studios, this is COVID-19: On The Frontlines. I'm Dr. Jennifer Shu. And joining me in this discussion is Dr. Ramiz Kseri, a dually board-certified Internist and Pediatrician and an Assistant Professor of Clinical Sciences at Florida State University College of Medicine. Dr. Kseri, welcome to the program.

Dr. Kseri: 
Thank you for having me.

Dr. Shu:
Now, Dr. Kseri, there are a multitude of layers that lead us to suspect that LGBTQ patients are at greater risk of both health and economic threats amid COVID-19. So can you give us an overview of the areas in which these individuals may be disproportionately impacted?

Dr. Kseri: 
That's a great question. Unfortunately, there are multiple areas where they are impacted. I'll take you back to March of last year when the lockdown order came. For a lot of LGBTQ plus members, their physical home environment might not be safe. So they're relied quite a bit on community resources and their chosen family and connecting with people. And with something like the pandemic where you're forced to be locked in at home at times in an unsafe environment, that definitely can take a toll on your mental health. That's at least one part of it.

And then the other part of it, especially when you talk about transgender patient and non-binary patients, is where's the access to care? Are they able to access telehealth? Are they able to get their hormone refilled? There has been a huge disruption to the health care of LGBTQ plus patients, generally speaking. But then on top of it, if you compound that with being somewhere, where I practice where it's a more rural area, and limited access to care, it just becomes very challenging for those patients to get the high-quality care they deserve.

Dr. Shu:
So you describe the domino effect that job loss can have on an individual's life, including loss of healthcare coverage. But can you explain why unemployment during the pandemic may be higher among LGBTQ individuals?

Dr. Kseri: 
So I'll just give you a story instead of an answer, how about that? Because it happened yesterday. I was taking care of a transgender patient. And I've been seeing them I would say for about three to four months at this point in time. And we were looking at their vitals generally, and I saw they gained quite a bit of weight in the past four months. Now, one of the simplest things is, you know, as clinician we recommend is increased physical activity. And this trans woman’s response to me was something that made me stop and pause and realize how privileged I am. Because I was asking her, is it possible for you to walk maybe 30 minutes around the block? And she looked at me and she goes, “I don't feel safe walking around by myself.” And that was a simple suggestion that I had for this patient. And it made me pause and realize this person cannot even walk outside the door just to have a simple walk to work on their health. So imagine the kind of prosecution those individuals get when it comes to employment, when it comes to really any service whatsoever. And on top of it, you know, again, circling back to my first answer, if you're in an unsafe home environment and end up leaving that environment, then you might leave it young, you might leave it as an adolescent without full education, without the necessary degree. And then with those hurdles in mind, how are you going to be able to get employment with those qualifications? So it's a vicious cycle that goes for the LGBTQ community between trying to get out of unsafe situation only to land in another unsafe situation.

Dr. Shu:
So what can you say about this vicious cycle and its impact on our patients mental health?

Dr. Kseri: 
I see it in my practice all the time. You know, some of the patients that I prescribe hormone for, when I first meet them, they say, “I came here ready to fight with you.” And I always find this to be kind of a little bit comical, because I say, “Why is that?” “Only because any time I've tried to get care, it's been so challenging, that my guards are up. Every time I go to a physician, I expect that you're going to make this miserable in order for me to see care.” And I see that level of burnout, and I see that level of exhaustion. And again, circling back to home environment, if they're in a situation where they're not able to escape, that can take a tremendous toll on your mental health. So that's why for me, I become a therapist, counselor, as well as a clinician, because I want to make sure if I'm the only outlet that the patient has, that it's a good outlet, that it’s a safe space, that the patient is able to at least unload and know if nothing else, one person in this world is advocating for them.

Dr. Shu:
You mentioned a little bit about burnout; what are you seeing in terms of depression, anxiety, maybe suicidal ideation or homicidal ideation in your patients?

Dr. Kseri: 
Honestly, it's through the roof all across the board. And this is not just LGBTQ patients. One of the things that is very hard to navigate, especially when we talk about LGBTQ patients, is body image. And just like the general population has dealt with a ton of weight gain, so did the LGBTQ plus population. So being able to navigate those conversations without sounding critical, without sounding judgmental, and with truly being motivational in terms of like genuinely care about your well-being and trying to lift someone up can be very hard when they're already down and depressed. And for the reasons you mentioned, lack of access to care, lack of job security, and sometimes lack of home security.

Dr. Shu:
Are you finding that pediatricians are having to prescribe more medications for anxiety and depression than pre-pandemic? Or are you still able to send them to psychiatrists, for example, for that kind of treatment?

Dr. Kseri:
I'm pretty comfortable in my own practice prescribing some of those medications. I think again, it goes back to access to care, right? So as I was telling you and the area that I'm in, it's very hard for me to get specialists to see some folks. And especially if someone is struggling mentally, if I send them to anyone, if they circle back and say like, “Yes, we'll see them in four weeks,” that becomes very hard because I need the patient to be seen right now. So sometimes I end up mitigating things myself where I might start a medication. And in the interim, have you come down, like for weekly checks, where I can do, you know, a safety assessment and make sure that the patient is safe just being at home by themselves. But generally speaking, I would say yes, there's has been a lot more anxiety all across the board. And I actually would say, almost all my patients, or 80% of them, get referred to counseling one way or the other just because people have a lot on their mind.

Dr. Shu:
Yeah, and we talked about a little bit about unemployment and employment before. I have seen patients having difficult transitions, you know, going virtual for working and then going back in person, and that goes for schools as well. Are you seeing that too?

Dr. Kseri: 
Yeah, there's something to be said about social anxiety, too, especially for folks who have been very diligent about following the CDC guidelines. You know, you've been cooped up in a space for a year. And now, a lot of places, especially Florida, we are pushing the envelope in terms of “returning back to normal” and some people might not feel, you know, emotionally and mentally ready for that. Because, you know, the vaccine rollout and the facts around the coronavirus have been very politically controversial that you can't really, move forward with the understanding that we're all on the same page because there are people who believe in the vaccine and people who don't. Or at least you try, but sometimes it's challenging.

Dr. Shu:
So let's talk about the COVID-19 vaccines for just a moment. Have you seen any resistance in particular in the LGBTQ community? And if so, what are the most common concerns that you hear?

Dr. Kseri:
I don't think that there is necessarily a concern; I think it's sometimes a dismissed population. So the problem that I see oftentimes, is that LGBTQ plus patients are just grateful to be seen by a provider, because you know, in the area that I'm in within a couple of hours of a driving distance, you literally can count them on one hand the amount of provider who would be willing to prescribe hormone-affirming therapy. So once you get those patients and they're actually part of your practice, there's a level of trust that you just cannot overlook. So when it comes to health screening and stuff like that, more often than not those patients are actually eager because previously they have been not given care or good care. So now that they're part of our clinic, and you recommend something that you're able to back up with data, I find a lot of folks are very agreeable to the vaccine.

Dr. Shu:
Excellent. And do you find that some of that might also have to do with the fact that the COVID-19 vaccine has been approved for use in adults for some time now?

Dr. Kseri: 
Part of it is that. Part of it is, to be honest, LGBTQ plus patients tend to be very smart. And I mean that in a way that they often deal with provider that doesn't know much about how to help them in terms of medically treating them. So a lot of those folks tend to be very well read. And when they come to the clinic, even if we're talking about transgender care, a lot of times I'm being taught by my patients, “Oh, there was a study that was done here, and it showed this,” or “Recently, I was in a conference and it said that.” So more often than not, I'm getting to learn from my patients, not the other way around.

Dr. Shu:
And just to bring this all together, Dr. Kseri, what advice can you share on how we can make a positive impact on our LGBTQ plus patients, both amid the COVID-19 pandemic and beyond?

Dr. Kseri: 
As cliche as it may sound, at the end of the day, we made an oath to treat patients, we didn't make an oath to treat a gender, a sexuality, a race, or religion. So every patient that walks through your door is a blank slate. And I think we're at a stage in our society and in medicine where saying I'm not comfortable is not enough. I personally don't have diabetes, but I don't have a problem treating diabetes. I'm a male doctor, and I treat female patients. Using the crutch of, “Oh, I don't know this,” is no longer acceptable. Doing LGBTQ care is just like the same as anything else in medicine. It’s not something that you know, but you definitely can learn and even be good at. It just takes an effort and initiative on your end.

Dr. Shu:
Well, it's clear from our discussion today that this patient population is at risk of a variety of health and economic threats, especially amid the COVID-19 pandemic. And I want to thank my guest, Dr. Ramiz Kseri, for joining me to share how we can help keep our patients safe. Dr. Kseri, it was great having you on the program.

Dr. Kseri: 
Thank you for having me.

Dr. Shu: 
I'm Dr. Jennifer Shu. To access this and other episodes in our series, visit ReachMD.com/COVID-19, where you can be part of a knowledge. Thanks for listening.