- About 4.5% of Americans identify themselves as either lesbian, gay or bisexual, while another 0.3% identify as transgender.

Individuals who identify as LGBT or people who come from all different economic backgrounds.

They are of all races, ethnicities and religion.

The show will focus on health, equity and the existing barriers to health care access in the LGBTQ community.

Before we begin, we would like to share a video with you.

Dr Rachel Levine, the Pennsylvania health secretary a highly visible trans woman leading the fight against Covid-19 in Pennsylvania, was a victim of transphobic social media attacks last summer.

She not only addresses her harassers, but all Pennsylvanians to come together in unity, to fight discrimination and create a welcoming atmosphere for the LGBTQ community.

- I call on you and all Pennsylvanians to work towards a spirit of not just tolerance, but a spirit of acceptance and welcoming towards LGBTQ individuals.

- Welcome to A Su Salud, Cheers To Good Health.

I'm your host, Genesis Ortega.

We're broadcasting from inside the PPL Public Media Center in Bethlehem, Pennsylvania.

Joining us today is returning guest Dr Tyler Gifford.

Dr Gifford is a gynecologist and obstetrician with St Luke's University Health Network.

It's nice to see you again, Dr Gifford.

Thanks for joining us.

- Thanks for having me.

- Let's start here.

Dr Gifford, you know, the LGBTQ community and health equity.

In your opinion, how does the medical profession fare in this area?

- This is kind of a hot topic right now, it's something that we are actively working on improving, that is our access to care and our awareness of the inequalities and health equity for the LGBT community.

So it's very good timing that we talk about this on the air.

- To your knowledge, what type of training or instruction is available as far as working with the LGBTQ community as a health professional?

- We at St Luke's are actually in the process of doing diversity, equity and inclusion training as a formal part of the medical education curriculum.

So that is an ongoing process that involves both the the residents as well as the physicians.

So we recently had a session led by a professional trainer in this area, and this was a chance for us to learn how to use the right words, to talk to our patients about LGBT issues, specifically about sexual orientation and gender identity, acknowledging the importance of knowing this information for our patients because it will allow us to provide better care to them.

- So let's break down some of these concerns.

You know, there are some patients that fear discrimination from their health care providers if they disclose their sexual practices.

I mean, is that fear justified?

- That's definitely justified based on the history of what has happened in the medical profession, and we have a job to do to compensate for that and to help allay those fears.

And sometimes that means talking directly with our patients, as we often do about those issues, and sometimes it means being ready and receptive to questions on a more confidential level.

I think one important principle is to make sure that this is something that we talk about with everyone.

And one way that we do that and that we use technology to our advantage is to ask some private and important screening questions at the beginning of an encounter in a confidential way.

So through a computer or online or with a questionnaire, we can do optional questions that can teach us some valuable information about our patients' health.

- Dr Gifford, what are the health care barriers for the LGBTQ community?

- There are both social and medical barriers, for example, insurance may not cover necessary treatment like hormone therapy or gender confirmation surgery or even infertility treatments for same-sex female couple that's looking to conceive.

And then there are barriers based on concern for discrimination or not feeling comfortable talking to your doctor about your sexuality, sexual orientation, gender identity, etc.

- That's a good point.

I mean, what about gender identity?

How does that factor into this conversation?

- In order for us to take good care of our patients, we need to understand their health.

Their specific needs and their risk factors, and that includes gender identity, which is a very important part of our identity as people and does play into risk factors for health in general.

Unfortunately, minorities and members of the LGBT community are at increased risk of adverse health outcomes.

That could be drug and alcohol and substance abuse.

It could be specific health problems, could be mental health, depression and higher risk for suicide.

These are all things that we need to be attuned to and be proactive about helping to treat.

- Good mental health I know is important for everyone, but especially for the LGBT community.

I mean, how how can how can people who identify as LGBT deal with depression, deal with loneliness or even substance abuse?

- Well, I think especially with Covid and all the changes that have come with how we interact with one another and how we get care and mental health is a perfect opportunity to provide care in multiple platforms.

Sometimes it can be face to face, but it can often be done really well remotely by phone or by video.

This is a major pillar of the foundation of taking care of the LGBT community and that we are working on an offering that care in multiple ways, whether that's in person or online.

- Now, Doctor, we're running out of time, but I do want to end on this very important note.

I mean, mental health overall for everyone, you know, has been at the forefront of this pandemic.

But for the LGBT community, I mean, has Covid-19 affected any other areas of health?

- I mean, it's affected pretty much every part of our life from our ability to go shopping and get healthy food to our ability to seek preventive care, which is a really important part of staying healthy to our ability to see our doctors face to face.

I think one important thing about good health care is that it's based on relationships.

And as a member of the LGBT community myself, I try to use that to my advantage in making relationships with my patients.

And studies have shown that a stronger relationship between a doctor and a patient and a patient being able to identify and see elements of themselves in their provider leads to better outcomes, better compliance and better health overall.

So despite all the barriers of Covid-19, I think it's important to think about relationships and all the positive that can come from knowing your doctor and letting your doctor know you.

And and that's what this is about.

- Well, I appreciate your time.

That's a great note to end this interview on.

I know just before we brought you on, you brought a baby girl into this world.

So go back to bringing babies in.

And thanks again for your time.

- Thanks, Genesis.

Thanks for having me.

- Take care.

A new statewide health assessment for the LGBTQ community reveals ongoing challenges right here in Pennsylvania.

The assessment is thanks due to a partnership between our next guest and the Pennsylvania Department of Health.

Adrian Shanker is the founder and executive director of the Bradbury -Sullivan LGBT Community Center in Allentown.

Thank you, Adrian, for joining us today.

- So glad to be here with you today.

- Let's get right into it, Covid-19 a part of this conversation stems from the fact that there are disparities brought to light by the pandemic.

And because you are an expert with the latest statewide health assessment, can you just explain to us how Covid-19 has impacted the LGBTQ community?

- Yeah, and to be sure, I mean, Covid-19 is a dangerous virus that is challenging for all of us in different ways, right.

But Covid also has unmasked the existing disparities that were already keeping marginalized and minoritized communities from achieving the dream of health equity.

And for LGBTQ Pennsylvanians, it looks it looks very similar to what we're seeing with other marginalized communities as well.

And so for Covid-19, we know that this is a respiratory virus and LGBTQ community members consume tobacco at more than double the rates of the majority population.

Early indicators from Covid-19 research has shown that smokers receive worsened health outcomes from Covid than nonsmokers.

So that's one, and also many more LGBTQ people are living with immunocompromised bodies from cancer and suppressed HIV than the majority population.

So many more of us are at risk of experiencing worse effects of the virus.

And then the one other piece that's really important is that in the beginning of the pandemic, we were all told, you know, if you feel sick, go to your doctor.

But as our needs assessment shows, a lot of LGBTQ+ people don't have a doctor.

About one in five LGBT Pennsylvanians doesn't have a primary care doctor.

So when we...

It's actually more than that.

It's actually a quarter of LGBT Pennsylvanians don't have a primary care doctor.

So who are they supposed to call, right?

And I think that we have to remember that this is a pandemic that is affecting everyone.

And it's also a pandemic where some communities are more vulnerable to being left behind throughout this process.

And our whole society has to come together to ensure that, you know, that all of us can navigate this pandemic in equitable ways.

- Now, you listed some, but when it comes to the LGBTQ community, what are some barriers to care?

- Yeah, there's a variety of barriers to care.

Maybe I should quickly define that term.

So when we say barriers to care, we mean we mean structural things that prevent LGBTQ+ people or all people from achieving that dream of health equity, from achieving access to the care that we need.

And for LGBTQ Pennsylvanians, barriers to care can look like a lot of things.

It can look like geographic barriers to care, meaning that maybe, maybe there's a transgender person living in a county where there isn't a trans-affirming therapist in that county.

Well, right now, Pennsylvania's telework expansion doesn't allow for insurance coverage across county lines.

So, that's a barrier to care.

Another barrier to care would be intake forms that that require that people describe themselves in ways that don't reflect who they are or how they perceive themselves to be.

Those intake forms can can mean that LGBT people don't want to seek care from certain providers.

And when I say restrictive intake forms, I mean questions that ask, you know, that ask about our relationship status or our family status or our gender or sometimes even our name in ways that don't reflect how our community sees ourselves.

These are barriers to care.

And when these barriers to care add up, sometimes they look like small things.

But when they add up all together, what the impact of that is, is that LGBTQ+ people are much less likely to seek health care than the majority population.

And when we when we don't seek preventative care, we end up not being able to detect things that require treatment until sometimes when it's too late.

So these barriers to care can lead to very serious, worsened health outcomes if we don't address the barriers to care head on.

- Now, Adrian, one thing that stood out at me when I took a look at the assessment was that a little over a third of the community doesn't feel that their physician has the medical expertize related to their needs as an LGBTQ person.

I mean, is there a solution for that?

- Yeah, training.

Medical providers receive training every year they're required to to to receive continuing medical education.

Nurses receive continuing nursing education, social workers and counselors receive continuing education every year.

We need for some of this training to be focused on LGBT medical needs.

An example is that many primary care clinicians in the Lehigh Valley say that they're not... That they don't know how to prescribe PrEP or pre-exposure prophylaxis, a once-a-day pill to prevent the spread of HIV.

And there's really no reason why a primary care doctor can't be the the prescriber of PrEP.

Most people don't have an infectious disease doctor if they are not already living with an infectious disease.

So the relationship with the primary care doctor is really important.

But there's there's a knowledge gap.

There's there's many other examples as well where, you know, an endocrinologist that frequently provides hormone therapy for the majority population will tell transgender patients that they don't know how to provide hormone therapy for transgender patients.

Hormone therapy is hormone therapy.

Really what it requires is learning about the community and learning about some of the community's needs.

And, yes, there are some specific medical needs that need to be learned as well.

But all of this can be addressed through better training.

- OK, one other thing which is striking.

Over 70% of the LGBTQ community have said that they faced or experienced mental health challenges.

Would you say that acknowledging these challenges is an issue?

- So acknowledging the challenges is not the issue we want.

We want to have open conversations about mental health.

We need to destigmatize mental health in our community and in our society.

So it's actually very important that people talk about mental health challenges openly.

What is challenging is that of the 70%, you know, 30% have not received counseling or mental health treatment in the past year.

So, you know, three of those seven out of ten people have not received mental health counseling or treatment.

That is a really big challenge.

That's the difference between acknowledging mental health challenges in our community and barriers to care to accessing mental health services and treatment.

And what what we need is to remove those barriers.

We need to improve the access to mental health care.

We need to have better referral relationships established.

And we need to ensure that mental health services that do exist are provided in an LGBT medically and culturally appropriate way to really address the mental health needs in the LGBT community and broadly in our whole society.

- Well, thank you, Adrian, for sharing your insight with us today and the work that you're doing and the work that the center is doing.

Keep it up.

Thank you.

- Thank you.

So nice to be here with you.

- Our next guest is a 58-year-old preoperative trans woman named Jodi Lynn Devine.

Jodi is here to tell us her story and share her experiences with health care since living her life as a trans woman.

Thanks for joining us today, Jodi.

- Oh, you're welcome, thank you for having me.

- Before we jump into the interview, why don't we start here?

Can you take a few minutes to tell us about your story and your journey, how long you've been living as a trans woman?

- Oh, yeah.

Um.

I've always known that I was different.

And about four years ago in 2016, I separated from my wife.

And decided that I was going to be true to myself.

So I started going out dressing up as a woman and meeting people and going to support groups.

And then in...

The early part of 2020 when I lost my job, I decided that I was going to go whole hog and start living as the real me.

Instead of being 50/50 guy at work girl after work, I decided to be a woman full-time, living and working with my true persona.

And so far to date, I have no regrets.

- Does your health care provider know have they walked you through this process as you've become a trans woman?

- Yes.

My health care provider, my PCP, and his office has been very supportive.

They, um...

They have...

Accepted me, they've used proper pronouns and they've treated me with the utmost respect as a patient.

- What medical concerns have you experienced that might be unique to your situation?

- Medical concerns would be by heart.

My family has a history of heart problems, and sometimes hormones can affect your heart and how it functions.

And it's a concern I brought up with my PCP and they have monitored me closely.

And so far, there are no problems, no complications.

- It's great to hear that you have a great relationship with your doctor, with your PCP.

You know, unfortunately, there are cases of people that don't have that same experience.

And I'm curious, I mean, have you heard from anyone or do you know anyone that has had a negative experience?

- Yes, I actually know a few trans women that have had negative reports about how they've been treated medically.

One trans woman I know, her doctor would not prescribe her hormones that she requested.

And in desperation, she went out-of-system, offline, and purchased out-of-country hormones.

Without doctor supervision, she ended up having a stroke due to the medication she was taking.

She's still recovering.

Wow, now, Jodi, how important is it to you that your medical providers respect you?

- It is important.

It's a scary thing.

When you go to your doctor the first time and you're presenting as a gender you were not assigned at birth.

I spoke to my doctor's office prior to my first visit as a trans woman and explained to them who I was and what I was doing, but it was still nerve racking.

You know would they treat me with respect, would they laugh at me?

What would other patients in the waiting room think?

And how would they act?

And I was very happily surprised to be treated just like any other person.

- Now, Jodi, besides the physical health issues, I mean, as a trans woman, have you experienced any issues with your own mental health or do you know anyone who has?

- Several trans women I know, and trans men...

Suffer from... Several mental health issues.

Depression is very common.

As a trans woman, we undergo stressors that the common person doesn't have.

For example, a gay or lesbian person, you wouldn't be able to tell they were gay or lesbian just by looking at them.

But If you saw me walking down the street, you'll say, "Oh, that must be a trans person."

So there is a lot of stress, there is a lot of mental health issues.

It's I think, the number one concern for the trans community.

I know several people who have repeatedly been in psychiatric treatment for self harm due to conditions around being transgender.

- What are some ways, not only for yourself, but that you would recommend other people to be more welcoming?

- Um...

Accept people for who they are.

If someone tells you, for example, "I'm a Republican," you don't turn around and say, "Oh, no, you're not.

"You're not really a Republican."

If someone tells you they're transgender, accept it.

Don't try to dictate to them who they are.

I've been very fortunate that I have not had any negative encounters.

But it's not so much the question collection of if but when.

Eventually, I'm going to run to somebody who's very hostile and I have to know how I'm going to deal with that when it happens.

I know several people who've been assaulted because of who they are.

And you're not monsters some people make us out to be.

- What suggestion, I mean, as we're talking about health care, do you have any suggestions from those conversations that you've had with other trans men and trans women about how members of the medical profession can better treat their patients?

- I think there is still a lot of ignorance in the medical community regarding trans people.

Not a lot of physicians have experience dealing with us, you know, so for them, it's, "I don't know what to do.

"Is there anything physically wrong with you?"

You know, "How do I treat you?"

You know, "Do I call you Ms or Mr?"

But like I said, in my experience, I haven't had any negative experience with the medical profession, but there is a lot of education that needs to be done even in the medical community.

They don't quite understand us or how we came to be.

I couldn't tell you, I couldn't tell you why I am the way I am now.

So it's even more difficult for a doctor to say "You're this because A, B and C." - There's still a lot of work that needs to be done, like you said, Jodi.

But let me ask you this.

I want to end on this.

We're running out of time.

What else would you like to say?

What would you like for people to know overall?

What's what's your main message?

- My main message is that we're people.

We... Feel.

We hurt.

We have wants, you know?

I was questioned by a woman.

Who I've known for many, many, many years who asked me if her children were safe around me.

And my response to her was, "I don't spend two and a half hours getting pretty "to chase after little boys or little girls."

You know, some people consider trans people and pedophiles to be the same.

And we are worlds apart.

I think a lot of people can't wrap their heads around the idea that somebody who was born and assigned as a certain gender wants to... jump ship, so to speak, and join the other team.

They don't understand it.

And people fear what they don't understand.

So I try in my daily interactions with people to be somewhat of an ambassador for the trans community, I try to present myself the best I can and show people that I'm just like them.

- Well, Jodi, I appreciate your time today and sharing your story as a trans woman and that message, we still have a long way to go.

But, you know, the first step is just talking about it and educating people.

So I appreciate you coming on and being an ambassador for the trans community.

- Well, thank you very much.

And thank you again for having me on.

- I want to thank our St Luke's University Health Network expert, Dr Tyler Gifford, and our other guests, Adrian Shanker and Jodi Lynn Divine for being with us today.

And thank you for tuning in.

We look forward to seeing you again soon.

If there is a medical subject, you'd like for us to cover send me a message on social media.

You can find me on Facebook and Instagram.

Plus, you can tune in to hear more of my reporting on 91.3 FM, WLVR News, your local NPR news source.

I'm Genesis Ortega and from all of us here at Lehigh Valley Public Media, stay safe, be healthy, and cheers to your health.