LGBT Health and Well-being
HHS LGBT Issues Coordinating Committee 2012 Report
HHS LGBT Issues Coordinating Committee
“It’s at the heart of the American dream: the belief that if you work hard, if you're responsible in your community, if you take care of your family, then that’s how you should be judged. Not by what you look like, not by how you worship, not by where you come from, and not by whom you love. This belief means ensuring that LGBT Americans have the same protections and opportunities as their neighbors, colleagues, and family members. And over the last three years, this Administration has undertaken a broad agenda to do just that.”
Secretary Kathleen Sebelius at the
White House LGBT Conference on Health
February 16, 2012
In April 2010, President Barack Obama asked Secretary of Health and Human Services Kathleen Sebelius to identify steps the Department could take to improve the health and well-being of lesbian, gay, bisexual, and transgender (“LGBT”) individuals and families. In response, Secretary Sebelius set up a Department-wide LGBT Issues Coordinating Committee, currently co-chaired by Assistant Secretary for Health Dr. Howard Koh, Administrator of the Administration for Community Living and Assistant Secretary for Aging Kathy Greenlee, and Deputy General Counsel Ken Choe (who replaced former Acting Assistant Secretary for Children and Families David Hansell). The Committee, on behalf of the Secretary, developed the Secretary’s Recommended Actions to the President to Improve LGBT Health and Well-Being (“2011 objectives”), which were sent to the President and released to the public in April 2011 (http://www.hhs.gov/lgbt/resources/reports/health-objectives-2011.html). As the Department continues its efforts in support of all communities, it is pleased to present in this report both its accomplishments from this past year and its goals for this coming year with respect to the LGBT community.
The Department’s 2012 objectives are as follows:
- The National Institutes of Health (“NIH”) will release a report that identifies the gaps and opportunities in its portfolio in light of the recommendations that the Institute of Medicine made in its 2011 report entitled The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. This report will inform NIH and the greater research community about important areas in which to advance biomedical research on LGBT health.
- Through the Ryan White HIV/AIDS Program’s Special Projects of National Significance, the Health Services and Resources Administration (“HRSA”) will award up to eight grants to organizations to support the development, implementation, and evaluation of interventions to improve timely entry and retention of quality HIV care for transgender women of color. The primary focus of this project will be to identify and successfully retain in care transgender women of color who are at high risk of HIV infection or are infected with HIV but are unaware of their HIV status; are aware of their HIV infection but have never been engaged in care; or have dropped out of care. This project aligns with the White House’s National HIV/AIDS Strategy which notes that “[s]ome studies have found that as many as 30 percent of transgender individuals are HIV-positive. Yet, historically, efforts targeting this specific population have been minimal.”
- Building on HHS’s existing anti-obesity efforts, the HHS Office on Women’s Health will fund pilot studies in five locations across the nation to identify and test effective and innovative ways of reducing obesity in lesbian and bisexual women. A 2011 Institute of Medicine report commissioned by the NIH highlighted obesity as a key research area in which to study lesbian and bisexual women. These populations have higher rates of obesity than heterosexual women, and little intervention research has been funded thus far to address these health inequities. The focus will be on women with risk factors for conditions that are caused by obesity, such as hypertension, diabetes, and back pain. Modifications to existing interventions in other areas – such as increasing physical activity and movement– may be tested.
- A number of Community Transformation Grant awardees under the Affordable Care Act have included LGBT communities among their target populations. The Centers for Disease Control and Prevention (“CDC”) will work with these grantees, including by providing additional funds, to assess the impact of chronic disease prevention programs on these communities. These assessments will provide much needed information regarding LGBT chronic disease prevention and health promotion.
- For the first time, CDC will release data from the National Intimate Partner and Sexual Violence Survey on sexual violence, stalking, and intimate partner violence by sexual orientation. Following the release of these data, CDC will provide resources that expand the visibility of these data for LGB communities and bring attention to these concerns more broadly.
- Building on HHS’ existing tobacco control efforts, the Food and Drug Administration (“FDA”) will launch multiple advertising programs targeted to a host of youth and young adult audiences who are at risk of using tobacco. FDA will be focusing on priority populations within the 13-17 and 18-24 year-old demographics, including LGBT youth, who have high prevalence of tobacco use. FDA will be developing integrated advertising campaigns, such as about the risks of tobacco use, designed to both prevent initiation and inspire cessation among these audiences. With every campaign FDA produces, formative research will be conducted among priority audiences to understand perceptions, opinions, attitudes, and beliefs around tobacco use. Insights from this research will lead to advertising designed to speak to these audiences in a relevant way so as to motivate attitudinal and behavioral change toward tobacco. Campaigns will then be run in paid media across all appropriate channels and platforms to reach priority audiences where they will be most likely to hear and engage with the messages. The ultimate goal is to educate at-risk youth and young adults about the dangers of tobacco to inspire them to live tobacco free.
- The Substance Abuse and Mental Health Services Administration (“SAMHSA”) and HRSA will create and execute a plan to disseminate existing tools to behavioral health and primary care practitioners to help them assess, treat, and refer LGBT clients in a culturally competent manner. SAMHSA will conduct a comprehensive review of LGBT cultural competency training curricula in place; will consult with stakeholder groups on critical components of provider training curricula designed to increase skills in delivering integrated health services to LGBT clients; and will fold LGBT issues into the current SAMSHA/HRSA-funded National Technical Assistance Center which is focused on the integration of behavioral health and primary care.
- The Administration for Children and Families (“ACF”) will take steps to establish core competencies and non-discriminatory service expectations for all runaway homeless youth program grantees that are inclusive of sexual orientation and gender identity considerations. The Office of the Assistant Secretary for Planning and Evaluation (“ASPE”) will disseminate resources and information on the intersection between LGBT youth and runaway and homeless youth on www.FindYouthInfo.gov, a cross-cutting federal website on youth issues. ASPE will also conduct research to further examine the health and human service needs of LGBT homeless youth. ASPE’s research will culminate in brief products written for a broad audience of stakeholders including policymakers, providers, and the public, which will be disseminated broadly.
- The Centers for Medicare and Medicaid Services (“CMS”), in partnership with the Administration for Community Living (“ACL”), will release a training video to educate long-term care ombudsmen, surveyors, healthcare providers, and state and local government officials about LGBT older Americans, the impacts of the social stigma on the community, and the rights of consumers in nursing homes, hospice, and home health care. The video will highlight best practices, identify resources to support LGBT older adults, and give instruction on what to do if one becomes aware of discrimination based on sexual orientation or gender identity. In addition, CMS will clarify its rules governing nursing home visitation rights, which are already in place and apply equally to those with same-sex domestic partners.
In addition, HHS recommits to its 2011 objective of increasing the number of federally-funded health and demographic surveys that collect and report sexual orientation and gender identity data.
The Department has satisfied its 2011 objectives and also advanced the health and well-being of LGBT Americans in many additional ways over the past year. Notably, work in many of these areas continues in 2012. To view the full list of HHS’ 2011 objectives, see http://www.hhs.gov/lgbt/resources/reports/health-objectives-2011.html.
Research suggests that LGBT individuals and families may face significant disparities in access to health care and health coverage. To begin to address some of these disparities, last summer, HHS announced plans to begin collecting health data on LGBT populations. Under the plan, HHS continues field testing on a sexual identity question, which will be integrated into the National Health Interview Survey in 2013. Also, HHS held two listening sessions with transgender health research experts and is continuing to discuss strategies and mechanisms for data collection on special populations. Notably, some HHS programs, such as ACF’s Runaway and Homeless Youth Program, HRSA’s Ryan White HIV/AIDS Program’s Special Projects of National Significance, and all SAMHSA grant programs that collect client-level data already collect gender identity data. The Department continues to evaluate the feasibility of expanded program-level data collection. The LGBT Data Progression Plan referenced above can be found at: http://www.healthcare.gov/news/factsheets/2011/06/lgbt06292011a.html.
Last year, the Institute of Medicine (IOM) released a report commissioned by the NIH on the state of research and science regarding the health needs of LGBT people. The report provides the NIH and the scientific community with the first comprehensive overview of health‐related research on LGBT health issues – an important step in identifying research gaps and opportunities. To address the IOM’s recommendations, NIH formed an internal committee to review the report and determine how NIH can strengthen LGBT health research. The NIH committee will release a report that includes a scientific portfolio analysis and identifies areas of opportunity in which to advance biomedical research in LGBT health.
Every ten years, HHS develops national, science‐based objectives for promoting health and preventing disease for the following decade. In 2010, as part of this initiative – “Healthy People 2020” – for the first time, a formal workgroup was established to examine scientific literature on LGBT health. As a result, Healthy People 2020 proposed the first-ever objective regarding LGBT health data collection. The objective has two sub-measures – one for LGB health data collection and the other for health data collection in transgender communities. Also, Healthy People 2020 held a webinar on transgender health in May 2012; the webinar is archived on the Healthy People website (http://www.healthypeople.gov/2020/connect/webinarsArchive.aspx). Additional webinars are planned for the coming year.
In April 2012, the Agency for Healthcare Research and Quality (AHRQ) released the 2011 National Healthcare Disparities Report, which focuses on disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations. For the first time, the report includes a focus on health care for LGBT populations. The report can be viewed online at: http://www.ahrq.gov/qual/nhdr11/nhdr11.pdf.
Since the Department released its 2011 objectives, agencies across HHS have worked to increase research funding related to LGBT communities. Numerous agencies, including NIH and HRSA, released funding opportunity announcements (FOAs) specifically focused on LGBT health. Other agencies, including ACF and SAMHSA, released FOAs encouraging LGBT community-serving organizations to apply.
LGBT Children and Families
In addition to the hospital visitation regulations that went into effect in 2011, HHS took steps to ensure equal treatment of LGBT children and families.
In April 2011, ACF issued an Information Memorandum to State, Tribal, and Territorial Agencies to encourage child welfare agencies, foster and adoptive parents, and others who work with young people to ensure that children, including lesbian, gay, bisexual, and transgender (LGBT) youth, are protected and supported while they are in foster care. The memorandum provides information on LGBT youth, workforce development, foster and adoptive parent training and recruitment, and the safety needs of LGBT youth in foster care and sets forth a list of resources available to child welfare agencies on LGBT issues and child welfare. The Information Memorandum can be located online at: http://www.acf.hhs.gov/programs/cb/laws_policies/policy/im/2011/ im1103.htm.
Federal law protects certain assets, such as a home in which a spouse resides, in the event that a married individual receives nursing home care through Medicaid. In June 2011, CMS issued guidance to states making clear that states have the flexibility to extend this protection to same‐sex domestic partners.
In September 2011, at the same time that CMS stepped up enforcement of hospital visitation rights, it also clarified that same‐sex couples have the same rights as other couples in terms of having a representative who can make medical decisions on an incapacitated hospital patient’s behalf, consistent with state law. Existing rules protect the rights of hospital patients to have representatives who can act on their behalf if they are incapacitated. CMS has updated the guidance explaining these rules to make it easier for family members, including same‐sex domestic partners, to make informed care decisions for loved ones who have become incapacitated.
In October 2011, HRSA issued Women’s Health USA 2011, the tenth edition of an annual data book identifying priorities, trends and disparities in women’s health. The 2011 edition featured data on the health of lesbian and bisexual women. The data book is available online at http://mchb.hrsa.gov/whusa11/.
Agencies across HHS continue to improve cultural competency with respect to LGBT populations among health care providers, HHS grantees, employees, and the greater health care community. As cultural competency trainings continue, HHS agencies are engaging in ongoing conversations about how to improve LGBT cultural competency across the country.
In September 2011, HRSA awarded a grant to the Fenway Institute to create a National Training and Technical Assistance Center to help more than 8,500 community health center sites improve the health of LGBT populations. The Fenway Institute is the research, training and policy arm of Fenway Health, a community health center that has served the LGBT community in Boston for over 40 years. The new center will offer training and technical assistance based on The Fenway Guide to LGBT Health, the only clinical text book on LGBT health, published in collaboration with the American College of Physicians in 2008.
Furthermore, HRSA held trainings for the National Health Service Corps to provide an introduction to culturally competent care for LGBT patients and to focus on strategies to ensure better service to these populations. HRSA also held a technical assistance conference call for health center providers that focused on the importance of recognizing and addressing the unique health experiences and needs of LGBT populations. Additionally, HRSA, through its Geriatric Education Program, provided a grant to address the cultural competency of individuals who provide geriatric care for elderly populations. A curriculum developed by Howard Brown Health Center of Chicago entitled “Health Education about Lesbian, Gay, Bisexual and Transgender Elders” has been presented to health care providers and was published in the Journal of Nursing Management in February 2012. Finally, HRSA continues to improve workforce outreach and recruitment activities related to LGBT communities in the National Health Service Corps scholarship and loan repayment programs.
Also in 2011, SAMHSA’s Center for Substance Abuse Treatment re-released A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals, a publication that seeks to inform administrators and clinicians about appropriate diagnosis and treatment approaches that help ensure the development or enhancement of effective LGBT-sensitive programs.
SAMHSA also released the Top Health Issues for LGBT Populations Information & Resource Kit, a publication for health care providers and prevention specialists about health experiences of LGBT populations, which includes health information sheets and a PowerPoint presentation.
SAMHSA created Larkin Street Stories, a new three-part video series that offers tips on best practices for providers serving homeless LGBT youth and their families. The series features LGBT youth talking about their experiences coping with bullying, homophobia, and hate speech between youth, and effective strategies on how to respond to them.
SAMHSA and HRSA held a joint listening session in November 2011 to discuss LGBT cultural competency with health care providers. Participants heard from stakeholder organizations about training challenges for providers, strategies that are needed to increase culturally competent care for LGBT patients, advancing cultural competency through health professions trainings, and using health professions grants to encourage inclusion of cultural competency materials.
HHS also encouraged its employees to participate in LGBT cultural competency trainings. The sessions increased awareness and educated employees on sexual orientation and gender identity and provided employees with information regarding current sexual orientation and gender identity anti-discrimination requirements.
HHS and its agencies continue to address discrimination, harassment, and violence against all individuals, including LGBT individuals, through domestic violence and other violence prevention programs.
In May 2011, ACF’s Family Violence Prevention and Services Program (“FVPS”) published a series of FOAs for FVPS National and Special Issue Resource Centers. Each FOA included language about LGBT populations. Additionally, ACF released FOAs for $18 million to provide shelter services as an alternative for runaway and homeless youth and for $2 million to conduct outreach designed to build relationships between grantee staff and runaway, homeless, and street youth. All of these FOAs required that applicants document both their ability to adequately train staff on LGBT youth issues and their policies that prohibit harassment based on sexual orientation and gender identity.
As part of the anti-bullying task force “Federal Partners in Bullying Prevention, Intervention, and Recovery,” HHS continues to work with other federal agencies to address bullying. Through the task force, HHS participated in two Federal Youth Bullying Prevention Summits. In September 2011, Secretary Sebelius provided the opening keynote at the second annual Federal Youth Bullying Prevention Summit, and numerous HHS employees led workshops and engaged in dialogue with youth, parents, teachers, community leaders, and non-profit organizations.
As part of this effort, federal anti-bullying activities across the government were consolidated, and a new website – www.stopbullying.gov – was created. HHS launched the website on March 9, 2011, and, the following day, Secretary Sebelius participated in the White House Conference on Bullying Prevention to further highlight the importance of making schools and communities safe for all students. HHS recently re-launched www.stopbullying.gov with new resources and updated information for LGBT youth.
Lastly, through a cross-departmental public-private partnership, the National Action Alliance for Suicide Prevention coordinates suicide prevention efforts, particularly among at-risk groups such as LGBT youth. SAMHSA leads a task force on LGBT Youth Suicide, which recommends ways to improve the National Strategy for Suicide Prevention to prevent LGBT youth suicide.
The Affordable Care Act
The Affordable Care Act benefits LGBT Americans like all other Americans. Many LGBT Americans, including LGBT seniors, have access to free preventive services; LGBT youth without their own coverage can stay on their parents’ health plans until they turn 26; and many LGBT Americans living with pre-existing conditions, such as those living with HIV/AIDS, can obtain health insurance under the Pre-Existing Condition Insurance Plan (www.pcip.gov). In 2014, Affordable Insurance Exchanges and the expansion of Medicaid eligibility will help LGBT Americans access affordable health care coverage. The Affordable Care Act will fill current gaps in coverage by expanding Medicaid eligibility to millions of Americans previously ineligible, including, for the first time, adults who are childless and do not have disabilities. To help LGBT Americans understand the benefits of the health care law, HealthCare.gov has a fact sheet about how the Affordable Care Act helps LGBT Americans. See www.HealthCare.gov/news/factsheets/new_options_for_lgbt_americans.html.
As noted above, in 2014, one-stop marketplaces known as Affordable Insurance Exchanges will allow individuals, families, and small businesses to choose a private health insurance plan from the same range of options as members of Congress. In March 2012, HHS released a final rule to provide states with the guidance they need to establish and operate the Exchanges and certify the qualified health plans that will be offered in the Exchanges. In that rule, HHS prohibited discrimination by Exchanges on the basis of, among other things, sexual orientation or gender identity. The rule also prohibits qualified health plans from discriminating because of, among other things, a person’s sexual orientation or gender identity.
To improve access to information about new programs, benefits, and rights under the Affordable Care Act, HHS launched www.HealthCare.gov in 2010. The new website provides consumers with information and resources that can help connect them to quality, affordable health coverage along with up-to-date information about health care reform and access to consumer-friendly tools to help them understand their health insurance options and compare health care providers. Based on feedback from LGBT stakeholders, in September 2011, HealthCare.gov began providing information about same-sex domestic partner coverage in the health coverage finder with respect to small business health insurance plans. In February 2012, the health coverage finder was updated to include information about same-sex domestic partner coverage with respect to plans available on the individual market as well. To access this feature, go to http://finder.HealthCare.gov.
In addition, the Affordable Care Act is funding preventive efforts for communities, including millions of dollars to use evidence-based interventions to address tobacco control, obesity prevention, HIV-related health disparities, better nutrition and physical activity. The Affordable Care Act is making other investments that will help improve the health of LGBT communities. Funding is going toward building a more diverse and culturally competent health care workforce, as well as investing in community health centers to serve millions of more patients.
HHS Funding Opportunities
Throughout 2011, various HHS agencies reached out to LGBT community-serving organizations through listserv messages, social media, stakeholder engagement, and conference exhibits to highlight funding opportunities that could benefit LGBT communities and to help these organizations understand how to apply for HHS competitive grants.
HHS held two workshop sessions at the first ever White House Conference on LGBT Health to provide information about how to participate in the grant funding process. In addition, SAMHSA and HRSA broadly disseminated HRSA’s webinar on “Navigating and Preparing a HRSA Application: Responding to a Funding Opportunity Announcement” to LGBT-serving organizations.
Some of HHS’ grant making agencies updated their policies and funding opportunity announcements to include LGBT populations, as appropriate. HRSA issued an internal grants policy on cultural competency that is inclusive of sexual orientation and gender identity and updated its health center program application to include LGBT in the list of populations served by community health center applicants.
SAMHSA encouraged that all Substance Abuse Prevention and Treatment Block Grant applications and the Mental Health Block Grant applications consider and include the evolving needs of LGBT populations in program design, implementation and reporting. SAMHSA also included LGBT populations in a funding opportunity announcement to develop a comprehensive strategic plan for improving and expanding services provided by systems of care for children and youth with serious emotional disturbances and their families.
Through two of its funding opportunity announcements that target homeless and runaway youth, ACF required applicants to document their policies and procedures for ensuring competence in serving LGBT youth. ACF’s Office of Refugee Resettlement identified LGBT refugees as a vulnerable population in need of targeted services.
In February 2012, NIH reissued a program announcement, Research on the Health of LGBTI Populations, seeking applications for basic, social, behavioral, clinical and health services research relevant to the missions of the sponsoring Institutes and Centers and the health of lesbian, gay, bisexual, transgender, intersex (LGBTI) and other sexual and gender minority populations.
In the last twelve months, HHS has provided support for LGBT organizations across the country. To highlight some examples, the following competitive grant awards were announced:
- HRSA awarded health center planning grants to Mazzoni Center of Philadelphia and the AIDS Foundation of Chicago. The awards will fund both organizations as they seek to provide a more comprehensive range of primary health care services and expand their services to the larger community. These grants are part of awards that aid 129 organizations across the country.
- SAMHSA announced new grants to provide behavioral health services in communities most impacted by HIV/AIDS over a three-year period. These grants are part of the funding for the “12 Cities” program, which is being used to develop and expand networks of primary care, HIV/AIDS and behavioral health service providers serving racial and ethnic minorities, including LGBT individuals, with or at high risk for HIV/AIDS. As part of this new funding opportunity, staff working with providers serving LGBT clients in this program will receive training to assure the delivery of culturally relevant services to them.
- SAMHSA’s Garrett Lee Smith Suicide Prevention grant program, funded in part by the Affordable Care Act Prevention and Public Health Fund, awarded 38 new grants for state and tribal suicide prevention. Ten of these grants will include a focus on LGBT youth utilizing some of the following activities: outreach to LGBT-focused organizations, development of a web presence/Facebook page focusing on LGBT youth suicide prevention, and adaptation of best practices in suicide prevention to be culturally relevant to the LGBT population.
- ACF announced the creation of a first-ever training and technical assistance center to support the resettlement of LGBT refugees, which will be housed at the Heartland Alliance of Chicago.
- ACF awarded grants to the LA Gay and Lesbian Community Center to conduct street outreach to LGBT homeless youth.
- SAMHSA in partnership with the Administration on Aging announced new grants to prevent suicide and prescription drug misuse by older adults in five communities. These grants are designed to enhance the array of behavioral health services offered by the programs receiving the grant awards. Of the five grants awarded, two are specifically addressing the needs of LGBT elders. Jewish Family Service of Los Angeles will expand its W.I.N. II program to include a focus on the prevention of suicide and prescription drug misuse and abuse among older adults. The Montrose Counseling Center in Houston, Texas also received an award for its Seniors Preparing for Rainbow Years (SPRY) program. The SPRY program aims to raise awareness among LGBT seniors about suicide prevention and prescription drug misuse; screens disenfranchised seniors for depression symptoms and alcohol use; and intervenes and educates LGBT seniors identified with depression symptoms and prescription drug misuse risk through case management.
Throughout the year, Secretary Sebelius, other senior HHS officials, and HHS regional offices placed a focus on improving outreach to the LGBT community. Outreach efforts included sharing information not only about HHS’s activities to improve LGBT health and well-being, but also about funding opportunities for LGBT community-serving organizations and the effects of new programs, benefits, and rights under the Affordable Care Act and other HHS priorities on members of the LGBT community. Finally, HHS made a concerted effort to receive input and feedback from stakeholders across the country on how to improve LGBT health.
In February 2012, HHS partnered with the White House Office of Public Engagement and Mazzoni Center to co-sponsor the first ever White House LGBT Conference on Health in Philadelphia. More than 300 people attended the event at Thomas Jefferson University. The conference included workshop sessions focused on LGBT aging, LGBT youth, substance abuse and mental health in LGBT communities, LGBT cultural competency, HIV/AIDS, transgender health, and health care reform.
Secretary Sebelius and other senior HHS officials spoke about ongoing LGBT-related health work, funding opportunities, and other HHS initiatives at a range of conferences, including the annual meetings of the National Coalition for LGBT Health and the Gay and Lesbian Medical Association and the biennial meeting of the World Professional Association for Transgender Health.
Finally, HHS held more than a dozen regional listening sessions across the country to solicit input and feedback on the Department’s work toward improving LGBT health.
The Department of Health and Human Services is committed to continuing its work to improve the health and well-being of all LGBT Americans. While the Department has made significant strides with regard to LGBT health, we realize there is still much work to be done. We will continue this work in 2012 and beyond – and we look forward to the continued engagement of LGBT health experts, advocates, and community members in addition to health care providers and other partners who work hard every day to address health concerns in these communities.