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Download the full report in English. A substantial body of research indicates that lesbian, gay, bisexual, and transgender LGBT populations across the United States encounter ificant barriers to health care. Many LGBT people have difficulty finding providers who are knowledgeable about their needs, encounter discrimination from insurers or providers, or delay or forego care because of concerns about how they will be treated. In the absence of federal legislation prohibiting healthcare discrimination based on sexual orientation and gender identity, LGBT people are often left with little recourse when discrimination occurs.

In Maythe US Department of Health and Human Services HHS aled it would roll back regulations that prohibit discrimination against transgender people in federally funded healthcare programs. At the same time, HHS has recently proposed regulations that would give providers wide latitude to discriminate or refuse to provide certain key services to LGBT people, women, and others by asserting a moral or religious objection. Together, these developments threaten to exacerbate the barriers to care that LGBT people already encounter, and give insurers Women Slovakia wanting sex providers who would deny services to LGBT people, women, and others a to discriminate against them.

This report documents some of the barriers that LGBT people face in obtaining health care, and the toll that sweeping moral or religious exemptions can take on the health and well-being of those who are turned away by providers.

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It illustrates the scarcity of competent healthcare services for LGBT people in many states, the discrimination that LGBT people too often experience from providers, and the ways that negative experiences can deter LGBT people from seeking and obtaining the care they need. The rollback of federal healthcare antidiscrimination protections and the expansion of religious exemptions for healthcare providers are each likely to impede LGBT people from obtaining healthcare services. Taken together, these moves will be devastating for many LGBT people, women, and others.

Lawmakers at the federal, state, and local levels should enact laws and regulations that expressly prohibit discrimination based on sexual orientation and gender identity in health care, and should repeal or revise sweeping religious exemption laws that allow insurers and providers to deny healthcare services to LGBT people and women seeking reproductive care. Human Rights Watch conducted the research for this report between August and July To identify interviewees, a researcher conducted outreach through national and state LGBT groups, legal advocates, and service providers who circulated information about the project to their networks.

The outreach for this report primarily focused on Mississippi and Tennessee, two of the states where statewide antidiscrimination protections do not prohibit discrimination based on sexual orientation and gender identity and where lawmakers have recently enacted exemptions permitting some providers to refuse service to LGBT people because of their religious or moral beliefs.

A researcher conducted a total of 81 interviews specifically related to healthcare discrimination, including 33 with individuals who said they had been discriminated against in medical settings and 48 with advocates and providers working with affected individuals. Most interviews were conducted in person from November to Februarywith additional interviews conducted by telephone. No compensation was paid to interviewees. The researcher obtained verbal informed consent from interviewees, and notified interviewees why Human Rights Watch was conducting the research and how it would use their s, that they did not need to answer any questions, and that they could stop the interview at any time.

Interviewees were given the option of using pseudonyms in published materials for the project; where pseudonyms are used in this report, that is reflected in the footnote citation. Under the Obama administration, US federal agencies issued a series of rules and regulations prohibiting discrimination based on sexual orientation and gender identity in federally funded programs.

The Departments of Education, Justice, Housing and Urban Development, and Health and Human Services, among others, issued guidance or regulations clarifying that discrimination based on gender identity is impermissible as a form of sex discrimination under federal law. Sincethe Trump administration has undercut or outright reversed many of these steps, rescinding guidance protecting transgender youth in schools, [2] delaying implementation of regulations protecting transgender people experiencing homelessness, [3] and opposing inclusive interpretations of federal employment discrimination laws in court.

As this report describes, many LGBT people already face difficulties obtaining accessible, inclusive health care. A substantial body of social science and medical research has found that LGBT people are at heightened risk for physical and mental health problems. When LGBT people require care, they often face higher barriers to accessing it.

LGBT individuals are twice as likely to be uninsured as non-LGBT individuals and many have difficulty finding providers who will treat them without passing judgment on their sexual orientation or gender identity or offer the services they need, particularly in rural areas.

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Some have difficulty finding providers who will treat them at all. The health issues that LGBT people experience are often exacerbated by the discrimination they face in society. In one nationally representative survey from LGBT people also have unique needs related to their sexual orientation and gender identity.

Same-sex couples who decide to have children, for example, may seek out fertility specialists or utilize assisted reproductive technologies as part of the process. While not limited to LGBT people, gay and bisexual men and transgender women may be more in need of HIV-related health care, including treatment for those who are living with HIV and access to preventive care such as pre-exposure prophylaxis PrEPa daily pill that ificantly lowers the risk of HIV infection.

Transgender people who medically transition may seek access to puberty blockers, hormone replacement therapy HRTor gender-affirming surgeries as part of their transition. Yet LGBT people—and particularly transgender people—continue to face high rates of discrimination in healthcare settings. In a nationally representative survey conducted by the Center for American Progress in8 percent of lesbian, gay, and bisexual respondents and 29 percent of transgender respondents reported that a healthcare provider had refused to see them because of their sexual orientation or gender identity in the past year.

Discrimination deters many LGBT people from seeking care. In the Center for American Progress survey, 8 percent of LGBT respondents had delayed or foregone medical care because of concerns of discrimination in healthcare settings—and those who had ly experienced discrimination were particularly likely to avoid seeking care.

This data and interviews conducted Women Slovakia wanting sex Human Rights Watch suggest that transgender and gender non-conforming people are at a particularly high risk of discrimination in health care. LGB interviewees most often encountered discrimination when they disclosed their sexual orientation or mentioned a same-sex partner, and occasionally described how they would not disclose these facts to providers to avoid discrimination.

Nondisclosure was more difficult for many transgender interviewees, particularly when their medical records did not align with their gender identity, providers perceived them to be transgender, or they sought or were undertaking medical transition. While there are ificant barriers to care for LGB people, especially in fertility and sexual health services, discrimination against transgender and gender non-conforming people is particularly acute.

When LGBT people face discrimination in health care, the options for recourse are usually limited. As of this writing in June37 states do not expressly prohibit health insurance discrimination based on sexual orientation and gender identity, and New Jersey prohibits discrimination based on gender identity alone. Women Slovakia wanting sex 18 states and the District of Columbia, the state policy expressly covers transition-related care for transgender people, while 22 states have no policy on transgender health coverage and 10 states expressly exclude that coverage. Recognizing the obstacles that LGBT people face, the Obama administration introduced rules that sought to curb discrimination in health care.

Section of the Affordable Care Act, enacted inprohibits discrimination in health care based on race, color, national origin, sex, age, or disability. It clarifies that transgender people should be treated in accordance with their gender identity, and that insurance providers cannot presumptively deny coverage for transition-related care or refuse treatments to transgender people in a discriminatory manner. Shortly after the final rule was implemented, eight states and religious healthcare providers challenged it in court, and a federal judge in Texas Women Slovakia wanting sex the rule from taking effect.

Instead of taking action to remedy the discrimination and healthcare disparities that LGBT people experience, the Trump administration has advanced two regulatory changes that are likely to exacerbate these problems. First, in Maythe Department of Health and Human Services began the process of rolling back the rule clarifying section Rather than defending the rule in court, the Trump administration announced it planned to eliminate language clarifying that sex discrimination includes discrimination based on gender identity.

Second, in earlythe Department of Health and Human Services issued a proposed rule that would give sweeping discretion to insurers and providers to decline to serve patients based on their moral or religious beliefs. These redefinitions risk greatly exacerbating the healthcare discrimination and barriers that LGBT people, women, and others already experience. Among the definitions that give cause for concern are the following:.

The expanded definition would allow people with only a tangential connection to the provision of healthcare services, including administrative or technical personnel, to refuse to perform a task because they can identify some connection, no matter how attenuated, to a service they consider objectionable.

The decisions to roll back the rule protecting transgender people and to expand protections for those who refuse to provide healthcare services based on religious beliefs strengthen the ability of insurers and providers to refuse care to LGBT people, and particularly transgender people. Between the fall of and the fall ofthe Office of Civil Rights OCR received more than 30, complaints alleging civil rights or privacy violations in healthcare settings.

In a roughly similar period, OCR received just 34 complaints alleging violations of existing federal laws that permit religious refusals. In addition to these federal developments, three US states have enacted laws or regulations that give wider latitude to discriminate in the provision of healthcare services.

As the research in this report illustrates, many LGBT people in the United States face ificant obstacles when seeking healthcare services. Retreating from antidiscrimination protections while expanding exemptions that permit insurers and providers to deny care based on their moral or religious convictions is a dangerous combination. The withdrawal of antidiscrimination protections and expansion of religious exemptions is occurring in a climate in which LGBT people already face ificant barriers to accessible and inclusive health care. LGBT people in states that enacted exemptions described four major obstacles, independent of the proposed federal changes, to obtaining the care they need: lack of accessible services, discrimination by insurers and providers, refusals by providers, and reluctance to seek care.

As discussed in this section, each of these obstacles is exacerbated where legal protections against discrimination are absent or unclear and where the expansion of religious exemptions allows providers to refuse care. Even before approaching healthcare providers, LGBT people can encounter difficulty finding the specific services they need. If they experience discrimination, they may not have alternative providers available. In part, this is because there may be few providers who are known to provide care to LGBT individuals without passing judgment on their sexual orientation or gender identity or are equipped to provide certain types of care, especially in more rural areas.

The creation of LGBT competency modules in physician training programs is a relatively recent development; a survey of US medical schools conducted in found that only 16 percent of respondent institutions had comprehensive LGBT-competency training, and 52 percent had no LGBT-competency training at all. Even where there are multiple providers in an area, material and logistical barriers may prevent LGBT people from being able to access them.

When providers are not trained on LGBT issues or services are scarce in an area, LGBT people may have few options when a provider discriminates against them or turns them away. Huge, huge, huge swathes of our state not only have no pediatricians, but have as few as two or three physicians per county. The lack of providers was especially acute in rural areas, but certain services were difficult to find in metropolitan areas as well. As one mother of a transgender child noted:.

While some of the scarce services were related to sexual orientation or gender identity, others were general medical services that providers denied to LGBT people.

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Interviewees described how one transgender man in East Tennessee had to travel three hours to obtain a hysterectomy, [54] and others noted that breast surgeries that were available to cisgender individuals were not similarly available to transgender individuals. Many interviewees told Human Rights Watch that some services were available only from a small of providers.

A survey by the National Center for Transgender Equality found that 29 percent of transgender people who are able to access transition-related care have to travel more than 25 miles to obtain it. Several providers and LGBT individuals noted that they knew of very few providers in their areas who would prescribe PrEP, a medication that ificantly lowers the risk of HIV infection by preventing HIV from taking hold in the body. Other interviewees identified a limited of fertility and reproductive health providers who worked with same-sex couples.

A lesbian woman in Mississippi recalled that, when she and her wife sought a fertility doctor inthey were unable to find options in their area and contacted a clinic in Alabama. When that clinic informed the couple that they only treated heterosexual, married couples, they did not find an LGBT-friendly provider for a year. And these are the ones who have been somewhat vetted as being LGBT friendly. And a lot of those, the T is silent, most of the time. In some instances, services existed but were not advertised to the community.

One doctor in a rural state noted that her hospital had extensive services for transgender youth, but they were not allowed to Women Slovakia wanting sex or advertise those services because administrators were concerned about repercussions from the state legislature.

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When a limited of providers were known to the community to be competent and welcoming, they could be overwhelmed with demand. For many LGBT people, unemployment and poverty combine with other barriers to care to make particular types of care virtually unattainable.

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A study examining data collected from to found that households headed by same-sex couples are more likely than those headed by demographically similar heterosexual couples to live in poverty. Transgender Survey indicated that 15 percent of transgender respondents were unemployed and 29 percent were living in poverty. In earlyan estimated 25 percent of transgender individuals were uninsured. Transgender Survey, a third of the transgender respondents indicated that they had foregone medical care they needed in the past year because of concerns about cost.

Interviewees described how cost and distance made certain services unattainable. Sandra Women Slovakia wanting sex. The nearest in-state surgeon she could find who would do the procedure was located in Ann Arbor, an hour away, which was prohibitively difficult because she did not have her own transportation. She was told that to obtain surgery from that provider, she would have to undergo electrolysis. The only transgender-friendly electrolysis providers she could find were in Lansing and Ann Arbor, and she could not determine if they would take her insurance or if it was a covered procedure.

Although she was able to find a surgeon in Pennsylvania who did not require electrolysis, her insurance would not cover out-of-state procedures, and she had thus far been unable to navigate her insurance to determine how she could proceed. People might be 40 miles, 50 miles, from the nearest therapist who takes their health insurance….

When LGBT people did access healthcare services, many encountered discriminatory language or treatment related to their sexual orientation or gender identity. As noted above, a nationally representative survey released in January found that 9 percent of lesbian, gay, and bisexual respondents and 21 percent of transgender respondents had experienced harsh or abusive language from a medical provider in the year. Multiple interviewees noted that they not only encountered discrimination from their medical provider, but from administrative staff.

Beyond the intake, some interviewees faced humiliation or discrimination from providers themselves. Renae T. Although many interviewees described negative experiences in hospitals, discrimination occurs in counseling and therapy as well, as described elsewhere in this report. KT Hiestand, a therapist in Memphis, observed:. These discriminatory incidents can deter LGBT people from returning for medical care. As Carla B. In many instances, this discriminatory treatment was overtly moralistic. Trevor L. This kind of overt discrimination can be especially damaging to those seeking mental health care.

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